Meneu-Diaz J C, Blazquez L A, Vicente E, Nuño J, Quijano Y, Lopez-Hervás P, Devesa M, Fresneda V
Departamento de Cirugía General y del Aparato Digestivo, Hospital Universitario Ramón y Cajal, Universidad de Alcalá de Henares, Madrid, Spain.
Am J Surg. 2000 Jun;179(6):508-13. doi: 10.1016/s0002-9610(00)00384-6.
There is an increasing interest in the role of combined therapy to achieve long-term survival for patients with resectable esophageal neoplasms. Surgery provides excellent palliation with relatively low morbidity and mortality rates, but cure remains elusive.
From January 1988 to January 1998, a total of 137 patients met eligibility criteria for a combined multimodal therapy, prospective, nonrandomized protocol of induction chemoradiation therapy followed by surgical resection, based on radiological and endoscopic assessment of the extension (all patients were initially considered to be at clinical stages I to III, locoregional). Consequently, patients with high grade Barrett's dysplasia or any squamous carcinoma in situ (stage 0) and those with distant metastatic disease (stage IV) were excluded. Among this group, 48 operable patients with biopsy-proven esophageal cancer finally entered and completed the protocol and are the sample of the present study. Multivariate logistic regression models were used to identify risk factors for death or recurrence. Actuarial survival was calculated since the beginning of the induction protocol by the Kaplan-Meier method, and comparisons between groups were made by the log-rank test.
Mean age was 61.6 (range 45 to 71), and 72.9% were male. The majority of the tumors (70.8%) were located at the lower third/cardia and as many as 18.8% were adenocarcinoma. After a mean of 7.5 weeks (range 5 to 12) after the completion of the induction phase, 68.7% underwent a transthoracic esophagectomy and 31.3% a transhiatal esophagectomy. The in-hospital mortality rate was 10.4% (5 patients). A complete response (no evidence of tumor within the specimen: pT0) was achieved in 25% (12 patients). After a mean follow-up of 20.2 months, mean survival for the entire group was 18.2 months (95% confidence interval 14 to 22). At the end of the study, 25% (12) remained alive. Actuarial survival rates at 12, 23, and 37 months were 56.2%, 36.9%, and 21.9%, respectively.
Esophageal resection after induction therapy seems to be related to a slightly higher mortality rate compared with historical series, and for this reason, neoadjuvant therapy must be considered still experimental. However, no statistical significant difference in survival is showed in those cases with complete pathological response (pT0). Factors influencing survival are recurrence and age. Surgery alone remains the standard therapy for esophageal cancer.
对于可切除食管肿瘤患者，联合治疗在实现长期生存方面的作用日益受到关注。手术能提供良好的缓解效果，且发病率和死亡率相对较低，但治愈仍难以实现。
1988年1月至1998年1月，共有137例患者符合联合多模式治疗的入选标准，这是一项前瞻性、非随机的方案，即先进行诱导放化疗，然后根据影像学和内镜对肿瘤范围的评估进行手术切除（所有患者最初均被认为处于临床I至III期，即局部区域期）。因此，排除了高级别巴雷特异型增生或任何原位鳞状癌（0期）患者以及远处转移疾病（IV期）患者。在这组患者中，48例经活检证实为食管癌且可手术的患者最终进入并完成了该方案，他们是本研究的样本。使用多变量逻辑回归模型来确定死亡或复发的危险因素。自诱导方案开始起，采用Kaplan-Meier法计算精算生存率，并通过对数秩检验进行组间比较。
平均年龄为61.6岁（范围45至71岁），72.9%为男性。大多数肿瘤（70.8%）位于食管下三分之一/贲门处，腺癌占18.8%。诱导期结束后平均7.5周（范围5至12周），68.7%的患者接受了经胸段食管切除术，31.3%的患者接受了经裂孔食管切除术。住院死亡率为10.4%（5例患者）。25%（12例患者）实现了完全缓解（标本内无肿瘤证据：pT0）。平均随访20.2个月后，整个组的平均生存期为18.2个月（95%置信区间14至22个月）。研究结束时，25%（12例）患者仍存活。12个月、23个月和37个月时的精算生存率分别为56.2%、36.9%和21.9%。
与历史系列相比，诱导治疗后进行食管切除术的死亡率似乎略高，因此，新辅助治疗仍被认为是试验性的。然而，在病理完全缓解（pT0）的病例中，生存率无统计学显著差异。影响生存的因素是复发和年龄。单纯手术仍然是食管癌的标准治疗方法。
