Suntharalingam M, Haas M L, Sonett J R, Doyle L A, Hausner P F, Schuetz J, Greenwald B, Krasna M J
Department of Radiation Oncology, Greenebaum Cancer Center, University of Maryland Medical System, Baltimore 21201, USA.
Cancer J. 2001 Nov-Dec;7(6):509-15.
The diagnosis of esophageal carcinoma has historically been associated with a poor prognosis. Recently, investigators have reported improved outcomes for this patient population with the use of trimodality therapy. These results have fueled the debate regarding which patients may benefit from this aggressive treatment course. This retrospective analysis was conducted in order to evaluate the importance of regional lymph node involvement, determined by surgical staging before the initiation of therapy.
Between July 1991 and June 1999, 45 patients underwent surgical staging with thoracoscopy and/or laparoscopy followed by induction chemoradiation and surgical resection. All patients underwent consultation in our thoracic multidisciplinary clinic. Thoracoscopy included nodal sampling from American Thoracic Society levels 5, 6, 8, and 9 within the mediastinum. Laparoscopy included inspection of the liver and nodal sampling from the lesser curvature and the celiac axis. Preoperative chemoradiation consisted of two cycles of 5-fluorouracil (1000 mg/M2) and cisplatin (100 mg/M2) weeks 1 and 4 with 50.4 Gy. Radiotherapy was delivered at 1.8 Gy/fraction with 39.6 Gy being delivered to the large-field and 10.8 Gy to a small-field boost. The routine surgical procedure was an Ivor-Lewis esophagectomy performed 4 to 6 weeks after completion of induction therapy.
The median follow up was 24 months for all patients. The median overall survival was 23 months, with 1-, 2-, and 3-year survivals of 64%, 42%, and 34%, respectively. Thirty patients had pathological evidence of lymph node disease before therapy. The pathological complete response rate for the entire group was 51%. Node-positive patients had a path complete response rate of 14%, as compared with 59% for those who were NO. The median survival for these two groups was 15 months versus 35 months. Patients whose nodes were cleared by chemoradiation had a 3-year survival of 40%, whereas all patients with persistent nodal disease were dead by 2 years. Twenty-one patients have experienced recurrence of their disease. Thirteen patients had evidence of distant metastasis only, three local only, and five with both.
Trimodality therapy offers patients with esophageal cancer an opportunity for long-term survival. Our experience has shown that minimally invasive pretreatment surgical staging provides useful information that can predict complete response and can help in the selection of appropriate patients for aggressive therapy.
食管癌的诊断历来与预后不良相关。最近，研究人员报告称，采用三联疗法可改善该患者群体的预后。这些结果引发了关于哪些患者可能从这种积极的治疗方案中获益的争论。进行这项回顾性分析是为了评估区域淋巴结受累情况的重要性，该情况通过治疗开始前的手术分期来确定。
1991年7月至1999年6月期间，45例患者接受了胸腔镜和/或腹腔镜手术分期，随后进行诱导放化疗及手术切除。所有患者均在我们的胸科多学科诊所接受会诊。胸腔镜检查包括从纵隔内美国胸科学会第5、6、8和9组淋巴结进行采样。腹腔镜检查包括肝脏检查以及从小弯侧和腹腔动脉进行淋巴结采样。术前放化疗包括在第1周和第4周给予两个周期的5-氟尿嘧啶（1000mg/M²）和顺铂（100mg/M²），同时给予50.4Gy放疗。放疗以1.8Gy/分次进行，其中39.6Gy给予大野照射，10.8Gy给予小野加量照射。常规手术为Ivor-Lewis食管切除术，在诱导治疗完成后4至6周进行。
所有患者的中位随访时间为24个月。中位总生存期为23个月，1年、2年和3年生存率分别为64%、42%和34%。30例患者在治疗前有淋巴结疾病的病理证据。整个组的病理完全缓解率为51%。淋巴结阳性患者的病理完全缓解率为14%，而淋巴结阴性患者为59%。这两组的中位生存期分别为15个月和35个月。经放化疗清除淋巴结的患者3年生存率为40%，而所有持续性淋巴结疾病患者在2年内均死亡。21例患者出现疾病复发。13例患者仅有远处转移证据，3例仅有局部转移，5例两者均有。
三联疗法为食管癌患者提供了长期生存的机会。我们的经验表明，微创术前手术分期可提供有用信息，能够预测完全缓解，并有助于选择适合积极治疗的患者。
