食管癌患者治疗效果及长期生存率的改善：放化疗的影响及治疗策略的改变
Improvement in treatment results and long-term survival of patients with esophageal cancer: impact of chemoradiation and change in treatment strategy.
作者信息
Law Simon, Kwong Dora L W, Kwok Ka-Fai, Wong Kam-Ho, Chu Kent-Man, Sham Jonathan S T, Wong John
机构信息
Division of Esophageal Surgery, Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong.
出版信息
Ann Surg. 2003 Sep;238(3):339-47; discussion 347-8. doi: 10.1097/01.sla.0000086545.45918.ee.
OBJECTIVE
To identify prognostic factors and reasons for improved survival over time in patients with esophageal cancer.
SUMMARY BACKGROUND DATA
Management strategies for esophageal cancer have evolved with time. The impact of chemoradiation in the overall treatment results has not been adequately studied.
METHODS
From 1990 to 2000, 399 (62.4%) of 639 patients with intrathoracic squamous cancers underwent resection. Two study periods were analyzed: period I (01/1990-06/1995), and period II (07/1995-12/2000); during period II, chemoradiation was introduced. Prognostic factors were identified by multivariate analysis and the 2 periods compared.
RESULTS
Hospital mortality rate after resection decreased from 7.8% to 1.2%, P = 0.002. Five favorable prognostic factors were identified: female gender (female vs. male, HR = 0.66), infracarinal tumor location (infra vs. supra-carinal, HR = 0.63), low pTNM stage (III/IV vs. 0/I/II/T0N1, HR = 1.76), pM0 stage (M1a/b vs. M0, HR = 1.56), and R0 category (R1/2 vs. R0, HR = 2.49). Median survival was 15.8 and 25.6 months in periods I and II, respectively, P = 0.02. More R0 resections were evident in period II, being possible in 63% (period I) and 79% (period II) of patients, P = 0.001. This was attributed to tumor downstaging by chemoradiation and more stringent patient selection for resection in period II. Performing less R1/2 resections in period II coincided with using primary chemoradiation in treating advanced tumors. In patients treated without resection, survival also improved from 3 (period I) to 5.8 months (period II), P < 0.01.
CONCLUSIONS
Survival has improved; chemoradiation enabled better patient selection for curative resections and also resulted in more R0 resections by tumor downstaging. This treatment strategy led to overall better outcome for the whole patient cohort, even in those treated by nonsurgical means.
目的
确定食管癌患者的预后因素以及生存时间改善的原因。
总结背景数据
食管癌的管理策略随时间而演变。放化疗对总体治疗结果的影响尚未得到充分研究。
方法
1990年至2000年，639例胸段鳞状细胞癌患者中有399例（62.4%）接受了手术切除。分析了两个研究阶段：第一阶段（1990年1月 - 1995年6月）和第二阶段（1995年7月 - 2000年12月）；在第二阶段引入了放化疗。通过多因素分析确定预后因素并比较两个阶段。
结果
切除术后的医院死亡率从7.8%降至1.2%，P = 0.002。确定了五个有利的预后因素：女性（女性与男性相比，HR = 0.66）、隆突下肿瘤位置（隆突下与隆突上相比，HR = 0.63）、低pTNM分期（III/IV期与0/I/II/T0N1期相比，HR = 1.76）、pM0期（M1a/b期与M0期相比，HR = 1.56）以及R0分类（R1/2期与R0期相比，HR = 2.49）。第一阶段和第二阶段的中位生存期分别为15.8个月和25.6个月，P = 0.02。在第二阶段，更多的R0切除明显可见，第一阶段63%的患者和第二阶段79%的患者可行R0切除，P = 0.001。这归因于放化疗使肿瘤降期以及第二阶段对手术切除患者选择更严格。第二阶段减少R1/2切除与对晚期肿瘤采用原发放化疗相一致。在未接受手术治疗的患者中，生存期也从第一阶段的3个月提高到第二阶段的5.8个月，P < 0.01。
结论
生存率有所提高；放化疗使根治性切除的患者选择更好，并且通过肿瘤降期导致更多的R0切除。这种治疗策略使整个患者队列的总体结果更好，即使是那些接受非手术治疗的患者。
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