Division of Thoracic and Foregut Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA.
J Am Coll Surg. 2010 Apr;210(4):418-27. doi: 10.1016/j.jamcollsurg.2010.01.003.
BACKGROUND: Endoscopic resection and ablation have advanced the treatment of intramucosal esophageal adenocarcinoma and have been promoted as definitive therapy for selected superficial submucosal tumors. Controversy exists regarding the prevalence of nodal metastases at various depths of mucosal and submucosal invasion. Our aim was to clarify this prevalence and identify predictors of nodal spread. STUDY DESIGN: An expert gastrointestinal pathologist retrospectively reviewed 54 T1 adenocarcinomas from 258 esophagectomy specimens (2000 to 2008). Tumors were classified as intramucosal or submucosal, the latter being subclassified as SM1 (upper third), SM2 (middle third), or SM3 (lower third) based on the depth of tumor invasion. The depth of invasion was correlated with the prevalence of positive nodes. Fisher's exact test and univariate and multivariate logistic regression were used to identify variables predicting nodal disease. RESULTS: Nodal metastases were present in 0% (0 of 25) of intramucosal, 21% (3 of 14) of SM1, 36% (4 of 11) of SM2, and 50% (2 of 4) of SM3 tumors. The differences were significant between intramucosal and submucosal tumors (p < 0.0001), although not between the various subclassifications of submucosal tumors (p = 0.503). Univariate logistic regression identified poor differentiation (p = 0.024), lymphovascular invasion (p = 0.049), and number of harvested lymph nodes (p = 0.037) as significantly correlated with nodal disease. Multivariate logistic regression did not identify any of the tested variables as independent predictors of the prevalence of positive lymph nodes. CONCLUSIONS: All depths of submucosal invasion of esophageal adenocarcinoma were associated with an unacceptably high prevalence of nodal metastases and a marked increase relative to intramucosal cancer. Accurate predictors of nodal spread, independent of tumor depth, are currently lacking and will be necessary before recommending endoscopic resection with or without concomitant ablation as curative treatment for even superficial submucosal neoplasia.
背景：内镜下切除和消融技术的进步推动了黏膜内食管腺癌的治疗，并被推荐为选择的黏膜下浅层肿瘤的根治性治疗方法。在不同黏膜和黏膜下浸润深度的淋巴结转移的发生率方面存在争议。我们的目的是阐明这种发生率并确定淋巴结转移的预测因素。
研究设计：一位胃肠病理专家回顾性分析了 2000 年至 2008 年间 258 例食管切除标本中的 54 例 T1 腺癌。肿瘤分为黏膜内或黏膜下，后者根据肿瘤浸润深度分为 SM1（上三分之一）、SM2（中三分之一）或 SM3（下三分之一）。肿瘤浸润深度与阳性淋巴结的发生率相关。采用 Fisher 确切检验和单因素及多因素逻辑回归分析来确定预测淋巴结疾病的变量。
结果：0%（25 例中 0 例）的黏膜内、21%（14 例中 3 例）的 SM1、36%（11 例中 4 例）的 SM2 和 50%（4 例中 2 例）的 SM3 肿瘤存在淋巴结转移。黏膜内和黏膜下肿瘤之间的差异有统计学意义（p<0.0001），但黏膜下肿瘤的各种亚分类之间无差异（p=0.503）。单因素逻辑回归分析确定低分化（p=0.024）、血管淋巴管侵犯（p=0.049）和采集的淋巴结数量（p=0.037）与淋巴结疾病显著相关。多因素逻辑回归分析未确定任何测试变量是阳性淋巴结发生率的独立预测因素。
结论：食管腺癌的所有黏膜下浸润深度均与淋巴结转移的发生率高且明显高于黏膜内癌有关。目前缺乏独立于肿瘤深度的淋巴结转移的准确预测因素，在推荐内镜下切除联合或不联合消融作为治疗甚至是浅层黏膜下肿瘤的根治性治疗之前，这些预测因素是必要的。
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