Division of Thoracic Surgery, Department of Cardiothoracic Surgery, New York Presbyterian Hospital, Weill Cornell Medical College, New York, New York 10021, USA.
Ann Thorac Surg. 2011 Aug;92(2):491-6; discussion 496-8. doi: 10.1016/j.athoracsur.2011.04.004. Epub 2011 Jun 24.
No consensus exists on the optimal treatment strategy for clinical T2-T3N0M0 esophageal cancer. This study was conducted to determine rates of nodal positivity (N+) and to evaluate results of treatment strategies in this cohort.
Surgically treated patients with cT2-T3N0M0 esophageal cancer were reviewed. Adequacy of lymph node dissection was assessed by guidelines applied to clinical stage. Survival was determined by Kaplan-Meier analysis. Univariate and multivariate analyses were done for predictors of N+ and survival.
We identified 102 patients, 51 cT2N0 and 51 cT3N0, 39 (38%) of whom had induction therapy. Despite being clinically node negative, 61 patients (60%) had nodal metastases. Applied to cT classification, adequate nodal dissection was achieved in 64 patients (63%). Transthoracic esophagectomy was more likely than transhiatal esophagectomy to achieve adequate nodal dissection (69% versus 31%, p=0.005). Adequate nodal dissection was more likely to document pN+ disease in both the surgery alone group (70% versus 50%, p=0.13) and induction therapy group (71% versus 33%, p=0.02). Five-year overall survival was 44% with surgery alone and 55% with induction therapy. On multivariate analysis, pN+ was the strongest predictor of overall survival (relative risk 2.73, confidence interval: 1.29 to 5.78).
Most cT2-T3N0M0 patients have pN+ disease. Despite induction therapy, more than 50% have persistent nodal disease. Transthoracic esophagectomy is more likely to detect pN+ disease and more likely to meet criteria of adequate nodal dissection than is transhiatal esophagectomy. Therefore, the majority of patients with cT2-T3N0M0 should be considered for neoadjuvant protocols and should be treated by transthoracic resection whenever possible.
对于临床 T2-T3N0M0 期食管癌，目前尚无最佳治疗策略的共识。本研究旨在确定淋巴结阳性（N+）的发生率，并评估该队列的治疗策略结果。
回顾性分析接受手术治疗的 cT2-T3N0M0 期食管癌患者。根据临床分期应用指南评估淋巴结清扫的充分性。采用 Kaplan-Meier 分析确定生存情况。对 N+和生存的预测因素进行单因素和多因素分析。
我们共纳入 102 例患者，其中 51 例为 cT2N0，51 例为 cT3N0，39 例（38%）接受了诱导治疗。尽管临床淋巴结阴性，但 61 例（60%）患者存在淋巴结转移。根据 cT 分类，64 例（63%）患者实现了充分的淋巴结清扫。与经胸食管切除术相比，经食管裂孔切除术更不可能实现充分的淋巴结清扫（69%与 31%，p=0.005）。在单纯手术组（70%与 50%，p=0.13）和诱导治疗组（71%与 33%，p=0.02）中，充分的淋巴结清扫更有可能记录到 pN+疾病。单纯手术组的 5 年总生存率为 44%，诱导治疗组为 55%。多因素分析显示，pN+是总生存的最强预测因素（相对风险 2.73，置信区间：1.29 至 5.78）。
大多数 cT2-T3N0M0 期患者存在 pN+疾病。尽管接受了诱导治疗，但仍有超过 50%的患者存在持续的淋巴结疾病。与经食管裂孔切除术相比，经胸食管切除术更有可能发现 pN+疾病，并更有可能满足充分淋巴结清扫的标准。因此，大多数 cT2-T3N0M0 期患者应考虑接受新辅助方案，并尽可能采用经胸切除术进行治疗。
