Department of Molecular medicine and Surgery, Karolinska Institutet, Stockholm, Sweden (MvdS, AJ, PL, JL); Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands (BW); Division of Cancer Studies, King's College London, London, UK (JL).
J Natl Cancer Inst. 2015 Mar 5;107(5). doi: 10.1093/jnci/djv043. Print 2015 May.
It is unclear how the extent of surgical lymph node clearance influences prognosis after surgery for esophageal cancer.
This nationwide, population-based cohort study included 1044 esophageal cancer patients who had undergone esophagectomy between 1987 and 2010 in Sweden, with follow-up until 2012. The independent role of lymph node removal in relation to survival was analyzed using Cox proportional hazards regression, providing hazard ratios (HRs) with 95% confidence intervals (CIs), adjusted for age, sex, comorbidity, tumor (T) stage, neo-adjuvant treatment, surgeon volume, and calendar period. Statistical tests were two-sided, except tests for trend.
Analyzed as a linear variable, a higher number of lymph nodes removed did not influence the overall five-year mortality (adjusted HR = 1.00, 95% CI = 0.99 to 1.01). Patients in the third (7-15 nodes) and fourth (16-114 nodes) quartiles of removed nodes did not demonstrate any decreased overall five-year mortality compared with those in the lowest two quartiles (<7 nodes) (HR = 1.13, 95% CI = 0.95 to 1.35 and HR = 1.17, 95% CI = 0.94 to 1.46, respectively). In early T stages (Tis-T1) the hazard ratios indicated a worse survival with more lymphadenectomy using the median as cutoff (HR = 1.53, 95% CI = 1.13 to 2.06). Increased lymph node removal did not decrease mortality in any specific T stage. A greater number of metastatic nodes and a higher positive-to-negative node ratio were associated with strongly increased mortality. All results were similar when disease-specific mortality was analyzed.
This population-based study indicates that more extensive lymph node clearance during surgery for esophageal cancer may not improve survival. These results challenge current clinical guidelines, and further research is needed to change clinical practice.
目前尚不清楚手术切除淋巴结的范围如何影响食管癌手术后的预后。
这是一项全国范围内的基于人群的队列研究，纳入了 1987 年至 2010 年间在瑞典接受食管癌切除术的 1044 例食管癌患者，随访至 2012 年。使用 Cox 比例风险回归分析淋巴结清除范围与生存之间的独立关系，提供风险比（HR）及其 95%置信区间（CI），调整因素包括年龄、性别、合并症、肿瘤（T）分期、新辅助治疗、外科医生手术量和日历时间。除趋势检验外，所有统计检验均为双侧检验。
作为线性变量分析，切除的淋巴结数量增加并不影响总体五年死亡率（调整 HR = 1.00，95%CI = 0.99 至 1.01）。与切除淋巴结数量最低的两个四分位数（<7 个）相比，切除淋巴结数量处于第三（7-15 个）和第四（16-114 个）四分位数的患者并未显示出总体五年死亡率降低（HR = 1.13，95%CI = 0.95 至 1.35 和 HR = 1.17，95%CI = 0.94 至 1.46）。在早期 T 分期（Tis-T1）中，使用中位数作为截断值时，更多淋巴结清扫术的 HR 表明生存率更差（HR = 1.53，95%CI = 1.13 至 2.06）。在任何特定的 T 分期中，增加淋巴结清扫术并未降低死亡率。更多的转移性淋巴结和更高的阳性淋巴结与阴性淋巴结比值与死亡率显著增加相关。当分析疾病特异性死亡率时，所有结果均相似。
本基于人群的研究表明，食管癌手术中更广泛的淋巴结清扫术可能无法提高生存率。这些结果对当前的临床指南提出了挑战，需要进一步研究以改变临床实践。
