Javidfar Jeffrey, Speicher Paul J, Hartwig Matthew G, D'Amico Thomas A, Berry Mark F
Division of Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina.
Department of Cardiothoracic Surgery, Stanford University Medical Center, Stanford, California.
Ann Thorac Surg. 2016 Mar;101(3):1060-7. doi: 10.1016/j.athoracsur.2015.09.005. Epub 2015 Nov 11.
Multimodality treatment that includes esophagogastrectomy may represent the best option for curing accurately staged patients with esophageal cancer. We analyzed the impact of incomplete resection on outcomes after esophagogastrectomy for esophageal cancer.
The incidence of positive margins for patients who underwent esophagogastrectomy without induction therapy for pathologic T1-3N0-1M0 esophageal cancer of the mid and lower esophagus from 2003 to 2006 in the National Cancer Database was analyzed with multivariate logistic regression. The impact of positive margins on survival was assessed using Kaplan-Meier and Cox proportional hazards analysis.
Positive margins occurred in 342 of 3,125 patients (10.9%) who met study criteria. Increasing clinical T status was an independent predictor of positive margins in multivariate analysis, but the chance of positive margins decreased with larger facility case volumes. The presence of clinical nodal disease was not predictive of an incomplete resection. The 5-year survival of patients with positive margins (13.8%, 95% confidence interval [CI]: 10.5% to 18.1%) was significantly worse than that for patients with negative margins (46.3%, 95% CI: 44.4% to 48.3%, p < 0.001). Both microscopic residual disease (hazard ratio 1.37, 95% CI: 1.16 to 1.60, p < 0.001) and gross residual disease (hazard ratio 1.98, 95% CI: 1.62 to 2.42, p < 0.001) predicted worse survival in multivariate analysis of the entire cohort. Receiving adjuvant chemoradiation therapy slightly improved 5-year survival of patients with positive margins (16.9%, 95% CI: 11.3% to 23.6%, versus 13.5%, 95% CI: 9% to 20.3%, p < 0.001).
Positive margins are associated with poor survival, and adjuvant therapy only marginally improved prognosis. Future studies are needed to better evaluate whether induction therapy can lower the incidence of positive margins.
包括食管胃切除术在内的多模式治疗可能是治愈准确分期食管癌患者的最佳选择。我们分析了食管癌食管胃切除术后切缘阳性对预后的影响。
利用多因素逻辑回归分析2003年至2006年国家癌症数据库中接受食管胃切除术且未接受诱导治疗的食管中下段病理T1-3N0-1M0食管癌患者切缘阳性的发生率。采用Kaplan-Meier法和Cox比例风险分析法评估切缘阳性对生存的影响。
在符合研究标准的3125例患者中，342例（10.9%）切缘阳性。在多因素分析中，临床T分期增加是切缘阳性的独立预测因素，但随着医疗机构病例数增加，切缘阳性的几率降低。临床淋巴结疾病的存在并不能预测切除不完全。切缘阳性患者的5年生存率（13.8%，95%置信区间[CI]：10.5%至18.1%）显著低于切缘阴性患者（46.3%，95%CI：44.4%至48.3%，p<0.001）。在整个队列的多因素分析中，镜下残留病灶（风险比1.37，95%CI：1.16至1.60，p<0.001）和肉眼残留病灶（风险比1.98，95%CI：1.62至2.42，p<0.001）均预示生存较差。接受辅助放化疗可使切缘阳性患者的5年生存率略有提高（16.9%，95%CI：11.3%至23.6%，对比1%，95%CI：9%至20.3%，p<0.001）。
切缘阳性与生存不良相关，辅助治疗仅略微改善预后。需要进一步研究以更好地评估诱导治疗是否能降低切缘阳性的发生率。
