Samson Pamela, Puri Varun, Broderick Stephen, Patterson G Alexander, Meyers Bryan, Crabtree Traves
Division of Cardiothoracic Surgery, Washington University in St. Louis, St. Louis, Missouri.
St. Luke's Hospital, Division of Cardiothoracic Surgery, Chesterfield, Missouri.
Ann Thorac Surg. 2017 Feb;103(2):406-415. doi: 10.1016/j.athoracsur.2016.08.010. Epub 2016 Dec 23.
National Comprehensive Cancer Network (NCCN) guidelines recommend sampling 15 or more lymph nodes during esophagectomy. The proportion of patients meeting this guideline is unknown, as is its influence on overall survival (OS).
Univariate analysis and logistic regression were performed to identify variables associated with sampling 15 or more lymph nodes among patients undergoing esophagectomy in the National Cancer Data Base (NCDB). The NCCN guideline was evaluated in Cox proportional hazards modeling, along with alternative lymph node thresholds. Positive to examined node (PEN) ratios were calculated, and OS was compared using Kaplan-Meier analysis.
From 2006 to 2012, only 6,961 of 18,777 (37.1%) patients undergoing esophagectomy had sampling of 15 or more lymph nodes. Variables associated with sampling 15 or more lymph nodes included income greater than or equal to $38,000, procedure performed in an academic facility, and increasing clinical T and N stages. Induction therapy was associated with a decreased likelihood of 15 or more lymph nodes being sampled. The largest decrease in mortality hazard in patients undergoing upfront esophagectomy was detected when 25 lymph nodes or more were sampled (hazard ratio [HR], 0.77; 95% confidence interval [CI], 0.67-0.89; p < 0.001), whereas for patients undergoing induction therapy, sampling of 10 or 15 or more lymph nodes was associated with optimal survival benefit (HR, 0.81; 95% CI, 0.74-0.90; p < 0.001). PEN ratios of 0 to 0.10 were associated with maximum survival benefit among all patients undergoing esophagectomy. For patients with a PEN ratio of 0, increases in OS were detected with higher lymph node sampling (85.3 months for sampling of 20 or more lymph nodes versus 52.0 months for sampling 1-9 lymph nodes; p < 0.001).
For patients undergoing upfront esophagectomy, there may be an increased survival benefit for examining 20 to 25 lymph nodes, which is higher than current recommendations. However, only a minority of patients are meeting current guidelines.
美国国立综合癌症网络（NCCN）指南建议在食管癌切除术中清扫15个或更多淋巴结。达到该指南标准的患者比例以及其对总生存期（OS）的影响尚不清楚。
在国家癌症数据库（NCDB）中，对接受食管癌切除术的患者进行单因素分析和逻辑回归，以确定与清扫15个或更多淋巴结相关的变量。在Cox比例风险模型中评估NCCN指南以及其他淋巴结阈值。计算阳性与检查淋巴结（PEN）比率，并使用Kaplan-Meier分析比较总生存期。
2006年至2012年，18777例接受食管癌切除术的患者中，只有6961例（37.1%）清扫了15个或更多淋巴结。与清扫15个或更多淋巴结相关的变量包括收入大于或等于38000美元、在学术机构进行手术以及临床T和N分期增加。诱导治疗与清扫15个或更多淋巴结的可能性降低相关。在接受 upfront 食管癌切除术的患者中，当清扫25个或更多淋巴结时，死亡率风险下降最大（风险比[HR]，0.77；95%置信区间[CI]，0.67 - 0.89；p < 0.001），而对于接受诱导治疗的患者，清扫10个或15个及以上淋巴结与最佳生存获益相关（HR，0.81；95%CI，0.74 - 0.90；p < 0.001）。在所有接受食管癌切除术的患者中，PEN比率为0至0.10与最大生存获益相关。对于PEN比率为0的患者，随着淋巴结清扫数量增加，总生存期延长（清扫20个或更多淋巴结的患者为85.3个月，清扫1 - 9个淋巴结的患者为52.0个月；p < 0.001）。
对于接受 upfront 食管癌切除术的患者，清扫20至25个淋巴结可能比当前建议清扫数量更多，从而增加生存获益。然而，只有少数患者达到当前指南标准。
