Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, 19104, USA.
Ann Surg Oncol. 2018 Jan;25(1):318-325. doi: 10.1245/s10434-017-6238-z. Epub 2017 Nov 16.
In early-stage esophageal adenocarcinoma (EAC), esophagectomy improves staging but also increases mortality compared with endoscopic resection. Our objective was to quantify esophagectomy mortality and lymph node metastasis (LNM) risk in early-stage EAC to improve surgical treatment allocation.
We identified National Cancer Database (2004-2014) patients with nonmetastatic, Tis, T1a, or T1b EAC who had primary surgical resection and microscopic examination of at least 15 lymph nodes. Univariate and multivariable logistic regression identified predictors of LNM. Cox regression identified predictors of death. The Kaplan-Meier method predicted overall survival (OS).
In 782 patients, LNM rates were: all patients 13.8%, Tis 0%, T1a 3.6%, T1b 23.4%. Independent predictors of LNM were submucosal invasion, lymphovascular invasion (LVI), decreasing differentiation, and tumor size ≥ 2 cm (P < 0.05). For T1a tumors with poor differentiation or size ≥ 2 cm, LNM rates were 10.2 and 6.7%, respectively; 90-day mortality was 3.1%. The LNM rate in well differentiated T1b tumors < 2 cm was 4.2%; 90-day mortality was 6.0%. Estimated 5-year OS was 80.2% versus 64.4% (T1a vs. T1b). LNM increased risk of death for T1a (hazard ratio [HR] 8.52, 95% confidence interval [CI] 3.13-23.22, P < 0.001) and T1b tumors (HR 2.52, 95% CI 1.59-4.00, P < 0.001).
In T1a EAC with poor differentiation or size ≥ 2 cm, esophagectomy should be considered, whereas in T1b EAC with low-risk features (well-differentiated T1b EAC < 2 cm without LVI), endoscopic resection may be sufficient. Treatment guidelines for early-stage EAC should include all high-risk tumor features for LNM and stage-specific esophagectomy mortality.
在早期食管腺癌（EAC）中，与内镜切除术相比，食管切除术可改善分期，但也会增加死亡率。我们的目的是量化早期 EAC 中食管切除术的死亡率和淋巴结转移（LNM）风险，以改善手术治疗的分配。
我们从国家癌症数据库（2004-2014 年）中确定了非转移性、Tis、T1a 或 T1b EAC 患者，这些患者接受了原发性手术切除和至少 15 个淋巴结的显微镜检查。单变量和多变量逻辑回归确定了 LNM 的预测因素。Cox 回归确定了死亡的预测因素。Kaplan-Meier 方法预测了总生存期（OS）。
在 782 例患者中，LNM 率为：所有患者 13.8%，Tis 0%，T1a 3.6%，T1b 23.4%。LNM 的独立预测因素包括黏膜下浸润、淋巴血管侵犯（LVI）、分化程度降低和肿瘤大小≥2cm（P<0.05）。对于分化不良或肿瘤大小≥2cm 的 T1a 肿瘤，LNM 率分别为 10.2%和 6.7%；90 天死亡率为 3.1%。分化良好且肿瘤大小<2cm 的 T1b 肿瘤的 LNM 率为 4.2%；90 天死亡率为 6.0%。估计的 5 年 OS 率为 80.2%，而 T1a 和 T1b 分别为 64.4%。LNM 增加了 T1a（危险比[HR]8.52，95%置信区间[CI]3.13-23.22，P<0.001）和 T1b 肿瘤（HR 2.52，95%CI 1.59-4.00，P<0.001）的死亡风险。
对于分化不良或肿瘤大小≥2cm 的 T1a EAC，应考虑进行食管切除术，而对于具有低风险特征（分化良好且肿瘤大小<2cm 且无 LVI 的 T1b EAC）的 T1b EAC，内镜切除术可能已足够。早期 EAC 的治疗指南应包括所有 LNM 高危肿瘤特征和特定于阶段的食管切除术死亡率。
