Department of Surgery, Southern Illinois University School of Medicine, Springfield, IL.
Office of Population Science and Policy, Southern Illinois University School of Medicine, Springfield, IL.
Ann Surg. 2019 Aug;270(2):295-301. doi: 10.1097/SLA.0000000000002782.
We hypothesized that patients with cT1N0 esophageal cancer undergoing local excision would have lower survival compared with esophagectomy due to potential discordant staging.
Local excision has become an attractive alternative for management of early esophageal cancer, avoiding the morbidity of esophagectomy. It is uncertain if occult nodal metastasis impacts survival.
An observational study was conducted using the National Cancer Database (1998-2012) for patients with clinical T1N0 esophageal cancer who underwent local excision (n = 1625) or esophagectomy (n = 3255).
The proportion of patients undergoing local excision increased from 12% in 1998 to 50% in 2012 (P < 0.001). After esophagectomy, 61% of cT1N0 cancers had concordant clinical and pathological staging, with 5.2% having positive nodal disease; 37% were staged concordant after local excision, with excess missing data (60%). Ninety-day mortality was 7.4% after esophagectomy compared with 2.8% after local excision (P < 0.001). While no significant difference was seen in unadjusted survival, adjusted Cox regression analysis indicated worse survival after esophagectomy compared with local excision for all cases [hazard ratio (HR) 1.57, 95% confidence interval (CI) 1.27-1.95] and for patients with concordant staging (HR 1.68, 95% CI 1.23-2.28).
Local excision for cT1N0 esophageal cancer has increased over time. Contrary to our hypothesis, despite incomplete nodal staging, patients undergoing local excision have favorable survival, particularly in the adenocarcinoma subgroup. This may reflect early differences in mortality due to differences in procedure-related complications and/or selection bias. As this study has limited power to compare outcomes between T1a and T1b cancers, further analysis is warranted.
我们假设，由于潜在的分期不一致，接受局部切除术的 cT1N0 食管癌患者的生存率可能低于接受食管切除术的患者。
局部切除术已成为早期食管癌管理的一种有吸引力的替代方法，可避免食管切除术的发病率。目前尚不确定隐匿性淋巴结转移是否会影响生存率。
使用国家癌症数据库（1998-2012 年）对接受局部切除术（n=1625）或食管切除术（n=3255）的临床 T1N0 食管癌患者进行了一项观察性研究。
接受局部切除术的患者比例从 1998 年的 12%增加到 2012 年的 50%（P<0.001）。在接受食管切除术的患者中，61%的 cT1N0 癌症具有临床和病理分期一致，5.2%的患者存在阳性淋巴结疾病；37%的患者在接受局部切除术后分期一致，但存在大量缺失数据（60%）。食管切除术的 90 天死亡率为 7.4%，而局部切除术为 2.8%（P<0.001）。虽然未调整的生存情况无显著差异，但调整后的 Cox 回归分析表明，与局部切除术相比，所有病例的食管切除术预后较差[风险比（HR）1.57，95%置信区间（CI）1.27-1.95]，且与分期一致的病例（HR 1.68，95%CI 1.23-2.28）。
随着时间的推移，cT1N0 食管癌的局部切除术有所增加。与我们的假设相反，尽管淋巴结分期不完全，接受局部切除术的患者仍具有良好的生存率，尤其是在腺癌亚组中。这可能反映了由于与手术相关的并发症和/或选择偏倚的差异导致的早期死亡率差异。由于本研究比较 T1a 和 T1b 癌症的结局的能力有限，因此需要进一步分析。
