Gottlieb-Vedi Eivind, Kauppila Joonas H, Mattsson Fredrik, Hedberg Jakob, Johansson Jan, Edholm David, Lagergren Pernilla, Nilsson Magnus, Lagergren Jesper
Upper Gastrointestinal Surgery, Department of Molecular medicine and Surgery, Karolinska Institutet, and Karolinska University Hospital, Stockholm, Sweden.
cancer and Translational Medicine Research Unit, Medical Research center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland.
Ann Surg. 2023 Mar 1;277(3):429-436. doi: 10.1097/SLA.0000000000005028. Epub 2021 Jun 25.
To examine the hypothesis that survival in esophageal cancer increases with more removed lymph nodes during esophagectomy up to a plateau, after which it levels out or even decreases with further lymphadenec-tomy.
There is uncertainty regarding the ideal extent of lymphadenectomy during esophagectomy to optimize long-term survival in esophageal cancer.
This population-based cohort study included almost every patient who underwent esophagectomy for esophageal cancer in Sweden or Finland in 2000-2016 with follow-up through 2019. Degree of lymphadenectomy, divided into deciles, was analyzed in relation to all-cause 5-year mortality. Multivariable Cox regression provided hazard ratios (HR) with 95% confidence intervals (95% CI) adjusted for all established prognostic factors.
Among 2306 patients, the second (4-8 nodes), seventh (21-24 nodes) and eighth decile (25-30 nodes) of lymphadenectomy showed the lowest all-cause 5-year mortality compared to the first decile [hazard ratio (HR) = 0.77, 95% CI 0.61-0.97, HR = 0.76, 95% CI 0.59-0.99, and HR = 0.73, 95% CI 0.57-0.93, respectively]. In stratified analyses, the survival benefit was greatest in decile 7 for patients with pathological T-stage T3/T4 (HR = 0.56, 95% CI0.40-0.78), although it was statistically improved in all deciles except decile 10. For patients without neoadjuvant chemotherapy, survival was greatest in decile 7 (HR = 0.60, 95% CI 0.41-0.86), although survival was also statistically significantly improved in deciles 2, 6, and 8.
Survival in esophageal cancer was not improved by extensive lymphadenectomy, but resection of a moderate number (20-30) of nodes was prognostically beneficial for patients with advanced T-stages (T3/T4) and those not receiving neoadjuvant therapy.
检验以下假设，即食管癌患者在食管切除术中切除更多的淋巴结，其生存率会随之提高，直至达到一个平台期，此后随着进一步的淋巴结清扫，生存率趋于平稳甚至下降。
关于食管切除术中淋巴结清扫的理想范围，以优化食管癌患者的长期生存率，目前仍存在不确定性。
这项基于人群的队列研究纳入了2000年至2016年在瑞典或芬兰接受食管癌食管切除术的几乎所有患者，并随访至2019年。将淋巴结清扫程度分为十分位数，分析其与全因5年死亡率的关系。多变量Cox回归提供了风险比（HR）及95%置信区间（95%CI），并对所有已确定的预后因素进行了调整。
在2306例患者中，与第一分位数相比，淋巴结清扫的第二分位数（4 - 8个淋巴结）、第七分位数（21 - 24个淋巴结）和第八分位数（25 - 30个淋巴结）的全因5年死亡率最低[风险比（HR）分别为0.77，95%CI 0.61 - 0.97；HR = 0.76，95%CI 0.59 - 0.99；HR = 0.73，95%CI 0.57 - 0.93]。在分层分析中，对于病理T分期为T3/T4的患者，第七分位数的生存获益最大（HR = 0.56，95%CI 0.40 - 0.78），尽管除第十分位数外，所有分位数的生存率均有统计学意义的提高。对于未接受新辅助化疗的患者，第七分位数的生存率最高（HR = 0.60，95%CI 0.41 - 0.86），尽管第二、六和八分位数的生存率也有统计学意义的显著提高。
广泛的淋巴结清扫并不能提高食管癌患者的生存率，但切除中等数量（20 - 30个）的淋巴结对晚期T分期（T3/T4）患者和未接受新辅助治疗的患者在预后方面有益。
