Van Raemdonck D, Van Cutsem E, Menten J, Ectors N, Coosemans W, De Leyn P, Lerut T
Department of Thoracic Surgery, University Hospitals, UZ Gasthuisberg, Leuven, Belgium.
Eur J Cardiothorac Surg. 1997 May;11(5):828-37. doi: 10.1016/s1010-7940(97)01194-9.
Complete resection of a locally advanced oesophageal carcinoma is not always feasible when invading mediastinal structures. The use of induction therapy prior to surgical exploration in patients with these clinical T4 tumours is anticipated to improve the resectability rate.
Patients, 18, who presented with a carcinoma of the thoracic oesophagus with clinical invasion into the carina (n = 6), trachea (n = 5), aorta (n = 4), lung (n = 2) and diaphragm (n = 1) were treated with concurrent chemotherapy and radiotherapy followed by surgical exploration. Follow-up was complete (mean of 17 +/- 3 months in all patients and 27 +/- 2 months in surviving patients).
All patients completed the induction therapy with acceptable toxicity and no mortality. Subjective improvement in dysphagia was substantial in 11 patients (in 8/11 patients (73%) however, there was still viable tumour in the resected specimen), it was minimal in six patients and absent in one patient. Objective response on imaging was complete in one patient, partial in eight patients and minimal in nine patients [in two of these nine patients (22%) nevertheless, the primary tumour had disappeared completely in the resected specimen (pT0)]. Resection was complete (R0) in 14 patients (78%) and incomplete (R1) in one patient (5%). Resection of the primary tumour was impossible (R2) in three patients (17%) because of macroscopic airway (n = 2) and hilar (n = 1) invasion on exploration. In these three patients the tumour was bypassed using a retrosternal split stomach. One patient was proven at the time of surgery to have a previously unidentified lung metastasis. In three patients (17%), no residual tumour cells were found in the resected oesophagus nor in the lymph nodes (pT0N0M0). There have been no in-hospital deaths. Actuarial 3 year survival was 43% in all patients, 55% in completely resected patients and 100% in sterilized patients (pT0N0M0). Median survival was 18 months in all patients.
Chemo/radiotherapy followed by surgery in patients with a clinical T4 oesophageal carcinoma is feasible with acceptable toxicity and no treatment-related mortality. Operability and resectability rate were high (100 and 83%, respectively) compared with historical controls. The primary tumour disappeared completely (pT0N0-1M0-1) in 28%. Tumour sterilization rate was 17%. Survival looks promising compared with historical controls. Subjective neither objective response following induction therapy clearly correlated with the final pTNM staging. This indicates that, in the absence of tumour progression, neither the patient nor the treating physician should jeopardize the chance for ultimate cure by denying surgical exploration following induction therapy.
当局部晚期食管癌侵犯纵隔结构时，完整切除并不总是可行的。预计对这些临床T4期肿瘤患者在手术探查前使用诱导治疗可提高切除率。
18例表现为胸段食管癌且临床侵犯隆突（n = 6）、气管（n = 5）、主动脉（n = 4）、肺（n = 2）和膈肌（n = 1）的患者接受同步放化疗，随后进行手术探查。随访完整（所有患者平均17±3个月，存活患者平均27±2个月）。
所有患者均完成诱导治疗，毒性可接受，无死亡病例。11例患者吞咽困难有显著主观改善（然而，在切除标本中8/11例患者（73%）仍有存活肿瘤），6例患者改善极小，1例患者无改善。影像学客观反应完全缓解1例，部分缓解8例，微小缓解9例[在这9例患者中的2例（22%），切除标本中原发肿瘤已完全消失（pT0）]。14例患者（78%）切除完整（R0），1例患者（5%）切除不完整（R1）。3例患者（17%）因探查时肉眼可见气道（n = 2）和肺门（n = 1）侵犯而无法切除原发肿瘤（R2）。在这3例患者中，采用胸骨后劈开胃绕过肿瘤。1例患者在手术时被证实有先前未发现的肺转移。3例患者（17%）切除的食管及淋巴结中未发现残留肿瘤细胞（pT0N0M0）。无院内死亡病例。所有患者3年精算生存率为43%，完整切除患者为55%，肿瘤清除患者（pT0N0M0）为100%。所有患者中位生存期为个月。
临床T4期食管癌患者先进行化疗/放疗再手术是可行的，毒性可接受，无治疗相关死亡。与历史对照相比，可手术率和切除率较高（分别为100%和83%）。28%的患者原发肿瘤完全消失（pT0N0 - 1M0 - 1）。肿瘤清除率为17%。与历史对照相比，生存率看起来很有希望。诱导治疗后的主观和客观反应均与最终的pTNM分期无明显相关性。这表明，在无肿瘤进展的情况下，患者和治疗医生都不应因拒绝诱导治疗后的手术探查而危及最终治愈的机会。
