摘要/Abstract

摘要： 目的·回顾Ⅰ期食管鳞癌患者的外科治疗结果，分析此类早期肿瘤的临床生物学特征，并确定外科治疗是否是值得推荐的治愈性策略选择。方法·回顾性分析上海交通大学附属胸科医院2015年—2019年的379例Ⅰ期食管鳞癌外科患者临床资料。分期定义按照《美国癌症联合委员会分期手册》第8版确定。采用Kaplan-Meier法估计不同临床特征Ⅰ期食管鳞癌患者的生存情况，采用Log-rank检验比较各组生存率。并对年龄、性别、病理分期T、临床分期T、肿瘤直径、淋巴结清扫数等影响生存的指标进行单因素、多因素分析，评估影响预后的危险因素。结果·全组患者共379例，占同期所有接受食管癌根治术患者的11.9%。男性占79.2%。肿瘤在胸上、中、下段分布为14.2%、43.8%、42.0%。81.5%的患者采用了微创手术。R₀切除率96.0%。淋巴结清扫数为（18.0±9.3）枚。术后并发症Clavien-Dindo分级Ⅲ级以上发生率为20.8%，其中吻合口瘘、喉返神经损伤、肺炎、呼吸功能不全的发生率分别为12.4%、14.2%、13.5%、2.9%。术后30 d内和90 d内死亡率分别为0.5%和1.3%。术后肿瘤病理显示T_1a、T_1b、T₂比例为20.6%、69.4%、10.0%；术后病理肿瘤直径为（2.1±1.1）cm，小于术前内镜下肿瘤直径［（3.2±2.2）cm］；淋巴管侵犯阳性率5.8%。随访时间为1~61个月，中位随访时间为24个月。随访期间，总体复发率为8.2%，局部区域复发率和远处转移率分别为7.4%和2.9%。单因素分析显示年龄、淋巴结清扫数与总体生存（overall survival，OS）相关（P=0.025，P=0.011），临床分期T、病理分期T、淋巴结清扫数与无病生存（disease-free survival，DFS）相关（P=0.017，P=0.005，P=0.001）。多因素分析显示OS的独立危险因素为年龄≥65岁、淋巴结清扫数少于15枚，DFS的独立危险因素为淋巴结清扫数少于15枚、临床分期为T₂或T₃。结论·Ⅰ期食管鳞癌患者经过以微创手术为主的外科治疗后，可以获得满意的肿瘤控制和远期生存。更彻底的淋巴结清扫术是改善预后的关键。
关键词: 食管鳞癌, 早期食管癌, 生物学特征, 食管癌根治术, 生存
Abstract:
Objectives·To review the results of surgical treatment for the patients with stage Ⅰ esophageal squamous cell carcinoma, analyze the clinical biological characteristics, and determine whether surgical treatment is a recommended curative strategy.
Methods·A total of 379 patients undergoing esophagectomy with stage Ⅰ squamous cell esophageal carcinoma from 2015 to 2019 in Shanghai Chest Hospital, Shanghai Jiao Tong University, were reviewed. The stage definition was determined according to the 8th edition of the American Joint Committee on Cancer (AJCC ) cancer staging manual. Survival was calculated using the Kaplan-Meier method and was then compared by the Log-rank test. Univariate and multivariate analysis with the Cox proportional hazards model was used to investigate the effect of different factors on survival, including age, gender, pathological T stage, clinical T stage, tumor diameter, the number of dissected lymph nodes.
Results·Three hundred and seventy-nine patients were included, accounting for 11.9% of all of patients undergoing esophagectomy during the same period. Male accounted for 79.2%. Tumors were located in the upper, middle, and lower segments of thoracic esophagus at 14.2%, 43.8%, and 42.0%. A total of 81.5% of patients underwent minimally invasive surgery. The R₀ resection rate was 96.0%. The average number of lymph node dissections was 18.0±9.3. The incidence of postoperative complications of the Clavien-Dindo grade Ⅲ or higher was 20.8%. The incidences of anastomotic fistula, recurrent laryngeal nerve injury, pneumonia, and respiratory insufficiency were 12.4%, 14.2%, 13.5% and 2.9%, respectively. The 30-d and 90-d mortality rates were 0.5% and 1.3%, respectively. Postoperative surgical pathology showed that T_1a, T_1b and T₂ ratios were 20.6%, 69.4% and 10.0%. The diameter of tumor in surgical sample was (2.1±1.1) cm, but larger in preoperative endoscopy evaluation [(3.2±2.2) cm], and the lymphovascular invasion rate was 5.8%. The follow-up time was 1 to 61 months, and the median follow-up time was 24 months. During the follow-up, the overall recurrence rate was 8.2%, and the local recurrence rate and distant metastasis rate were 7.4% and 2.9%, respectively. Univariate analysis showed that the factors of age and number of dissected lymph nodes were related to overall survival (OS) (P=0.025, P=0.011), while clinical and pathological T stage and number of dissected lymph nodes were related to disease-free survival (DFS) (P=0.017, P=0.005, P=0.001). Multivariate analysis showed that the independent risk factors for OS were older than 65 years, less than 15 lymph node dissections. The independent risk factors for DFS were less than 15 lymph node dissections, clinical stage T₂ or T₃.
Conclusions·Patients with stage Ⅰ esophageal squamous cell carcinoma can obtain satisfactory tumor control and long-term survival after surgical treatment based on minimally invasive surgery. More thorough lymph node dissection would be the key to improve the current prognosis.

Key words: esophageal squamous cell carcinoma, early stage esophageal cancer, biological characteristics, esophagectomy, survival


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