Surgical Management of Early-Stage Esophageal Adenocarcinoma Based on Lymph Node Metastasis Risk
Surgical Management of Early-Stage Esophageal Adenocarcinoma Based on Lymph Node Metastasis Risk
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DOI：
10.1245/s10434-017-6238-z
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发表时间：
2018-01-01
影响因子：
3.7
通讯作者：
Singhal, Sunil
中科院分区：
文献类型：
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作者：
Newton, Andrew D.;Predina, Jarrod D.;Singhal, Sunil
在早期食管腺癌（EAC）中，与内镜切除术相比，食管切除术改善了分期，但也增加了死亡率。我们的目标是量化早期 EAC 的食管切除术死亡率和淋巴结转移 (LNM) 风险，以改善手术治疗分配。我们在国家癌症数据库 (2004-2014) 中确定了患有非转移性、Tis、T1a 或 T1b EAC 的患者，这些患者接受了初次手术切除并至少对 15 个淋巴结进行了显微镜检查。单变量和多变量逻辑回归确定了 LNM 的预测因素。考克斯回归确定了死亡的预测因素。 Kaplan-Meier法预测总生存期（OS）。782例患者中，LNM发生率为：所有患者13.8%，Tis 0%，T1a 3.6%，T1b 23.4%。 LNM 的独立预测因素是粘膜下浸润、淋巴管浸润 (LVI)、分化程度降低和肿瘤大小 >= 2 cm (P < 0.05)。对于分化差或大小>= 2 cm的T1a肿瘤，LNM率分别为10.2%和6.7%； 90 天死亡率为 3.1%。 < 2 cm 分化良好的 T1b 肿瘤的 LNM 率为 4.2%； 90 天死亡率为 6.0%。估计 5 年 OS 分别为 80.2% 和 64.4%（T1a 与 T1b）。 LNM 增加 T1a 肿瘤（风险比 [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。在分化较差或大小 >= 2 cm 的 T1a EAC 中，应行食管切除术考虑到，而对于具有低风险特征的 T1b EAC（分化良好的 T1b EAC < 2 cm，无 LVI），内镜切除可能就足够了。早期 EAC 的治疗指南应包括 LNM 的所有高风险肿瘤特征和阶段特异性食管切除术死亡率。
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.