A Retrospect And Improvement Study Of Several Clinical Staging Standards For Esophageal Carcinoma Patients Treated With No Operation

Objective: To analyze the value of three kinds of clinical staging standards on patients with esophageal carcinoma received non-surgical therapy,and then to find out a more reasonable clinical staging standard which can guide the therapy regiment.Methods:From January 2006 to December 2012,701 patients with esophageal carcinoma received definitive radiotherapy or chemoradiotherapy were studied retrospectively.All patients were classified by 2004 edition staging standard,2009 edition staging standard and the standard based on GTV-T clinical staging,respectively.Then to compare the prognosis of 3 groups,and to get the modified editions,which should be verified by all patients.Survival analysis was performed by method of Kaplan-Meier,and difference and univariate tested by using log-rank.Multivariate analysis was worked out by Cox regression model.Results: 1 Follow-up and survival: All patients were followed up to February 2016,with the following rate 97.7%.The 1-year,3-year,and 5-year survival rates of the whole group were 70.8%,31.6%,and 18.3%（median survival time 20 months）,respectively.The 1-year,3-years,and 5-years local control rates were 75.5%,48.1%,and 41.9%（median local control time 17.7 months）.2 Observation of different staging standards: All of three kinds of T staging standards could reveal the prognosis very well,and the difference in each group was significant（P<0.05）.However,for the staging standard of 2004 edition,we merged stages T_2a and T_2b（χ²=2.360,P=0.124）,T_3a and T_3b（χ²=0.710,P=0.400）,which means that the overall survival rate was statistically different when changing 6 groups to 4 groups（χ²=56.893,P<0.05）.Based on the volume of GTV at ≤30 cm³,31⁵0 cm³,51¹00 cm³,>100 cm³,the whole group were classified into four T stages,among which there was no significant difference between stage T₃ and T₄（χ²=0.021,P=0.885）.The define of all staging standards of N stages were the same.There were significant differences of survival rates among N₀、N₁ and N₂（χ²=48.221,P<0.05）.In clinical stages,the clinical staging that GTV volume combined with N stage alone showed no significant difference of survival rates between staging III and IV（χ²=1.411,P=0.235）,whereas the other three staging standards performed very well（P<0.05）.3 The modification of staging based on GTV volume: After classified by volume of GTV as above,we regrouped T stage into the next level when adjacent organs or structures just like trachea and arteriae aorta invaded by tumor,the new T stages turned out having a better separation on survival curve（χ²=59.702,P<0.05）.N stage was just the same as the others.Considering the T staging standard of GTV voloum,all patients were classified to 4 groups by the new TNM stage standards(stage I:T₁N₀M₀ stage II:T₁N₁M₀,T₂N₀M₀ stageIII:T₁N₂M₀,T₂N₁M₀,T₃N_0-1M₀,T₄N₀M₀ stage IV:T₂N₂M₀,T₃N₂M₀,T₄N_1-2M₀,any M₁),and the overall survival rate was statistically different（χ²=82.577,P<0.05）.4 The modification of clinical staging standards of 2004 and 2009 edition: Comprehensively considering about the length and diameter of tumor,four grades were made according to the length as ≤3cm,3.1⁵ cm,5.1⁷ cm,>7 cm,and diameter of ≤2cm,2.1⁴ cm,4.1⁶ cm,>6 cm,with each grade scoring 1 point.In addition,the one with tumor invaded would get 1 point too.The final score was designed by this:（score of length + score of diameter）/2+ score of invasion,and the T stage was classified to 4 grades by the score,which had significant differences on survival rates（χ²=74.804,P<0.05）.The new clinical staging was also connected to lymph node metastasis,and the four clinical stages revealed patients’ prognosis well（χ²=90.488,P<0.05）.5 Analysis of compatibility showed that the staging of score corresponded with the stage of 2004 edition and the one based on GTV volume and tumor invasion in T stage and clinical stage（Kappa=0.42,0.40,0.41,0.50,P<0.05）.6 Prognostic factors analysis of esophageal carcinoma: The univariate analysis of the prognosis showed that eating situation,the symptom of cerchnus,tumor length,the maximum diameter of tumor,clinical T staging,clinical N staging,clinical TNM staging,the target range,structures and organs invaded by tumor,acute irradiated pneumonery,short-term effect,cycles of chemotherapy,recurrence and distant metastasis after treatment were influencing factors of prognosis.The multivariate analyses indicated that short-term effect,the symptom of cerchnus,volume of GTV,clinical T staging（2004 editon and GTV with tumor invasion）,clinical N staging,clinical TNM staging（GTV with tumor invasion）,recurrence and distant metastasis,cylcles of chemotherapy were only factors influencing prognosis.Conclusions:1 Each clinical staging standard of esophageal carcinoma could reveal prognosis of patients very well.2 Considering adjacent organs or structures invaded,the new staging standard based on GTV volume could predict the prognosis statistically,which proved to be more convenient.3 The staging of score could accurately indicated prognosis,which we need more cases to verify.