The Failure Modalities And Value Of Postoperative Prophylactic Radiotherapy For Stage PT_2-3N₀M₀ Thoracic Esophageal Squamous Carcinoma Treated By Radical Resection

Objective: To analyze the prognostic factors of stage pT_2-3N₀M₀ thoracic esophageal squamous carcinoma treated by radical resection.Meanwhile,compare the failure modalities of patients between surgery alone and postoperative prophylactic radiotherapy,then evaluate the effect of postoperative prophylactic radiotherapy for patients of stage pT_2-3N₀M₀ thoracic esophageal squamous cell carcinoma.Methods: We collected patients of stage pT_2-3N₀M₀ thoracic esophageal squamous cell carcinoma who received initial radical resection in our hospital from January 2007 to December 2010.There were 702 eligible cases,482 male and 220 female.The median age was 60 years old?range 38⁸0years?.There were 91 cases' lesions located in the upper-,495 cases in the middle-,and 116 cases in the lower-thoracic esophagus.680 cases had finished electronic gastroscope or esophagoscope,623 cases?91.6%?got lesion length by gastroscope or esophagoscope,but 57 cases had none of lesion length since gastroscope or esophagoscope couldn't through the narrow location of esophagus.All patients received the radical resection,644 cases radical resected through left thorax,17 cases radical resected through right thorax,11 cases resected through neck and abdomen,and 30 cases dealt with three-field lymphadenectomy?cervical,mediastinal,abdominal?.89 cases anastomosed at neck,553 cases anastomosed above aortic arch,and 60 cases anastomosed under aortic arch.373 cases were founded that the lesion mild adherent to surrounding structures in the operation,and 274 cases were moderate to severe adhesion.The median number of lymph node dissection was 8?range0³2?.The median length of lesions during operation was 5.0cm?range0.8¹2.0cm?,the esophagus cavity were dissected and flattened,then measured the median width of lesions was 3.0cm?rang0.5¹0.0cm?,and the median depth of lesions was 3.0cm?rang0.2¹0.0cm?.Since the lesions were too small to measure,5cases?0.7%?didn't get lesion length,29 cases?4.1%?didn't get lesion width,and 31 cases?4.4%?didn't get lesion depth.The stage of pathology was pT₂N₀M₀ in 216 cases,and pT₃N₀M₀ in 486 cases,38 cases with stump-positive.There were 343 cases treated by radical surgery alone,279 cases treated by postoperative chemotherapy,40 cases treated by postoperative radiotherapy,and 40 cases treated by postoperative chemoradiotherapy.SPSS19.0 statistical software was used for the statistical analysis,The overall survival rate and progression free survival rate were calculated by the Kaplan-Meier method and checked by the log-rank test;Cox proportional hazard model was used for multivariate analysis of prognostic factors.The comparison of failure modalities was analyzed by ?2 test or Fisher method if necessary.Differences were statistically significant when P<0.05.Results: 1 All the 702 patients Follow-up ended on December 31,2015,14 cases were lost,the follow-up rate was 98.0%.There were 394 cases survived,including 31 cases survived with tumor.The 1-,3-and 5-year overall survival rate were 91.2%,73.8%,62.6%,and the median survival time was 67.2 months.Univarate analysis showed that overall survival and progression-free survival were significantly associated with sex,the lesion length with gastroscope or esophagoscope,the location of lesion,method of surgery,the location of anastomosis,the degree of intraoperative adhesion,stage of postoperative pathology,postoperative adjuvant therapy,the history of hypertension,smoking,alcohol drinking and treatment in ICU.Multivariate analysis revealed that the location of lesion,degree of intraoperative adhesion,stage of postoperative pathology,number of lymph node dissection,postoperative adjuvant therapy,the history of hypertension,smoking and treatment in ICU were all independently prognostic factors for overall survival and progression-free survival.2 Compared with surgery alone,postoperative adjuvant therapy could improve 1-,3-,5-year local contral rate;postoperative chemotherapy and chemoradiotherapy could improve 1-,3-,5-year overall survival rate and progression free survival rate.3 The rate of overall locoregional recurrence,distant metastasis,and combined locoregional recurrence with distant metastasis were 37.5%?263/702?,16.7%?117/702?,and 9.1%?64/702?respectively.In the surgery alone group,the overall failure rate was 54.8%?188/343?,including 143 cases?41.7%?locoregional recurrence,58 cases?16.9%?distant metastasis,32 cases?9.3%?locoregional recurrence combine with distant metastasis.In the local recurrence locations,110 cases?32.1%?lymph node metasasis were in mediastinum,21 cases?6.1%?in the bilateral supraclavicular areas,18 cases?5.2%?in the anastomosis,7 cases?2.0%?in cervical areas,and 6 cases?1.7%?in abdominal cavity.4 Locoregional recurrence rate of pT₃N₀M₀ was clearly higher than pT₂N₀M₀ stage patients?P=0.019?,but distant metastasis rate had no statistical significance between pT₂N₀M₀ and pT₃N₀M₀ group.The locoregional recurrence rate of upper-,middle-,lower-thoracic esophagus cancer were 68.0%,38.1%,33.3% respectively?P < 0.001?,but distant metastasis rate had no statistical significance with in different lesion location.5 Compared with surgery alone,postoperative radiotherapy could obviously decrease the rate of mediastinal lymphatic metastasis?P=0.034?,but the other local recurrence regions and distant metastasis had no significant difference.Postoperative prophylactic radiotherapy had improved the progression free survival rate of pT₃N₀M₀ stage patients?P=0.024?,and the overall survival rate was closed to statistical significance in the postoperative radiotherapy group?P=0.053?.But it didn't show overall survival or progression free survival benefit for pT₂N₀M₀ stage patients?P =0.067,0.132?.Conclusions:1 The negative prognostic factors for patients of stage pT_2-3N₀M₀ thoracic esophageal squamous carcinoma treated by radical resection were upper-thoracic esophagus cancer,moderate to severe adhesion,stage of pT₃N₀M₀,fewer lymph nodes excision,Not accepted postoperative adjuvant therapy,the history of smoking,hypertension and treatment in ICU.Postoperative adjuvant therapy could obviously improve local contral rate;postoperative chemotherapy and chemoradiotherapy all could improve overall survival rate and progression free survival rate.2 Regional recurrence mainly occurred in mediastinum,bilateral supraclavicular areas,and anastomosis in radical surgery alone group,so the postoperative prophylactic irradiated fields should include the above areas.Locoregional failure rate of pT₃N₀M₀ stage patients was clearly higher than pT₂N₀M₀ stage patients,and locoregional failure rate of upper-thoracic patients was significant higher than the middle-and lower-thoracic patients.3 Postoperative prophylactic radiotherapy could obviously decrease mediastinal lymph node recurrence or metastasis,and improve progression free survival rate of pT₃N₀M₀ stage patients.