| Objective: To observe the local/regional failure after radical resection of thoracic esophageal carcinoma,and to explore the influence of different radiotherapy target area,irradiation dose and treatment mode on survival.Methods: From January 2008 to December 2015,a total of 703 cases of thoracic esophageal carcinoma patients were eligible for retrospectively analysing.All patients with esophageal squamous cell carcinoma,including532(75.7%)males,171(24.3%)females;77 cases(10.9%)with upper-thoracic esophageal carcinoma,486(69.0%)cases with middle-thoracic esophageal carcinoma,140(20.1%)cases with lower-thoracic esophageal cancer;64(9.1%)patients with stage ?,86(12.2%)with stage ?a,250(35.5%)with stage ?b,283(40.3%)patients with stage ?,20(2.9%)patients with stage ?;Local/regional failure was defined as the metastasis of supraclavicular,mediastinal and abdominal lymph nodes and anastomotic recurrence after radical resection.All patients were treated with 3DCRT or IMRT and the prescribed dose of GTV was 45~72Gy(median,60Gy),1.8~2.2Gy/F.110 cases(15.6%)were involved in field irradiation(A group),398 cases(56.6%)were treated with selective extended field irradiation(B group),195 cases(27.7%)were treated with T type field irradiation(group C).Radiotherapy alone in 463 cases(65.9%),radiotherapy combined with chemotherapy in 240 cases(34.1%),including 96 cases with concurrent chemoradiotherapy,144 with sequential chemoradiotherapy.A total of 151 cases underwent less than 4 cycles chemotherapy,89 cases underwent no less than 4 cycles of chemotherapy.Age,gender,whether with medical diseases,Karnofsky score,failure time,failure to position and failure area number,radiation dose,target irradiation range,short-term curative effect,different treatment modalities,cycles of chemotherapy and chemotherapy,anemia and its effect on the prognosis were analyzed.Results:1 The recrudescence-time was 1 ~ 246 months,and median recrudescence-time was 13 months.The overall median survival time was13.86 months and 1-,2-,3-,5-year survival rates were 53.1%,27.5%,18.9%,11.4%.Six hundred and three patients died,with 370 cases died of local/regional failure,199 cases died of distant metastasis,10 cases died of cardiovascular diseases,5 cases died of respiratory diseases,2 cases died of accident,17 cases with unknown cause of death.2 Local/regional failure distribution2.1 Local/regional failure position:supraclavicular lymph node metastasis accounted for 35%(246/703),mediastinal lymph node metastasis for 72.7%(511/703),anastomotic recurrence for 13.1%(92/703),abdominal lymph node metastasis for 17.5%(123/703).Mediastinal lymph node metastases in the upper mediastinum,middle mediastinum,lower mediastinum accounted for54.6%(384/703),22.8%(160/703),18.8%(132/703),respectively.2.2 Local/regional failure region number: a total of 452(64.3%)patients with one part local / regional failure,233(33.1%)patients with two parts local/regional failure,18(2.3%)patients with three parts local/regional failure,of 70(10.0%)patients with supraclavicular lymph node metastasis,285(40.5%)with mediastinal lymph node metastasis,39(5.5%)with anastomotic recurrence,58(8.3%)with abdominal lymph node metastasis.The number with supraclavicular plus mediastinal lymph node metastasis was 136(19.3%),8(1.1%)with supraclavicular lymph node metastasis plus anastomotic recurrence,14(2.0%)with supraclavicular plus abdominal lymph node metastasis,4(0.6%)with supraclavicular plus mediastinal plus anastomotic recurrence,14(2.0%)with supraclavicular plus mediastinal plus abdominal lymph node metastasis,38(5.4%)with mediastinal plus anastomotic recurrence,34(4.8%)with mediastinal plus abdominal lymph node metastasis,and 3(0.4%)with abdominal plus anastomotic recurrence.2.3 Local/regional failure lesion number: there were 1137 local/regional failure lesions.The ratio of supraclavicular,anastomotic,mediastinum and abdominal were 21.6%,8.1%,59.5%,10.8%,respectively.According to the number of failed lesions,the proportion of mediastinal lesions was the highest,followed by supraclavicular area.In the patients with mediastinal lymph node metastasis,the proportion of the lesions in the upper,middle and lower mediastinum were 56.8%(384/676),23.7%(160/676),19.5%(132/676),respectively.3 Analysis of clinical and pathological factors of local/regional failure:(1)Primary tumor site: there were statistical differences in supraclavicular lymph node metastasis(?2=9.917,P=0.007),anastomotic recurrence(?2=11.581,P=0.003),superior mediastinum lymph node metastasis(?2=24.553,P=0.000),middle mediastinum lymph node metastasis(?2=13.279,P=0.001),inferior mediastinum lymph node metastasis(?2=24.553,P=0.000),abdominal lymph node metastasis(?2=39.836,P=0.000)comparison by upper thoracic,mid-thoracic and lower thoracic esophageal cancer.The most common site of local/regional failure of the upper and middle thoracic esophageal carcinoma was the superior mediastinum,followed by the supraclavicular(?2=100.245,P=0.000 and ?2=344.094,P=0.000);The lower thoracic esophageal carcinoma was the superior mediastinum,followed by the abdominal(?2=30.690,P=0.000).(2)Surgical modes: The most common site of local/regional failure of the two and three field dissection was the superior mediastinum,followed by the supraclavicular(?2=316.396,P=0.000 and?2=77.490,P=0.000).Three field dissection supraclavicular,lower mediastinal and abdominal lymph node metastasis rate were lower than those in the two field dissection(?2=6.194,P=0.013 and ?2=7.527,P=0.006 and ?2=6.249,P=0.012);Anastomotic recurrence in three field dissection rate was 21.25%,higher than 12.04% in the two field dissection(?2=5.289,P=0.021).(3)Stump stuation: the most common site of local/regional failure of the negtive stump stuation was superior mediastinum,followed by supraclavicular(?2=26.160,P=0.000);The positive stump stuation was superior mediastinum,followed by supraclavicular(?2=362.422,P=0.000).The recurrence rate in negative stump stuation was lower than that of patients with positive stump stuation(?2=8.786,P=0.003).(4)Tumor T staging: The most common site of local/regional failure of the T1 + T2 stage and T3 + T4 stage was superior mediastinum,followed by supraclavicular(?2=226.495,P=0.000;?2=179.398,P=0.000).Middle and inferior mediastinum lymph node metastasis rate with T1+T2 stage was lower than that of patients with T3+T4 stage(?2=9.200,P=0.002;?2=12.783,P=0.000).(5)N staging: The most common site of local/regional failure of the N0 and N + stage was superior mediastinum,followed by supraclavicular(?2=285.175,P=0.000;?2=127.731,P=0.000).Supraclavicular and abdominal lymph node metastasis rate with N+ stage was higher than that of patients with N0 stage(?2=4.114,P=0.043;?2=10.618,P=0.001).(6)Tumor embolia: The most common site of local/regional failure without tumor embolia was superior mediastinum,followed by supraclavicular(?2=374.878,P=0.000);There was no statistical differences in local/regional failure of patients with tumor embolia(?2=8.480,P=0.132).Abdominal lymph node metastasis rate with tumor embolia was higher than that of patients without tumor embolia(?2=5.408,P=0.020).(7)Tumor differentiation degree:The most common site of local/regional failure with high and poorly differentiation was superior mediastinum,followed by supraclavicular(?2=266.398,P=0.000;?2=119.414,P=0.000).Lymph node metastasis rate with poorly differentiation was higher than that of patients with high differentiation(?2=10.686,P=0.001).(8)Postoperative adjuvant chemotherapy: The most common site of local/regional failure with and without adjuvant chemotherapy was superior mediastinum,followed by supraclavicular(?2=146.357,P=0.000;?2=238.137,P=0.000).Mediastinum lymph node metastasis rate with adjuvant chemotherapy was lower than that of patients without adjuvant chemotherapy(?2=5.880,P=0.015).4 Short-term efficacy evaluation In the whole group were treated with salvage radiotherapy /chemotherapy,126 cases of short-term efficacy of CR(17.9%),352 cases of PR(50.1%),189 cases of SD(26.9%),36 cases of PD(5.1%).The objective response rate(ORR)was 68.0%,the disease control rate(DCR)was 94.9%.5 Survival factor analysis(1)The survival rate of patients without basic disease was significantly higher than that of patients with basic disease(?2=4.160,P=0.041).(2)The survival rate with KPS score > 70 was significantly higher than that with KPS score no more than 70(?2=64.878,P=0.000)(3)The survival rates in supraclavicular,mediastinal,anastomotic,abdominal recurrence were 16.5%,15.7%,10.2%,6.9%,respectively(?2=11.747,P=0.008).(4)The survival rate of a regional recurrence group was significantly higher than that of two regional recurrence and three regional recurrence groups(?2=7.826,P=0.020).(5)The survival rate of CR+PR group was significantly higher than that of SD+PD group(?2=398.121,P=0.000).(6)The survival rates of radiation dose no less than 60 Gy and less 70 Gy or no less than 70 Gy were significantly higher than that of radiation dose less than 60Gy(?2=81.214,P=0.000).(7)There was no significant difference in the survival rate of different irradiation fields(?2=1.834,P=0.400).(8)The survival rates were significantly different among different treatment modes,of concurrent chemoradiotherapy was the highest,and radiotherapy alone had the worst prognosis(?2=21.567,P=0.000).The survival rate of the concurrent chemoradiotherapy group was significantly higher than that of sequential chemoradiotherapy group(?2=5.320,P=0.021).There was no significant difference in survival rate between sequential chemoradiotherapy and radiotherapy alone group(?2=2.499,P=0.021).(9)Survival rate with no less than 4 cycles of chemotherapy was significantly higher than that with less than 4 cycles group(?2=26.733,P=0.000).(10)The survival rate without anemia group was significantly higher than that with anemia group(?2=12.020,P=0.001). (11)There was no significant difference in survival between the groups of age,gender,failure time and different chemotherapy regimens(?2=0.081,P=0.775;?2=0.834,P=0.361;?2=2.450,P=0.118;?2=0.063,P=0.802).Multivariate Cox regression analysis showed that KPS score,short-term efficacy,and radiotherapy combined with chemotherapy were independent prognostic factors for survival.6 Toxic reaction Incidence rates of bone marrow suppression,residual gastritis,radioactive radiation pneumonitis were 33.1%,14.8%,8.1%,of which no less than 3 grade myelosuppression,radioactive residual gastritis and radiation pneumonitis were 4.4%,3.6%,2.6%,respectively.Conclusions:1 The most common sites of local/regional failure after radical resection of thoracic esophageal carcinoma are upper mediastinal and supraclavicular lymph nodes,followed by abdominal lymph node metastasis,anastomotic recurrence is the least.However,the common failure sites are associated with some clinicopathological features.The most common site of esophageal carcinoma in the lower thoracic segment is upper mediastinum,followed by abdominal lymph node;The positive stump stuation of anastomotic recurrence is higher than that of abdominal lymph node metastasis;The individualized design of the target area is needed for postoperative radiation therapy.2 Basic diseases,Karnofsky score,failure location,failure region number,radiation dose,short-term effects,different treatment modalities,whether anemia are prognostic factors for the survival of patients with localized/regional failure after radical resection of thoracic esophageal carcinoma.3 Karnofsky score,short-term effects,different treatment modalities are independent prognostic factors for the survival of patients with localized/regional failure after radical resection of thoracic esophageal carcinoma.4 Overall survival rates in involved field irradiation,local irradiation and T-irradiation have no obvious difference,recommended for involved field radiation for local/regional failure patients,and radiation dose more than 60 Gy.Concurrent radiochemotherapy is suggested if habitus can be tolerated.5 Local failure is the leading cause of death after salvage treatment of local/regional failure after radical resection of thoracic esophageal carcinoma. |
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