非手术食管癌临床分期的研究与应用
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摘要
第一部分食管癌术前分期准确性的临床研究
目的以术后病理分期为标准对比分析食管内镜超声(EUS)、CT及食道造影对食管癌术前T、N分期的准确性,探讨非手术食管癌临床分期的应用价值。
方法收集中国医学科学院肿瘤医院2003年4月至2010年10月符合入组条件、首程治疗为手术的食管鳞癌患者390例。根据术后病理分期比较每种检查手段的准确性,并结合EUS、CT两种检查结果对患者进行临床分期,进一步根据临床分期对患者进行生存分析。
结果中位随访时间39.6个月(1.6-112.9个月)。96例(24.6%)患者因食管局部狭窄内镜超声无法通过。334例(85.6%)患者有完备CT影像资料。337例(86.4%)患者行食道造影检查。EUS、CT和食道造影对T分期总的准确率、kappa值分别为80.95%、0.671；71.25%和0.490;50.70%、0.386。EUS和CT对N分期的准确率、kappa值分别为69.4%、0.243；78.2%和0.467。结合EUS和CT术前检查将患者进行术前临床分期(按2002年UICC TNM分期系统)。其结果显示,临床分期与术后病理分期的比较其准确率为71.2%。临床分期各期别间的生存率差异有显著性(p=0.000)。EUS能否完全通过和食道造影示病变长度(≤3cm和>3cm)均对预后有影响(p=0.000,p=0.000)。
结论EUS和CT检查对食管癌的临床分期与病理分期有很好的一致性,且临床分期所示的不同期别与预后有明显的相关性。EUS联合CT是非手术食管癌临床分期的有效手段。
第二部分非手术食管癌临床分期的有效性及预测预后的临床价值
目的探讨非手术食管癌临床分期的有效性及预测预后的临床价值。
方法选择2003.4-2010.10期间在我院行食管癌根治术,术前有食管腔内超声、食管镜、CT、食道造影等详细检查,术后有详细的病理分期共358例。分析术前影像学分期与术后病理分期的预测值。依据2002年、2009年UICC病理分期及基于影像学的临床分期,分析患者的无瘤生存及总生存。
结果全组中位随访时间为47个月。有EUS+CT检查并能进行有效分期305例(85.2%)。在305例中,临床T分期对病理T分期的预测值为0-88.6%,其中T1最高为88.6%；T4最低。临床N分期(N0/N1)的预测值为62.5%-100%。虽然2002年和2009年UICC分期的总生存率及无瘤生存率差异均有显著性(p=0.000,p=0.000)。但2002年分期总生存的组间差异明显,除Ⅳ只有2例与各期别间差异没有显著性外,其余期别两两比较差异均有显著性。2009年分期总生存组间差异多不显著。按2002年UICC TNM分期标准对305例进行EUS+CT的临床分期,总生存率及无瘤生存差异均显著性(p=0.000,p=0.000)。
结论影像学检查不能有效、准确的提供淋巴结转移个数,但对淋巴结定性的预测值较高。EUS+CT的临床分期能有效的预测非手术食管癌的预后。
第三部分食管腔内超声参与非手术食管癌的临床分期与预后的相关性研究
目的探讨有腔内超声(EUS)参与的非手术食管癌临床分期的实用性以及对预后的预测价值。
方法收集我院2003年11月至2012年3月符合入组条件、非手术治疗的食管鳞癌290例。结合EUS、CT检查按2002年UICC分期标准对全组患者进行临床分期,并分析各期别间患者的生存率以及预后因素。采用Kaplan-Meier法进行生存分析。用Logrank法进行显著性检验及单因素分析,用Cox回归模型进行多因素预后分析。
结果EUS完全通过并能进行有效地T、N分期的有178例(61.4%)。T1-4的总生存率差异无统计学意义(P=0.247)。但在45例EUS NO的患者中,T1-4分期总生存及无进展生存均有统计学差异(OS p=0.000; PFS p=0.006)。EUSNO与N1总生存及无进展生存率差异有显著性(OS p=0.012; PFS p=0.016)。腔内超声不能通过112例(38.6%),不能通过的患者无论是总生存率还是无进展生存率均较能通过的患者差(OSp=0.001;PFSp=0.003)=CT的T和N分期对总生存及无进展生存均有影响(OS p=0.004, PFS p=0.030; OS p=0.024, PFS p=0.020)。全组1,3,5年总生存率分别为61.7%,27.8%,19.8%,中位生存时间为16.7个月。2002UICC临床分期各期别间的总生存率及无进展生存率差异均有显著性(x2=22.197, p=0.000; χ2=19.540,p=0.000)。多因素分析显示性别、年龄和临床分期是总生存的独立预后因素(p=0.004,0.020,0.002)。
结论有EUS参与的食管癌临床分期能够预测非手术治疗患者的预后,建议将EUS作为我国食管癌疗前分期检查的基本手段。
Part I:Evaluation and accuracy of preoperative stage of esophageal carcinoma
Objective The purpose of this study was to (1) assess endoscopic ultrasonography (EUS) staging, computed tomography (CT) staging and esophagography accuracy of esophageal cancer and to (2) evaluate the effort of the clinical stage grouping on survival in the same population.
Methods A total of390esophageal cancer patients treated with surgery as first-time treatment were retrospectively reviewed for evaluation of preoperative EUS, CT and esophagography. The accuracy of T staging and N staging for each test were compared with the postoperative histopathological stage as the gold standard. The strength of the agreement between the radiological stage and the histopathological stage was determined by means of the Kappa statistic. Kaplan-Meier survival curves were generated for each stage and the log-rank test was used to test for significant differences in survival.
Results The total accuracy and Kappa value of T stage was80.95%and0.671for EUS,71.25%and0.490for CT, and50.70%and0.386for esophagography. The accuracy and Kappa value of N stage was69.4%and0.243for EUS, and78.2%and0.467for CT. The accuracy of clinical stage based on T stage by EUS and N stage by CT was71.2%compared with UICC stage2002. Survival analysis showed the clinical stage to predict survival (p=0.000). An obstructing lesion and tumor length based (≤3cm vs.>3cm) on esophagography were prognostic factors (p=0.000,p=0.000)
Conclusions The clinical stage grouping based on EUS T stage and CT N stage compares favorably with UICC stage2002. And the most important is the clinical stage grouping can predict survival in patients with esophageal cancer.
Part II:Efficacy and predicting value of non-surgical clinical stage for esophageal carcinoma
Objective To investigate the efficacy and predicting value of clinical stage in non-surgical patients with esophageal carcinoma (EC).
Methods A retrospective study was conducted in358EC patients who received radical surgery in our hospital From April2003to October2010and had preoperative work-up such as EUS, thoracic CT scan. Positive (PPV) and negative (NPV) predictive value of Clinical T/N stage based on CT+EUS were calculated compared with pathological stage. And the overall survival (OS) and disease-free survival (DFS) were performed according to2002,2009UICC TNM stage and clinical stage groupings, respectively.
Results The media following-up time was47months.305patients were analyzed with clinical stage based on EUS+CT. Among them, the predictive value of clinical T stage were0-88.6%, and88.6%for cTl. Predictive value of clinical N stage (N0/N1) were62.5%-100%. The significant differences in OS and DFS rates based on both2002and2009TNM stage were noted (p=0.000, p=0.000). For2002TNM stage, comparisons between the individual stage groupings showed a significant difference in overall survival in most of comparisons. There were305patients staged clinically based on EUS and CT according to2002TNM stage. A significant difference in OS and DFS rates based on clinical stage were noted (p=0.000, p=0.000).
Conclusions1. Image modalities showed good predictive value for N stage (N0/N1), even they couldn't provide precisely number of Lymph nodes metastasis.2. The clinical stage based on EUS+CT could predict the prognosis for non-surgical patients with esophageal carcinoma.
Part Ⅲ:Clinical staging of non-surgical esophageal cancer based on endoscopic ultrasonography and CT and its prognostic value
Objective To investigate the clinic stageing of non-surgical esophageal cancer based on endoscopic ultrasonography (EUS) and computed tomography (CT) and its prognostic value.
Methods A total of290patients with esophageal squamous cell carcinoma treated with non-surgical treatment were retrospectively reviewed from November2003to March2012. The clinical stage of each patient was evaluated based on EUS and CT according to the2002UICC TNM staging system. Kaplan-Meier survival curves were generated for each stage and significant differences in survival and univariate prognostic factor was analyzed by log-rank test. Multivariate prognostic factor was analyzed by Cox regression model.
Results One hundred seventy eight patients (61.4%) were staged by EUS since EUS could be completely performed. Comparison of different EUS T-stages found no difference in overall survival (OS)(p=0.247). Comparison of different EUS T-stages among patients having EUS NO stage found significant difference in survivals (OS p=0.000; PFS p=0.006). EUS N-stages showed significant difference in survivals (OS p=0.012; PFS p=0.016). EUS was not completely performed in112patients (38.6%), and patients who had a stenotic tumor were poorer OS and PFS (OS p=0.001; PFS p=0.003). CT T-stages, and N-stages also affected OS and PFS(OS p=0.004, PFS p=0.030; OS p=0.024, PFS p=0.020).The1-,3-and5-OS rates were61.7%,27.8%,19.8%and the median survival time was16.7months. OS and PFS varied significantly between patients of different2002UICC clinical stages (p=0.000, p=0.000). The multivariate analyzed revealed sex, age and clinical stage were independent prognostic factors(p=0.004,0.020,0.002).
Conclusions:The clinical stage grouping based on EUS and CT can predicts survival in esophageal carcinoma patients treated with non-surgical method. We recommend EUS as basic pretreatment examination was performed in patients with esophageal carcinoma in China.
目的以术后病理分期为标准对比分析食管内镜超声(EUS)、CT及食道造影对食管癌术前T、N分期的准确性,探讨非手术食管癌临床分期的应用价值。
方法收集中国医学科学院肿瘤医院2003年4月至2010年10月符合入组条件、首程治疗为手术的食管鳞癌患者390例。根据术后病理分期比较每种检查手段的准确性,并结合EUS、CT两种检查结果对患者进行临床分期,进一步根据临床分期对患者进行生存分析。
结果中位随访时间39.6个月(1.6-112.9个月)。96例(24.6%)患者因食管局部狭窄内镜超声无法通过。334例(85.6%)患者有完备CT影像资料。337例(86.4%)患者行食道造影检查。EUS、CT和食道造影对T分期总的准确率、kappa值分别为80.95%、0.671；71.25%和0.490;50.70%、0.386。EUS和CT对N分期的准确率、kappa值分别为69.4%、0.243；78.2%和0.467。结合EUS和CT术前检查将患者进行术前临床分期(按2002年UICC TNM分期系统)。其结果显示,临床分期与术后病理分期的比较其准确率为71.2%。临床分期各期别间的生存率差异有显著性(p=0.000)。EUS能否完全通过和食道造影示病变长度(≤3cm和>3cm)均对预后有影响(p=0.000,p=0.000)。
结论EUS和CT检查对食管癌的临床分期与病理分期有很好的一致性,且临床分期所示的不同期别与预后有明显的相关性。EUS联合CT是非手术食管癌临床分期的有效手段。
第二部分非手术食管癌临床分期的有效性及预测预后的临床价值
目的探讨非手术食管癌临床分期的有效性及预测预后的临床价值。
方法选择2003.4-2010.10期间在我院行食管癌根治术,术前有食管腔内超声、食管镜、CT、食道造影等详细检查,术后有详细的病理分期共358例。分析术前影像学分期与术后病理分期的预测值。依据2002年、2009年UICC病理分期及基于影像学的临床分期,分析患者的无瘤生存及总生存。
结果全组中位随访时间为47个月。有EUS+CT检查并能进行有效分期305例(85.2%)。在305例中,临床T分期对病理T分期的预测值为0-88.6%,其中T1最高为88.6%；T4最低。临床N分期(N0/N1)的预测值为62.5%-100%。虽然2002年和2009年UICC分期的总生存率及无瘤生存率差异均有显著性(p=0.000,p=0.000)。但2002年分期总生存的组间差异明显,除Ⅳ只有2例与各期别间差异没有显著性外,其余期别两两比较差异均有显著性。2009年分期总生存组间差异多不显著。按2002年UICC TNM分期标准对305例进行EUS+CT的临床分期,总生存率及无瘤生存差异均显著性(p=0.000,p=0.000)。
结论影像学检查不能有效、准确的提供淋巴结转移个数,但对淋巴结定性的预测值较高。EUS+CT的临床分期能有效的预测非手术食管癌的预后。
第三部分食管腔内超声参与非手术食管癌的临床分期与预后的相关性研究
目的探讨有腔内超声(EUS)参与的非手术食管癌临床分期的实用性以及对预后的预测价值。
方法收集我院2003年11月至2012年3月符合入组条件、非手术治疗的食管鳞癌290例。结合EUS、CT检查按2002年UICC分期标准对全组患者进行临床分期,并分析各期别间患者的生存率以及预后因素。采用Kaplan-Meier法进行生存分析。用Logrank法进行显著性检验及单因素分析,用Cox回归模型进行多因素预后分析。
结果EUS完全通过并能进行有效地T、N分期的有178例(61.4%)。T1-4的总生存率差异无统计学意义(P=0.247)。但在45例EUS NO的患者中,T1-4分期总生存及无进展生存均有统计学差异(OS p=0.000; PFS p=0.006)。EUSNO与N1总生存及无进展生存率差异有显著性(OS p=0.012; PFS p=0.016)。腔内超声不能通过112例(38.6%),不能通过的患者无论是总生存率还是无进展生存率均较能通过的患者差(OSp=0.001;PFSp=0.003)=CT的T和N分期对总生存及无进展生存均有影响(OS p=0.004, PFS p=0.030; OS p=0.024, PFS p=0.020)。全组1,3,5年总生存率分别为61.7%,27.8%,19.8%,中位生存时间为16.7个月。2002UICC临床分期各期别间的总生存率及无进展生存率差异均有显著性(x2=22.197, p=0.000; χ2=19.540,p=0.000)。多因素分析显示性别、年龄和临床分期是总生存的独立预后因素(p=0.004,0.020,0.002)。
结论有EUS参与的食管癌临床分期能够预测非手术治疗患者的预后,建议将EUS作为我国食管癌疗前分期检查的基本手段。
Part I:Evaluation and accuracy of preoperative stage of esophageal carcinoma
Objective The purpose of this study was to (1) assess endoscopic ultrasonography (EUS) staging, computed tomography (CT) staging and esophagography accuracy of esophageal cancer and to (2) evaluate the effort of the clinical stage grouping on survival in the same population.
Methods A total of390esophageal cancer patients treated with surgery as first-time treatment were retrospectively reviewed for evaluation of preoperative EUS, CT and esophagography. The accuracy of T staging and N staging for each test were compared with the postoperative histopathological stage as the gold standard. The strength of the agreement between the radiological stage and the histopathological stage was determined by means of the Kappa statistic. Kaplan-Meier survival curves were generated for each stage and the log-rank test was used to test for significant differences in survival.
Results The total accuracy and Kappa value of T stage was80.95%and0.671for EUS,71.25%and0.490for CT, and50.70%and0.386for esophagography. The accuracy and Kappa value of N stage was69.4%and0.243for EUS, and78.2%and0.467for CT. The accuracy of clinical stage based on T stage by EUS and N stage by CT was71.2%compared with UICC stage2002. Survival analysis showed the clinical stage to predict survival (p=0.000). An obstructing lesion and tumor length based (≤3cm vs.>3cm) on esophagography were prognostic factors (p=0.000,p=0.000)
Conclusions The clinical stage grouping based on EUS T stage and CT N stage compares favorably with UICC stage2002. And the most important is the clinical stage grouping can predict survival in patients with esophageal cancer.
Part II:Efficacy and predicting value of non-surgical clinical stage for esophageal carcinoma
Objective To investigate the efficacy and predicting value of clinical stage in non-surgical patients with esophageal carcinoma (EC).
Methods A retrospective study was conducted in358EC patients who received radical surgery in our hospital From April2003to October2010and had preoperative work-up such as EUS, thoracic CT scan. Positive (PPV) and negative (NPV) predictive value of Clinical T/N stage based on CT+EUS were calculated compared with pathological stage. And the overall survival (OS) and disease-free survival (DFS) were performed according to2002,2009UICC TNM stage and clinical stage groupings, respectively.
Results The media following-up time was47months.305patients were analyzed with clinical stage based on EUS+CT. Among them, the predictive value of clinical T stage were0-88.6%, and88.6%for cTl. Predictive value of clinical N stage (N0/N1) were62.5%-100%. The significant differences in OS and DFS rates based on both2002and2009TNM stage were noted (p=0.000, p=0.000). For2002TNM stage, comparisons between the individual stage groupings showed a significant difference in overall survival in most of comparisons. There were305patients staged clinically based on EUS and CT according to2002TNM stage. A significant difference in OS and DFS rates based on clinical stage were noted (p=0.000, p=0.000).
Conclusions1. Image modalities showed good predictive value for N stage (N0/N1), even they couldn't provide precisely number of Lymph nodes metastasis.2. The clinical stage based on EUS+CT could predict the prognosis for non-surgical patients with esophageal carcinoma.
Part Ⅲ:Clinical staging of non-surgical esophageal cancer based on endoscopic ultrasonography and CT and its prognostic value
Objective To investigate the clinic stageing of non-surgical esophageal cancer based on endoscopic ultrasonography (EUS) and computed tomography (CT) and its prognostic value.
Methods A total of290patients with esophageal squamous cell carcinoma treated with non-surgical treatment were retrospectively reviewed from November2003to March2012. The clinical stage of each patient was evaluated based on EUS and CT according to the2002UICC TNM staging system. Kaplan-Meier survival curves were generated for each stage and significant differences in survival and univariate prognostic factor was analyzed by log-rank test. Multivariate prognostic factor was analyzed by Cox regression model.
Results One hundred seventy eight patients (61.4%) were staged by EUS since EUS could be completely performed. Comparison of different EUS T-stages found no difference in overall survival (OS)(p=0.247). Comparison of different EUS T-stages among patients having EUS NO stage found significant difference in survivals (OS p=0.000; PFS p=0.006). EUS N-stages showed significant difference in survivals (OS p=0.012; PFS p=0.016). EUS was not completely performed in112patients (38.6%), and patients who had a stenotic tumor were poorer OS and PFS (OS p=0.001; PFS p=0.003). CT T-stages, and N-stages also affected OS and PFS(OS p=0.004, PFS p=0.030; OS p=0.024, PFS p=0.020).The1-,3-and5-OS rates were61.7%,27.8%,19.8%and the median survival time was16.7months. OS and PFS varied significantly between patients of different2002UICC clinical stages (p=0.000, p=0.000). The multivariate analyzed revealed sex, age and clinical stage were independent prognostic factors(p=0.004,0.020,0.002).
Conclusions:The clinical stage grouping based on EUS and CT can predicts survival in esophageal carcinoma patients treated with non-surgical method. We recommend EUS as basic pretreatment examination was performed in patients with esophageal carcinoma in China.
引文
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