P. van Hagen , N Engl J Med 2012
生存影响
MFT: 45.4 ( 25.5-80.9) month, Cancer death: CRT+S 85%, S 94%
Median OS: CRT + S 49.4 mo S only, 24 month
P. van Hagen , N Engl J Med 2012
3.30, P < 0.001) for rate of R0 resection
小结
与单纯手术相比，食管癌新辅助放化疗，能够 提高生存率
亚组分析结果：
不同组织学类型的食管癌新辅助放化疗后的生存获益相似 不同组织学类型的食管癌新辅助化疗后的生存获益有差异：鳞癌
组无统计学意义，腺癌组有统计学意义
单纯放疗 64Gy/32次/6.4周
Herskovic, NEJM, 1992, 326:1593-1598
RTOG 8501 - 总生存
百 分 率
Coooper JS. JAMA, 1999, 281:1623-1627
RTOG 8501 - 失败模式
百 分 率
Cooper JS. JAMA, 1999, 281:1623-1627
低分化(G3)、未分化(G4) 局部晚期定义: stage IIb to IIIc, N1-3, T4.
Edge and Compton, 2010
I IIa
单纯手术疗效
、 期 疗 效 佳
期 疗 效 差
Ⅲ
化疗
单纯化疗疗效有限 主要用于转移性食管癌 很少单独用于局限期食管癌
5-FU median duration of response 1-5 m
111 (69%) 49 (30%) 1 ( 1%)
47 (29%)
NA
52 (32%)
32 (20%)
29 (18%)
1 ( 1%)
P. van Hagen , N Engl J Med 2012
p-value <0.001
<0.001 0.77 <0.001 <0.001
死亡风险
P. van Hagen , N Engl J Med 2012
2次/天 ；CRT：放疗同上，4周期PF方案化疗 结果：中位生存时间分别为：23.9 m 和 30.8 m ；5 ys 生存
率分别为 28%和 40%。3/4级急性副反应发生率分别为 25% 和46% ；CRT 5级急性毒副反应发生率6%
Staging –AJCC 7th Edition
Major changes from AJCC 6th edition: (1) 包括食管胃交界和胃近端5cm延伸到贲门或食管的肿瘤 (2) 根据病理将分期归类 (SCC vs. ADC). (3) T4根据肿瘤能否切除和与周围器官组织的关系分为：
新辅助放化疗&新辅助化疗:总生存 率
mortality after surgery in CRTS group was similar to that in S group . OR was 1.31(0.88-1.94, P = 0.185) complications after surgery in CRTS group was similar to that in S group. OR was 0.99(0.81-1.23, P = 0.954) patients treated with CRTS had fewer local-regional cancer recurrences than those treated with S, OR was 0.62(0.45-
可手术食管癌 术前新辅助放化疗或化疗
13篇比较新辅助放化疗&单纯手术 10篇比较新辅助化疗&单纯手术 2篇比较新辅助放化疗&新辅助化疗
Cheng J, Li B, et al.
新辅助放化疗&单纯手术：总生存 率
新辅助放化疗&单纯手术：组织学亚组总生存率
新辅助化疗&单纯手术：总生存率
新辅助化疗&单纯手术：组织学亚组总生存率
食管癌的综合治疗-2014
食管癌UICC TNM 病理分期新旧版对比
2002第6版
T1 侵及粘膜固有层或粘膜下层 T4 肿瘤侵及邻器官 N1 有区域淋巴结
M1a 上段癌转移到锁骨上 下段癌转移到腹腔淋巴结
M1b 其它远处转移
2009第7版
T1a 侵及粘膜固有层 T1b 侵及粘膜下层 T4a 侵及胸膜 心包 膈肌 T4b 侵及其它器官 N1a 1-2个区域淋巴结 N1b 3-5个区域淋巴结 N2 6-9个区域淋巴结 N3 ≥10个区域淋巴结 M1 有远处转移
Appendix 2
降期与R0
Pathology results
Pathologic findings in the resection specimen (n=161 in both arms).
CRT + surgery (n=161)
Surgery alone (n=161)
Pathologic findings
3 cm from the upper sphinctor Length <= 8 cm Width <= 5 cm T1N1, T2-3N0-1 Chemo Weekly: Carbo 2 AUC Paclitaxel 50 mg RT: 41.4 Gy at 1.8 Gy/Fx Surgery: 4-6 weeks after RT
方法：入组63 例，T1a 23例，T1b 40例， CRT: 放疗55-66 Gy及高剂量率后装治疗 10-12 Gy/2-3f + 同时DDP/5-FU 1-3 周期
结果：5-y OS和无瘤生存率分别为 66.4%和 63.7%; 食管保全 率89.2%
结论： T1N0M0 食管癌CRT治疗后生存情况与手术相似且
0.86, P = 0.003) ) for local-regional cancer recurrence patients treated with CRTS had similar distant cancer recurrence than those treated with S . OR was 1.03(0.73-1.45,
0 ( 0%) 0 ( 0%) 13 ( 8%) 19 (12%) 126 (78%) 3 ( 2%) 0 ( 0%)
111 (69%) 50 (31%)
41 (26%) 120 (75%)
15 (9-21)
18 (12.5-27)
0 (0-1)
2 (1-6)
148 (92%) 13 ( 8%) 0 ( 0%)
pT-stage§ pTis pT0 pT1 pT2 pT3 pT4 Unknown
pN-stage§ pN0 pN1
No. of LNs resected Median (p25-p75)
No. of pos LNs Median (p25-p75)
Radicality of resection# R0 resection R1 resection Not available
90%保全食管
JCOG9706 5-y OS 76%
Yamada K, IJROBP2006
可手术新辅助放化疗
Histology: SCC, ADC, or large-cell undifferentiated carcinoma of the esophagus or esophagogastric junction Tumor size location:
与新辅助化疗相比，新辅助放化疗有获益趋势， 但无统计学差异（仅有两篇随机对照研究，说服力不强）
早期（T1N0M0）放化疗 VS 手术值得研究
不可手术食管癌 放化综合治疗
放化疗 vs. 放疗 －RTOG 8501
129例, 鳞癌85% T1-3N0-1M0/KPS>50
5-Fu 1g/m2, d1-4 x 4 DDP75mg/m2, d1 x 4 同步放疗50Gy/25次/5周
T4a – resectable: pleura, pericardium, or diaphragm T4b – unresectable: trachea, aorta, or vertebral body (4) N分期按转移数目划分: N1 (1–2), N2 (3–6), and N3 (>6) (5) 癌细胞的组织学分型 鳞癌(H1)及腺癌(H2) (6) 癌细胞分化程度 高分化(G1) 、中分化(G2)
INT 0123 – 生存
Minsky BD. JCO, 2002, 20:1167-1174
INT 0123 – 局部复发
Minsky BD. JCO, 2002, 20:1167-1174
INT 0123 – 治疗毒性
Minsky BD. JCO, 2002, 20:1167-1174
INT 0123 – 死亡病例
Tumor regression grade◊
Grade 1 (ypT0N0) Grade 2 Grade 3 Grade 4 Missing
Legend
No. of patients (percentage&)
1 ( 1%) 62 (39%) 15 (10%) 32 (20%) 49 (30%) 1 ( 1%) 1 ( 1%)
P = 0.876) for distant cancer recurrence patients treated with CRTS had a higher rate of R0 resection than those treated with S (Table 2). OR was 2.50(1.90-