進行食道癌術前化学放射線療法後の手術適応に関する臨床的検討 [in Japanese] Clinical Analysis of the Surgical Indication after Neoadjuvant Chemoradiotherapy for the Advanced Esophageal Cancer [in Japanese]
Access this Article
はじめに: 進行食道癌の予後改善を目的に術前化学放射線療法 (CRT) が行われているが, その後の手術適応について判断に迷う例も少なくない. そこでCRT後の手術の安全性と手術例の予後規定因子より手術適応の明確化を試みた. 対象・方法: 1989年以降の当科入院食道癌患者のうちCRT後の切除例28例をCRT手術群, 術前無治療の切除例194例を対照手術群とした. CRT手術群と対照手術群で手術侵襲, 周術期免疫能, 在院死・合併症の頻度, 在院日数を比較した. CRT手術群の予後規定因子として有意な影響を示す因子から, 比例ハザードモデルにより独立した予後規定因子を求めた. 結果: CRT手術群はUt症例, 3領域郭清例を多く含み, 対照手術群に比べて手術時間・出血量ともに多く, 末梢血リンパ球数は9PODまで, リンパ球幼若化反応は1PODで低値を示した. 縫合不全の発生率, 在院死の頻度が有意に高かったが, 他の合併症・手術関連死の頻度, 術後在院日数に差はなかった. CRT手術群では, 手術的根治度と組織学的深達度が独立した予後規定因子となり, 対照手術群と異なる特徴を示した. 考察: CRT後の手術は, 侵襲が増大し免疫能の低下した条件下で行われるが, 安全性は許容範囲内と考えた. 早期再燃による在院死が多く, 予後規定因子である根治度Aの手術が可能な症例にのみ手術を行うべきである.
Introduction: Chemoradiotherapy (CRT) has been widely used for advanced esophageal cancer patients to improve their prognosis. There were some cases in which we could not be sure that neoadjuvant CRT should be followed by surgery. Therefore, to define the indication of surgery, we evaluated the risk of surgery after CRT and also determined the significant prognostic factors in patients after such surgery. Methods: Esophageal cancer patients who were treated in our department since 1989 were classified into two groups: 28 patients who underwent surgery following neoadjuvant CRT (CRT-op group) and 194 patients who under-went surgery without any previous treatment (control-op group). The surgical stress, immunocompetence, in-cidence of postoperative complications and hospital death, and duration of hospital stay were compared be-tween the CRT-op group and the control-op group. The significant prognostic factors were analyzed in the CRT-op group. Results: The CRT-op group included significantly more patients with upper thoracic esopha-geal ancer and also patients who underwent three-field lymph node dissection compared with the control-op group. The mean operating time and blood loss were significantly more in the CRT-op group. Total lympho-cyte counts were significantly lower by postoperative day (POD) 9 in the CRT-op group than in the controlop group. The CRT-op group also showed significantly lower immunological function assessed with lymphocyte transformation test on the POD 1 compared with the control-op group. Although anastomotic leakage and hospital death were observed more frequently in the CRT-op group than in the control-op group, there was no significant difference in the incidence of operation-related death and the duration of postoperative hospital stay. It was characteristic of the CRT-op group that the independent prognostic factors were revealed to be surgical curability and histological depth of tumor. Conclusion: Surgery following CRT appeared to be safe despite of the increased surgical stress and damaged immunological competence. Because the hospitaldeath due to regrowth of the tumor occurred more frequently in the CRT-op group, surgery following neoad-juvant CRT must be indicated in the patients for whom the surgical procedure will be completely curative.
- The Japanese Journal of Gastroenterological Surgery
The Japanese Journal of Gastroenterological Surgery 37(2), 99-106, 2004
The Japanese Society of Gastroenterological Surgery