食管癌下颈部淋巴结转移危险因素分析及下颈部淋巴结靶区的精确勾画研究

发布时间：2018-09-03 18:23

【摘要】：背景与目的放射治疗是食管癌的重要治疗策略,部分研究中已经将累及野照射运用于食管癌的根治性放疗或术前新辅助治疗。然而,基于我们的观察以及部分研究显示,局部晚期食管癌接受累及野放射治疗后下颈部区域有较高的复发率。因此,对于下颈部淋巴结区高危复发的患者预防性放射治疗必要性需要进一步研究。而且目前关于食管癌下颈部区域预防性照射的指证和临床靶区,尚无精确推荐。本回顾性研究通过分析食管癌下颈部区域淋巴结转移(LNM)的危险因素以及下颈部区域LNM的特点,为食管癌下颈部淋巴结区行预防性照射及靶区精确勾画提供参考。方法我们回顾性分析了于2010年1月到2015年7月在我院初诊的食管鳞癌(ESCC)患者的临床病理因素。并且将下颈部淋巴引流区细分为4个亚区域,包括Ⅰ亚组(100组淋巴结,颈部表浅淋巴结):Ⅱ亚组(101组淋巴结,颈段食管旁淋巴结);Ⅲ亚组(104组淋巴结,锁骨上淋巴结);Ⅳ亚组(颈后淋巴结组)。本研究分析了患者的临床因素与下颈部区域LNM的相关性。并且根据原始的CT图像或者PET-CT图像将的具体节点转移点解剖位置进行手工绘制在一个CT图像模板上。识别出每个淋巴结的体积中心并绘制在模板CT图像上,最后形成一个节点体积概率分布图。结果1.本研究分析了患者的临床因素与下颈部区域LNM的相关性。单因素分析显示:肿瘤原发灶位置,肿瘤T分期,纵隔1区、2区、4区、5区LNM以及阳性淋巴结个数目是下颈部区域淋巴结转移的危险因素。logistic多因素分析显示:肿瘤T分期,纵隔1区、2区、4区淋巴结转移以及阳性淋巴结个数是下颈部LNM的独立危险因素。2.本研究总共入组239例食管癌患者,其中有89例患者存在下颈部区域LNM,转移率为37.2%。其中67例(75.3%)患者Ⅲ亚组区域有淋巴结转移,62例(69.7%)Ⅱ亚组区域有转移,4例(4.5%)Ⅰ亚组区域转移,1例(1.1%)Ⅳ亚组区域转移。Ⅱ亚区和Ⅲ亚区淋巴结阳性的患者占下颈部转移患者的94.4%(84/89),而仅仅只有5例(5.6%)患者淋巴结转移在Ⅰ亚区和Ⅳ亚区。另外,我们进一步分析了阳性淋巴结的解剖分布。89例临床诊断下颈部区域LNM的食管癌患者中,有151枚考虑转移,中位阳性淋巴结个数为2个(范围:1-5枚)。其中4/151枚(2.6%)淋巴结分布在Ⅰ亚区,68/151枚(45%)淋巴结分布在Ⅱ亚区,77/151枚(51%)淋巴结分布在Ⅲ亚区,2/151枚(1.4%)淋巴结分布在Ⅳ亚区。结论基于我们的研究,对于包含以下高危因素的食管患者我们推荐给予下颈部淋巴结区预防性放射治疗:肿瘤浸润较深,纵隔1区、2区、4区淋巴结转移以及LNM个数较多。对于下颈部淋巴结靶区范围我们推荐:CTVn包括下颈部淋巴结的Ⅱ亚区和Ⅲ亚区即可。背景与目的临床实践中对于EC患者行锁骨上区预防性放射治疗的CTV范围仍然没有统一共识。精确的靶区勾画是治疗的前提,做到小而不漏,减少不必要的照射进而减少治疗损伤。本研究中,我们分析我院的食管癌患者术后随访的CT图像,通过描绘术后锁骨上淋巴结复发的患者的锁骨上转移淋巴结的具体转移位置分布图,进而分析锁上各个亚区转移的概率,并以此为依据来指导食管癌术后锁骨上区预防性放射治疗的靶区勾画。方法本研究总共入组了101例食管癌根治性术后锁骨上淋巴结复发的患者.锁骨上区被进一步细分为四个亚区域。通过描绘食管癌患者术后淋巴结复发的位置在模板CT图像上,最终形成一个淋巴结空间位置分布图。结果在101例食管癌根治术后患者中,锁骨上区有158枚淋巴结临床诊断为阳性淋巴结,其中,74枚位于左侧锁骨上区,84枚位于右侧锁骨上区,其中7枚(4.4%)位于Ⅰ亚组区域,78枚(49.37%)位于Ⅱ亚组,72枚(45.6%)位于Ⅲ亚组,1枚(0.63%)位于Ⅳ亚组区域。结论根据我们的研究结果,锁骨上的Ⅱ亚区和III亚区为食管鳞癌根治术后淋巴结复发的高危区域,该区域被定义为预防性照射区域。
[Abstract]:BACKGROUND AND OBJECTIVE Radiotherapy is an important therapeutic strategy for esophageal cancer. Involved field irradiation has been used in some studies for radical or preoperative neoadjuvant therapy of esophageal cancer. Preventive radiation therapy for patients at high risk of recurrence in the lower cervical lymph node region requires further study. Currently, there is no precise recommendation on the indications and clinical targets for prophylactic radiation in the lower cervical region of esophageal cancer. This retrospective study analyzed the risk factors for lymph node metastasis (LNM) in the lower cervical region of esophageal cancer. Methods We retrospectively analyzed the clinical and pathological factors of patients with ESCC who were first diagnosed in our hospital from January 2010 to July 2015, and subdivided the lymphatic drainage area of the lower cervical region into four sub-regions. Subgroup I (100 lymph nodes, superficial cervical lymph nodes): subgroup II (101 lymph nodes, paraesophageal cervical lymph nodes); subgroup III (104 lymph nodes, supraclavicular lymph nodes); and subgroup IV (posterior cervical lymph node group). This study analyzed the correlation between clinical factors and LNM in the lower cervical region. The anatomical location of the node metastases was manually plotted on a CT image template. The volume center of each node was identified and plotted on the template CT image. Finally, a probability distribution map of node volume was formed. Results 1. The correlation between clinical factors and LNM in the lower cervical region was analyzed. The location of primary tumor, T stage, LNM in mediastinum 1, 2, 4, 5 and the number of positive lymph nodes were risk factors for LNM in lower cervical region. Logistic multivariate analysis showed that T stage, mediastinum 1, 2, 4 lymph node metastasis and the number of positive lymph nodes were independent risk factors for LNM in lower cervical region. A total of 239 patients with esophageal cancer were enrolled in this study, of which 89 had LNM in the lower cervical region, with a metastatic rate of 37.2%. Of these, 67 (75.3%) had lymph node metastasis in the third subgroup, 62 (69.7%) had regional metastasis in the second subgroup, 4 (4.5%) had regional metastasis in the first subgroup, and 1 (1.1%) had regional metastasis in the fourth subgroup. Sexual metastases accounted for 94.4% (84/89) of the patients with lower cervical metastases, while only 5 (5.6%) of the patients had lymph node metastases in subregions I and IV. In addition, we further analyzed the anatomical distribution of the positive lymph nodes. Of 89 patients with lower cervical LNM, 151 considered metastasis, and the median number of positive lymph nodes was 2. Of these, 4/151 (2.6%) lymph nodes were located in subregion I, 68/151 (45%) lymph nodes in subregion II, 77/151 (51%) lymph nodes in subregion III, and 2/151 (1.4%) lymph nodes in subregion IV. Preventive radiotherapy in the lower cervical lymph node target area: CTVn includes the second and third subareas of the lower cervical lymph nodes. Background and objective: The clinical practice of supraclavicular preventive radiotherapy in EC patients with CTV. In this study, we analyzed the CT images of the patients with esophageal cancer who were followed up after surgery to describe the specific metastasis of supraclavicular lymph nodes in patients with recurrence of supraclavicular lymph nodes. Methods A total of 101 patients with recurrence of supraclavicular lymph nodes after radical esophagectomy were enrolled in this study. The supraclavicular region was further subdivided into four subregions. Results Among 101 patients after radical esophagectomy, 158 lymph nodes in supraclavicular region were clinically diagnosed as positive lymph nodes, 74 in left supraclavicular region and 84 in right supraclavicular region. Seven of them (4.4%) were located in subgroup I, 78 (49.37%) in subgroup II, 72 (45.6%) in subgroup III, and one (0.63%) in subgroup IV.
【学位授予单位】：济南大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R735.1

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