【摘要】：背景與目的放射治療是食管癌的重要治療策略,部分研究中已經(jīng)將累及野照射運用于食管癌的根治性放療或術(shù)前新輔助治療。然而,基于我們的觀察以及部分研究顯示,局部晚期食管癌接受累及野放射治療后下頸部區(qū)域有較高的復(fù)發(fā)率。因此,對于下頸部淋巴結(jié)區(qū)高危復(fù)發(fā)的患者預(yù)防性放射治療必要性需要進一步研究。而且目前關(guān)于食管癌下頸部區(qū)域預(yù)防性照射的指證和臨床靶區(qū),尚無精確推薦。本回顧性研究通過分析食管癌下頸部區(qū)域淋巴結(jié)轉(zhuǎn)移(LNM)的危險因素以及下頸部區(qū)域LNM的特點,為食管癌下頸部淋巴結(jié)區(qū)行預(yù)防性照射及靶區(qū)精確勾畫提供參考。方法我們回顧性分析了于2010年1月到2015年7月在我院初診的食管鱗癌(ESCC)患者的臨床病理因素。并且將下頸部淋巴引流區(qū)細分為4個亞區(qū)域,包括Ⅰ亞組(100組淋巴結(jié),頸部表淺淋巴結(jié)):Ⅱ亞組(101組淋巴結(jié),頸段食管旁淋巴結(jié));Ⅲ亞組(104組淋巴結(jié),鎖骨上淋巴結(jié));Ⅳ亞組(頸后淋巴結(jié)組)。本研究分析了患者的臨床因素與下頸部區(qū)域LNM的相關(guān)性。并且根據(jù)原始的CT圖像或者PET-CT圖像將的具體節(jié)點轉(zhuǎn)移點解剖位置進行手工繪制在一個CT圖像模板上。識別出每個淋巴結(jié)的體積中心并繪制在模板CT圖像上,最后形成一個節(jié)點體積概率分布圖。結(jié)果1.本研究分析了患者的臨床因素與下頸部區(qū)域LNM的相關(guān)性。單因素分析顯示:腫瘤原發(fā)灶位置,腫瘤T分期,縱隔1區(qū)、2區(qū)、4區(qū)、5區(qū)LNM以及陽性淋巴結(jié)個數(shù)目是下頸部區(qū)域淋巴結(jié)轉(zhuǎn)移的危險因素。logistic多因素分析顯示:腫瘤T分期,縱隔1區(qū)、2區(qū)、4區(qū)淋巴結(jié)轉(zhuǎn)移以及陽性淋巴結(jié)個數(shù)是下頸部LNM的獨立危險因素。2.本研究總共入組239例食管癌患者,其中有89例患者存在下頸部區(qū)域LNM,轉(zhuǎn)移率為37.2%。其中67例(75.3%)患者Ⅲ亞組區(qū)域有淋巴結(jié)轉(zhuǎn)移,62例(69.7%)Ⅱ亞組區(qū)域有轉(zhuǎn)移,4例(4.5%)Ⅰ亞組區(qū)域轉(zhuǎn)移,1例(1.1%)Ⅳ亞組區(qū)域轉(zhuǎn)移。Ⅱ亞區(qū)和Ⅲ亞區(qū)淋巴結(jié)陽性的患者占下頸部轉(zhuǎn)移患者的94.4%(84/89),而僅僅只有5例(5.6%)患者淋巴結(jié)轉(zhuǎn)移在Ⅰ亞區(qū)和Ⅳ亞區(qū)。另外,我們進一步分析了陽性淋巴結(jié)的解剖分布。89例臨床診斷下頸部區(qū)域LNM的食管癌患者中,有151枚考慮轉(zhuǎn)移,中位陽性淋巴結(jié)個數(shù)為2個(范圍:1-5枚)。其中4/151枚(2.6%)淋巴結(jié)分布在Ⅰ亞區(qū),68/151枚(45%)淋巴結(jié)分布在Ⅱ亞區(qū),77/151枚(51%)淋巴結(jié)分布在Ⅲ亞區(qū),2/151枚(1.4%)淋巴結(jié)分布在Ⅳ亞區(qū)。結(jié)論基于我們的研究,對于包含以下高危因素的食管患者我們推薦給予下頸部淋巴結(jié)區(qū)預(yù)防性放射治療:腫瘤浸潤較深,縱隔1區(qū)、2區(qū)、4區(qū)淋巴結(jié)轉(zhuǎn)移以及LNM個數(shù)較多。對于下頸部淋巴結(jié)靶區(qū)范圍我們推薦:CTVn包括下頸部淋巴結(jié)的Ⅱ亞區(qū)和Ⅲ亞區(qū)即可。背景與目的臨床實踐中對于EC患者行鎖骨上區(qū)預(yù)防性放射治療的CTV范圍仍然沒有統(tǒng)一共識。精確的靶區(qū)勾畫是治療的前提,做到小而不漏,減少不必要的照射進而減少治療損傷。本研究中,我們分析我院的食管癌患者術(shù)后隨訪的CT圖像,通過描繪術(shù)后鎖骨上淋巴結(jié)復(fù)發(fā)的患者的鎖骨上轉(zhuǎn)移淋巴結(jié)的具體轉(zhuǎn)移位置分布圖,進而分析鎖上各個亞區(qū)轉(zhuǎn)移的概率,并以此為依據(jù)來指導食管癌術(shù)后鎖骨上區(qū)預(yù)防性放射治療的靶區(qū)勾畫。方法本研究總共入組了101例食管癌根治性術(shù)后鎖骨上淋巴結(jié)復(fù)發(fā)的患者.鎖骨上區(qū)被進一步細分為四個亞區(qū)域。通過描繪食管癌患者術(shù)后淋巴結(jié)復(fù)發(fā)的位置在模板CT圖像上,最終形成一個淋巴結(jié)空間位置分布圖。結(jié)果在101例食管癌根治術(shù)后患者中,鎖骨上區(qū)有158枚淋巴結(jié)臨床診斷為陽性淋巴結(jié),其中,74枚位于左側(cè)鎖骨上區(qū),84枚位于右側(cè)鎖骨上區(qū),其中7枚(4.4%)位于Ⅰ亞組區(qū)域,78枚(49.37%)位于Ⅱ亞組,72枚(45.6%)位于Ⅲ亞組,1枚(0.63%)位于Ⅳ亞組區(qū)域。結(jié)論根據(jù)我們的研究結(jié)果,鎖骨上的Ⅱ亞區(qū)和III亞區(qū)為食管鱗癌根治術(shù)后淋巴結(jié)復(fù)發(fā)的高危區(qū)域,該區(qū)域被定義為預(yù)防性照射區(qū)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.
【學位授予單位】：濟南大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R735.1

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