食管癌淋巴结清扫的质量控制.ppt

1、各位专家好,食管癌淋巴结清扫的质量控制,中山大学肿瘤防治中心胸科 林 鹏,背 景, 目前尚无统一意见 焦点主要在于上纵隔及颈根部的清扫 无法规范化，成合理治疗、疗效比较的一大障碍,一，食管癌淋巴结清扫范围,第七版食管癌TNM分期示意图,明天毛友生教授、方文涛教授 将分别详述相关的 新版诊治规范 淋巴结转移规律指导外科手术切除,二，执行新分期后对诊治的影响, 原发灶位置整体上移淋巴清扫及放疗野设计 N分级以区域转移淋巴结个数为界、清扫总数多于15枚（行新辅助后手术者缺）转移野数、区域数、转移率、融合/破碎计数 cTNM（包括非手术治疗）N分级的不确定性影响涵盖分期治案选择、疗效比较,出路, 术前

2、/非手术病例寻找最高级别的诊断组合证据，如PET-CT、EUS-FNA、US-FNA、（Marker、纵隔镜、胸腹腔内镜？） 手术病例寻找兼顾诊治的合理清扫范围,颈IV区,包括下颈淋巴结，位于颈内静脉下1/3周围。胸锁关节上缘上2CM为颈IV区下界。其它各边界定义，上界：环状软骨下缘；前界和后界与颈III区相同，即胸锁乳突肌的前内缘和后缘；外界：锁乳突肌内缘；内界：颈内动脉的内缘和椎旁肌,颈V区,指颈后三角区淋巴结，沿着脊副神经下段和颈横血管分布。舌骨体上缘是颈V区上界可靠的标志。颈横血管下缘为颈V区下界。其它边界分别为：外界：颈阔肌和皮肤；内界：头夹肌、肩胛提肌和斜角肌；前界：胸锁乳突肌后缘

3、；后界：斜方肌前侧缘,颈VI区,也称为前颈淋巴结，位于器官周围，如气管前和气管旁淋巴结、甲状腺周围淋巴结（包括喉返神经周围淋巴结）。颈VI区上界：甲状软骨体下缘；下界：胸骨柄上缘；前界：颈阔肌和皮肤；后界：气管和食管之间的间隙。外界：甲状腺内缘、皮肤和胸锁乳突肌前内缘,No. 101Cervical paraesophageal LN,Lymph nodes located around the cervical esophagus, including lymph nodes located along the recurrent laryngeal nerve and the cervic

4、al paratracheal lymph nodes. The lateral boundary is the medial border of the carotid sheath,No. 104Supraclavicular LN,Lymph nodes located in the supraclavicular fossa, extending from the lower border of the cricoid cartilage superiorly, to the clavicle inferiorly, including the lower internal deep

5、cervical lymph nodes. The medial boundary is the medial border of the carotid sheath,No. 106rec Recurrent nerve LN,Lymph nodes located along the recurrent laryngeal nerves in the mediastinum. The superior boundary is drawn from the cephalic border of the subclavian arteries to the suprasternal notch

6、, and the inferior boundary is the caudal border of the recurrent laryngeal nerve curving upward on both sides,No. 106recLLeft recurrent nerve LN,Lymph nodes located along the left recurrent laryngeal nerve,No. 106recRRight recurrent nerve LN,Lymph nodes located along the right recurrent laryngeal n

7、erve,No. 106pre Pretracheal LN,Lymph nodes in front of the anterior wall of the thoracic trachea, and anterior to the right vagus nerve,No. 106tb Tracheobronchial LN,Lymph nodes located in the tracheobronchial angle,No. 106tbL Left tracheobronchial LN,The superior border is the inferior wall of the

8、aortic arch, and the lymph nodes are located in the area surrounded by the medial wall of the aortic arch,No. 106tbR Right tracheobronchial LN,The superior border is the inferior wall of the azygos vein,No. 111Supradiaphragmatic LN,Lymph nodes located in the area surrounded by the diaphragm, pericar

9、dium, and esophagus,No. 112Posterior mediastinal LN,Lymph nodes located in the area surrounded by the descending aorta, inferior pulmonary vein, and pericardium,No. 112aoThoracic paraaortic LN,Lymph nodes located around the descending aorta, including lymph nodes along the thoracic duct,No. 112pulPu

10、lmonary ligament LN,Lymph nodes located in the pulmonary ligament(s), including lymph nodes adjacent to the pericardium and the inferior pulmonary vein,No. 113 Ligamentum arteriosum LN (Botallo LN),Lymph nodes located on the left side of the arterial ligament,No. 114Anterior mediastinal LN,Lymph nod

11、es located anterior to the superior vena cava, including lymph nodes of the brachiocephalic venous and lymph nodes around the thymus gland,附图1,食管淋巴系的外科解剖学特性,（1）胃肠癌,有系统和完整的系膜，癌转移先始于器官近旁淋巴结，再向形成系膜的血管周围淋巴结发展，故有较为统一的标准术式，其原则是沿形成系膜两侧的筋膜进行剥离,（2）食管癌,也应遵循这一原则，但食管的淋巴系统复杂： 长，跨颈胸腹 壁内纵行淋巴管是横行的6倍，易纵向远处转移 与纵隔内大血管

12、交错，使其系膜结构复杂，不易理解, 食管的系膜构造从颈部到上中纵隔分为左右两叶 上中段食管与气管共有系膜 胸部大血管、胸导管、主淋巴干左右不对称，食管的淋巴系统也是,食管的胚胎发生,（1）, 由胚胎的前肠发育而成 与气管发生源自同一部位，两者拥有共同的淋巴系和血管系 在发生阶段受鳃弓构造的影响，使其血管和神经的支配变得复杂（接受上下双方向）,（2）, 淋巴系统也存在此特点，食管癌的淋巴转移往往可以远离原发灶，实际上可以是早期转移的第一站淋巴结 三野清扫的目的在于将容易发生转移的食管系膜内（甲状腺下动脉和腹腔动脉之间）的淋巴结一并切除,食管癌淋巴结清扫的基础,（1), 评价淋巴结清扫术效果时，需

13、特别强调对操作的量化质控，要求清扫正确部位和足够数量的淋巴 淋巴结清扫术在治疗意义上应视为预防性手术，淋巴结清扫术的安全缘，可通过满足规范清扫术时的淋巴结转移度（阳性淋巴结数与切除淋巴结数之比）来体现和评估,（2）, 有研究显示低于20者可能治愈。实践中意味着清扫淋巴结数目需超过阳性淋巴结数目5倍。按此要求，重要的是需意识到，淋巴结转移播散的范围大于常规病理技术的检测水平；单抗免疫组化提示，40用标准组织学技术诊断的pN0有微转移，且经生存分析为独立预后因子,（3）, 和对待原发灶的处理原则中要求安全切缘一样，提供淋巴引流安全切缘的概念，也是保证完全切除肿瘤的重要方面，在清扫术和淋巴结转移范围一样时，由于淋巴结微转移超出常规病理检查的检出范围，生存无法提高,（4）, 三野清扫，认为可减少淋巴结转移度和保证淋巴引流的安全缘。但由于解剖边界、比邻重要结构的原因，食管癌的淋巴结清扫范围受到限制，清扫范围越大，并发症、死亡率随之增加,（5