新辅助放化疗对食管癌手术和预后的影响

目的对术前放化疗(新辅助放化疗,CRTS)与单纯手术(S)治疗食管癌的随机对照试验研究(RCTs)进行Me-ta分析,探讨CRTS对食管癌手术及预后的影响。方法 PubMed及手工检索所有已发表的关于CRTS与S治疗食管癌的RCTs。检验异质性,并根据异质性结果选择相应的效应模型。结果 14项RCTs纳入本研究,共1737例食管癌患者,文献质量评价根据Cochrane Reviewers′ Handbook4.2.2为A或B。CRTS组与S组比较,1年生存率差异无统计学意义,但CRTS组2年、3年、4年、5年生存率明显提高。相对危险度(RR)分别为1.06(95%CI0.99～1.13;P=0.1)、1.18(95%CI1.04～1.33;P=0.01)、1.39(95%CI1.23～1.58;P<0.00001)、1.27(95%CI1.04～1.55;P=0.02)、1.41(95%CI1.18～1.69;P=0.0001)。切除率二者差异无统计学意义,RR1.01(95%CI0.97～1.05;P=0.67),但CRTS组有较高的完全切除率,RR1.44(95%CI1.23～2.74;P=0.008)。总体死亡率二者比较,差异无统计学意义,RR1.12(95%CI0.89～2.48;P=0.503),但CRTS组手术相关死亡率相对较高,RR1.70(95%CI1.12～2.56;P=0.01)。二者并发症发生率差异无统计学意义,RR1.23(95%CI0.93～1.78;P=0.13)。二组远处转移率及总体肿瘤复发率比较,均差异无统计学意义,RR分别为1.18(95%CI0.75～1.68;P=0.71)、1.07(95%CI0.76～1.56;P=0.18),但CRTS组局部区域复发率降低,RR1.18(95%CI1.22～1.61;P=0.0001)。CRTS组病理完全缓解率达10.0%～45.5%。同步CRTS与序贯性CRTS比较,前者(RR1.34,95%CI1.06～1.89,P=0.013)比后者(RR0.86,95%CI0.67～1.38,P=0.29)更有益于提高患者5年生存率。结论与S治疗食管癌相比,CRTS降低了肿瘤局部区域复发率,提高了患者的3年、5年生存率;手术切除率二者差异无统计学意义,而CRTS完全切除率提高,但其手术相关死亡率相对较高。二者并发症发生率比较差异无统计学意义。

Impact of neoadjuvant chemoradiotherapy on prognosis and surgery for esophageal carcinoma

Objective To evaluate the role of neoadjuvant chemoradiotherapy on prognosis and surgery for esophageal carcinoma by performing a meta-analysis of randomized controlled trials （RCTs） that compared neoadjuvant chemoradiotherapy and surgery with surgery alone for esophageal carcinoma.Methods PubMed and manual searches were done to identify all published RCTs that compared neoadjuvant chemoradiotherapy and surgery with surgery alone for esophageal cancer. According to the test of heterogeneity,a fixed-effects model or a random effects model was used and the relative risk （RR） was the principal measure of effect.Results Fourteen RCTs that included 1737 patients were selected with quality assessment ranging from A to C （Cochrane Reviewers＇ Handbook 4.2.2）. Relative risk （95% confidence interval CI]; P value）,expressed as chemoradiotherapy and surgery versus surgery alone chemoradiotherapy-surgery（CRTS） versus surgery alone（S）; value 1 favor CRTS）,was 1.06 （95% CI 0.99~1.13; P=0.1） for 1-year survival,1.18 （95% CI 1.04~1.33; P=0.01） for 2-year survival,1.39 （95% CI 1.23~1.58; P0.00001） for 3-year survival,1.27 （95% CI 1.04~1.55; P=0.02） for 4-year survival,1.41 （95% CI 1.18~1.69; P=0.0001） for 5-year survival,1.01 （95% CI 0.97~1.05; P=0.67） for rate of resection,1.44 （95% CI 1.23~2.74; P=0.008） for rate of complete resection,1.70 （95% CI 1.12～2.56; P=0.01） for operative mortality,1.12 （95% CI 0.89-2.48; P=0.503） for all treatment mortality,1.23 （95% CI 0.93~1.78; P=0.13） for the rate of adverse treatment,1.18 （95% CI 1.22~1.61; P=0.0001） for local-regional cancer recurrence,1.18 （95% CI 0.75~1.68; P=0.71） for distant cancer recurrence,and 1.07 （95% CI 0.76~1.56; P=0.18） for all cancer recurrence. A complete pathological response to chemoradiotherapy occurred in 10%~45.5% of patients. The 5-year survival benefit was most pronounced when chemotherapy and radiotherapy were given concurrently （RR 1.34,95% CI 1.06~1.89,P=0.013） instead of sequentially （RR 0.86,95% CI 0.67~1.38,P=0.29）.Conclusions Compared with surgery alone,neoadjuvant chemoradiotherapy and surgery improved 3-year,5-year survival and reduced local-regional cancer recurrence. It was associated with a higher rate of complete （R0） resection and operative mortality although no significance about the rate of esophageal resection,There was a nonsignificant trend toward increased all treatment mortality with neoadjuvant chemoradiotherapy. Concurrent administration of neoadjuvant chemotherapy and radiotherapy was superior.