食道がん化学放射線療法後のsalvage手術

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4 Daly JM, et al. J Am Coll Surg 2000;190:

5 Esophageal Cancer: Results of an American College of Surgeons Patient Care Evaluation Study Daly JM, et al. J Am Coll Surg 2000;190:

6 Esophageal Cancer: Results of an American College of Surgeons Patient Care Evaluation Study Daly JM, et al. J Am Coll Surg 2000;190:

7 Esophageal Cancer: Results of an American College of Surgeons Patient Care Evaluation Study Daly JM, et al. J Am Coll Surg 2000;190:

8 Esophageal Cancer: Results of an American College of Surgeons Patient Care Evaluation Study Daly JM, et al. J Am Coll Surg 2000;190:

9 Esophageal Cancer (PDQ ): Treatment Stage III Esophageal Cancer Treatment of stage III esophageal cancer may include the following: Surgery. Clinical trials of chemotherapy plus radiation therapy, with or without surgery. Clinical trials of new therapies used before or after surgery.

10 Esophageal Cancer (PDQ ): Treatment Stage III Esophageal Cancer Standard treatment options: Surgical resection of T3 lesions. Treatment options under clinical evaluation: Chemotherapy plus radiation therapy with or without subsequent surgery.[1,2] Information about ongoing clinical trials is available from the NCI Web site.

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12 Comprehensive Registry of Esophageal Cancer

13 Comprehensive Registry of Esophageal Cancer in 2000

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15

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17 Stage II Stage III

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19

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22 Stage II, III: T

23

24 1?

25 EMR (T4) M1-org)

26 Number (n=259) Male : female 225 : 34 Age (mean+sd) ( ) Upper 39 Middle 141 Lower 79 Squamous 254 Adenocarcinoma 2 Others 3

27 ctnm staging Number (n=259) T1 147 T2 17 T3 95 N0 158 N1 101 Stage I 130 Stage II, III 101 Stage IV(Lym) 28 Stage IV(LYM): metastasis in cervical or celiac lymph node

28 Stage I CDDP 80mg/mm 2 5FU 800mg/mm 2 Radiation 2Gy x2

29 Stage II, III, IV(LYM) CDDP 40mg/mm 2 5FU 400mg/mm 2 Radiation 2Gy x 2 CDDP 80mg/mm 2 5FU 800mg/mm x 2 -

30 Survival rate Stage I (n=130) Stage II, III (n=101) Stage IV (Lym) (n=28) year Kaplan-Meier)

31 Stage I Surgery (n=72) Survival rate Chemoradiotherapy (n=130) year Kaplan-Meier)

32 Stage I Chemorad 130 CR % Rec(-) 88 68% Rec(+) 35 Salvage(+) 25 Esophagectomy: 6 Dissection 1 EMR: 18 Salvage(-) 10 Alive 74 Died 14 Alive 17 Died 8 Alive 0 Died 10 Non-CR 7 Chemorad: chemoradiotherapy, CR: complete response, Rec: recurrence, EMR: endoscopic mucosal resection Salvage(+) 5 Esophagectomy: 4 EMR: 1 Salvage(-) 2 Alive 3 Died 2 Alive 1 Died 1

33 Stage II, III Survival rate Surgery (n=350) Chemoradiotherapy (n=101) year Kaplan-Meier)

34 Stage IV(Lym) Survival rate year Surgery (n=97) Chemoradiotherapy (n=28) Kaplan-Meier)

35 1

36 JCOG9708 (phase II) Stage I (T1N0M0) (CDDP/5-FU)II T1N0M05FU CDDP JCOG 0502 (phase III) cstage I ct1n0m0

37 2?

38 Salvage Survival rate Stage I (n=130) Stage II, III (n=101) Stage IV (Lym) (n=28) year Kaplan-Meier)

39 Stage I Chemorad 130 CR % Rec(-) 88 68% Rec(+) 35 Salvage(+) 25 Esophagectomy: 6 Dissection 1 EMR: 18 Salvage(-) 10 Alive 74 Died 14 Alive 17 Died 8 Alive 0 Died 10 Non-CR 7 Chemorad: chemoradiotherapy, CR: complete response, Rec: recurrence, EMR: endoscopic mucosal resection Salvage(+) 5 Esophagectomy: 4 EMR: 1 Salvage(-) 2 Salvage(+) 30 Esophagectomy:10 Dissection 1 EMR: 19 Alive 3 Died 2 Alive 1 Died 1

40 Stage II, III Chemorad 101 CR 66 65% Non-CR 35 Chemorad: chemoradiotherapy, CR: complete response, Rec: recurrence, EMR: endoscopic mucosal resection Rec(-) 38 38% Rec(+) 27 Salvage(+) 13 Esophagectomy: 5 Dissection 1 EMR: 7 Salvage(-) 14 Salvage(+) 10 Esophagectomy: 8 Dissection 1 EMR: 1 Salvage(-) 25 Salvage(+) 23 Esophagectomy:13 Dissection 2 EMR: 8 Alive 33 Died 5 Alive 9 Died 4 Alive 2 Died 12 Alive 4 Died 6 Alive 1 Died 24

41 Stage IV(Lym) CR 9 Rec(-) 4 15% Alive 4 Died 0 32% Salvage(+) 0 Chemorad 28 Rec(+) 5 Salvage(-) 5 Alive 1 Died 4 Non-CR 19 Chemorad: chemoradiotherapy, CR: complete response, Rec: recurrence, EMR: endoscopic mucosal resection Salvage(+) 3 Esophagectomy: 3 Salvage(-) 16 Salvage(+) 3 Esophagectomy: 3 Alive 1 Died 2 Alive 0 Died 16

42 59 2 CRT CR- EMR Salvage Surgery

43 2 Salvage

44 Ishikura S, et al. J Clin Oncol 2003;21:

45 Ishikura S, et al. J Clin Oncol 2003;21:

46

47

48

49

50

51

52 3 Salvage Salvage

53 59 1 CR non-cr

54 Stage I Chemorad 130 CR % Rec(-) 88 68% Rec(+) 35 Salvage(+) 25 Esophagectomy: 6 Dissection 1 EMR: 18 Salvage(-) 10 Alive 74 Died 14 Alive 17 Died 8 Alive 0 Died 10 Non-CR 7 Chemorad: chemoradiotherapy, CR: complete response, Rec: recurrence, EMR: endoscopic mucosal resection Salvage(+) 5 Esophagectomy: 4 EMR: 1 Salvage(-) 2 Alive 3 Died 2 Alive 1 Died 1

55 Stage I Chemorad 130 CR % Rec(-) 88 68% Rec(+) 35 Salvage(-) :10 PUL 2 HEP: 2 PLE: 1 LYM: 3 PS: 1 Reject: 1 Non-CR 7 Chemorad: chemoradiotherapy, CR: complete response, Rec: recurrence Salvage(-) : 2 Complication: 1 Reject: 1

56 Stage II, III Chemorad 101 CR 66 65% Non-CR 35 Chemorad: chemoradiotherapy, CR: complete response, Rec: recurrence, EMR: endoscopic mucosal resection Rec(-) 38 38% Rec(+) 27 Salvage(+) 13 Esophagectomy: 5 Dissection 1 EMR: 7 Salvage(-) 14 Salvage(+) 10 Esophagectomy: 8 Dissection 1 EMR: 1 Salvage(-) 25 Alive 33 Died 5 Alive 9 Died 4 Alive 2 Died 12 Alive 4 Died 6 Alive 1 Died 24

57 Stage II, III CR 66 65% Rec(-) 38 38% Rec(+) 28 PUL: 3 BON: 2 LYM: 5 T4: 1 Reject: 4 Chemorad 101 Non-CR 35 Chemorad: chemoradiotherapy, CR: complete response, Rec: recurrence Salvage(-) : 15 Salvage(-) : 26 PUL: 2 HEP: 1 BON: 2 PLE: 2 KID: 1 T4: 3 PS: 6 Complication: 1 Reject: 8

58 3 Salvage Salvage

59 59 3 Stage II,IIISurgery vs CRT Stage II, III (CRT) -Surgery vs CRT - EMR Salvage Surgery

60 JCOG 9906 (phase II) Stage II,III II prospective Phase II Stage II,III +/-Salvage surgery

61 Surgeon A Surgeon B Surgeon C Non-Salvage Salvage 1 14(25%) 2

62 Salvage

63 Salvage surgery CRT Salvage surgery n=62

64 Salvage surgery CRT Salvage surgery n=62 n=4 T4: 2 LYM: 2 n=58

65 Salvage surgery CRT Salvage surgery n=62 n=58 n=4 T4: 2 LYM: 2 n=7 T4: 6 n=51 PUL: 1 PER: 1

66 Salvage (n=62) (n=185) R0 51 (82%) 171 (92%) R1, R2 7 (11%) 14 (8%) Probe 4 (6%)

67 Salvage Esophagectomy Radical R1, R2 Probe ct1 13 ct2 6 ct T4: 4 T4: 2 PER:1 Lym:1 ct T4: 2 T4: 1 PUL:1

68 Salvage

69 Salvage surgery CRT Salvage surgery

70 Salvage Salvage 60Gy

71 Salvage Salvage (n=58) Age mean SD Male : female 55 : 2 Tumor location Upper 13 (22%) Middle 26 (45%) Lower 19 (33%) ctnm stage Stage I 12 (21%) Stage II 16 (28%) Stage III 22 (38%) Stage IV 8 (14%)

72 Chemoradiotherapy Patients n=58) National Cancer Center Hospital 36 (62%) Other hospital 22 (38%) Radiation dose 60 Gy 55 (95%) 70 Gy 3 (5%) Chemotherapy Platinum+5FU 56 (97%) Platinum alone 2 (3%) Chemotherapy course 2 20 (34%) (57%) (9%)

73 Chemoradiotherapy Patients n=58) non-cr 34 (59%) Recurrence after CR 24 (41%) Duration after chemoradiotherapy 6 months 21 (36%) > 6 months 27 (47%) > 12 months 10 (17%)

74 Salvage Esophagectomy Salvage (n=58) (n=185) Right thoracotomy 54 (93%) 184 (99%) Left thoracotomy 1 (.5%) Transhiatal 4 (7%) 3-field 25 (43%) 169 (91%) others 33 (57%) 16 (9%)

75 Reconstruction Salvage (n=58) (n=185) 22 (38%) 161 (87%) 33 (57%) 22 (12%) 3 (5%) 2 (1%) 55 (95%) 163 (88%) 3 (5%) 22 (12%) 41 (71%) 175 (95%) 14 (24%) 9 (5%) 3 (5%) 1 (.5%)

76 Salvage (n=58) (n=185) 20 (34%) 51 (28%) 19 (33%) 34 (18%) 5 (9%) 7 (4%) 11 (19%) 21 (11%) (59%) 147 (80%) (30%) 32 (17%) 7 (12%) 6 (3%)

77 Salvage surgery CRT Salvage surgery n=58 n=7 Operative: 1 Hospital: 5 Salvage

78 Salvage

79 Salvage?

80 Salvage No.1 No.2 No.3 No.4 No.5 No.6 No.7 No.8 CV

81 Lateral longitudinal anastomosis Lateral longitudinal anastomosis

82 Salvage No.1 No.2 No.3 No.4 No.5

83 5 Salvage

84 Salvage surgery CRT Salvage surgery n=62 n=51 n=11 n=7 n=44

85 Salvage No.1 CO2 20M 14M No.2 CO2 21M 12M No.3 CO2 19M 12M

86 Salvage surgery CRT Salvage surgery n=62 n=51 n=11 n=7 n=3 n=44

87 Salvage surgery n=51 n=7 n=3 n=14 Local: 6 Lym: 5 Org: 3 n=44 Salvage

88 6 Salvage?

89 Without preoperative therapy (n=185) Survival rate Salvage esophagectomy (n=58) year Kaplan-Meier)

90 Salvage Survival rate Recurrence after CR (n=24) non-cr (n=34) year Kaplan-Meier)

91 Salvage Survival rate R0 (n=51) R1, R2 (n=7) year Kaplan-Meier)

92 Salvage Survival rate ct1 (n=13) ct2 (n=6) ct3 (n=35) ct4 (n=4) year Kaplan-Meier)

93 6 Salvage

94 Salvage surgery CRT Salvage surgery n=62 n=51 n=11 n=7 n=3 n=14 n=44

95 Salvage Salvage

96

97 Salvage Salvage

98

99 (

100 2003 4

101 QOL

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