早读 | 指南解读，食管癌可切除的治疗！
可切除的食管或食管胃交界癌
侵犯黏膜下层（T1b）或更深的肿瘤通常选择手术治疗；虽然多个、多站淋巴结转移是手术的相对禁忌证，当有区域淋巴结转移（N+），T1-T3肿瘤也可以切除，此时需要考虑患者的年龄和身体状况等因素；T4肿瘤累及胸膜、心包或隔膜是可切除的。
不可切除的食管或食管胃交界癌
T46肿瘤累及心脏、大血管、气管、椎体或邻近腹腔器官包括肝脏、胰腺和脾脏）是不可切除的；肿瘤位于食管胃交界伴锁骨上淋巴结转移的患者应考虑为不可切除；伴有远处转移（包括非区域淋巴结及IV期）患者考虑为不可切除。
可选的手术方式
颈段或胸段食管癌距环咽肌<5cm首选根治性同步放化疗，放疗后可考虑巩固化疗。McKeown术式（经腹+经右胸+颈部吻合术），Ivor Lewis术式（经腹+经右胸手术），微创McKeown术式，微创1vor Lewis术式，纵隔镜+腹腔镜下食管部分切除+食管-管胃颈部吻合术（经腹＋颈部手术。）机器人辅助微创McKeown/Lvor Lewis术式，左胸或胸腹联合切口食管部分切除和食管-管胃（或结肠或空肠）胸部/颈部吻合术。食管胃交界部癌的治疗。可采用替代，胃、结肠、空肠。
可采用的淋巴结清扫
颈部无可疑肿大淋巴结，胸中下段食管临建议行胸腹完全二野淋巴结清扫（标准胸腹二野+上纵隔，特别是双钢喉返神经链淋巴结），颈部有可疑肿大淋巴结和胸上段食管癌患者，推荐颈胸腹三野淋巴结清扫（双下颈及锁骨上+上法完全二野淋巴结）。对于食管癌交界部癌，SiewertⅠ型建议参照食管癌治疗；Siewert Ⅲ型建议参照胃癌治疗；Siewert Ⅱ型治疗争议较大，目前更多是由胸外科和胃肠外科医生的习惯和对每种术式的熟练程度决定。术前未接受过新辅助治疗的患者行食管癌或食管胃交界部癌切除术时，应该清扫至少15个淋巴结以得到充分的淋巴结分期。
对于局部晚期食管癌，有条件的医院建议术前行新辅助治疗，食管癌术前同步放化疗循证医学证据更充分（食管胃交界部腺癌围手术期化疗证据也很充分），因此可以作为常规推荐。
研究证实，对于可手术食管癌，术前放化疗联合手术的治疗模式较单纯手术可获得明显生存获益。而术前同步放化疗的长期生存获益是否优于术前化疗尚无定论，但绝大部分研究认为放化疗综合治疗可提高局部区域控制率和根治性手术切除率。新辅助治疗后建议的手术时机是在患者身体条件允许情况下，放化疗结束后4~8周，化疗结束后3~6周。对于拒绝手术或者不能耐受手术者，可以选择根治性同步放化疗、单纯放疗等。
对于边缘可切除食管癌或交界部癌（可疑累及周围器官但未明确CT4b），建议先行新辅助治疗，疗后进行肿瘤的二次评估，可根治性切除者手术治疗，不能切除者继续完成根治性同步放化疗。研究证实，同步放化疗在肿瘤降期、RO切除率和病理缓解率等方面疗效优于单纯放疗。因此，仅在患者无法耐受同步放化疗时选择单纯放疗方案。病理类型为腺癌的患者，放疗前或放疗后建议加入化疗。
同步化疗方案
紫杉醇＋卡铂（1A类），顺铂＋5-FU或卡培他滨（1A类）或替吉奥（2B类），长春瑞滨+顺铂（1A类）,紫杉醇+顺铂，奥沙利铂+5-FU或卡培他滨或替吉奥（2B类证据，推荐腺癌），紫杉醇+5-FU或卡培他滨或替吉奥（2B类）。或老年患者可考虑单药卡培他滨或替吉奥（2B类）。
治疗剂量
术前放疗剂量：DT 40-50Gy，目前两个Ⅲ期前瞻性研究采用40-41.4Gy；根治性同步放化疗剂量：DT 50-60Gy，大部分单位采用> 60Gy。根治性单纯放疗剂量：DT 60-70Gy，放疗每日1次，每周5次。有条件的医院也可采用同步加量技术。
放疗
建议采用三维适形和调强放疗的精确放疗技术。已有多个放射物理方面的研究表明，相较于既往的常规二维放疗技术，三维适形或调强放疗在靶区剂量分布和正常组织和器官保护等方面均表现优异，特别是对于心脏和肺的保护等方面，可降低放疗相关不良反应。初步研究结果提示质子放疗的毒性和术后并发症方面比光子调强放疗有所降低。
对于经外科评估可切除的局部进展期食管癌，围手术期免疫治疗尚缺乏充分的循证医学证据，因此推荐在临床研究范畴内开展。食管癌术前新辅助免疫治疗推荐与放化疗或化疗的联合模式，周期数2~4周期。
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