第六章、食道癌患者之追蹤監測與副作用照護

6.1 階段性追蹤建議

• 復發時間特徵：九成以上的復發發生在局部治療完成後的最初2年內。但在局部治療結束5年以後，臨床上仍會偵測到需治療的延遲性復發。

• 異時性惡性腫瘤 (Metachronous malignancy)：對於長期存活者，必須考慮到發生異時性二重癌的風險 (例如殘留食道中長出新癌症，或在鱗狀細胞癌患者的其他器官中長出第二種癌症)。

6.1.1 分期與治療模式導向的追蹤建議^[13]

6.2 食道癌患者之初期症狀治療

6.2.1 吞嚥困難 (Dysphagia)

吞嚥困難 (Dysphagia) 是食道癌最常見的症狀之一。評估時應使用標準量表監測吞嚥功能的受損程度，並確立引發吞嚥困難的確切病因。

• 吞嚥困難分級量表 (Dysphagia Grading Scale)：^[13]

  • 第0級：能正常進食固體食物，無需特別注意食物大小或咀嚼程度。

  • 第1級：能吞嚥固體食物，但需切成直徑 < 18 mm 的碎塊並經過充分咀嚼。

  • 第2級：僅能吞嚥半固體食物 (如嬰兒食品稠度)。

  • 第3級：僅能吞嚥液體。

  • 第4級：無法吞嚥液體或唾液。

• 自擴式金屬支架 (Self expandable metallic stent, SEMS)：是緩解管腔阻塞的最快手段，但使用前需考量支架對後續治療的影響。

  • 手術考量：若未來有手術機會，通常不建議先放支架，以防併發症干擾手術。對於長期照護者，覆蓋膜型支架可預防腫瘤向內生長。

  • 副作用考量：若病人在CCRT期間裝有食道支架，可能會增加副作用發生比率。在一篇回溯性研究顯示，裝有食道支架患者接受CCRT，其3級以上 (含) 副作用發生率為71%，顯著高於未裝有食道支架的27% (p < 0.01)。^[64]

  • 併發症-支架相關疼痛：患者在放置食道支架後，若出現嚴重的無法控制之疼痛，應立即透過內視鏡將支架移除。

• 放射治療：短療程放射 (1-2週) 可提供長效的吞嚥改善，雖生效較慢，但風險較低。

6.2.2 食道阻塞 (Esophageal obstruction)

• 臨床上依據阻塞的嚴重程度，採取分級處置策略：

表6.2.2 食道阻塞之分級處置策略

6.3 食道癌患者治療相關併發症之處理

6.3.1 術後胃腸道功能障礙與營養^[65]

• 胃腸道併發症：食道癌與胃食道交界處 (EGJ) 癌患者在經歷根治性手術後，因上消化道結構與長度改變，導致的長期胃腸道併發症。其中包括術後6個月內必經之營養不良，以及胃排空延遲、傾倒症候群、或是胃食道逆流。

• 傾倒症候群 (Dumping syndrome)：為食道癌、胃癌或胃縮短手術後常見的併發症。

  • 幽門生理功能：調控胃部消化完的糜狀食物進入腸道的速度，同時嚴密防止鹼性的十二指腸液反流回胃部。

  • 傾倒症候群機制：胃幽門功能失調或被手術破壞，使得高滲透壓食物 (特別是高糖、精緻碳水化合物) 未經充分消化，便直接傾倒進幽門後方的十二指腸/空腸中。

  • 早期傾倒 (細胞脫水)：高滲透壓的食物殘渣進入小腸後，周邊血管的大量水分會因滲透壓而被迅速抽吸進入腸腔。這將導致腸道急速擴張、組織液暴增 (引發腹痛、腹瀉)，同時伴隨全身血容量驟降 (引發頭暈、心悸、臉色蒼白、甚至休克)。

  • 晚期傾倒 (反應性低血糖)：高濃度的糖分瞬間被小腸吸收進入血液，會刺激胰臟報復性分泌過量的胰島素，導致血糖在餐後1–3小時內雪崩式暴跌，引發嚴重的低血糖症狀 (冒冷汗、手抖、昏厥)。

6.3.2 放療相關心臟毒性^[66]

• 心臟毒性原因：由於食道位置與心臟極近，接受胸腔放療的食道癌患者發生心血管疾病導致死亡的風險顯著增加。

• 心臟相關死亡風險：SEER資料庫分析經放射治療的食道癌患者，其心臟疾病相關的絕對死亡風險隨時間上升，於5年、10年、20年分別高達2.8%、5.3%和9.4%。依據原發部位劃分，中段食道癌的心臟相關死亡風險最高。

• 發病時間與臨床表現：文獻回顧分析顯示，具臨床意義放療相關心臟毒性總體發生率為10.8%，且多數事件發生在治療後2年內。其中以心包膜積水 (Pericardial effusion)最常見，發生率高但多數無症狀，僅在影像學追蹤中被發現。

• 風險因子：年齡、女性、心臟接受超過 50 Gy 照射的絕對體積 (V50)。

放射線誘發的心臟併發症主要包括：

• 心包膜疾病：可表現為急性心包膜炎或慢性心包膜積水 (後者多數無症狀)。

• 心肌病變 ：病理學特徵通常為瀰漫性心肌纖維化，可導致LVEF下降，有時會引發心律不整。

• 冠狀動脈粥狀硬化：放療會加速冠狀動脈的硬化進程，可能導致心肌梗塞。

• 瓣膜性心臟病：表現為瓣膜纖維化、瓣膜鈣化與狹窄，這些改變會導致射血分數降低與瓣膜逆流。

• 心律不整：通常以室上性 (Supraventricular) 心律不整為主。

6.3.3 化學治療誘發的周邊神經病變 (CIPN)^[67]

• 化療藥物前評估：若患者本身已存在神經病變，或患有容易引發神經病變的共病症 (如糖尿病、具備家族或個人遺傳性神經病變病史)，在給予已知會導致 CIPN 的化療藥物前，應深切評估其風險與益處。

• 預防性非藥物措施：ASCO針對化療引起的神經病變之指引提及，雖然以下非藥物預防措施，在部分研究得到正向結果，但仍需更大樣本量的決定性研究來證實療效。

  • 針灸 (Acupuncture)

  • 冷凍療法/低溫冷凍 (Cryotherapy，如冰敷手腳)

  • 加壓療法 (Compression therapy，如戴緊實手套)

  • 運動療法 (Exercise therapy)

• 已被證實無效藥物：包括如鈣/鎂、Gabapentin/pregabalin、N-acetylcysteine、維生素B、維生素E、Glutamate等，ASCO指引不建議使用。

• 發生CIPN時的處置：

  • 藥物與劑量調整：按照嚴重程度決定以下的劑量或療程調整。包括延遲給藥、降低劑量 、更換為不會引發CIPN的替代藥物。

  • Duloxetine：為目前唯一具備實證基礎的CIPN止痛藥物

  • 其他尚缺乏實證之處置與藥物治療：如運動療法、針灸、電療、Gabapentin/pregabalin等。

結語

• 食道癌依照病理型態分為鱗狀細胞癌與腺癌兩大類，其發病與菸酒、肥胖或胃食道逆流密切相關，且初期缺乏典型症狀導致多數患者確診時已屬晚期。

• 精確的疾病診斷高度仰賴內視鏡切片，內視鏡超音波、電腦斷層與正子攝影等影像學評估。

• 局限性食道癌的治癒手段以微創切除手術或精準放射線治療為主，且患者在治療後必須落實階段性追蹤，並妥善防範吞嚥困難、傾倒症候群或心臟毒性等長期併發症。

• 針對局部區域性腫瘤，透過術前化放療、圍手術期化療或術後免疫輔助等全身性綜合治療介入，能有效縮小腫瘤分期並顯著提升患者的長期存活率。

• 晚期與轉移性食道癌的治療已走向個人化精準醫療，強烈建議應先確認HER2、PD-L1(CPS評分)與CLDN18.2等生物標記狀態，以量身打造最適切的標靶或免疫合併化療方案。

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