气腔播散对手术决策的影响及冰冻切片识别气腔播散准确性的系统评价与Meta分析  

Impact of tumor spread through air spaces on surgical decision-making and accuracy of identifying spread through air spaces on frozen sections:A systematic review and metaanalysis

作　　者：徐奕 陈东来 徐学君 张永胜[3] 段善州[1] 陈勇兵[1] 谭黎杰 XU Yi;CHEN Donglai;XU Xuejun;ZHANG Yongsheng;DUAN Shanzhou;CHEN Yongbing;TAN Lijie(Department of Thoracic and Cardiac Surgery,The Second Affiliated Hospital of Soochow University,Suzhou,215004,Jiangsu,P.R.China;Department of Thoracic Surgery,Zhongshan Hospital,Fudan University,Shanghai,200032,P.R.China;Department of Pathology,The Second Affiliated Hospital of Soochow University,Suzhou,215004,Jiangsu,P.R.China)

机构地区：[1]苏州大学附属第二医院胸心外科,江苏苏州215004 [2]复旦大学附属中山医院胸外科,上海200032 [3]苏州大学附属第二医院病理科,江苏苏州215004

出　　处：《中国胸心血管外科临床杂志》2024年第6期900-909,共10页Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

基　　金：国家自然科学基金-面上项目(82172076);江苏省科技厅社会发展-重点项目(BE2020653);江苏省卫健委重点科研项目(ZD2021033);苏州市姑苏卫生领军人才项目(GSWS2021020);苏州大学附属第二医院学科建设托举工程项目(XKTJ-XK202004);苏州市卫健委科研项目(LCZX202004);苏州市科技计划项目(SYS2020140)。

摘　　要：目的分析气腔播散(spread through air spaces,STAS)阳性对肺叶切除或亚肺叶切除Ⅰ~Ⅲ期非小细胞肺癌(non-small cell lung cancer,NSCLC)患者预后的影响,同时探究冰冻切片指导STAS潜在阳性患者切除术式的可靠性。方法计算机检索PubMed、EMbase、The Cochrane Library、Web of Science数据库,纳入不同手术方式与STAS阳性Ⅰ~Ⅲ期NSCLC患者预后关系的研究,以及研究通过冰冻切片识别STAS准确度的文献,检索时限为建库至2022年7月。两位研究员独立检索、筛选、评价文献和提取资料。采用RevMan 5.4和STATA15.0进行统计学分析。使用纽卡斯尔-渥太华量表(Newcastle-Ottawa Scale,NOS)对研究进行质量评价。结果纳入26篇STAS相关文献,涉及手术的文献23篇(共12266例患者),其中11篇直接比较了肺叶切除和亚肺叶切除对STAS阳性患者术后生存的影响。NOS评分≥6分。Meta分析显示,STAS阳性为Ⅰ~Ⅲ期NSCLC患者肺叶切除和亚肺叶切除术后预后不利因素[无复发生存期(recurrence-free survival,RFS):HR=2.27,95%CI(1.96,2.63),P<0.01;总生存期(overall survival,OS):HR=2.08,95%CI(1.74,2.49),P<0.01],而在STAS阳性患者中,肺叶切除相比亚肺叶切除可带来更大的生存获益[RFS:HR=1.97,95%CI(1.59,2.44),P<0.01;OS:HR=1.91,95%CI(1.47,2.48),P<0.01]。在纳入4篇探究术中冰冻切片识别STAS准确性的研究后,灵敏度合并值为55%[95%CI(45%,64%)],特异度合并值为92%[95%CI(77%,97%)],而合并后曲线下面积为0.68[95%CI(0.64,0.72)]。结论本研究证实STAS阳性是早期NSCLC患者预后的重要危险因素之一,且STAS阳性患者肺叶切除相比亚肺叶切除可带来更大的生存获益,因此当术中快速冰冻提示STAS阳性时,应首选肺叶切除作为根治术式。术中冰冻切片识别STAS的特异度较高,可对术中术式的选择提供一定的参考,但由于其敏感性及准确性较低,还需要探索其他更为灵敏的检测方式以指导外科决策。Objective To investigate the significance of spread through air spaces(STAS)in early-stage nonsmall cell lung cancer(NSCLC)patients undergoing either sublobar resection or lobectomy by pooling evidence available,and to assess the accuracy of frozen sections in determining types of resection among patients with suspected presence of STAS.Methods Studies were identified by searching databases including PubMed,EMbase,Web of Science,and The Cochrane Library from inception to July 2022.Two researchers independently searched,screened,evaluated literature,and extracted data.Statistical analysis was conducted using RevMan 5.4 and STATA 15.0.The Newcastle-Ottawa Scale(NOS)was used to evaluate the quality of the study.Results A total of 26 studies involving 23 surgical related studies(12266 patients)were included,among which,11 compared the outcomes of lobectomy with sublobar resection in the STASpositive patients.NOS score≥6 points.Meta-analysis indicated that presence of STAS shortened patients'survival in both lobectomy group and sublobar resection group(RFS:HR=2.27,95%CI 1.96-2.63,P<0.01;OS:HR=2.08,95%CI 1.74-2.49,P<0.01).Moreover,lobectomy brought additional survival benefits to STAS-positive patients compared with sublobar resection(RFS:HR=1.97,95%CI 1.59-2.44,P<0.01;OS:HR=1.91,95%CI 1.47-2.48,P<0.01).Four studies were included to assess the accuracy of identifying presence of STAS on intraoperative frozen sections,of which the pooled sensitivity reached 55%(95%CI 45%-64%),the pooled specificity reached 92%(95%CI 77%-97%),and the pooled area under the curve was 0.68(95%CI 0.64-0.72)based on the data available.Conclusion This study confirms that presence of STAS is a critical risk factor for patients with early-stage NSCLC.Lobectomy should be recommended as the first choice when presence of STAS is identified on frozen sections,as lobectomy can prolong patients'survival compared with sublobar resection in STAS-positive disease.The specificity of identifying STAS on frozen sections seems to be satisfactory,which may

关 键 词：非小细胞肺癌 气腔播散 亚肺叶切除 肺叶切除 预后 冰冻切片 系统评价/META分析 

分 类 号：R73[医药卫生—肿瘤]