摘要:目的 系统评价肾癌瘤栓分级对肾切除术患者预后的影响。方法 在 PubMed、Embase和 Cochrane图书馆中检索文章。根据研究是否重复、类型是否符合需求、是否找到全文以及浏览全文等方法筛选研究,并提取数据。使用 ReVman 和 Stata 软件进行荟萃分析。结果 对 63 项研究中 21 937 例接受肾切除的患者的汇总分析表明,有瘤栓的肾细胞癌 (renal cell carcinoma,RCC) 患者的预后比无瘤栓的患者差[CSS:2.45 (1.34,4.46),P=0.003]。肾静脉瘤栓的预后优于下腔静脉瘤栓[CSS:1.39 (1.27,1.52),P<0.000 01;OS:1.32 (1.13,1.54),P=0.000 6],瘤栓分级越高,肾细胞癌患者的预后越差。此外,3级和 4级瘤栓的预后无显著差异[CSS:1.24(0.92,1.66),P=0.16;OS:1.24(0.85,1.82),P=0.26]。结论 对于接受肾切除术的患者来说,肾癌瘤栓分级越高,预后越差,梅奥肾癌瘤栓分级系统的 3 级和 4 级瘤栓可合并为一个研究级别。最好进一步细分 TNM 分期系统对于肾切除术后患者的 pT3级别,以肝静脉作为 pT3b和 pT3c的边界更为合理。
图1 纳入研究的流程图
表1 纳入研究的特征
表2 根据梅奥肾癌瘤栓分级系统的荟萃分析结果
图2 根据梅奥肾癌瘤栓分级系统的荟萃分析结果 (CSS:a~l;OS:m~s)
表3 根据梅奥分级系统合并的 CSS 结果的亚组分析
表4 根据 the NEVES and ZINCKE 分级系统的荟萃分析结果
图3 根据 the NEVES and ZINCKE 分级系统的荟萃分析结果
表5 根据梅奥分级系统合并的 OS 结果的亚组分析
表6 根据 the NEVES and ZINCKE 分级系统合并的OS 结果的亚组分析
图4 根据梅奥肾癌瘤栓分级系统癌症特异性生存率的漏斗图 (a~c)
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[1]周潇,罗广承.肾癌瘤栓分级对肾切除术患者预后影响:Meta分析[J].泌尿外科杂志(电子版),2022,14(02):51-68.DOI:10.20020/j.CNKI.1674-7410.2022.02.11.
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肾细胞癌 (renal cell carcinoma,RCC) 是泌尿系统常见肿瘤,占所有癌症的 2%~3%。在过去20 年中,这种癌症的发病率每年增加约 2%[1]。其中,4%~10%的肾肿瘤会侵犯下腔静脉(inferior vena cava,IVC) [2]。目前,根治性肾切除术 (radicalnephrectomy,RN) 仍然是 RCC 伴瘤栓患者的主要治疗方法,梅奥肾癌瘤栓分级系统是瘤栓的主要分级方法。梅奥肾癌瘤栓分级系统的定义如下:0级(瘤栓局限于肾静脉)、1级 (瘤栓延伸至下腔静脉,但在肾静脉上方 2 cm 之下)、2 级 (瘤栓延伸至肾静脉上方 2 cm 但在肝静脉下)、3级 (瘤栓延伸至肝静脉上方但在膈肌下方) 和 4 级 (瘤栓延伸至膈肌上方) [3-4]。此外,NEVES[5]等人提出的 NEVES 和ZINCKE分级也用于一些研究,其定义为 a级 (与梅奥 1级相同)、b级 (瘤栓延伸至肾静脉上方 2 cm 但低于肝内的腔静脉)、c级 (瘤栓延伸至肝内下腔静脉但低于膈肌) 和 d级 (与梅奥 4级相同)。然而,伴有瘤栓的肾细胞癌患者的术后生存率仍然不高[6]。
关于 RCC 静脉瘤栓预后意义的许多研究已经发表,但他们之间存在大样本差异、不同的治疗方法和不同的时间跨度等问题。因此,外科医生对瘤栓分级的预后价值仍然没有共识[7]。GU[8]等人在 2018年进行了一项荟萃分析,他们认为,肾癌瘤栓侵犯下腔静脉的预后比侵犯肾静脉的差,但他们没有进一步讨论侵犯不同下腔静脉高度的不同分级的瘤栓的预后差异。这项荟萃分析的目的是研究肾切除术后不同分级的肾癌瘤栓对患者预后的影响。
3 讨论
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