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STATA 15.0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12 266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.
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 meta-analysis
Objective To investigate the significance of spread through air spaces(STAS)in early-stage non-small 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(12 266 patients)were included,among which,11 compared the outcomes of lobectomy with sublobar resection in the STAS-positive 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 be helpful in determining types of resection.However,more robust methods are urgently in need to make up for the limited sensitivity and accuracy of frozen sections.
Non-small cell lung cancerspread through air spacessublobar resectionlobectomyprognosisfrozen sectionssystematic review/meta-analysis
NETL
NSTL
万方数据
