盆腔及腹主动脉旁淋巴结清扫术对子宫内膜癌患者预后影响的系统评价和Meta分析

Prognosis of patients with endometrial cancer after pelvic and para-aortic lymph node dissection:A systematic review and meta-analysis

背景腹盆腔淋巴结转移是评估子宫内膜癌(endometrial cancer,EC)患者预后的重要因素。EC患者行系统性淋巴结切除术(盆腔及腹主动脉旁淋巴结清扫术)是分期手术的重要部分,不仅可以明确分期、指导进一步治疗,还可以评估患者的预后。然而鉴于淋巴结清扫的手术风险及对术后生存质量的影响,淋巴结清扫范围仍有争议。目的评价系统性盆腔及腹主动脉旁淋巴结清扫术与单纯盆腔淋巴结清扫术对EC患者生存结局的影响。方法此文符合PRISMA指南中针对干预研究的Meta分析要求。检索数据库为PubMed、EMBASE、MEDLINE、CNKI、维普、万方。检索词包括盆腔(pelvic)、腹主动脉旁(para-aortic)、淋巴结切除(lymphadenectomy)、子宫内膜癌(endometrial carcinoma)、预后(prognosis)。检索时间截至2021年1月。纳入经子宫内膜活检病理诊断为EC的初治患者,实施规范手术(全子宫、双附件切除术+盆腔淋巴结清扫术,实施或不实施腹主动脉旁淋巴结清扫术)。观察组为实施系统性盆腔及腹主动脉旁淋巴结清扫术的EC患者,对照组为单纯实施盆腔淋巴结清扫术的EC患者。研究主要结局是3年复发率和总生存率,次要指标是手术时间、术中出血量、淋巴结切除数量、术后并发症。应用Review Manager 5.3软件分析比较行盆腔及腹主动脉旁淋巴结清扫术(观察组)与单纯盆腔淋巴结清扫术(对照组)EC患者的术中情况和生存预后指标。结果纳入17项(4篇英文,13篇中文)研究,包括2409例EC患者。所有研究均为回顾性研究,没有符合纳入标准的RCT或队列研究。两组患者年龄、肿瘤分期、分型差异无统计学意义。与单纯行盆腔淋巴结清扫术的EC患者相比,接受系统性盆腔及腹主动脉旁淋巴结清扫术的EC患者3年生存率提高96%(OR:1.96,95%CI:1.44~2.67),3年复发率降低65%(OR:0.35,95%CI:0.26~0.48),但手术时间相对延长(P<0.01),而术中出血量(P=0.09)、手术并发症(P=0.26)并无明显增加。结论行系统性盆腔及腹主动脉旁淋巴结清扫术的EC患者较单纯行盆腔淋巴结清扫术的EC患者有更好的生存结局,复发率更低,且术中出血量及手术并发症并无明显增加。

Background Abdominal and pelvic lymph node metastasis is an important factor in evaluating the prognosis of patients with endometrial cancer(EC).Systematic lymphadenectomy(pelvic and para-aortic lymphadenectomy)for patients with endometrial cancer is an important part of staging surgery,which can not only define staging,guide further treatment,but also assess prognosis.However,due to the risk of surgery and the impact on the postoperative quality of life,the extent of lymph node dissection is still controversial.Objective To compare the effect of systematic pelvic and para-aortic lymph node dissection versus simple pelvic lymph node dissection on the survival outcome of patients with endometrial cancer.Methods This paper met the requirements of meta-analysis for intervention studies in PRISMA guidelines.The retrieval databases included PubMed,Embase,Medline,CNKI,VIP and Wanfang journals.Search terms were pelvic,para-aortic,lymphadenectomy,endometrial cancer and prognosis.The search period was up to January 2021.Patients included in the study were initially treated for endometrial cancer confirmed by endometrial biopsy.They all underwent standard surgical treatment(whole uterus+double adnexectomy+pelvic lymph node cleaning±para-aortic lymph node cleaning).The observation group was EC patients who underwent systematic pelvic and para-aortic lymph node dissection,and patients in the control group only underwent pelvic lymph node dissection.The primary outcome indexes included 3-year overall survival and 3-year recurrence rate,and the secondary indexes were operation time,blood loss,lymph nodes dissection and postoperative complications.Review Manager 5.3 software was used to analyze and compare the differences in intraoperative conditions and survival outcome between the two groups.Results Totally 2409 EC patients were included in 17 retrospective studies.There was no significant difference in age,tumor stage or type between the two groups.The observation group had higher 3-year OS(96%)and lower 3-year recurrence rate(65%)than those of the control group(OS,OR:1.96,95%CI[1.44-2.67];recurrence,OR:0.35,95%CI[0.26-0.48]).However,the operation time was prolonged(P<0.01).There was no significant difference in blood loss(P=0.09)or postoperative complications(P=0.26)between the observation group and the control group.Conclusion Patients with endometrial cancer undergoing pelvic and para-aortic lymph node dissection have better survival outcome,lower recurrence rate,and no significant increases in intraoperative blood loss or surgical complications are found when compared with those undergoing pelvic lymph node dissection alone.