亚临床库欣综合征患者手术治疗后代谢获益及预测因素分析

Analysis of metabolic benefit and predictive factors after surgical treatment in patients with subclinical Cushing's syndrome

目的 明确亚临床库欣综合征(SCS)术后代谢合并症改善情况,探究预测SCS术后代谢改善的因素。方法 回顾性纳入确诊为肾上腺腺瘤型SCS患者144例,根据是否接受手术将其分为手术组(97例)和未手术组(47例);根据不同代谢结局将手术组中术前存在代谢合并症的65例患者再分为代谢改善组(44例)和代谢无改善组(21例)。收集所有患者一般临床资料和CT检查结果并分组进行比较。采用logistic回归分析评估术前指标对SCS术后代谢获益的影响因素并得出回归方程,构建列线图评分模型,运用校准图和拟合优度检验校准效能。采用受试者工作特征(ROC)曲线评估模型及相关指标的预测价值。结果 手术组肾上腺肿瘤直径、1 mg地塞米松抑制试验(DST)皮质醇、2 mg-DST皮质醇水平及女性、脂代谢异常患者比例均显著高于未手术组,8∶00血浆促肾上腺皮质激素(ACTH)及血清硫酸脱氢表雄酮(DHEAS)水平均显著低于未手术组(P<0.05)。代谢改善组术前肾上腺肿瘤直径、1 mg-DST皮质醇水平、术前合并高血压病和合并2种及以上代谢合并症患者比例均显著高于代谢无改善组(P<0.05)。多因素logistic回归分析结果显示,肾上腺肿瘤直径、1 mg-DST皮质醇、合并2种及以上代谢合并症均为SCS术后代谢改善的独立影响因素(P<0.05)。构建列线图评分模型预测SCS术后代谢改善的ROC曲线下面积为0.871,敏感度为75.0%、特异度为90.5%,预测效能优于各指标单独预测。结论 手术治疗后SCS患者代谢结局存在异质性,联合肾上腺肿瘤直径、1 mg-DST皮质醇及是否合并2种及以上代谢合并症的列线图评分模型可预测其术后代谢改善概率。

Objective To clarify the improvement of postoperative metabolic complications in patients with subclinical Cushing's syndrome(SCS),explore the factors predict postoperative metabolic benefits in SCS patients.Methods A total of 144 patients diagnosed with adrenal adenoma-type SCS were retrospectively enrolled.According to whether received surgery or not,they were divided into surgery group(97 cases)and non-surgery group(47 cases).According to different metabolic outcomes,65 patients in surgery group with metabolic comorbidities before surgery were divided into metabolic improvement group(44 cases)and metabolic non-improvement group(21 cases).General clinical data and CT examination results of all patients were collected and compared in groups.Logistic regression analysis was used to evaluate the influencing factors of preoperative indicators on postoperative metabolic benefits of SCS,and the regression equation was obtained to construct a nomogram scoring model.The calibration chart and goodness of fit were used to test the calibration efficiency.Receiver operating characteristic(ROC)curve was used to evaluate the predictive value of the model and related indicators.Results Adrenal tumor diameter,1 mg dexamethasone suppression test(DST)cortisol,2 mg-DST cortisol,the proportion of female and patients with abnormal lipid metabolism in surgery group were significantly higher than those in non-surgical group,and the plasma ACTH and serum DHEAS level at 8∶00 were significantly lower than those in non-surgery group(P<0.05).Preoperative adrenal tumor diameter,1 mg-DST cortisol level,the proportion of patients with preoperative hypertension and two or more metabolic comorbidities in metabolism improved group were significantly higher than those in metabolism no-improved group(P<0.05).Multivariate logistic regression analysis showed that adrenal tumor diameter,1 mg-DST cortisol,and two or more metabolic comorbidities were independent factors influencing the metabolic improvement of SCS after surgery(P<0.05).The area under the ROC curve of the nomogram scoring model to predict the metabolic improvement of SCS was 0.871,the sensitivity was 75.0%and the specificity was 90.5%,which was better than the prediction value of each index alone.Conclusion There is heterogeneity in the metabolic outcomes of SCS patients after surgical treatment.The nomogram scoring model combined with adrenal tumor diameter,1 mg-DST cortisol and whether there are two or more metabolic comorbidities can be used to predict the probability of postoperative metabolic improvement.