乳腺癌腔镜腋窝淋巴结清扫术Meta分析
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摘要
[目的]探讨腔镜下腋窝淋巴结清扫术在乳腺癌外科治疗中的可行性、有效性及安全性。[方法]检索Cochrane、Pubmed、EMbase、中国知网、维普及万方数据库相关文献,时间截止在2017年6月以前,对符合纳入标准的所有文献进行相关的质量评价和荟萃分析。[结果]最终纳入12项随机对照试验,共包括1983例患者。腔镜与传统开放性腋窝淋巴结清扫手术相比,前者在术中出血量(SMD=-4.71,95%CI:-6.15～-3.27,P<0.01)、术后腋窝引流量(SMD=-4.26,95%CI:-5.10～-3.42,P<0.01)、住院时间(SMD=-1.24,95%CI:-1.75～-0.74,P <0.01)及术后相关并发症发生率(OR=0.22,95%CI:0.11～0.42,P<0.01)均少于后者,两组方案在手术时间(SMD=-0.47,95%CI:-1.42～0.48,P=0.34)、术中清扫淋巴结数目(SMD=0.10,95%CI:-0.05～0.24,P=0.18)、住院费用(SMD=1.65,95%CI:-1.32～4.63,P=0.28)及术后复发转移发生率(OR=0.75,95%CI:0.33～1.71,P=0.49)差异无统计学意义。[结论]在保证不影响患者预后的前提下,腔镜下腋窝淋巴结清扫术可以减轻对患者的创伤,同时可以减少术后并发症的发生,为该微创技术在我国临床领域的进一步开展提供了参考依据。
[Objective] To investigate the feasibility,effectiveness and safety of mastoscopic axillary lymph node dissection for patients with breast cancer. [Methods] Relevant studies were retrieved from Cochrane,Pubmed,EMbase,CNKI,VIP,Wanfang database from inception to June 2017,the literatures meeting the inclusion criteria were reviewed and meta-analysis was performed. [Results] Twelve randomized controlled studies were finally included involving 1983 breast cancer patients. Meta-analysis showed that the intraoperative blood loss(SMD =-4.71,95% CI:-6.15 ～-3.27,P <0.01),postoperative drainage(SMD =-4.26,95% CI:-5.10 ～-3.42,P <0.01),length of hospital stay(SMD =-1.24,95% CI:-1.75～-0.74,P<0.01) and postoperative complications(OR=0.22,95%CI:0.11～0.42,P<0.01) were less in mastoscopic axillary lymph node dissection than those in conventional axillary lymph node dissection.There was no significant difference in the operation time(SMD=-0.47,95%CI:-1.42～0.48,P=0.34),the number of axillary lymph nodes dissected(SMD =0.10,95% CI:-0.05 ～0.24,P =0.18),hospitalization costs(SMD =1.65,95% CI:-1.32 ～4.63,P =0.28),postoperative recurrence and metastasis rates(OR =0.75,95%CI:0.33～1.71,P=0.49) between the two groups. [Conclusion] Mastoscopic axillary lymph node dissection can reduce the trauma and the incidence of postoperative complications without affecting the prognosis of patients.
[Objective] To investigate the feasibility,effectiveness and safety of mastoscopic axillary lymph node dissection for patients with breast cancer. [Methods] Relevant studies were retrieved from Cochrane,Pubmed,EMbase,CNKI,VIP,Wanfang database from inception to June 2017,the literatures meeting the inclusion criteria were reviewed and meta-analysis was performed. [Results] Twelve randomized controlled studies were finally included involving 1983 breast cancer patients. Meta-analysis showed that the intraoperative blood loss(SMD =-4.71,95% CI:-6.15 ～-3.27,P <0.01),postoperative drainage(SMD =-4.26,95% CI:-5.10 ～-3.42,P <0.01),length of hospital stay(SMD =-1.24,95% CI:-1.75～-0.74,P<0.01) and postoperative complications(OR=0.22,95%CI:0.11～0.42,P<0.01) were less in mastoscopic axillary lymph node dissection than those in conventional axillary lymph node dissection.There was no significant difference in the operation time(SMD=-0.47,95%CI:-1.42～0.48,P=0.34),the number of axillary lymph nodes dissected(SMD =0.10,95% CI:-0.05 ～0.24,P =0.18),hospitalization costs(SMD =1.65,95% CI:-1.32 ～4.63,P =0.28),postoperative recurrence and metastasis rates(OR =0.75,95%CI:0.33～1.71,P=0.49) between the two groups. [Conclusion] Mastoscopic axillary lymph node dissection can reduce the trauma and the incidence of postoperative complications without affecting the prognosis of patients.
引文
[1]Salvat J,Knopf JF,Ayoubi JM,et al.Endoscopic exploration and lymph node sampling of the axilla.preliminary findings of a randomized pilot study comparing clinical and anatomo-pathologic results of endoscopic axillary lymph node sampling with traditional surgical treatment[J].European Journal of Obstetrics,Gynecology,and Reproductive Biology,1996,70(2):165-173.
[2]Hüscher CGS,Barreca M,Di Paola M,et al.Quadrantectomy and video-assisted axillary dissection for stage Ibreast cancer[J].Minimally Invasive Therapy&Allied Technologies,2002,11(1):23-28.
[3]de Wilde RL,Schmidt EH,Hesseling M,et al.Comparison of classic and endoscopic lymphadenectomy for staging breast cancer[J].The Journal of the American Association of Gynecologic Laparoscopists,2003,10(1):75-79.
[4]Luo C,Guo W,Yang J,et al.Comparison of mastoscopic and conventional axillary lymph node dissection in breast cancer:long-term results from a randomized,multicenter trial[J].Mayo Clinic Proceedings,2012,87(12):1153-1161.
[5]Zhang J,Luo CY,Ji XX,et al.Randomized controlled trial of axillary lymph node dissection by endoscopic axillary lymph node dissection[J].Chinese Journal of Practical Surgery,2013,33(2):143-145.[张键,骆成玉,季晓昕,等.乳腔镜腋窝淋巴结清扫手术可行性随机对照研究[J].中国实用外科杂志,2013,33(2):143-145.]
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[7]Wu YX,Tan T,Huang LL,et al.Feasibility and effectiveness of mastoscopic axillary lymph node dissection for breast cancer[J].Zhejiang Clinical Medical Journal,2015,17(12):2069-2070.[吴永晓,覃天,黄临凌,等.乳腺癌行乳腔镜辅助下腋窝淋巴结清扫术的可行性与有效性[J].浙江临床医学,2015,17(12):2069-2070.]
[8]Liu J,Zhong L,Huang Q.Comparative observation of axillary lymph node dissection in early breast cancer with different surgical methods[J].Practical Clinical Journal of Integrated Traditional Chinese and Western Medicine,2015,15(8):72-73.[刘杰,钟玲,黄强.不同术式早期乳腺癌腋窝淋巴结清扫术疗效对比观察[J].实用中西医结合临床,2015,15(8):72-73.]
[9]Zhang YY.Comparative analysis of clinical efficacy of mastoscopic axillary lymph node dissection and conventional open surgery for breast cancer[J].Journal of Qiqihar University of Medicine,2015,36(21):3190-3191.[张延勇.乳腔镜辅助下乳腺癌腋窝淋巴清扫与传统开放手术临床效果的比较分析[J].齐齐哈尔医学院学报,2015,36(21):3190-3191.]
[10]Wang Y,Yuan XY,Zhang CX,et al.Clinical efficacy of endoscopic axillary lymph node dissection and conventional lymph node dissection in the treatment of breast cancer[J].Progress in Modern Biomedicine,2016,16(20):3887-3889,3901.[王妍,原晓燕,张春侠,等.乳腔镜腋窝淋巴结清扫术与常规淋巴结清扫术治疗乳腺癌的临床效果[J].现代生物医学进展,2016,16(20):3887-3889,3901.]
[11]Su LP,Lv YX.Comparison of clinical efficacy of mastoscopic axillary lymph node dissection and conventional dissection for patients with breast cancer[J].The Practical Journal of Cancer,2017,32(6):910-912.[苏丽萍,吕永祥.对比分析乳腔镜腋窝淋巴结清扫术与常规淋巴结清扫术对乳腺癌的临床疗效[J].实用癌症杂志,2017,32(6):910-912.]
[12]Gong JJ,Zhai XF,Wang R,et al.The contrast of mastoscopic axillary lymph node dissection and traditional operation[J].Journal of Nongken Medicine,2017,39(1):29-31.[龚建军,翟新法,王蓉,等.乳腺癌腔镜腋窝淋巴结清扫术与常规手术的比较[J].农垦医学,2017,39(1):29-31.]
[13]Zhao HY,Han GD,Yu FH.Analysis of the safety and effectiveness of endoscopic axillary lymph node dissection in the treatment of early breast cancer[J].Hainan Medical Journal,2015,26(16):2457-2459.[赵宏宇,韩国栋,于飞鸿.腔镜腋窝淋巴结清扫术在早期乳腺癌治疗中的安全性和有效性分析[J].海南医学,2015,26(16):2457-2459.]
[14]Wang N.Application of endoscopic axillary lymph node dissection in the treatment of breast cancer[J].Journal of Laparoscopic Surgery,2017,22(6):472-473.[王宁.腔镜腋窝淋巴结清扫在乳腺癌治疗中的应用进展[J].腹腔镜外科杂志,2017,22(6):472-473.]
[15]Howard PS,Oslin BD,Moore JR.Endoscopic transaxillary submuscular augmentation mammaplasty with textured saline breast implants[J].Annals of plastic surgery,1996,37(1):12-17.
[16]Kontos M,Felekouras E,Fentiman IS.Radiofrequency ablation in the treatment of primary breast cancer:no surgical redundancies yet[J].International Journal of Clinical Practice,2008,62(5):816-820.
[17]Vila J,Gandini S,Gentilini O.Overall survival according to type of surgery in young(≤40 years)early breast cancer patients:a systematic meta-analysis comparing breastconserving surgery versus mastectomy[J].Breast(Edinburgh,Scotland),2015,24(3):175-181.
[18]Lai HW,Chen ST,Chen DR,et al.Current trends in and indications for endoscopy-assisted breast surgery for breast cancer:results from a six-year study conducted by the taiwan endoscopic breast surgery cooperative group[J].PLoSΟne,2016,11(3):e0150310.
[19]Gu JM,Liu JX,Zhu ZJ,et al.Application value of endoscope in breast conserving surgery for breast cancer[J].Chinese Journal of Operative Procedures of General Surgery(Electronic),2017,11(4):348-350.[谷家梦,刘佳兴,朱中建,等.腔镜在乳腺癌保乳手术患者中的应用价值[J].中华普外科手术学杂志(电子版),2017,11(4):348-350.]
[20]Zhang J,Chen J,Zhang XM.Endoscopic breast-conserving therapy in breast cancer breast and axillary lymph node dissection for 50 cases of clinical analysis[J].Chinese Journal of Operative Procedures of General Surgery(Electronic),2016,10(6):493-496.[张建,陈杰,张新民.乳腔镜乳腺癌保乳术及腋窝淋巴结清扫50例临床分析[J].中华普外科手术学杂志(电子版),2016,10(6):493-496.]
[2]Hüscher CGS,Barreca M,Di Paola M,et al.Quadrantectomy and video-assisted axillary dissection for stage Ibreast cancer[J].Minimally Invasive Therapy&Allied Technologies,2002,11(1):23-28.
[3]de Wilde RL,Schmidt EH,Hesseling M,et al.Comparison of classic and endoscopic lymphadenectomy for staging breast cancer[J].The Journal of the American Association of Gynecologic Laparoscopists,2003,10(1):75-79.
[4]Luo C,Guo W,Yang J,et al.Comparison of mastoscopic and conventional axillary lymph node dissection in breast cancer:long-term results from a randomized,multicenter trial[J].Mayo Clinic Proceedings,2012,87(12):1153-1161.
[5]Zhang J,Luo CY,Ji XX,et al.Randomized controlled trial of axillary lymph node dissection by endoscopic axillary lymph node dissection[J].Chinese Journal of Practical Surgery,2013,33(2):143-145.[张键,骆成玉,季晓昕,等.乳腔镜腋窝淋巴结清扫手术可行性随机对照研究[J].中国实用外科杂志,2013,33(2):143-145.]
[6]Li GS,Li WM,Li FM,et al.Comparison of mastoscopic axillary lymph node dissection with conventional surgery[J].Chinese Journal of General Surgery,2013,22(11):1517-1519.[李果生,李文茂,李方明,等.乳腔镜腋窝淋巴结清扫与常规手术的对比[J].中国普通外科杂志,2013,22(11):1517-1519.]
[7]Wu YX,Tan T,Huang LL,et al.Feasibility and effectiveness of mastoscopic axillary lymph node dissection for breast cancer[J].Zhejiang Clinical Medical Journal,2015,17(12):2069-2070.[吴永晓,覃天,黄临凌,等.乳腺癌行乳腔镜辅助下腋窝淋巴结清扫术的可行性与有效性[J].浙江临床医学,2015,17(12):2069-2070.]
[8]Liu J,Zhong L,Huang Q.Comparative observation of axillary lymph node dissection in early breast cancer with different surgical methods[J].Practical Clinical Journal of Integrated Traditional Chinese and Western Medicine,2015,15(8):72-73.[刘杰,钟玲,黄强.不同术式早期乳腺癌腋窝淋巴结清扫术疗效对比观察[J].实用中西医结合临床,2015,15(8):72-73.]
[9]Zhang YY.Comparative analysis of clinical efficacy of mastoscopic axillary lymph node dissection and conventional open surgery for breast cancer[J].Journal of Qiqihar University of Medicine,2015,36(21):3190-3191.[张延勇.乳腔镜辅助下乳腺癌腋窝淋巴清扫与传统开放手术临床效果的比较分析[J].齐齐哈尔医学院学报,2015,36(21):3190-3191.]
[10]Wang Y,Yuan XY,Zhang CX,et al.Clinical efficacy of endoscopic axillary lymph node dissection and conventional lymph node dissection in the treatment of breast cancer[J].Progress in Modern Biomedicine,2016,16(20):3887-3889,3901.[王妍,原晓燕,张春侠,等.乳腔镜腋窝淋巴结清扫术与常规淋巴结清扫术治疗乳腺癌的临床效果[J].现代生物医学进展,2016,16(20):3887-3889,3901.]
[11]Su LP,Lv YX.Comparison of clinical efficacy of mastoscopic axillary lymph node dissection and conventional dissection for patients with breast cancer[J].The Practical Journal of Cancer,2017,32(6):910-912.[苏丽萍,吕永祥.对比分析乳腔镜腋窝淋巴结清扫术与常规淋巴结清扫术对乳腺癌的临床疗效[J].实用癌症杂志,2017,32(6):910-912.]
[12]Gong JJ,Zhai XF,Wang R,et al.The contrast of mastoscopic axillary lymph node dissection and traditional operation[J].Journal of Nongken Medicine,2017,39(1):29-31.[龚建军,翟新法,王蓉,等.乳腺癌腔镜腋窝淋巴结清扫术与常规手术的比较[J].农垦医学,2017,39(1):29-31.]
[13]Zhao HY,Han GD,Yu FH.Analysis of the safety and effectiveness of endoscopic axillary lymph node dissection in the treatment of early breast cancer[J].Hainan Medical Journal,2015,26(16):2457-2459.[赵宏宇,韩国栋,于飞鸿.腔镜腋窝淋巴结清扫术在早期乳腺癌治疗中的安全性和有效性分析[J].海南医学,2015,26(16):2457-2459.]
[14]Wang N.Application of endoscopic axillary lymph node dissection in the treatment of breast cancer[J].Journal of Laparoscopic Surgery,2017,22(6):472-473.[王宁.腔镜腋窝淋巴结清扫在乳腺癌治疗中的应用进展[J].腹腔镜外科杂志,2017,22(6):472-473.]
[15]Howard PS,Oslin BD,Moore JR.Endoscopic transaxillary submuscular augmentation mammaplasty with textured saline breast implants[J].Annals of plastic surgery,1996,37(1):12-17.
[16]Kontos M,Felekouras E,Fentiman IS.Radiofrequency ablation in the treatment of primary breast cancer:no surgical redundancies yet[J].International Journal of Clinical Practice,2008,62(5):816-820.
[17]Vila J,Gandini S,Gentilini O.Overall survival according to type of surgery in young(≤40 years)early breast cancer patients:a systematic meta-analysis comparing breastconserving surgery versus mastectomy[J].Breast(Edinburgh,Scotland),2015,24(3):175-181.
[18]Lai HW,Chen ST,Chen DR,et al.Current trends in and indications for endoscopy-assisted breast surgery for breast cancer:results from a six-year study conducted by the taiwan endoscopic breast surgery cooperative group[J].PLoSΟne,2016,11(3):e0150310.
[19]Gu JM,Liu JX,Zhu ZJ,et al.Application value of endoscope in breast conserving surgery for breast cancer[J].Chinese Journal of Operative Procedures of General Surgery(Electronic),2017,11(4):348-350.[谷家梦,刘佳兴,朱中建,等.腔镜在乳腺癌保乳手术患者中的应用价值[J].中华普外科手术学杂志(电子版),2017,11(4):348-350.]
[20]Zhang J,Chen J,Zhang XM.Endoscopic breast-conserving therapy in breast cancer breast and axillary lymph node dissection for 50 cases of clinical analysis[J].Chinese Journal of Operative Procedures of General Surgery(Electronic),2016,10(6):493-496.[张建,陈杰,张新民.乳腔镜乳腺癌保乳术及腋窝淋巴结清扫50例临床分析[J].中华普外科手术学杂志(电子版),2016,10(6):493-496.]