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微波消融与手术切除治疗肝细胞癌合并肝硬化效果及安全性的Meta分析
DOI: 10.12449/JCH240915
利益冲突声明：本文不存在任何利益冲突。
作者贡献声明：骆建兴、扈晓宇负责课题设计，资料分析，撰写论文；张扬、向讷参与收集数据，修改论文；扈晓宇负责拟定写作思路，指导撰写文章并最后定稿。
Efficacy and safety of microwave ablation versus hepatic resection in treatment of hepatocellular carcinoma with liver cirrhosis： A Meta-analysis
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摘要:
目的 通过Meta分析系统评价微波消融（MWA）和手术切除（HR）在肝细胞癌（HCC）合并肝硬化中的有效性及安全性。 方法 本研究根据PRISMA指南完成，PROSPERO注册号：CRD42024509185。检索PubMed、Cochrane Library、EMBASE、Web of Science、中国知网、维普、万方数据库，时间均为从建库至2023年11月，搜索MWA对比HR治疗HCC合并肝硬化的随机对照试验（RCT）和队列研究，采用Stata 12.0软件进行Meta分析。 结果 共纳入3项RCT和5项回顾性队列研究，共953例患者。Meta分析显示：MWA的1/2/3/5年总生存率（OS）与HR相比无统计学差异（P值均>0.05）。MWA的1/2/5年复发率与HR相比无统计学差异（P值均>0.05）。MWA的3年复发率高于HR（RR=1.59，95%CI：1.08～2.33，P=0.017）。MWA的1/3/5年无复发生存率（DFS）低于HR（RR=0.94，95%CI：0.89～0.99，P=0.018，I2=0.0%；RR=0.84，95%CI：0.72～0.98，P=0.023，I2=25.4%；RR=0.75，95%CI：0.58～0.98，P=0.032，I2=34.6%）。但亚组分析表明，在RCT组，MWA的1/2/3年OS和1/3年DFS与HR相比无统计学差异（P值均>0.05）。MWA的术中出血量、手术时间、住院时间、不良反应及肝功能均优于HR（SMD=-2.31，95%CI：-2.64～-1.97，P<0.001，I2=3.1%；SMD=-3.38，95%CI：-4.05～-2.71，P<0.001，I2=73.8%；SMD=-2.54，95%CI：-3.27～-1.80，P<0.001，I2=92.8%；RR=0.42，95%CI：0.30～0.59，P<0.001，I2=0.0%；SMD=-1.43，95%CI：-1.89～-0.97，P<0.001）。 结论 MWA与HR在局部复发、DFS及OS方面无明显差异。MWA术中出血量更少，手术时间更短，不良反应更少，对肝功能影响更小，住院时间更短。 Abstract:Objective To investigate the efficacy and safety of microwave ablation （MWA） versus hepatic resection （HR） in the treatment of hepatocellular carcinoma （HCC） with liver cirrhosis using a meta-analysis. Methods This study was conducted according to the PRISMA guideline， with a PROSPERO registration number of CRD42024509185. PubMed， the Cochrane Library， EMBASE， Web of Science， CNKI， VIP， and Wanfang Data were searched for randomized controlled trials （RCTs） and cohort studies on MWA versus HR in the treatment of HCC with liver cirrhosis published up to November 2023， and Stata 12.0 was used to perform the meta-analysis. Results A total of 3 RCTs and 5 retrospective cohort studies were included， with 953 patients in total. The meta-analysis showed that there were no differences between MWA and HR in 1-， 2-， 3-， and 5-year overall survival （OS） rates （all P>0.05） and 1-， 2-， and 5-year recurrence rates （all P>0.05）. Compared with HR， MWA had a significantly higher 3-year recurrence rate （risk ratio ［RR］=1.59， 95% confidence interval ［CI］： 1.08 — 2.33， P=0.017） and significantly lower 1-， 3-， and 5-year disease-free survival （DFS） rates （1-year DFS rate： RR=0.94， 95%CI： 0.89 — 0.99， P=0.018， I2=0.0%； 3-year DFS rate： RR=0.84， 95%CI： 0.72 — 0.98， P=0.023， I2=25.4%； 5-year DFS rate： RR=0.75， 95%CI： 0.58 — 0.98， P=0.032， I2=34.6%）. However， subgroup analysis showed that there were no significant differences between MWA and HR in 1-， 2-， and 3-year OS rates and 1- and 3-year DFS rates in the RCT subgroup （all P>0.05）. Compared with HR， MWA had significantly better intraoperative blood loss （standardized mean difference ［SMD］=-2.31， 95%CI： -2.64 to -1.97， P<0.001， I2=3.1%）， time of operation （SMD=-3.38， 95%CI： -4.05 to -2.71， P<0.001， I2=73.8%）， length of hospital stay （SMD=-2.54， 95%CI： -3.27 to -1.80， P<0.001， I2=92.8%）， adverse reactions （RR=0.42， 95%CI： 0.30 — 0.59， P<0.001， I2=0.0%）， and liver function （SMD=-1.43， 95%CI： -1.89 — -0.97， P<0.001）. Conclusion There are no significant differences between MWA and HR in local recurrence， DFS， and OS， but MWA tends to have a less intraoperative blood loss， a shorter time of operation， fewer adverse reactions， a less impact on liver function， and a shorter length of hospital stay. -
Key words:
- Carcinoma， Hepatocellular /
- Liver Cirrhosis /
- Meta-Analysis
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图 5 不良反应及手术相关指标森林图
注： a，不良反应；b，术中出血量；c，手术时间；d，住院时间。
Figure 5. Forest plots of adverse reaction and operation related indexes
表 1 纳入文献的基本特征
Table 1. The characteristics of studies
纳入研究 国家 例数
（T/C）
研究类型 年龄（岁）
（T/C）
男女比例
（T/C）
MWA方式 HBsAg阳性率（T/C，%） Child-Pugh分级 肿瘤个数及大小（cm） 随访时间（月） 结局指标 NOS（分） Zhang等2017［24］ 中国 31/42 RCS 51.2±6.93/
54.1±7.23
20∶11/
29∶13
PMWA 45.2/61.9 A或B 单发且直径≤5或3个且最大直径≤3 >60 ①④ 6 Zhang等2016［25］ 中国 68/122 RCS 55.4±9.9/
49.5±8.6
57∶11/
111∶11
PMWA 92.6/91.8 A 单个且直径<3 9～104 ①②③④⑧ 7 杨藩等2016［26］ 中国 98/152 RCS 55.4±7.9/
52.5±8.0
82∶16/
133∶19
PMWA 91.8/91.4 A或B 单发且直径≤3 9～96 ①③④⑧ 8 黄炎等2017［27］ 中国 26/24 RCS 57.6±6.0/
58.1±5.5
15∶11/
15∶9
LMWA - A或B 2.36±0.41/2.46±0.36；个数≤2 13～63/16～65 ①②④⑤⑥⑦⑧ 8 廖凌峰等2018［28］ 中国 40/68 RCT 52.36±8.62/
52.20±8.60
28∶12/
50∶18
PMWA 90.00/88.24 A或B 2.32±0.64/
2.12±0.60
12～36 ①③④ 陈红健等2018［29］ 中国 46/46 RCT 29～78 68∶24 UNK 100 A或B 单发且直径≤3或2个且直径之和≤3 24 ①④⑤⑥⑦⑧ 王辉坡等2019［30］ 中国 45/45 RCT 53.8±3.2/
54.3±2.9
23∶22/
18∶27
UNK - - - - ⑥⑦⑧ 黄志明等2016［31］ 中国 47/53 RCS 60.0±12.4/
55.8±11.3
42∶5/
48∶5
UNK - A或B 单发且直径≤3或3个且最大直径≤3 3～44 ①②④⑥⑧ 9 注：T，MWA组；C，HR组；UNK，未分类或未确定。①OS；②LR；③DFS；④不良反应；⑤肝功能；⑥手术时间；⑦术中出血量；⑧住院时间。-，未提供数据。
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表 2 消融方式的亚组分析
Table 2. Subgroup analysis-method of ablation
亚组 结局指标 纳入研究数量 效应值［RR或SMD （95%CI）］ 异质性（I2） P值 优势组 PMWA 1年OS 4 0.99（0.96～1.01） 0.0% 0.326 2年OS 1 0.94（0.83～1.08） 0.406 3年OS 4 0.93（0.97～1.00） 0.0% 0.067 1年LR 1 1.79（0.46～6.95） 0.397 不良反应 4 0.44（0.29～0.66） 24.0% <0.001 MWA 住院时间 2 -2.33（-2.84～-1.82） 75.4% <0.001 MWA LMWA 1年OS 1 - - 2年OS 1 0.97（0.80～1.16） 0.704 3年OS 1 0.97（0.75～1.26） 0.813 ALT 1 -0.99（-1.58～-0.40） 0.001 MWA AST 1 -0.88（-1.46～-0.30） 0.003 MWA Alb 1 1.97（1.29～2.65） <0.001 MWA 不良反应 1 0.42（0.17～1.03） 0.059 手术时间 1 -2.62（-3.39～-1.86） <0.001 MWA 住院时间 1 -2.25（-2.97～-1.54） <0.001 MWA 术中出血量 1 -1.89（-2.56～-1.22） <0.001 MWA 未分类 1年OS 2 0.98（0.91～1.07） 0.0% 0.711 2年OS 2 0.95（0.83～1.10） 0.0% 0.529 1年LR 1 1.25（0.43～3.59） 0.683 ALT 1 -3.06（-3.67～-2.45） <0.001 MWA AST 1 -6.48（-7.51～-5.45） <0.001 MWA Alb 1 0.30（-0.11～0.71） 0.153 不良反应 2 0.33（0.14～0.77） 0.0% 0.011 MWA 手术时间 3 -3.61（-4.34～-2.89） 71.8% <0.001 MWA 住院时间 3 -2.82（-4.73～-0.90） 96.9% 0.004 MWA 术中出血量 2 -2.45（-2.83～-2.06） 0.0% <0.001 MWA
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表 3 研究类型的亚组分析
Table 3. Subgroup analysis-type of research
亚组 结局指标 纳入研究数量 效应值［RR或SMD （95%CI）］ 异质性（I2） P值 优势组 RCT 1年OS 2 0.97（0.91～1.04） 0.0% 0.437 2年OS 2 0.95（0.85～1.06） 0.0% 0.324 3年OS 1 1.02（0.74～1.41） 0.904 1年DFS 1 0.92（0.81～1.04） 0.175 3年DFS 1 1.05（0.64～1.70） 0.855 ALT 1 -3.06（-3.67～-2.45） <0.001 MWA AST 1 -6.48（-7.51～-5.45） <0.001 MWA Alb 1 0.30（-0.11～0.71） 0.153 不良反应 2 0.36（0.15～0.90） 20.4% 0.029 MWA 手术时间 2 -3.93（-4.67～-3.19） 53.2% <0.001 MWA 术中出血量 2 -2.45（-2.83～-2.06） 0.0% <0.001 MWA 住院时间 2 -3.69（-5.17～-2.20） 89.1% <0.001 MWA RCS 1年OS 5 0.99（0.96～1.02） 0.0% 0.495 2年OS 2 0.96（0.83～1.13） 0.0% 0.652 3年OS 4 0.93（0.87～0.99） 0.0% 0.026 HR 1年DFS 2 0.95（0.89～1.00） 0.0% 0.050 3年DFS 2 0.81（0.69～0.95） 45.4% 0.009 HR ALT 1 -0.99（-1.58～-0.40） 0.001 MWA AST 1 -0.88（-1.46～-0.30） 0.003 MWA Alb 1 1.97（1.29～2.65） <0.001 MWA 不良反应 5 0.43（0.29～0.62） 0.0% <0.001 MWA 手术时间 2 -2.88（-3.34～-2.42） 0.0% <0.001 MWA 术中出血量 1 -1.89（-2.56～-1.22） <0.001 MWA 住院时间 4 -2.00（-2.65～-1.35） 89.1% <0.001 MWA
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