在靶向治疗和免疫治疗时代，细胞减积性肾切除术在转移性肾细胞癌中的作用：系统评价和荟萃分析。
The role of cytoreductive nephrectomy in metastatic renal cell carcinoma in the targeted therapy and immunological therapy era: a systematic review and meta-analysis.
机构信息
Department of Urology.
Institution of Urology, West China Hospital, Sichuan University, Chengdu, People's Republic of China.
出版信息
Int J Surg. 2023 Apr 1;109(4):982-994. doi: 10.1097/JS9.0000000000000314.
BACKGROUND
The role of cytoreductive nephrectomy (CN) in metastatic renal cell carcinoma (mRCC) remains controversial. In addition, several unanswered questions regarding the use of CN remain: Can CN provide survival benefits for patients with mRCC? Where do we place CN in the treatment sequence paradigm among patients with mRCC? How do we best stratify patients with mRCC for CN therapy?
MATERIALS AND METHODS
A search strategy was conducted in the PubMed, Embase, and Web of Science databases. Studies were included only in the English language. The risk of bias assessment was made by using ROBINS-I (Risk of Bias in Nonrandomized Studies of Interventions) and RoB 2 (Risk of Bias 2) tools. The expected outcomes were analyzed by meta-analyses with the fixed-effects model or random effects model, including overall survival (OS) and progression-free survival (PFS). The measure of effect was the hazard ratio (HR) with a 95% CI, and sensitivity analysis was conducted to assess the reliability of the final results.
RESULTS
A total of 30 studies were included in the qualitative analysis. The HR for OS was 0.55 (95% CI, 0.50-0.61), and PFS was 0.72 (95% CI, 0.66-0.80), favoring CN compared with no CN. The upfront CN plus targeted therapy (TT) group had superior OS (HR, 0.57; 95% CI, 0.51-0.64) compared with the TT alone group. Furthermore, upfront CN plus systemic therapy (ST) was associated with numerically inferior OS compared with ST plus deferred CN in patients with mRCC (HR, 1.31; 95% CI, 0.98-1.74). Finally, the leave-one-out test of sensitivity analysis indicated that the results of this meta-analysis were stable and reliable in the overall HR estimates for these survival outcomes.
CONCLUSIONS
First, CN was associated with better survival than no CN in patients with mRCC. Second, the combination of upfront CN and TT may lead to superior survival outcomes compared to TT alone in patients with mRCC. Survival outcomes were similar between the upfront CN+ST group and the ST+deferred CN group in patients with mRCC. Exact patient selection based on baseline prognostic factors is needed to promise maximal survival for patients with mRCC.
背景
细胞减灭性肾切除术（CN）在转移性肾细胞癌（mRCC）中的作用仍存在争议。此外，关于 CN 的使用仍存在一些悬而未决的问题：CN 能否为 mRCC 患者带来生存获益？在 mRCC 患者的治疗序贯范式中，我们应将 CN 置于何处？我们如何最好地对接受 CN 治疗的 mRCC 患者进行分层？
材料和方法
在 PubMed、Embase 和 Web of Science 数据库中进行了检索策略。仅纳入英语语言的研究。使用 ROBINS-I（干预措施非随机研究的偏倚风险）和 RoB 2（偏倚风险 2）工具进行偏倚风险评估。通过固定效应模型或随机效应模型进行荟萃分析，分析预期结果，包括总生存期（OS）和无进展生存期（PFS）。效应量的衡量标准是风险比（HR）及其 95%置信区间（CI），并进行敏感性分析以评估最终结果的可靠性。
结果
定性分析共纳入 30 项研究。与无 CN 相比，CN 组的 OS 风险比（HR）为 0.55（95%CI，0.50-0.61），PFS 为 0.72（95%CI，0.66-0.80）。与单独接受靶向治疗（TT）相比， upfront CN 联合 TT 组的 OS 更优（HR，0.57；95%CI，0.51-0.64）。此外，与接受 mRCC 患者的 ST 加延迟 CN 相比， upfront CN 加全身治疗（ST）与 OS 预后较差相关（HR，1.31；95%CI，0.98-1.74）。最后，敏感性分析的逐个剔除测试表明，在这些生存结局的整体 HR 估计中，该荟萃分析的结果是稳定且可靠的。
结论
首先，CN 与 mRCC 患者的无 CN 相比，生存获益更好。其次，与单独接受 TT 相比， upfront CN 联合 TT 可能为 mRCC 患者带来更好的生存结局。在 mRCC 患者中， upfront CN+ST 组与 ST+延迟 CN 组的生存结局相似。需要基于基线预后因素对患者进行精确选择，以保证 mRCC 患者的最大生存获益。
Zotero 插件