摘要
目的系统评价胸椎旁神经阻滞(TPVB)对乳腺癌根治术后患者免疫指标的影响。方法系统检索中国知网、万方数据库、维普、中国生物医学文献数据库、PubMed、Embase、the Cochrane Library和Web of Science等中英文数据库,收集TPVB应用于乳腺癌根治术患者的随机对照试验(RCT),检索时限为建库至2024年10月30日。对纳入文献进行质量评价并提取数据,应用Stata 16.0和RevMan 5.4软件对各项免疫指标进行Meta合并分析,将敏感性分析或亚组分析用于探讨异质性来源,采用漏斗图和Egger′s检验评估发表偏倚。结果共纳入27篇RCT进行Meta分析,包括2203例乳腺癌患者,其中1104例接受TPVB。Meta分析结果显示,接受TPVB的观察组(TPVB联合全身麻醉)乳腺癌患者术后12 h白细胞介素(IL)-1β(WMD=-7.30 pg/mL,95%CI:-8.27~-6.33 pg/mL,P<0.01)、术后各时间点IL-6(WMD=-23.04 pg/mL,95%CI:-25.04~-9.23 pg/mL,P<0.05)、术后12 h肿瘤坏死因子-α(WMD=-5.83 pg/mL,95%CI:-7.58~-0.47 pg/mL,P<0.05)、术后72 h肿瘤坏死因子-α(WMD=-4.43 pg/mL,95%CI:-6.77~-0.76 pg/mL,P<0.05)、术后超敏C反应蛋白(WMD=-5.34 mg/L,95%CI:-12.94~-2.26 mg/L,P<0.05)、术后单核细胞趋化蛋白-1(WMD=-16.73 pg/mL,95%CI:-20.53~-15.29 pg/mL,P<0.05)、术后基质金属蛋白酶-9(WMD=-92.34 pg/mL,95%CI:-112.34~-72.34 pg/mL,P<0.05)、术后2 h CD4^(+)CD25^(+)T细胞(WMD=-1.82%,95%CI:-2.18%~-1.47%,P<0.05)等指标水平低于对照组(接受全身麻醉)。观察组术后各时间点IL-10(WMD=5.34 pg/mL,95%CI:0.82~9.46 pg/mL,P<0.05)、术后6 h干扰素-γ(WMD=8.81 pg/mL,95%CI:6.31~11.33 pg/mL,P<0.01)、术后24 h干扰素-γ(WMD=0.33 pg/mL,95%CI:0.23~0.43 pg/mL,P<0.01)、术后CD4^(+)T细胞比例(WMD=2.82%,95%CI:1.73%~4.03%,P<0.01)、术后24 h CD8^(+)T细胞比例(WMD=3.14%,95%CI:0.69%~5.60%,P<0.05)、术后2 h自然杀伤细胞比例(WMD=1.44%,95%CI:0.22%~2.76%,P<0.01)等指标高于对照组。亚组分析结果显示,研究国家或地区、样本量的差异以及麻醉药物的选择可能是异质性的主要来源(亚组间P<0.05)。敏感性分析后异质性和效应量未发生大幅度变化,各研究间未发现明显的发表偏倚,整体合并结果较为可靠。结论TPVB在乳腺癌根治术后的应用对患者免疫功能具有显著的调节作用,TPVB可抑制术后应激反应和炎症反应,有助于促进机体抗肿瘤免疫的恢复。该研究为TPVB在乳腺癌术后患者免疫功能的优化提供了依据,未来尚需大样本、多中心RCT验证其临床价值。
Objective To systematically evaluate the effects of thoracic paravertebral block(TPVB)on immune markers in patients undergoing radical mastectomy for breast cancer.Methods A systematic search was conducted across CNKI,Wanfang Database,VIP Database,China Biology Medicine disc,PubMed,Embase,the Cochrane Library and Web of Science.Randomized controlled trials(RCTs)investigating TPVB in patients undergoing radical mastectomy were retrieved from inception to October 30,2024.Quality assessment and data extraction were performed on included studies.Meta-analysis of immune markers was executed using Stata 16.0 and RevMan 5.4 software.Sensitivity or subgroup analyses were employed to explore heterogeneity sources.Publication bias was assessed using funnel plots and Egger's test.Results A total of 27 RCTs,involving 2203 breast cancer patients(1104 receiving thoracic paravertebral block,TPVB)were included for Meta-analysis.The Meta-analysis results demonstrated that,compared with the control group(general anesthesia alone),interleukin(IL)-1β at 12 h postoperatively(WMD=-7.30 pg/mL,95%CI:-8.27 to-6.33 pg/mL;P<0.01),IL-6 at postoperative time points(WMD=-23.04 pg/mL,95%CI:-25.04 to-9.23 pg/mL;P<0.05),tumor necrosis factor-α(TNF-α)at 12 h postoperatively(WMD=-5.83 pg/mL,95%CI:-7.58 to-0.47 pg/mL;P<0.05),TNF-α at 72 h postoperatively(WMD=-4.43 pg/mL,95%CI:-6.77 to-0.76 pg/mL;P<0.05),postoperative high-sensitivity C-reactive protein(WMD=-5.34 mg/L,95%CI:-12.94 to-2.26 mg/L;P<0.05),postoperative monocyte chemoattractant protein-1(WMD=-16.73 pg/mL,95%CI:-20.53 to-15.29 pg/mL;P<0.05),postoperative matrix metalloproteinase-9(WMD=-92.34 pg/mL,95%CI:-112.34 to-72.34 pg/mL;P<0.05)and CD4^(+)CD25^(+)T cells at 2 h postoperatively(WMD=-1.82%,95%CI:-2.18%to-1.47%;P<0.05)levels in the observation group(TPVB combined with general anesthesia)were lower.Conversely,IL-10 at postoperative time points(WMD=5.34 pg/mL,95%CI:0.82 to 9.46 pg/mL;P<0.05),interferon-γ(IFN-γ)at 6 h postoperatively(WMD=8.81 pg/mL,95%CI:6.31 to 11.33 pg/mL;P<0.01),IFN-γ at 24 h postoperatively(WMD=0.33 pg/mL,95%CI:0.23 to 0.43 pg/mL;P<0.01),CD4^(+)T cell proportion at postoperative time points(WMD=2.82%,95%CI:1.73%to 4.03%;P<0.05),CD8^(+)T cell proportion at 24 h postoperatively(WMD=3.14%,95%CI:0.69%to 5.60%;P<0.05)levels and natural killer cell proportion at 2 h postoperatively(WMD=1.44%,95%CI:0.22% to 2.76%;P<0.01)in the observation group were significantly higher than those in the control group.Subgroup analysis indicated that differences in study country,sample size and choice of anesthetic agent might be the primary sources of heterogeneity(P<0.05 between subgroups).Heterogeneity and effect sizes remained stable without substantial changes upon sensitivity analysis.No significant publication bias was detected among the included studies,suggesting the overall pooled results are robust.Conclusion The application of TPVB following radical mastectomy was found to exert significant immunomodulatory effects in breast cancer patients.TPVB is suggested to suppress the postoperative stress response and inflammatory response,thereby aiding in the restoration of host anti-tumor immunity.This study provides evidence supporting the optimization of TPVB for postoperative immune function in breast cancer patients.Further validation of its clinical value through large-sample,multi-center RCTs is warranted.
作者
金亮
涂泽华
何建丽
JIN Liang;TU Zhehua;HE Jianli(Department of Anesthesiology,Xiaolan People's Hospital/Fifth People's Hospital of Zhongshan,Zhon;Department of Neurology,Xiaolan People's Hospital/Fifth People's Hospital of Zhongshan,Zhongshan,Guangdong 527300,China)
出处
《检验医学与临床》
2025年第18期2545-2552,共8页
Laboratory Medicine and Clinic
基金
广东省中山市医学科研项目(2021A020347)。
