Prognosis of patients with endometrial cancer after pelvic and para-aortic lymph node dissection: A systematic review and meta-analysis
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摘要:背景 腹盆腔淋巴结转移是评估子宫内膜癌(endometrial cancer，EC)患者预后的重要因素。EC患者行系统性淋巴结切除术(盆腔及腹主动脉旁淋巴结清扫术)是分期手术的重要部分，不仅可以明确分期、指导进一步治疗，还可以评估患者的预后。然而鉴于淋巴结清扫的手术风险及对术后生存质量的影响，淋巴结清扫范围仍有争议。目的 评价系统性盆腔及腹主动脉旁淋巴结清扫术与单纯盆腔淋巴结清扫术对EC患者生存结局的影响。方法 此文符合PRISMA指南中针对干预研究的Meta分析要求。检索数据库为PubMed、EMBASE、MEDLINE、CNKI、维普、万方。检索词包括盆腔(pelvic)、腹主动脉旁(para-aortic)、淋巴结切除(lymphadenectomy)、子宫内膜癌(endometrial carcinoma)、预后(prognosis)。检索时间截至2021年1月。纳入经子宫内膜活检病理诊断为EC的初治患者，实施规范手术(全子宫、双附件切除术+盆腔淋巴结清扫术，实施或不实施腹主动脉旁淋巴结清扫术)。观察组为实施系统性盆腔及腹主动脉旁淋巴结清扫术的EC患者，对照组为单纯实施盆腔淋巴结清扫术的EC患者。研究主要结局是3年复发率和总生存率，次要指标是手术时间、术中出血量、淋巴结切除数量、术后并发症。应用Review Manager 5.3软件分析比较行盆腔及腹主动脉旁淋巴结清扫术(观察组)与单纯盆腔淋巴结清扫术(对照组)EC患者的术中情况和生存预后指标。结果 纳入17项(4篇英文，13篇中文)研究，包括2 409例EC患者。所有研究均为回顾性研究，没有符合纳入标准的RCT或队列研究。两组患者年龄、肿瘤分期、分型差异无统计学意义。与单纯行盆腔淋巴结清扫术的EC患者相比，接受系统性盆腔及腹主动脉旁淋巴结清扫术的EC患者3年生存率提高96%(OR：1.96，95% CI：1.44 ~ 2.67)，3年复发率降低65%(OR：0.35，95% CI：0.26 ~ 0.48)，但手术时间相对延长(P＜0.01)，而术中出血量(P=0.09)、手术并发症(P=0.26)并无明显增加。结论 行系统性盆腔及腹主动脉旁淋巴结清扫术的EC患者较单纯行盆腔淋巴结清扫术的EC患者有更好的生存结局，复发率更低，且术中出血量及手术并发症并无明显增加。Abstract:Background Abdominal and pelvic lymph node metastasis is an important factor in evaluating the prognosis of patients with endometrial cancer (EC). Systematic lymphadenectomy (pelvic and para-aortic lymphadenectomy) for patients with endometrial cancer is an important part of staging surgery, which can not only define staging, guide further treatment, but also assess prognosis. However, due to the risk of surgery and the impact on the postoperative quality of life, the extent of lymph node dissection is still controversial.Objective To compare the effect of systematic pelvic and para-aortic lymph node dissection versus simple pelvic lymph node dissection on the survival outcome of patients with endometrial cancer.Methods This paper met the requirements of meta-analysis for intervention studies in PRISMA guidelines. The retrieval databases included PubMed, Embase, Medline, CNKI, VIP and Wanfang journals. Search terms were pelvic, para-aortic, lymphadenectomy, endometrial cancer and prognosis. The search period was up to January 2021. Patients included in the study were initially treated for endometrial cancer confirmed by endometrial biopsy. They all underwent standard surgical treatment (whole uterus+double adnexectomy+pelvic lymph node cleaning±para-aortic lymph node cleaning). The observation group was EC patients who underwent systematic pelvic and para-aortic lymph node dissection, and patients in the control group only underwent pelvic lymph node dissection. The primary outcome indexes included 3-year overall survival and 3-year recurrence rate, and the secondary indexes were operation time, blood loss, lymph nodes dissection and postoperative complications. Review Manager 5.3 software was used to analyze and compare the differences in intraoperative conditions and survival outcome between the two groups.Results Totally 2 409 EC patients were included in 17 retrospective studies. There was no significant difference in age, tumor stage or type between the two groups. The observation group had higher 3-year OS (96%) and lower 3-year recurrence rate (65%) than those of the control group (OS, OR:1.96, 95%CI [1.44-2.67]; recurrence, OR: 0.35, 95%CI [0.26-0.48]). However, the operation time was prolonged (P<0.01). There was no significant difference in blood loss (P=0.09) or postoperative complications (P=0.26) between the observation group and the control group.Conclusion Patients with endometrial cancer undergoing pelvic and para-aortic lymph node dissection have better survival outcome, lower recurrence rate, and no significant increases in intraoperative blood loss or surgical complications are found when compared with those undergoing pelvic lymph node dissection alone.
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Keywords:
- endometrial cancer /
- para-aortic /
- lymph node dissection /
- survival outcome rate /
- recurrence rate
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子宫内膜癌(endometrial cancer，EC)是最常见的女性生殖系统恶性肿瘤，其发病率和死亡率逐年上升[1-2]。国际癌症研究中心最新发布的GLOBOCAN 2020显示，2020年新发子宫体癌病例417 367例，占总体女性癌症发病数的4.5%，位于全球女性癌症发病率第6位[3]。因此，EC患者的规范诊治对降低患者死亡率、改善患者生存结局具有重要意义。早期EC患者首选全面分期手术，即全子宫、双侧附件切除术、盆腔和(或)腹主动脉旁淋巴结清扫术[4-5]。淋巴结清扫术是其中的重要部分，可以明确EC分期，为后续辅助治疗提供依据并判断预后。然而，不同研究认为EC患者行盆腔及腹主动脉旁淋巴结联合清扫术与单独盆腔淋巴结清扫术各有千秋[6-7]。所以，尽管淋巴结转移是判断预后的重要因素，但对于EC患者腹主动脉旁淋巴结清扫术的临床应用指征及价值仍存在争议。本文探讨EC患者行盆腔及腹主动脉旁淋巴结清扫术相比单纯盆腔淋巴结清扫术的潜在价值以及对生存和复发的影响。
资料与方法
1 检索策略
检索数据库为CNKI、万方、维普、Pubmed、Embase、MEDLINE；出版语言限制为中文和英文；检索时间截至2021年1月；检索词包括盆腔(pelvic)、腹主动脉旁(para-aortic)、淋巴结切除(lymphadenectomy)、子宫内膜癌(endometrial carcinoma)、预后(prognosis)。
2 纳入和排除标准
纳入标准：1)经子宫内膜活检病理诊断为EC的初治患者，实施规范手术(全子宫、双附件切除术+盆腔淋巴结清扫术，实施或不实施腹主动脉旁淋巴结清扫术)；2)观察组为实施系统性盆腔及腹主动脉旁淋巴结清扫术的EC患者，对照组为单纯实施盆腔淋巴结清扫术的EC患者；3)分析两组手术时间、术中出血量、手术并发症、3年生存率和复发率等指标。排除标准：1)未接受规范手术治疗的EC患者；2)复发或非原发初治EC患者；3)以未行淋巴结清扫术EC患者作为对照组的回顾性研究；4)病历资料不完整，难以提取统计指标的研究；5)会议摘要、系统综述、个案报道等类型文献。
3 研究设计和数据收集
两名研究者依据检索策略于上文所述数据库中独立检索文献，并收集研究相关指标。遇到争议时请教研究者所属医院高级别教授，协商达成一致后决定纳排。需要收集的文献信息有发表年月、第一作者、作者单位、研究地点、患者人群的一般资料、手术情况(手术时间、术中出血量、淋巴结切除数量、手术并发症及治疗情况)和预后情况(3年生存率及复发率)。
4 统计学分析
应用Review Manager 5.3软件录入纳入的研究，分析主要统计指标(3年生存率及复发率)和次要统计指标(手术时间、术中出血量、淋巴结切除数量、手术并发症)，分别计算OR、95% CI、Z和P。研究异质性检验采用I2统计量，I2＜50%提示异质性不明显，应用固定效应模型分析统计量；I2≥50%则存在显著异质性，应用随机效应模型分析统计量。漏斗图用于评估发表偏倚。
结 果
1 纳入研究情况
去除重复发表的文献，共检索到455篇条目，根据纳排标准共纳入17篇临床回顾性研究文献，见表1。除4篇英文文献的数据源自韩国和日本外，其余13篇文献均为中国医院数据。故本文以亚洲人群数据展开分析。
表 1 纳入文献概览Table 1. An overview of the included literaturesName/date Item Study site Ding L 2020[8] Effect of systemic lymph node dissection on the recurrence rate，survival rate and
complications in patients with endometrial cancerShandong Province, China Li YL 2019[9] The value of para aortic lymph node dissection in the treatment of endometrial cancer Henan Province, China Yao N 2019[10] Effect of systemic lymph node dissection on prognosis of endometrial carcinoma Henan Province, China Shen ST 2019[11] The clinical significance of para-aortic lymphadenectomy in patients with
endometrial carcinomaLiaoning Province, China Yao LJ 2013[12] Effect of para-aortic lymph node dissection on prognosis of endometrial carcinoma Guangxi Province, China Shen W 2018[13] The Significance of para-aortic lymph node dissection in endometrial carcinoma and its
influence on the prognosis of patients with endometrial carcinomaAnhui Province, China Wu XR 2017[14] Clinical significance of abdominal aortic lymph node resection in the treatment of
endometrial carcinomaGuangdong Province, China Jiang XL 2016[15] Efficacy of systematic lymph node dissection for endometrial cancer Shandong Province, China Zhang T 2019[16] The prognostic effect and safety of systematic lymph node dissection in the treatment of
endometrial carcinomaLiaoning Province, China Wang HX 2018[17] Efficacy and survival rate of systemic lymph node dissection in endometrial cancer Shanxi Province, China Song B 2015[18] Efficacy and safety evaluation of systematic lymph node dissection in endometrial carcinoma Hunan Province, China Cao X 2013[19] Significance of systematic pelvic and para-aortic lymph node dissection in patients with
early endometrial carcinomaJiangsu Province, China Kikuchi A 2017[20] The role of para-aortic lymphadenectomy in stage IIIC endometrial cancer: A single-
institute studyJapan Shao J 2014[21] Significance and safety of systematic lymphadenectomy in the treatment of patients with
endometrial cancerJiangsu Province, China Chang SJ 2008[22] Para-aortic lymphadenectomy improves survival in patients with intermediate to high-risk
endometrial carcinomaAjou University School
of MedicineFujimoto T 2007[23] Para-aortic lymphadenectomy may improve disease-related survival in patients with
multipositive pelvic lymph node stage IIIc endometrial cancerAkita University School
of MedicineTodo Y 2010[24] Survival effect of para-aortic lymphadenectomy in endometrial cancer (SEPAL study):
a retrospective cohort analysisHokkaido University Hospital 2 纳入文献的患者临床病理特征
应用SPSS和Review Manager比较一般资料异质性，发现两组患者年龄(Z=1.96，P=0.05)、病理分型(Z=1.21，P=0.23)、病理分期(Z=1.75，P=0.08)差异无统计学意义，资料具有可比性。见表2。
表 2 纳入文献临床病理特征Table 2. Clinical and pathological characteristics of the included studiesTrial No./
name/dateAge/yrs Pathological type Stage PLD+PALD PLD Z P PLD+PALD PLD Z P PLD+PALD PLD Z P Ⅰ/(n, %) Ⅱ/(n, %) Ⅰ/(n, %) Ⅱ/(n, %) Ⅰ Ⅱ Ⅲ Ⅳ Ⅰ Ⅱ Ⅲ Ⅳ Ding L 2020[8] 50.82±4.29 50.00±49.52 1.96 0.05 29(58.0) 21(42.0) 31(62.0) 19(38.0) 1.21 0.23 25 14 11 0 24 16 10 0 1.75 0.08 Li YL 2019[9] 48.19±0.71 46.72±0.68 19 11 10 0 20 12 8 0 Yao N 2019[10] 51.40±4.80 40.00±52.20 27(67.5) 13(32.5) 26(65.0) 14(35.0) 28 5 7 0 26 6 8 0 Shen ST 2019[11] 58.58±1.62 56.67±0.86 16 4 3 3 72 11 23 4 Yao LJ 2013[12] 49.33±8.20 51.50±8.74 66(72.5) 25(27.5) 122(78.7) 33(21.3) 41 9 31 10 105 16 29 12 Shen W 2018[13] 50.40±6.70 49.20±7.10 97(73.5) 35(26.5) 61(78.2) 17(21.8) 71 42 19 0 53 14 11 0 Wu XR 2017[14] 50.10±8.10 49.21±9.22 52(80.0) 13(20.0) 70(89.7) 8(10.3) 43 12 7 3 52 16 8 2 Jiang XL 2016[15] 56.90±3.80 55.40±3.40 23(57.5) 17(42.5) 24(60.0) 16(40.0) 20 14 6 0 18 15 7 0 Zhang T 2019[16] 54.30±8.10 54.50±8.20 22(64.7) 12(35.3) 23(67.6) 11(32.4) 22 12 0 0 23 11 0 0 Wang HX 2018[17] 52.61±3.51 52.15±3.42 31(67.4) 15(32.6) 27(61.4) 17(38.6) 21 14 11 0 22 15 7 0 Chang SJ 2008[22] 50.10±10.80 50.10±11.70 75(88.2) 10(11.8) 68(90.7) 7(9.3) 68 4 13 0 49 8 18 0 Fujimoto T 2007[23] 56.30±9.30 60.40±8.40 33(86.8) 5(13.2) 23(92.0) 2(8.0) Todo Y 2010[24] 56.00±9.20 56.30±9.20 318(91.9) 28(8.1) 298(91.7) 27(8.3) 220 29 86 11 219 36 59 11 3 预后分析
包含9个研究中1 573例EC患者行盆腔及腹主动脉旁淋巴结清扫术/单纯盆腔淋巴结清扫术的生存数据。根据统计分析，纳入研究无显著异质性(P=0.14，I2=35%)，故可用固定效应模型分析生存数据。观察组3年OS较对照组提高96%(OR=1.96，95% CI：1.44 ~ 2.67，Z=4.31，P＜0.01)。应用随机效应模型也得到相似的结局(OR=2.16，95% CI：1.37 ~ 3.42，Z=3.31，P=0.000 9)。对于3年复发率，研究间异质性检验差异无统计学意义(P=0.30，I2=9.49%)，根据固定效应模型分析得到观察组3年复发率降低65%，差异有统计学意义(OR=0.35，95% CI：0.26 ~ 0.48，Z=6.71，P＜0.01)。深入分析复发病例，均存在ESMO危险分层系统中提及的高危因素，如淋巴结阳性、深肌层浸润、高级别癌及淋巴脉管浸润等。见图1。
4 围术期情况
收集了源自9个研究的1 160例EC患者手术时间及术中出血量原始资料，研究异质性检验分析提示有显著异质性(P＜0.01，I2=95%)，故应用随机效应模型分析连续变量资料，观察组手术时间明显长于对照组(Z=6.95，P＜0.01)。术中出血量研究存在显著异质性(P＜0.01，I2=99%)，应用随机效应模型分析发现两组术中出血量差异无统计学意义(Z=1.68，P=0.09)。见图2。
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图 2 两组围术期情况 A：两组手术时间情况；B：两组术中出血量情况Figure 2. Perioperative condition in the two groups A: operation time in the two groups; B: blood loss in the two groups5 手术并发症
收集了源自11项研究的1 300例EC患者临床资料。收集整理两组患者淋巴囊肿、下肢水肿、肠梗阻、切口感染、尿潴留等手术并发症情况，应用随机效应模型分析，两组患者手术并发症发生率差异无统计学意义(Z=1.12，P=0.26)，根据固定效应模型分析也可得到一致结论(Z=2.05，P=0.04)。见图3。
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图 3 两组患者手术并发症发生率比较Figure 3. Comparison of the incidence of surgical complications between the two groups6 淋巴结清扫数量
观察组清扫淋巴结数量明显高于对照组，差异有统计学意义(Z=5.40，P＜0.01)。见图4。
7 发表偏倚
预后数据的发表偏倚漏斗图提示纳入研究无发表偏倚，符合质量控制标准。见图5。
讨 论
盆腔及腹主动脉旁淋巴结清扫术和前哨淋巴结活检术评估淋巴结状态是子宫内膜癌全面分期手术的重要组成部分，淋巴结转移是EC患者术后辅助治疗和评估预后的重要依据[25]。但对于EC患者淋巴结清扫的必要性及切除范围仍存在较大争议[26]。ESMO指南中不推荐低危、高-中分化的EC患者常规进行淋巴结清扫，而低分化、深肌层浸润和非子宫内膜样癌患者可考虑行淋巴结清扫术[27]。然而，GOG外科手术程序手册中推荐完整分期的淋巴结清扫术上接达肠系膜上动脉水平，未完全切除的淋巴结应被包含于后续的放疗靶区内，强调彻底性[28]。故基于学术争议，不同临床场所的具体应用不尽相同，一项涉及1030个德国妇科临床机构的淋巴结清扫情况标准化问卷横断面研究揭示仅7.3%的临床机构从未实施过淋巴结切除术，而29.7%的临床机构常规行淋巴结切除术。其中，65.2%的临床机构基于全面分期和提高总生存率等预后数据常规应用淋巴结切除术[29]。综上，本研究就EC患者行腹主动脉旁淋巴结联合盆腔淋巴结清扫术与单纯盆腔淋巴结清扫术的临床及预后数据做一汇总分析，指导临床诊疗。
本篇Meta分析综合亚洲不同国家的临床研究数据，就EC患者行腹主动脉旁淋巴结联合盆腔淋巴结清扫术(观察组)与单纯盆腔淋巴结清扫术(对照组)的手术时间、术中出血量及生存预后等数据进行比较分析，发现观察组生存预后结局明显优于对照组，差异有统计学意义。另外，尽管观察组手术时间较长，但两组术中出血量、手术并发症差异均无统计学意义。深究其原因，考虑联合淋巴结清扫手术更易早期发现、早期干预孤立的腹主动脉旁淋巴结转移以及隐匿性淋巴结转移。尽管孤立的腹主动脉旁淋巴结转移在早期EC中极为罕见(仅1.6%)[30]，但不可否认更广泛的淋巴结清扫手术使这部分患者受益明显。另外，有研究表明，腹主动脉旁淋巴结联合盆腔淋巴结清扫术避免了23.3%的早期EC患者行外照射放疗(external-beam radiation therapy，EBRT)，避免了39.5%中低分化的早期EC患者行EBRT治疗，避免EBRT造成的更高级别的疼痛和低水平的健康评分，并且使平均每100名早期EC患者节省37 161英镑的治疗费用[31]。除此之外，多项国外Meta分析和系统评价与本文研究结果一致，腹主动脉旁淋巴结联合盆腔淋巴结清扫可以减少46%的死亡风险和49%的复发风险，且提高了5年总生存率(85.0% vs 75.7%)和5年无病生存率(82.7% vs 65.4%)[32]。
然而，EC患者有众多淋巴结转移的高危因素影响生存预后数据。最新研究表明，术前血清CA125水平、脉管癌栓及深肌层浸润是影响盆腔淋巴结转移的独立危险因素，术前血清CA125水平、盆腔淋巴结转移是影响腹主动脉旁淋巴结转移的独立危险因素，存在淋巴结转移的高危EC患者预后较差[33]。另外，有研究揭示EC患者腹主动脉旁淋巴结清扫至肾静脉水平相较于清扫至肠系膜上动脉水平可降低淋巴结转移发生率(χ2=4.504，P=0.034)和复发率(χ2=5.628，P=0.024)，且不增加术后并发症，可显著改善患者的预后[34]。当然，淋巴结切除数量对于生存预后的影响也不可忽视，徐洁[35]研究发现，＞20个的淋巴结清扫数目是改善Ⅱ型EC患者总体生存的独立预后因素(HR=0.366，95% CI：0.166 ~ 0.810，P=0.013)。与此同时，朱诚程等[36]的研究提示前哨淋巴结联合病理超分期用于EC安全可行,已检测出传统病理染色不能发现的淋巴结微转移，为EC患者提供更精准的治疗方案。故针对临床早期EC患者，其细化危险分层后，应反复权衡淋巴结清扫范围，以提供患者精准优质的医疗选择。
本文就EC患者行腹主动脉旁淋巴结联合盆腔淋巴结清扫术的Meta分析，得到EC患者行腹主动脉旁淋巴结联合盆腔淋巴结清扫术受益明显的结论。期待未来更多前瞻性多中心大样本数据为EC患者淋巴结清扫术范围提供最优选择，并在临床应用推广。
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图 2 两组围术期情况 A：两组手术时间情况；B：两组术中出血量情况
Figure 2. Perioperative condition in the two groups A: operation time in the two groups; B: blood loss in the two groups
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图 3 两组患者手术并发症发生率比较
Figure 3. Comparison of the incidence of surgical complications between the two groups
表 1 纳入文献概览
Table 1 An overview of the included literatures
Name/date Item Study site Ding L 2020[8] Effect of systemic lymph node dissection on the recurrence rate，survival rate and
complications in patients with endometrial cancerShandong Province, China Li YL 2019[9] The value of para aortic lymph node dissection in the treatment of endometrial cancer Henan Province, China Yao N 2019[10] Effect of systemic lymph node dissection on prognosis of endometrial carcinoma Henan Province, China Shen ST 2019[11] The clinical significance of para-aortic lymphadenectomy in patients with
endometrial carcinomaLiaoning Province, China Yao LJ 2013[12] Effect of para-aortic lymph node dissection on prognosis of endometrial carcinoma Guangxi Province, China Shen W 2018[13] The Significance of para-aortic lymph node dissection in endometrial carcinoma and its
influence on the prognosis of patients with endometrial carcinomaAnhui Province, China Wu XR 2017[14] Clinical significance of abdominal aortic lymph node resection in the treatment of
endometrial carcinomaGuangdong Province, China Jiang XL 2016[15] Efficacy of systematic lymph node dissection for endometrial cancer Shandong Province, China Zhang T 2019[16] The prognostic effect and safety of systematic lymph node dissection in the treatment of
endometrial carcinomaLiaoning Province, China Wang HX 2018[17] Efficacy and survival rate of systemic lymph node dissection in endometrial cancer Shanxi Province, China Song B 2015[18] Efficacy and safety evaluation of systematic lymph node dissection in endometrial carcinoma Hunan Province, China Cao X 2013[19] Significance of systematic pelvic and para-aortic lymph node dissection in patients with
early endometrial carcinomaJiangsu Province, China Kikuchi A 2017[20] The role of para-aortic lymphadenectomy in stage IIIC endometrial cancer: A single-
institute studyJapan Shao J 2014[21] Significance and safety of systematic lymphadenectomy in the treatment of patients with
endometrial cancerJiangsu Province, China Chang SJ 2008[22] Para-aortic lymphadenectomy improves survival in patients with intermediate to high-risk
endometrial carcinomaAjou University School
of MedicineFujimoto T 2007[23] Para-aortic lymphadenectomy may improve disease-related survival in patients with
multipositive pelvic lymph node stage IIIc endometrial cancerAkita University School
of MedicineTodo Y 2010[24] Survival effect of para-aortic lymphadenectomy in endometrial cancer (SEPAL study):
a retrospective cohort analysisHokkaido University Hospital 
下载: 导出CSV
表 2 纳入文献临床病理特征
Table 2 Clinical and pathological characteristics of the included studies
Trial No./
name/dateAge/yrs Pathological type Stage PLD+PALD PLD Z P PLD+PALD PLD Z P PLD+PALD PLD Z P Ⅰ/(n, %) Ⅱ/(n, %) Ⅰ/(n, %) Ⅱ/(n, %) Ⅰ Ⅱ Ⅲ Ⅳ Ⅰ Ⅱ Ⅲ Ⅳ Ding L 2020[8] 50.82±4.29 50.00±49.52 1.96 0.05 29(58.0) 21(42.0) 31(62.0) 19(38.0) 1.21 0.23 25 14 11 0 24 16 10 0 1.75 0.08 Li YL 2019[9] 48.19±0.71 46.72±0.68 19 11 10 0 20 12 8 0 Yao N 2019[10] 51.40±4.80 40.00±52.20 27(67.5) 13(32.5) 26(65.0) 14(35.0) 28 5 7 0 26 6 8 0 Shen ST 2019[11] 58.58±1.62 56.67±0.86 16 4 3 3 72 11 23 4 Yao LJ 2013[12] 49.33±8.20 51.50±8.74 66(72.5) 25(27.5) 122(78.7) 33(21.3) 41 9 31 10 105 16 29 12 Shen W 2018[13] 50.40±6.70 49.20±7.10 97(73.5) 35(26.5) 61(78.2) 17(21.8) 71 42 19 0 53 14 11 0 Wu XR 2017[14] 50.10±8.10 49.21±9.22 52(80.0) 13(20.0) 70(89.7) 8(10.3) 43 12 7 3 52 16 8 2 Jiang XL 2016[15] 56.90±3.80 55.40±3.40 23(57.5) 17(42.5) 24(60.0) 16(40.0) 20 14 6 0 18 15 7 0 Zhang T 2019[16] 54.30±8.10 54.50±8.20 22(64.7) 12(35.3) 23(67.6) 11(32.4) 22 12 0 0 23 11 0 0 Wang HX 2018[17] 52.61±3.51 52.15±3.42 31(67.4) 15(32.6) 27(61.4) 17(38.6) 21 14 11 0 22 15 7 0 Chang SJ 2008[22] 50.10±10.80 50.10±11.70 75(88.2) 10(11.8) 68(90.7) 7(9.3) 68 4 13 0 49 8 18 0 Fujimoto T 2007[23] 56.30±9.30 60.40±8.40 33(86.8) 5(13.2) 23(92.0) 2(8.0) Todo Y 2010[24] 56.00±9.20 56.30±9.20 318(91.9) 28(8.1) 298(91.7) 27(8.3) 220 29 86 11 219 36 59 11
下载: 导出CSV
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