[摘要]"目的"探討淋巴細(xì)胞與C反應(yīng)蛋白比值(lymphocyte"to"C-reactive"protein"ratio,LCR)聯(lián)合纖維蛋白原與白蛋白比值(fibrinogen"to"albumin"ratio,F(xiàn)AR)對(duì)老年胃癌患者術(shù)后肺炎的診斷價(jià)值。方法"選取2017年9月至2024年3月于合肥市第一人民醫(yī)院行胃癌根治術(shù)的老年患者134例為研究對(duì)象,根據(jù)術(shù)后是否發(fā)生肺炎,將患者分為無并發(fā)癥組(n=109)和并發(fā)癥組(n=25)。比較兩組患者的一般資料和實(shí)驗(yàn)室檢查結(jié)果。采用多因素Logistic回歸模型探究胃癌患者術(shù)后肺炎的影響因素,繪制受試者操作特征曲線(receiver"operating"characteristic"curve,ROC曲線)計(jì)算不同指標(biāo)及其聯(lián)合應(yīng)用的曲線下面積(area"under"the"curve,AUC),預(yù)測(cè)其在術(shù)后肺炎方面的價(jià)值。結(jié)果"并發(fā)癥組患者的體質(zhì)量指數(shù)、淋巴細(xì)胞、白蛋白、LCR均顯著低于無并發(fā)癥組,白細(xì)胞、纖維蛋白原、C反應(yīng)蛋白、FAR、中性粒細(xì)胞與淋巴細(xì)胞比值、血小板與淋巴細(xì)胞比值均顯著高于無并發(fā)癥組(Plt;0.05)。多因素Logistic回歸分析結(jié)果顯示術(shù)前LCR降低和FAR升高均是胃癌患者術(shù)后肺炎的獨(dú)立危險(xiǎn)因素(Plt;0.05)。ROC曲線分析結(jié)果顯示,LCR和FAR診斷胃癌患者術(shù)后肺炎的AUC分別為0.727和0.719,二者聯(lián)合診斷的AUC為0.790(95%CI:0.702~0.879)。結(jié)論"術(shù)前LCR和FAR均是胃癌患者術(shù)后肺炎的獨(dú)立危險(xiǎn)因素,二者聯(lián)合可有效預(yù)測(cè)胃癌患者術(shù)后肺炎并發(fā)癥,從而指導(dǎo)臨床決策。
[關(guān)鍵詞]"淋巴細(xì)胞;C反應(yīng)蛋白;纖維蛋白原;白蛋白;胃癌;術(shù)后肺炎
[中圖分類號(hào)]"R619.3""""""[文獻(xiàn)標(biāo)識(shí)碼]"A""""[DOI]"10.3969/j.issn.1673-9701.2025.10.007
Value"of"LCR"combined"with"FAR"in"diagnosis"of"postoperative"pneumonia"in"elderly"patients"with"gastric"cancer
LIN"Zhihao,"TIAN"Yuan,"HE"Lei
Department"of"Gastrointestinal"Surgery,"Hefei"First"People’s"Hospital,"Hefei"230001,"Anhui,"China
[Abstract]"Objective"To"explore"the"diagnostic"value"of"lymphocyte"to"C-reactive"protein"ratio"(LCR)"combined"with"fibrinogen"to"albumin"ratio"(FAR)"for"postoperative"pneumonia"in"elderly"patients"with"gastric"cancer."Methods"A"total"of"134"elderly"patients"who"underwent"radical"gastrectomy"in"Hefei"First"People’s"Hospital"from"September"2017"to"March"2024"were"selected"as"study"objects."According"to"whether"pneumonia"occurred"after"surgery,"patients"were"divided"into"uncomplication"group"(n=109)"and"complication"group"(n=25)."General"data"and"laboratory"results"were"compared"between"two"groups."Multivariate"Logistic"regression"model"was"used"to"explore"the"influencing"factors"of"postoperative"pneumonia"in"patients"with"gastric"cancer."The"receiver"operating"characteristic"(ROC)"curve"was"plotted"to"calculate"the"area"under"the"curve"(AUC)"of"different"indicators"and"their"combined"application"in"order"to"predict"their"value"in"postoperative"pneumonia."Results"The"body"mass"index,"lymphocyte,"albumin"and"LCR"in"complication"group"were"significantly"lower"than"thosenbsp;in"uncomplication"group,"while"white"blood"cell,"fibrinogen,"C-reactive"protein,"FAR,"neutrophil"to"lymphocyte"ratio"and"platelet"to"lymphocyte"ratio"were"significantly"higher"than"those"in"uncomplication"group"(Plt;0.05)."Multivariate"Logistic"regression"analysis"showed"that"preoperative"LCR"reduction"and"FAR"increase"were"independent"risk"factors"for"postoperative"pneumonia"in"gastric"cancer"patients"(Plt;0.05)."ROC"curve"analysis"results"showed"that"the"AUC"of"postoperative"pneumonia"in"patients"with"gastric"cancer"diagnosed"by"LCR"and"FAR"was"0.727"and"0.719,"respectively,"and"the"AUC"of"combined"diagnosis"was"0.790"(95%CI:"0.702-0.879)."Conclusion"Preoperative"LCR"and"FAR"are"independent"risk"factors"for"postoperative"pneumonia"in"patients"with"gastric"cancer,"and"their"combination"can"effectively"predict"postoperative"pneumonia"complications"in"patients"with"gastric"cancer,"so"as"to"guide"clinical"decision-making.
[Key"words]"Lymphocyte;"C-reactive"protein;"Fibrinogen;"Albumin;"Gastric"cancer;"Postoperative"pneumonia
胃癌是人類第5大常見惡性腫瘤,在腫瘤相關(guān)死亡率中排第5位[1]。胃癌的發(fā)病率隨年齡增長(zhǎng)而升高,特別是55~80歲年齡段發(fā)病率達(dá)到峰值[2]。胃癌根治術(shù)是治療非遠(yuǎn)處轉(zhuǎn)移胃癌的有效手段,可延長(zhǎng)患者生存時(shí)間。然而術(shù)后易發(fā)生肺炎等感染性并發(fā)癥,嚴(yán)重影響患者的短期預(yù)后,甚至增加術(shù)后早期死亡的風(fēng)險(xiǎn)[3-4]。因此,準(zhǔn)確評(píng)估胃癌患者術(shù)后肺炎的風(fēng)險(xiǎn),對(duì)改善患者預(yù)后具有重要意義。炎癥反應(yīng)在腫瘤的發(fā)生、發(fā)展中發(fā)揮重要作用,亦可影響患者生存預(yù)后[5]。C反應(yīng)蛋白(C-reactive"protein,CRP)、淋巴細(xì)胞、中性粒細(xì)胞、單核細(xì)胞、中性粒細(xì)胞與淋巴細(xì)胞比值(neutrophil"to"lymphocyte"ratio,NLR)、血小板與淋巴細(xì)胞比值(platelet"to"lymphocyte"ratio,PLR)等多種炎癥標(biāo)志物已被證實(shí)能有效評(píng)估腫瘤患者的預(yù)后狀況[6-7]。淋巴細(xì)胞與CRP比值(lymphocyte"to"CRP"ratio,LCR)近年來在腫瘤學(xué)領(lǐng)域引起廣泛關(guān)注。LCR作為一種新型炎癥標(biāo)志物,在消化系統(tǒng)腫瘤如結(jié)直腸癌和胃癌中顯示出重要的預(yù)測(cè)價(jià)值[8]。纖維蛋白原(fibrinogen,F(xiàn)ib)不僅是一種關(guān)鍵的凝血因子,同時(shí)也參與機(jī)體炎癥反應(yīng)的調(diào)節(jié)[9]。白蛋白(albumin,Alb)作為機(jī)體營(yíng)養(yǎng)狀態(tài)的重要指標(biāo),同樣與炎癥狀態(tài)緊密相連。Alb水平下降意味著機(jī)體炎癥程度的升高和抵抗能力的減弱,血漿膠體滲透壓降低,導(dǎo)致胸腔肺組織水腫和積液增多[10]。外周血Fib與Alb比值(Fib"to"Alb"ratio,F(xiàn)AR)升高通常標(biāo)志著機(jī)體炎癥反應(yīng)的加劇及營(yíng)養(yǎng)狀況下降。有文獻(xiàn)報(bào)道胃癌患者術(shù)后出現(xiàn)感染相關(guān)并發(fā)癥與術(shù)前營(yíng)養(yǎng)不良存在關(guān)聯(lián)[11]。本研究旨在探討術(shù)前LCR和FAR與胃癌患者術(shù)后肺炎的關(guān)聯(lián)性,并進(jìn)一步評(píng)估LCR與FAR聯(lián)合應(yīng)用對(duì)預(yù)測(cè)老年胃癌患者術(shù)后肺炎的潛在價(jià)值。
1""資料與方法
1.1""研究對(duì)象
選取2017年9月至2024年3月于合肥市第一人民醫(yī)院接受胃癌根治術(shù)的134例老年患者為研究對(duì)象。納入標(biāo)準(zhǔn):①年齡≥60歲;②診斷為胃癌,并在本院胃腸外科接受胃癌根治術(shù)治療;③術(shù)前未接受放化療治療;④腫瘤未發(fā)生遠(yuǎn)處轉(zhuǎn)移,且未伴隨其他惡性腫瘤;⑤臨床資料完整。排除標(biāo)準(zhǔn):"①術(shù)前感染未得到控制、嚴(yán)重肝腎功能不全者;"②合并自身免疫病或血液系統(tǒng)疾病;③術(shù)前接受過抗凝治療。本研究經(jīng)合肥市第一人民醫(yī)院醫(yī)學(xué)倫理委員會(huì)批準(zhǔn)(倫理審批號(hào):倫審批第2025-003-01號(hào)),所有患者均簽署知情同意書。
1.2""資料來源
收集患者的一般資料及實(shí)驗(yàn)室檢查結(jié)果,包括性別、年齡、體質(zhì)量指數(shù)(body"mass"index,BMI)、美國(guó)麻醉醫(yī)師協(xié)會(huì)(American"Society"of"Anesthesiologists,ASA)分級(jí)、手術(shù)方式、手術(shù)時(shí)長(zhǎng)、術(shù)中失血量及腫瘤分期情況。手術(shù)前1周內(nèi),采集患者的血液樣本檢測(cè)血常規(guī)、生化指標(biāo)、腫瘤指標(biāo)、凝血功能等。
1.3""手術(shù)方法
所有手術(shù)均由同一組經(jīng)驗(yàn)豐富的醫(yī)生團(tuán)隊(duì)進(jìn)行。根據(jù)患者具體情況靈活選擇腹腔鏡或開腹手術(shù),術(shù)中于腹部放置引流管預(yù)防并發(fā)癥。術(shù)前常規(guī)預(yù)防性使用抗生素。若手術(shù)時(shí)間超過3h,為確保感染預(yù)防效果,追加一次抗生素給藥。術(shù)后抗生素治療預(yù)防術(shù)后感染。
1.4""術(shù)后肺炎的診斷標(biāo)準(zhǔn)
根據(jù)《中國(guó)胃腸腫瘤外科術(shù)后并發(fā)癥診斷登記規(guī)范專家共識(shí)(2018版)》[12]中的呼吸系統(tǒng)并發(fā)癥診斷標(biāo)準(zhǔn)定義肺炎為:存在咳嗽、痰黏稠,肺部濕啰音;發(fā)熱(gt;38.0℃)及炎癥指標(biāo)升高;影像學(xué)檢查顯示肺部存在炎癥病變;痰培養(yǎng)等病原學(xué)檢查陽性。
1.5""統(tǒng)計(jì)學(xué)方法
采用SPSS"26.0軟件對(duì)數(shù)據(jù)進(jìn)行統(tǒng)計(jì)分析。符合正態(tài)分布的計(jì)量資料以均數(shù)±標(biāo)準(zhǔn)差(")表示,比較采用獨(dú)立樣本t檢驗(yàn);不符合正態(tài)分布的計(jì)量資料以中位數(shù)(四分位數(shù)間距)[M(Q1,Q3)]表示,比較采用Mann-Whitney"U檢驗(yàn)。計(jì)數(shù)資料以例數(shù)(百分率)[n(%)]表示,比較采用χ2檢驗(yàn)。采用多因素Logistic回歸模型探究胃癌患者術(shù)后肺炎的影響因素。繪制受試者操作特征曲線(receiver"operating"characteristic"curve,ROC曲線)計(jì)算不同指標(biāo)及其聯(lián)合應(yīng)用的曲線下面積(area"under"the"curve,AUC)對(duì)術(shù)后肺炎的預(yù)測(cè)價(jià)值。Plt;0.05為差異有統(tǒng)計(jì)學(xué)意義。
2""結(jié)果
2.1""兩組患者的一般資料及實(shí)驗(yàn)室檢查比較
134例患者中共有25例患者術(shù)后出現(xiàn)肺炎,發(fā)生率為18.66%,納入并發(fā)癥組,其余患者納入無并發(fā)癥組。并發(fā)癥組患者的BMI、淋巴細(xì)胞、Alb、LCR均顯著低于無并發(fā)癥組,白細(xì)胞(white"blood"cell,WBC)、Fib、CRP、FAR、NLR、PLR均顯著高于無并發(fā)癥組(Plt;0.05),見表1。
2.2""老年胃癌患者術(shù)后肺炎的多因素回歸分析
由于淋巴細(xì)胞、CRP、Fib、Alb與LCR、FAR之間存在顯著的共線性關(guān)系,在多元分析中可能產(chǎn)生誤導(dǎo),因此將其排除在外。將其他具有統(tǒng)計(jì)學(xué)意義的變量納入多因素Logistic回歸分析,結(jié)果顯示術(shù)前LCR降低和FAR升高均是胃癌患者術(shù)后肺炎的獨(dú)立危險(xiǎn)因素(Plt;0.05),見表2。
2.3""聯(lián)合指標(biāo)的術(shù)后肺炎診斷效能
ROC曲線分析結(jié)果顯示,LCR和FAR診斷胃癌患者術(shù)后肺炎的AUC分別為0.727(95%CI:0.615~0.839)和0.719(95%CI:0.620~0.818)。二者聯(lián)合診斷的AUC為0.790(95%CI:0.702~0.879),見表3、圖1。
3""討論
肺炎是上腹部手術(shù)尤其是胃癌術(shù)后并發(fā)癥中不可忽視的重要部分,它不僅延長(zhǎng)患者的住院時(shí)間,增加患者的醫(yī)療支出,更為重要的是影響患者的生存質(zhì)量和預(yù)后,是外科醫(yī)生需要重點(diǎn)關(guān)注的問題[13]。既往研究證實(shí)全身炎癥反應(yīng)與機(jī)體的自身營(yíng)養(yǎng)狀態(tài)和腫瘤的發(fā)展存在相關(guān)性,是影響腫瘤患者預(yù)后的重要因素[14]。
外周淋巴細(xì)胞在宿主對(duì)腫瘤的細(xì)胞毒性免疫反應(yīng)中發(fā)揮關(guān)鍵作用,也可用于評(píng)估患者的健康狀況[15]。血清CRP是反映全身炎癥反應(yīng)最具代表性的標(biāo)志物,其水平與惡性腫瘤的預(yù)后和圍手術(shù)期并發(fā)癥相關(guān)聯(lián)[16]。Yildirim等[17]研究發(fā)現(xiàn)胃腸道腫瘤術(shù)后第5天的LCR可預(yù)測(cè)術(shù)后并發(fā)癥的發(fā)生。Okugawa等[18]研究發(fā)現(xiàn)術(shù)前LCR是結(jié)直腸癌患者術(shù)后總生存的影響因素。因此,術(shù)前LCR可作為胃癌圍手術(shù)期并發(fā)癥的一種全新預(yù)測(cè)及評(píng)估指標(biāo)。
Fib是一種長(zhǎng)效血漿急性期反應(yīng)物,醫(yī)源性損傷后其水平升高時(shí)間較長(zhǎng),并與多系統(tǒng)惡性腫瘤的發(fā)生和發(fā)展密切相關(guān)[19]。Alb是一種營(yíng)養(yǎng)生物標(biāo)志物,術(shù)后由于手術(shù)應(yīng)激和毛細(xì)血管滲漏增加,Alb通常會(huì)減少?;颊叩男g(shù)后生存質(zhì)量和預(yù)后與其營(yíng)養(yǎng)水平呈正相關(guān)。臨床早期篩選高?;颊叱S玫臓I(yíng)養(yǎng)指標(biāo)易受手術(shù)等多種因素影響,并不利于早期臨床篩選[20]。研究顯示術(shù)前血清Alb是胃癌患者術(shù)后恢復(fù)和長(zhǎng)期生存的預(yù)測(cè)因素,術(shù)前Alb水平降低是老年胃癌患者發(fā)生嚴(yán)重術(shù)后并發(fā)癥的潛在危險(xiǎn)因素[21]。Fib升高及Alb降低是包括胃癌在內(nèi)的多種惡性腫瘤的高危預(yù)后因素[22]。本研究結(jié)果顯示FAR、LCR均是老年胃癌患者術(shù)后肺炎的獨(dú)立危險(xiǎn)因素,與既往研究結(jié)果一致。FAR聯(lián)合LCR預(yù)測(cè)胃癌術(shù)后肺炎的能力優(yōu)于FAR、LCR單獨(dú)預(yù)測(cè),這一提升可歸因于二者聯(lián)合應(yīng)用綜合考量了凝血機(jī)制、營(yíng)養(yǎng)水平、免疫功能和炎癥狀態(tài)等多個(gè)方面,因此能更準(zhǔn)確地評(píng)估患者的整體病情[23]。
血清LCR和FAR與老年胃癌患者術(shù)后肺炎的發(fā)生密切相關(guān),二者聯(lián)合預(yù)測(cè)具有更高的診斷價(jià)值,可輔助臨床醫(yī)生在術(shù)前進(jìn)行更精準(zhǔn)的診斷,有效降低術(shù)后肺炎的發(fā)生風(fēng)險(xiǎn),進(jìn)而縮短患者的住院時(shí)間并減少住院費(fèi)用。
利益沖突:所有作者均聲明不存在利益沖突。
[參考文獻(xiàn)]
[1] BRAY"F,"LAVERSANNE"M,"SUNG"H,"et"al."Global"cancer"statistics"2022:"GLOBOCAN"estimates"of"incidence"and"mortality"worldwide"for"36"cancers"in"185"countries[J]."CA"Cancer"J"Clin,"2024,"74(3):"229–263.
[2] LUO"G,"ZHANG"Y,"GUO"P,"et"al."Global"patterns"and"trends"in"stomach"cancer"incidence:"Age,"period"and"birth"cohort"analysis[J]."Int"J"Cancer,"2017,"141(7):"1333–1344.
[3] MACHLOWSKA"J,"BAJ"J,"SITARZ"M,"et"al."Gastric"cancer:"Epidemiology,"risk"factors,"classification,"genomic"characteristics"and"treatment"strategies[J]."Int"J"Mol"Sci,"2020,"21(11):"4012.
[4] KIUCHI"J,"KOMATSU"S,"ICHIKAWA"D,"et"al."Putative"risk"factors"for"postoperative"pneumonia"which"affects"poor"prognosis"in"patients"with"gastric"cancer[J]."Int"J"Clin"Oncol,"2016,"21(5):"920–926.
[5] MURATA"M."Inflammation"and"cancer[J]."Environ"Health"Prev"Med,"2018,"23(1):"50.
[6] MUNGAN"?,"DICLE"?"B,"BEKTA?"?,"et"al."Does"the"preoperative"platelet-to-lymphocyte"ratio"and"neutrophil-"to-lymphocyte"ratio"predict"morbidity"after"gastrectomy"for"gastric"cancer?[J]."Mil"Med"Res,"2020,"7(1):"9.
[7] XIAO"Y,"WEI"G,"MA"M,"et"al."Association"among"prognostic"nutritional"index,"post-operative"infection"and"prognosis"of"stage"Ⅱ/Ⅲ"gastric"cancer"patients"following"radical"gastrectomy[J]."Eur"J"Clin"Nutr,"2022,"76(10):"1449–1456.
[8] HUANG"D,"GUO"B,"ZHENG"Z,"et"al."Clinical"value"of"preoperative"HPR,"LCR"and"CEA"levels"in"colorectal"cancer[J]."Minerva"Pediatr"(Torino),"2023,"75(5):"758–760.
[9] LUYENDYK"J"P,"SCHOENECKER"J"G,"FLICK"M"J."The"multifaceted"role"of"fibrinogen"in"tissue"injury"and"inflammation[J]."Blood,"2019,"133(6):"511–520.
[10] WIEDERMANN"C"J."Hypoalbuminemia"as"surrogate"and"culprit"of"infections[J]."Int"J"Mol"Sci,"2021,"22(9):"4496.
[11] FUKUDA"Y,"YAMAMOTO"K,"HIRAO"M,"et"al."Prevalence"of"malnutrition"among"gastric"cancer"patients"undergoing"gastrectomy"and"optimal"preoperative"nutritional"support"for"preventing"surgical"site"infections[J]."Ann"Surg"Oncol,"2015,"22"Suppl"3:"S778–S785.
[12] 中國(guó)胃腸腫瘤外科聯(lián)盟,"中國(guó)抗癌協(xié)會(huì)胃癌專業(yè)委員會(huì)."中國(guó)胃腸腫瘤外科術(shù)后并發(fā)癥診斷登記規(guī)范專家共識(shí)(2018版)[J]."中國(guó)實(shí)用外科雜志,"2018,"38(6):"589–595.
[13] MENG"Y,"ZHAO"P,"YONG"R."Modified"frailty"index"independently"predicts"postoperative"pulmonary"infection"in"elderly"patients"undergoing"radical"gastrectomy"for"gastric"cancer[J]."Cancer"Manag"Res,"2021,"13:"9117–9126.
[14] OCHOA"DE"OLZA"M,"NAVARRO"RODRIGO"B,"ZIMMERMANN"S,"et"al."Turning"up"the"heat"on"non-immunoreactive"tumours:"Opportunities"for"clinical"development[J]."Lancet"Oncol,"2020,"21(9):"e419–e430.
[15] JAKUBOWSKA"K,"KODA"M,"KISIELEWSKI"W,"et"al."Pre-"and"postoperative"neutrophil"and"lymphocyte"count"and"neutrophil-to-lymphocyte"ratio"in"patients"with"colorectal"cancer[J]."Mol"Clin"Oncol,"2020,"13(5):"56.
[16] SOCHA"M"W,"MALINOWSKI"B,"PUK"O,"et"al."C-reactive"protein"as"a"diagnostic"and"prognostic"factor"of"endometrial"cancer[J]."Crit"Rev"Oncolnbsp;Hematol,"2021,"164:"103419.
[17] YILDIRIM"M,"KOCA"B."Lymphocyte"C-reactive"protein"ratio:"A"new"biomarker"to"predict"early"complications"after"gastrointestinal"oncologic"surgery[J]."Cancer"Biomark,"2021,"31(4):"409–417.
[18] OKUGAWA"Y,"TOIYAMA"Y,"YAMAMOTO"A,"et"al."Lymphocyte-C-reactive"protein"ratio"as"promising"new"marker"for"predicting"surgical"and"oncological"outcomes"in"colorectal"cancer[J]."Ann"Surg,"2020,"272(2):"342–351.
[19] SASAKI"M,"MIYOSHI"N,"FUJINO"S,"et"al."Development"of"novel"prognostic"prediction"models"including"the"prognostic"nutritional"index"for"patients"with"colorectal"cancer"after"curative"resection[J]."J"Anus"Rectum"Colon,"2019,"3(3):"106–115.
[20] SIEGEL"R"L,"MILLER"K"D,"FUCHS"H"E,"et"al."Cancer"statistics,"2022[J]."CA"Cancer"J"Clin,"2022,"72(1):"7–33.
[21] YOU"X,"ZHOU"Q,"SONG"J,"et"al."Preoperative"albumin-to-fibrinogen"ratio"predicts"severe"postoperative"complications"in"elderly"gastric"cancer"subjects"after"radical"laparoscopic"gastrectomy[J]."BMC"Cancer,"2019,"19(1):"931.
[22] LIN"G"T,"MA"Y"B,"CHEN"Q"Y,"et"al."Fibrinogen-albumin"rationbsp;as"a"new"promising"preoperative"biochemical"marker"for"predicting"oncological"outcomes"in"gastric"cancer:"A"multi-institutional"study[J]."Ann"Surg"Oncol,"2021,"28(12):"7063–7073.
[23] 馬晶晶,"孫波,"郭翔,"等."FAR、NLR、PLR及其聯(lián)合應(yīng)用對(duì)慢性阻塞性肺疾病急性加重的預(yù)測(cè)價(jià)值[J]."解放軍醫(yī)學(xué)雜志,"2022,"47(6):"599–606.
(收稿日期:2025–01–02)
(修回日期:2025–03–02)