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通讯作者:

何志成,E-mail:zhicheng.he@njmu.edu.cn

中图分类号:R734.2

文献标识码:A

文章编号:1007-4368(2022)06-843-07

DOI:10.7655/NYDXBNS20220612

参考文献 1
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参考文献 10
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参考文献 12
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参考文献 13
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参考文献 14
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参考文献 15
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参考文献 17
刘剑,吉浩明,刘春桂,等.血清CEA、LDH对肺腺癌靶向治疗的临床疗效及预后的预测价值[J].实用癌症杂志,2017,32(2):178-180
参考文献 18
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参考文献 19
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参考文献 20
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参考文献 21
DAL BELLO M G,FILIBERTI R A,ALAMA A,et al.The role of CEA,CYFRA21⁃1 and NSE in monitoring tumor response to Nivolumab in advanced non ⁃ small cell lung cancer(NSCLC)patients[J].J Transl Med,2019,17(1):74
参考文献 22
UJIIE H,KADOTA K,CHAFT J E,et al.Solid predomi⁃nant histologic subtype in resected stage I lung adenocar⁃ cinoma is an independent predictor of early,extrathorac⁃ ic,multisite recurrence and of poor postrecurrence survi ⁃ val[J].J Clin Oncol,2015,33(26):2877⁃2884
参考文献 23
ZHAO Y,WANG R,SHEN X,et al.Minor components of micropapillary and solid subtypes in lung adenocarcino⁃ ma are predictors of lymph node metastasis and poor prog⁃ nosis[J].Ann Surg Oncol,2016,23(6):2099-2105
参考文献 24
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参考文献 25
王文涛,张国俊.CEA、CYFRA21⁃1、NSE、CA125联合检测在肺癌诊断中的价值[J].中国实验诊断学,2014,18(2):224-226
目录contents

    摘要

    目的:本研究旨在分析肺腺癌患者术前血清肿瘤标志物与肺腺癌微乳头及实体成分的关联。方法:回顾性筛选 2018年1月—2020年12月于南京医科大学第一附属医院胸外科就诊的浸润性肺腺癌患者,采集患者术前血清肿瘤标志物[癌胚抗原(carcinoembryonic antigen,CEA)、糖类抗原 199(carbohydrate antigen 199,CA19⁃9)、糖类抗原 724(carbohydrate antigen 724,CA724)、神经元特异性烯醇化酶(neuron specific enolase,NSE)、甲胎蛋白(alpha fetoprotein,AFP)及细胞角蛋白21片段抗原(cytokeratin 21 fragment antigen,CYFRA21⁃1)]、病理亚型等信息。采用Student’s t⁃检验、卡方检验、Logistic回归等方法分析血清肿瘤标志物与微乳头、实体成分等临床病理特征的关联。结果:共纳入2159例肺腺癌患者,分别有291例及248例患者含有微乳头、实体成分。6种肿瘤标志物中,CEA及CYFRA21⁃1与肿瘤大小、淋巴结转移显著相关(P < 0.001)。含实体成分的肺腺癌患者,其CEA(2.92 ng/mL vs.1.88 ng/mL,P < 0.001)及CYFRA21⁃1(2.20 ng/mL vs.2.02 ng/mL,P < 0.001)表达显著高于不含实体成分的患者。同样,CEA(2.59 ng/mL vs.1.92 ng/mL,P < 0.001)及CYFRA21⁃1(2.15 ng/mL vs.2.03 ng/mL,P=0.009)在含微乳头成分肺腺癌中的表达显著高于不含微乳头成分者。单因素回归分析显示,性别、肿瘤大小、CEA及CYFRA21⁃1与微乳头及实体成分有关。多因素回归分析表明,CEA与实体(OR = 2.87,95%CI:2.03~4.06,P < 0.001)、微乳头(OR = 2.36,95%CI: 1.68~3.32,P < 0.001)成分的关联仍然显著,而CYFRA21⁃1与微乳头、实体成分的关联不再具有统计学意义(P > 0.05)。结论:肺腺癌患者术前血清CEA及CYFRA21⁃1表达与微乳头、实体成分有关,可能作为肺腺癌微乳头、实体成分的预测因子。

    Abstract

    Objective:This study aims to analyze the associations between preoperative serum tumor markers and the micropapillary and solid components in patients with lung adenocarcinoma. Methods:Patients with invasive lung adenocarcinoma who underwent treatment in our department from January 2018 to December 2020 were retrospectively screened. Preoperative serum tumor markers [carcinoembryonic antigen(CEA),carbohydrate antigen 199(CA19⁃9),carbohydrate antigen 724(CA724),neuron specific enolase (NSE),alpha fetoprotein(AFP)and cytokeratin 21 fragment antigen(CYFRA21 ⁃ 1)],histopathological subtypes and other characteristics were collected. Student’s t ⁃test,χ2 test,logistic regression analyses were used to evaluate the relations between serum tumor markers and the micropapillary and solid components,as well as other clinicopathological characteristics. Results:A total of 2159 lung adenocarcinoma patients were enrolled in the current study. There were291 and 248 patients harboring micropapillary and solid components,respectively. Among these six tumor markers,CEA and CYFRA21⁃1 levels were significantly associated with tumor size and lymph node metastasis(P < 0.001). Patients with solid components had a higher CEA(2.92 ng/mL vs.1.88 ng/mL,P < 0.001) and CYFRA21⁃1(2.20 ng/mL vs.2.02 ng/mL,P < 0.001)level than those absence of solid components. Similarly,the expression levels of CEA(2.59 ng/mL vs.1.92 ng/mL,P < 0.001)and CYFRA21⁃1(2.15 ng/mL vs.2.03 ng/mL,P =0.009)in patients with micropapillary components were significantly higher than that in patients without micropapillary components. The univariate regression analysis indicated that gender,tumor size,CEA and CYFRA21⁃1 levels were significantly associated with solid and micropapillary components. However,the multivariate analysis showed that associations between CEA and solid(OR = 2.87,95%CI:2.03⁃4.06,P < 0.001),and micropapillary(OR = 2.36,95%CI:1.68⁃3.32,P < 0.001)components were still significant,while the associations between CYFRA21⁃1 and solid or micropapillary components were not significant anymore(P > 0.05). Conclusion:The levels of preoperative serum CEA and CYFRA21⁃1 were associated with the micropapillary and solid components in lung adenocarcinoma patients,which could serve as predictive factors for the micropapillary and solid components in lung adenocarcinoma.

  • 肺癌是我国发病及死亡人数最多的恶性肿瘤[1]。其中,肺腺癌是肺癌的主要病理亚型之一,约占肺癌的50%[2]。根据组织细胞学特征,肺腺癌又可进一步分为贴壁型、腺泡型、乳头型、微乳头型及实体型5个病理亚型[3]。研究表明,与贴壁型等其他3个亚型患者相比,微乳头及实体型肺腺癌患者预后更差[4-7]。此外,微乳头、实体型肺腺癌对于新辅助放化疗、免疫治疗等表现出不同的反应,可能需要更为保守的手术方式[48-13]。可见,深入探索微乳头、实体腺癌临床病理特征,对改善肺腺癌患者预后具有重大的临床意义。

  • 血清肿瘤标志物,如癌胚抗原(carcinoembryon⁃ ic antigen,CEA)、糖类抗原199(carbohydrate antigen 199,CA19⁃9)、神经元特异性烯醇化酶(neuron spe⁃ cific enolase,NSE)等,广泛应用于包括肺癌在内的多种恶性肿瘤的早期诊断及病理亚型鉴别等[14-16]。此外,肺癌患者术后血清肿瘤标志物的变化与肺癌患者辅助治疗反应及肿瘤复发密切相关[17-21]。而肺腺癌患者术前血清肿瘤标志物表达水平是否与微乳头及实体成分有关,目前研究尚不明确。

  • 因此,本研究通过回顾性筛选浸润性肺腺癌患者,采集患者术前血清肿瘤标志物、病理亚型等相关信息,分析探讨肺腺癌患者术前血清肿瘤标志物表达与微乳头、实体成分的关联。

  • 1 对象和方法

  • 1.1 对象

  • 本研究回顾性筛选2018年1月—2020年12月于南京医科大学第一附属医院胸外科接受手术治疗的肺癌患者。纳入标准:①原发肺癌;②组织病理学确诊的浸润性肺腺癌;③明确的肺腺癌亚型; ④单发的浸润性癌;⑤手术前1个月内行肿瘤标志物检测;⑥手术前未接受放化疗、靶向治疗、免疫治疗等其他治疗;⑦5年内无其他恶性肿瘤史。本研究通过南京医科大学第一附属医院伦理委员会批准。

  • 1.2 方法

  • 基于电子病历、检验及影像病理系统采集患者相关信息,包括年龄、性别等基线信息、肿瘤标志物6项、肿瘤大小、病理亚型等临床病理信息。其中,肿瘤标志物6项采用电化学发光法(electrochemilu⁃ miniscent assay)进行检测,包括:CEA、CA19⁃9、糖类抗原724(carbohydrate antigen 724,CA724)、NSE、甲胎蛋白(alpha fetoprotein,AFP)以及细胞角蛋白21片段抗原(cytokeratin 21fragment antigen,CYFRA21⁃1),其正常上限分别为4.7ng/mL、39.0U/mL、6.9U/mL、 16.3ng/mL、20.0ng/mL以及3.3ng/mL,表达水平高于上限视为阳性。病理亚型中,微乳头、实体成分占比不少于5%视为阳性,否则为不含微乳头或实体成分。

  • 1.3 统计学方法

  • 本研究采用Student’s t 检验或Kruskal检验进行计量资料组间差异的比较,计数资料用频数(百分比)表示,采用卡方检验或者费舍尔确切概率法进行组间比较。年龄、肿瘤大小用均数±标准差(x-±s)表示,肿瘤标志物表达水平采用中位数及四分位数[MP25P75)]进行展示。采用单因素及多因素Logistic回归分析评价肿瘤标志物水平与实体、微乳头成分的关联。所有统计分析基于R(3.60)完成,采用双侧检验,P< 0.05为差异有统计学意义。

  • 2 结果

  • 2.1 研究对象的特征

  • 本研究共纳入2 159例符合标准的肺腺癌病例。其中,男845例(39.1%),女1 314例(60.9%),平均年龄(59.15 ± 10.61)岁,平均肿瘤大小(17.15 ± 8.62)mm。术后病理发现291例含有微乳头成分, 248例含实体成分。发生淋巴结转移者153例。病理分期Ⅰ期1 987例(92.0%),Ⅱ期74例(3.4%),Ⅲ期98例(4.6%)。研究对象具体特征见表1。

  • 表1 研究对象的特征

  • Table1 Characteristics of study subjects

  • 2.2 术前肿瘤标志物与肿瘤大小、淋巴结转移的关联

  • 6种肿瘤标志物中,CEA、CA19⁃9及CYFRA21⁃1与肿瘤大小有关(P< 0.05,表2)。随着肿瘤直径的增大,CEA中位表达水平由1.52ng/mL(≤10mm)升至1.90ng/mL(>10~20mm)、2.85ng/mL(>20~30mm)、 3.27ng/mL(> 30mm)(P< 0.001)。CYFRA21⁃1中位表达水平由1.88ng/mL(≤10mm),升至2.05ng/mL(>10~20mm)、2.18ng/mL(>20~30mm)、2.46ng/mL (> 30mm)(P< 0.001)。同样,CEA阳性率由2.8%(≤10mm)升至7.3%(>10~20mm)、22.4%(>20~30mm)、34.1%(> 30mm)(P< 0.001)。进一步分析6种肿瘤标志物与淋巴结转移的关联,结果显示,未发生淋巴结转移的患者CEA及CYFRA21⁃1中位表达水平分别为1.92ng/mL、2.02ng/mL,而发生淋巴结转移的患者CEA及CYFRA21⁃1的表达为3.46ng/mL、 2.31ng/mL(P< 0.001,表3)。类似地,未发生淋巴结转移的患者,CEA及CYFRA21⁃1阳性率为8.3%、 12.0%,而发生淋巴结转移的患者CEA及CYFRA21⁃1阳性表达率为40.5%、24.2%(P< 0.001)。

  • 2.3 血清肿瘤标志物在含/不含微乳头、实体成分肺腺癌患者中的表达

  • 含微乳头、实体成分的腺癌较不含微乳头或实体成分的腺癌具有更大的肿瘤直径(P< 0.001)。6种肿瘤标志物中,AFP、CA19⁃9、CA724以及NSE在含/不含微乳头或实体成分的腺癌中表达差异无统计学意义(P> 0.05,表4),而含实体成分的腺癌,其CEA及CYFRA21⁃1表达较不含实体成分的腺癌更高(P< 0.001)。类似地,与不含微乳头成分的腺癌相比,含微乳头成分的肿瘤CEA及CYFRA21⁃1的表达均显著增高(P均< 0.05)。含实体或微乳头成分的肺腺癌患者,其CEA表达阳性率显著高于不含实体或微乳头成分的患者(P< 0.001)。此外,与既往研究报道一致,含实体或微乳头成分的腺癌较不含实体或微乳头成分的腺癌淋巴结转移率更高(P< 0.001)。

  • 2.4 血清肿瘤标志物与肺腺癌实体、微乳头成分相关性的回归分析

  • 单因素回归分析发现,性别(OR=0.43,95%CI: 0.33~0.57,P< 0.001)、肿瘤大小(OR=2.19,95%CI: 1.92~2.51,P< 0.001)、CEA阳性(OR=5.11,95%CI: 3.73~7.02,P< 0.001)及CYFRA21⁃1阳性(OR=1.70, 95%CI:1.20~2.40,P=0.003,表5)与包含实体成分显著有关。进一步的多因素回归分析显示,性别(OR=0.51,95%CI:0.39~0.68,P< 0.001)、肿瘤大小(OR=1.91,95%CI:1.65~2.20,P< 0.001)及CEA阳性 (OR=2.87,95%CI:2.03~4.06,P< 0.001)与实体成分的关联仍然显著。而CYFRA21⁃1阳性与实体成分的关联不再显著(OR=1.13,95%CI:0.76~1.67,P=0.552)。

  • 类似地,单因素回归分析表明,性别(OR=0.65, 95%CI:0.52~0.85,P< 0.001)、肿瘤大小(OR=2.22,95%CI:1.95~2.53,P< 0.001)、CEA阳性(OR=4.09, 95%CI:3.00~5.57,P< 0.001)及CYFRA21 ⁃ 1阳性 (OR=1.41,95%CI:1.00~1.97,P=0.048)与微乳头成分显著有关。多因素回归分析显示,在调整肿瘤大小、CEA表达后,性别与CYFRA21⁃1阳性不再与微乳头成分有关(P> 0.05);而肿瘤大小(OR=2.01, 95%CI:1.75~2.31,P< 0.001)及CEA阳性(OR=2.36,95%CI:1.68~3.32,P< 0.001)与微乳头成分的关联仍然显著(表5)。

  • 表2 血清肿瘤标志物与肺腺癌肿瘤大小的关联

  • Table2 Associations between serum tumor markers and lung adenocarcinoma size

  • 肿瘤标志物超过正常上限者视为阳性。

  • 表3 血清肿瘤标志物与肺腺癌淋巴结转移的关联

  • Table3 Associations between serum tumor markers and lymphnode metastasis in patients with lung adenocarcinoma

  • 肿瘤标志物超过正常上限者视为阳性。

  • 3 讨论

  • 大量研究表明,肺腺癌实体、微乳头成分与更高的淋巴结转移率、更差的预后有关[1222-23]。因此,肺腺癌实体、微乳头成分的早期识别对手术方式的选择及后续治疗具有重要指导意义。本研究发现,含实体、微乳头成分的肺腺癌患者,其术前血清CEA及CYFRA21⁃1水平显著高于不含实体或微乳头成分的患者。

  • CEA是长度约180kDa的糖蛋白,其在健康成人中的表达通常小于2.5ng/mL,而在恶性肿瘤患者中的表达水平显著增高[24]。既往研究表明,CEA在非小细胞肺癌中的表达高于小细胞肺癌,在肺腺癌中的表达高于鳞癌[1425]。值得注意的是,本研究发现,不含实体或微乳头成分的肺腺癌患者,CEA表达平均值分别为1.88ng/mL及1.92ng/mL,而含实体、微乳头成分的患者CEA平均水平为2.92ng/mL及2.59ng/mL,均大于2.5ng/mL。同样, CEA在不含实体或微乳头成分肺腺癌患者中的阳性率分别为8.0%及8.1%,而在含实体、微乳头成分患者中的阳性率分别升至30.6%及26.5%。多因素回归分析表明,在调整肿瘤大小、性别等混杂因素后,CEA与实体、微乳头成分的关联仍然显著。实体、微乳头腺癌患者,更大的肿瘤及更强的侵袭性可能是其血清CEA高表达的原因之一。

  • 表4 血清肿瘤标志物在含/不含实体、微乳头成分腺癌中的表达水平

  • Table4 Serum tumor markers expression levels in lung adenocarcinoma with/without solid or micropapillary components

  • 肿瘤标志物超过正常上限者视为阳性。

  • 表5 血清肿瘤标志物与实体、微乳头成分关联回归分析结果

  • Table5 Results of regression analysis of associations between serum tumor markers and solid or micropapillary compo⁃ nents

  • 单变量回归分析中P< 0.05的变量纳入多变量回归分析。

  • 除了CEA以外,本研究还发现CYFRA21⁃1在含实体、微乳头成分肺腺癌患者中的表达水平显著高于不含实体、微乳头成分的患者。CYFRA21⁃1在不含实体、微乳头成分肺腺癌患者中的阳性率为12.1%及12.3%,而在含实体、微乳头成分患者中的阳性率为19.0%及16.8%。既往研究表明,CYFRA21⁃1在非小细胞肺癌中的表达高于小细胞肺癌,且在肺鳞癌中的表达高于肺腺癌[1525]。单因素回归分析显示, CYFRA21⁃1、肿瘤大小、性别与实体及微乳头成分有关。然而,调整肿瘤大小、CEA、性别等因素后, CYFRA21⁃1与实体、微乳头成分无关。

  • 本研究样本量较大,同时检测了肿瘤标志物的表达水平与阳性率。然而,本研究92.0%的肺腺癌患者为Ⅰ期,限制了研究结果的适用范围,中晚期肺腺癌患者血清肿瘤标志物可能有不同的表达模式。

  • 综上,CEA及CYFRA21⁃1在含实体、微乳头成分肺腺癌患者血清中的水平显著高于不含实体或微乳头成分的患者。术前血清CEA及CYFRA21⁃1可能作为肺腺癌实体、微乳头成分的预测因子。

  • 参考文献

    • [1] BRAY F,FERLAY J,SOERJOMATARAM I,et al.Global cancer statistics 2018:GLOBOCAN estimates of inci⁃ dence and mortality worldwide for 36 cancers in 185 countries[J].CA:Cancer J Clin,2018,68(6):394-424

    • [2] CHENG T Y,CRAMB S M,BAADE P D,et al.The inter⁃ national epidemiology of lung cancer:latest trends,dispar⁃ ities,and tumor characteristics[J].J Thorac Oncol,2016,11(10):1653-1671

    • [3] CASO R,SANCHEZ⁃VEGA F,TAN K S,et al.The under⁃ lying tumor genomics of predominant histologic subtypes in lung adenocarcinoma[J].J Thorac Oncol,2020,15(12):1844-1856

    • [4] SU H,XIE H,DAI C,et al.Procedure⁃specific prognostic impact of micropapillary subtype may guide resection strategy in small ⁃ sized lung adenocarcinomas:a multi⁃ center study[J].Ther Adv Med Oncol,2020,12:1758835920937893

    • [5] PENG B,LI G,GUO Y.Prognostic significance of micro⁃ papillary and solid patterns in stage IA lung adenocarcino⁃ ma[J].Am J Transl Res,2021,13(9):10562-10569

    • [6] MOTONO N,MATSUI T,MACHIDA Y,et al.Prognostic significance of histologic subtype in stage I lung adenocar⁃ cinoma[J].Med Oncol,2017,34(6):100

    • [7] CHOI S H,JEONG J Y,LEE S Y,et al.Clinical implica⁃ tion of minimal presence of solid or micropapillary sub⁃ type in early⁃stage lung adenocarcinoma[J].Thorac Can⁃ cer,2021,12(2):235-244

    • [8] WANG C,YANG J,LU M.Micropapillary predominant lung adenocarcinoma in stage IA benefits from adjuvant chemotherapy[J].Ann Surg Oncol,2020,27(6):2051-2060

    • [9] QIAN F,YANG W,WANG R,et al.Prognostic signifi⁃ cance and adjuvant chemotherapy survival benefits of a solid or micropapillary pattern in patients with resected stage IB lung adenocarcinoma[J].J Thorac Cardiovasc Surg,2018,155(3):1227-1235.e2

    • [10] MA M,SHE Y,REN Y,et al.Micropapillary or solid pat⁃ tern predicts recurrence free survival benefit from adju⁃ vant chemotherapy in patients with stage IB lung adeno⁃ carcinoma[J].J Thorac Dis,2018,10(9):5384-5393

    • [11] TSAO M S,MARGUET S,LE TEUFF G,et al.Subtype classification of lung adenocarcinoma predicts benefit from adjuvant chemotherapy in patients undergoing com⁃ plete resection[J].J Clin Oncol,2015,33(30):3439-3446

    • [12] NITADORI J,BOGRAD A J,KADOTA K,et al.Impact of micropapillary histologic subtype in selecting limited re⁃ section vs.lobectomy for lung adenocarcinoma of 2 cm or smaller[J].J Natl Cancer Inst,2013,105(16):1212-1220

    • [13] 范啸,徐心峰,闻伟,等.ⅠA期肺腺癌胸腔镜肺叶切除与肺段切除预后分析[J].南京医科大学学报(自然科学版),2017,37(8):1005-1009

    • [14] 董芸,袁峥玺,姚原.肿瘤标志物SCC⁃Ag、Cyf21⁃1、 CEA、ProGRP、及NSE联合检测在肺癌诊断中的应用 [J].中国实验诊断学,2019,23(3):384-386

    • [15] 刘连红,罗建祥,徐月君,等.不同病理类型肺癌患者血清肿瘤标志物 CYFRA21⁃1、NSE 和CEA水平的比较 [J].武汉大学学报(医学版),2015,36(4):533-535,540

    • [16] ZHANG B,NIU X,ZHANG Q,et al.Circulating tumor DNA detection is correlated to histologic types in patients with early⁃stage non⁃small⁃cell lung cancer[J].Lung Can⁃ cer,2019,134:108-116

    • [17] 刘剑,吉浩明,刘春桂,等.血清CEA、LDH对肺腺癌靶向治疗的临床疗效及预后的预测价值[J].实用癌症杂志,2017,32(2):178-180

    • [18] ZHANG Z,YUAN F,CHEN R,et al.Dynamics of serum tumor markers can serve as a prognostic biomarker for Chinese advanced non ⁃ small cell lung cancer patients treated with immune checkpoint inhibitors[J].Front Im⁃ munol,2020,11:1173

    • [19] DALL’OLIO F G,ABBATI F,FACCHINETTI F,et al.CEA and CYFRA 21⁃1 as prognostic biomarker and as a tool for treatment monitoring in advanced NSCLC treated with immune checkpoint inhibitors[J].Ther Adv Med On⁃ col,2020,12:1758835920952994

    • [20] CHAI R,FAN Y,ZHAO J,et al.Prognostic nomogram on clinicopathologic features and serum indicators for ad⁃ vanced non ⁃ small cell lung cancer patients treated with anti⁃PD⁃1 inhibitors[J].Ann Transl Med,2020,8(17):1078

    • [21] DAL BELLO M G,FILIBERTI R A,ALAMA A,et al.The role of CEA,CYFRA21⁃1 and NSE in monitoring tumor response to Nivolumab in advanced non ⁃ small cell lung cancer(NSCLC)patients[J].J Transl Med,2019,17(1):74

    • [22] UJIIE H,KADOTA K,CHAFT J E,et al.Solid predomi⁃nant histologic subtype in resected stage I lung adenocar⁃ cinoma is an independent predictor of early,extrathorac⁃ ic,multisite recurrence and of poor postrecurrence survi ⁃ val[J].J Clin Oncol,2015,33(26):2877⁃2884

    • [23] ZHAO Y,WANG R,SHEN X,et al.Minor components of micropapillary and solid subtypes in lung adenocarcino⁃ ma are predictors of lymph node metastasis and poor prog⁃ nosis[J].Ann Surg Oncol,2016,23(6):2099-2105

    • [24] SILSIRIVANIT A.Glycosylation markers in cancer[J].Adv Clin Chem,2019,89:189-213

    • [25] 王文涛,张国俊.CEA、CYFRA21⁃1、NSE、CA125联合检测在肺癌诊断中的价值[J].中国实验诊断学,2014,18(2):224-226

  • 参考文献

    • [1] BRAY F,FERLAY J,SOERJOMATARAM I,et al.Global cancer statistics 2018:GLOBOCAN estimates of inci⁃ dence and mortality worldwide for 36 cancers in 185 countries[J].CA:Cancer J Clin,2018,68(6):394-424

    • [2] CHENG T Y,CRAMB S M,BAADE P D,et al.The inter⁃ national epidemiology of lung cancer:latest trends,dispar⁃ ities,and tumor characteristics[J].J Thorac Oncol,2016,11(10):1653-1671

    • [3] CASO R,SANCHEZ⁃VEGA F,TAN K S,et al.The under⁃ lying tumor genomics of predominant histologic subtypes in lung adenocarcinoma[J].J Thorac Oncol,2020,15(12):1844-1856

    • [4] SU H,XIE H,DAI C,et al.Procedure⁃specific prognostic impact of micropapillary subtype may guide resection strategy in small ⁃ sized lung adenocarcinomas:a multi⁃ center study[J].Ther Adv Med Oncol,2020,12:1758835920937893

    • [5] PENG B,LI G,GUO Y.Prognostic significance of micro⁃ papillary and solid patterns in stage IA lung adenocarcino⁃ ma[J].Am J Transl Res,2021,13(9):10562-10569

    • [6] MOTONO N,MATSUI T,MACHIDA Y,et al.Prognostic significance of histologic subtype in stage I lung adenocar⁃ cinoma[J].Med Oncol,2017,34(6):100

    • [7] CHOI S H,JEONG J Y,LEE S Y,et al.Clinical implica⁃ tion of minimal presence of solid or micropapillary sub⁃ type in early⁃stage lung adenocarcinoma[J].Thorac Can⁃ cer,2021,12(2):235-244

    • [8] WANG C,YANG J,LU M.Micropapillary predominant lung adenocarcinoma in stage IA benefits from adjuvant chemotherapy[J].Ann Surg Oncol,2020,27(6):2051-2060

    • [9] QIAN F,YANG W,WANG R,et al.Prognostic signifi⁃ cance and adjuvant chemotherapy survival benefits of a solid or micropapillary pattern in patients with resected stage IB lung adenocarcinoma[J].J Thorac Cardiovasc Surg,2018,155(3):1227-1235.e2

    • [10] MA M,SHE Y,REN Y,et al.Micropapillary or solid pat⁃ tern predicts recurrence free survival benefit from adju⁃ vant chemotherapy in patients with stage IB lung adeno⁃ carcinoma[J].J Thorac Dis,2018,10(9):5384-5393

    • [11] TSAO M S,MARGUET S,LE TEUFF G,et al.Subtype classification of lung adenocarcinoma predicts benefit from adjuvant chemotherapy in patients undergoing com⁃ plete resection[J].J Clin Oncol,2015,33(30):3439-3446

    • [12] NITADORI J,BOGRAD A J,KADOTA K,et al.Impact of micropapillary histologic subtype in selecting limited re⁃ section vs.lobectomy for lung adenocarcinoma of 2 cm or smaller[J].J Natl Cancer Inst,2013,105(16):1212-1220

    • [13] 范啸,徐心峰,闻伟,等.ⅠA期肺腺癌胸腔镜肺叶切除与肺段切除预后分析[J].南京医科大学学报(自然科学版),2017,37(8):1005-1009

    • [14] 董芸,袁峥玺,姚原.肿瘤标志物SCC⁃Ag、Cyf21⁃1、 CEA、ProGRP、及NSE联合检测在肺癌诊断中的应用 [J].中国实验诊断学,2019,23(3):384-386

    • [15] 刘连红,罗建祥,徐月君,等.不同病理类型肺癌患者血清肿瘤标志物 CYFRA21⁃1、NSE 和CEA水平的比较 [J].武汉大学学报(医学版),2015,36(4):533-535,540

    • [16] ZHANG B,NIU X,ZHANG Q,et al.Circulating tumor DNA detection is correlated to histologic types in patients with early⁃stage non⁃small⁃cell lung cancer[J].Lung Can⁃ cer,2019,134:108-116

    • [17] 刘剑,吉浩明,刘春桂,等.血清CEA、LDH对肺腺癌靶向治疗的临床疗效及预后的预测价值[J].实用癌症杂志,2017,32(2):178-180

    • [18] ZHANG Z,YUAN F,CHEN R,et al.Dynamics of serum tumor markers can serve as a prognostic biomarker for Chinese advanced non ⁃ small cell lung cancer patients treated with immune checkpoint inhibitors[J].Front Im⁃ munol,2020,11:1173

    • [19] DALL’OLIO F G,ABBATI F,FACCHINETTI F,et al.CEA and CYFRA 21⁃1 as prognostic biomarker and as a tool for treatment monitoring in advanced NSCLC treated with immune checkpoint inhibitors[J].Ther Adv Med On⁃ col,2020,12:1758835920952994

    • [20] CHAI R,FAN Y,ZHAO J,et al.Prognostic nomogram on clinicopathologic features and serum indicators for ad⁃ vanced non ⁃ small cell lung cancer patients treated with anti⁃PD⁃1 inhibitors[J].Ann Transl Med,2020,8(17):1078

    • [21] DAL BELLO M G,FILIBERTI R A,ALAMA A,et al.The role of CEA,CYFRA21⁃1 and NSE in monitoring tumor response to Nivolumab in advanced non ⁃ small cell lung cancer(NSCLC)patients[J].J Transl Med,2019,17(1):74

    • [22] UJIIE H,KADOTA K,CHAFT J E,et al.Solid predomi⁃nant histologic subtype in resected stage I lung adenocar⁃ cinoma is an independent predictor of early,extrathorac⁃ ic,multisite recurrence and of poor postrecurrence survi ⁃ val[J].J Clin Oncol,2015,33(26):2877⁃2884

    • [23] ZHAO Y,WANG R,SHEN X,et al.Minor components of micropapillary and solid subtypes in lung adenocarcino⁃ ma are predictors of lymph node metastasis and poor prog⁃ nosis[J].Ann Surg Oncol,2016,23(6):2099-2105

    • [24] SILSIRIVANIT A.Glycosylation markers in cancer[J].Adv Clin Chem,2019,89:189-213

    • [25] 王文涛,张国俊.CEA、CYFRA21⁃1、NSE、CA125联合检测在肺癌诊断中的价值[J].中国实验诊断学,2014,18(2):224-226