不同部位自体皮瓣即刻重建对乳腺癌预后的影响

Effect of immediate reconstruction of autogenous flaps on prognosis of breast cancer

目的探讨腹直肌皮瓣(TRAM)和背阔肌皮瓣(LDMF)在乳腺癌术后乳房即刻重建中的应用效果及对肿瘤复发转移的影响。方法回顾性分析2014年1月至2017年1月联勤保障部队第九○九医院普通外科收治的117例乳腺癌患者临床资料,观察组采用TRAM即刻重建(n=63)、对照组采用LDMF即刻重建(n=54),随访13~60个月,中位随访时间47个月;Kaplan-Meier法绘制生存曲线,并用log-rank法比较两组3年无瘤生存率和5年无瘤生存率;采用单因素和多因素Cox分析乳腺癌术后复发转移危险因素。结果两组患者重建乳房对称性、术后坏死或脂肪液化率、供区积液或感染率对比差异无统计学意义(P>0.05);术后6个月TRAM皮瓣痛觉、触觉、两点辨别觉异常率低于LDMF皮瓣(P<0.05);TRAM皮瓣3年和5年无瘤生存率为74.60%(47/63)、60.31%(38/63)低于LDMF皮瓣87.03%(47/54)、75.92%(41/54)(P<0.05);单因素分析糖尿病史、吸烟史、乳腺癌家族史、肿瘤直径、TNM分期、病理类型、淋巴结转移、皮瓣来源是肿瘤复发转移危险因素(P<0.05);多因素分析肿瘤直径≥4 cm、乳腺癌Ⅱ或Ⅲ期、病理类型为浸润性特殊型癌、淋巴结转移≥4个是乳腺癌重建术后复发转移的独立危险因素(P<0.05)。结论乳腺癌乳房重建应用TRAM皮瓣和LDMF皮瓣相比,TRAM能够加快神经感觉恢复,但可能增加术后肿瘤复发转移发生率。

Objective To investigate the effect of transverse rectus abdominis myocutaneous flap(TRAM)and latissimus dorsi myocutaneous flap(LDMF)on tumor recurrence and metastasis in breast cancer patients receiving immediate breast reconstruction.Methods The clinical data of 117 patients with breast cancer admitted to the Department of General Surgery,909th Hospital of Joint Logistic Support Force from January 2014 to December 2017 were retrospectively analyzed.Immediate reconstructions were performed with rectus abdominis flap in the observation group(n=63)and latissimus dorsi flap in the control group(n=54).The patients were followed up for 13 to 60 months with a median follow-up of 47 months.Kaplan-meier method was used to draw the survival curves.And the log-rank method was used to compare the 3-year and 5-year disease-free survival rates between the two groups.Univariate and multivariate Cox were used to analyze the risk factors for recurrence and metastasis of breast cancer after surgery.Results There was no significant difference in breast symmetry reconstruction,postoperative necrosis and fat liquefaction rate,effusion at donor site and infection rate between the two groups(P>0.05).Six months after surgery,the abnormal rates of pain,touch and two-point discrimination in observation group were lower than those of the control group(P<0.05).The 3-year and 5-year disease-free survival rates of the patients in observation group were 74.60%(47/63)and 60.31%(38/63),which were lower than those of 87.03%(47/54)and 75.92%(41/54)in control group(P<0.05).Univariate analysis showed that diabetes history,smoking history,family history of breast cancer,tumor diameter,TNM stage,pathological type,lymph node metastasis and source of skin flap were risk factors for tumor recurrence and metastasis(P<0.05).Multifactor analysis showed that tumor diameter≥4 cm,breast cancer stageⅡ-Ⅲ,invasive special type cancer and more than 4lymph nodes metastasis were the independent risk factors for breast cancer recurrence and metastasis after reconstruction(P<0.05).Conclusions Compared with LDMF flaps,TRAM flaps in breast reconstruction accelerates the recovery of nerve sensation,but may increase the rate of postoperative tumor recurrence and metastasis.