查詢結果分析
相關文獻
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頁籤選單縮合
題 名 | Breast Cancer Patients with and without Transverse Rectus Abdominus Myocutaneous Flap Reconstruction: Better Conformity with Practice Guideline Is Associated with Improved Survival and Reduced Local Recurrence=乳癌患者與是否合併橫向腹直肌肌皮瓣重建的關係:較好的臨床路徑遵從性和較好的存活率與較低的局部復發率相關 |
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作 者 | 謝東穎; 林運男; 林幸道; 賴春生; 張高評; 李書欣; 黃書鴻; 侯明鋒; 陳芳銘; 歐陽賦; | 書刊名 | 臺灣整形外科醫學會雜誌 |
卷 期 | 23:4 2014.12[民103.12] |
頁 次 | 頁291-305 |
分類號 | 416.414 |
關鍵詞 | 乳癌; 乳房重建; 橫向腹直肌肌皮瓣; 存活; Conformity; TRAM; Breast reconstruction; Survival; |
語 文 | 英文(English) |
中文摘要 | 背景:最近運用美國癌症登記的研究顯示:立即性的乳房重建與較佳的乳癌存活率相關,在本醫院也是有同樣的發現,但相關的機轉則未知。目的:這篇研究試著探討,是否乳房全切除後合併立即橫向腹直肌肌皮瓣乳房重建手術的患者相較於沒有重建的患者有較好的臨床路徑遵從性,因為有較好的遵從性,進而有較佳的乳癌存活率與較低的局部復發率。方法:這篇研究回朔2002年1月至2009年12月總共734位於本院接受乳房全切除的病人,其中226位患者合併立即橫向腹直肌肌皮瓣乳房重建手術(MRM-TRAM組),另外508位則沒有合併重建(MRM組)。若符合以下任何條件其中的一項以上(也就是違背我們醫院的乳癌治療臨床路徑)則定義為“差的遵從性":1.乳癌大於1公分,但患者於乳房切除後拒絕接受後續化療。2.雌激素受體呈陽性反應,但患者拒絕接受後續賀爾蒙治療。3.陽性淋巴結大於或等於三顆,但患者拒絕後續放射線治療。若沒有前述三項的情形,則定義為“好的遵從性"。接續比較“好的遵從性"與“差的遵從性"兩組間存活率與局部復發率的差異。資料蒐集包含年齡、乳癌的組織學、分化、分期、雌激素受體、黃體素受體、後續輔助性治療(放射線、化療、賀爾蒙治療)等。結果:MRM-TRAM組226人(82.3%)相對於MRM組508人(74.4%)有顯著較好的臨床路徑遵從性(p=.019)。相較於“差的遵從性",“好的遵從性"有顯著較佳的乳癌存活率(p<.001)。“好的遵從性"組的乳癌五年存活率(87.0%)顯著優於“差的遵從性"組(75.3%)(p<.001)。“好的遵從性"組與“差的遵從性"組的五年存活率依乳癌期別分別是:第一期,94.1%、97.6%、p=.502;第二期,87.8%、86.1%、p=.401;第三期,74.5%、51.6%、p=.001。存活率的多重回歸分析顯示“好的遵從性"、乳房重建、早期乳癌,這些為存活率的獨立預測因子。接受乳房重建的病人相對於沒有接受重建的病人有顯著較低的死亡風險(HR,.495;95% CI,.276-.886;p=.018),同時“差的遵從性"的病人相對於有“好的遵從性"的病人會增加73.4%的死亡風險(HR, 1.734; 95% CI, 1.136-2.645; p=.011)。關於乳癌的局部復發,“差的遵從性"的病人(25.3%)相對於“好的遵從性"的病人(14.7%)有較高的五年局部復發機會(p<.001)。局部復發的多重回歸分析顯示“好的遵從性"和早期乳癌是獨立的改善因子。結論:近期的文獻及我們醫院的相關研究發現乳癌患者若有合併乳房重建,她們的乳癌存活率會顯著優於沒有重建的患者。本篇研究發現乳房全切除後合併立即橫向腹直肌肌皮瓣乳房重建手術的病人相較於沒有重建的病人有較好的臨床路徑遵從性,而多重回歸分析指出乳房重建及較好的遵從性皆是存活的獨立預測因子。因此MRM-TRAM組的病人相較於MRM組,同時擁有乳房重建及較好的臨床路徑遵從性這兩項特性,進而擁有較好存活率。 |
英文摘要 | Background: Based on data from the Surveillance, Epidemiology, and End Results database, recent studies have reported an improved breast-cancer-specific survival in patients who undergo breast reconstruction immediately following mastectomy, and research by our institution obtained consistent findings. However, the relationship between improved survival and breast reconstruction remains unclear. Aim and Objectives: We evaluated whether conformity with the practice guideline among breast cancer patients who underwent transverse rectus abdominis myocutaneous (TRAM) flap reconstructions immediately following modified radical mastectomy (MRM) was better than that of patients who underwent MRM alone. We also evaluated whether better conformity with the practice guideline could improve survival and reduce local recurrence. Materials and Methods: We analyzed the data of all women who had received TRAM flap reconstruction immediately after unilateral MRM at a single institution from January 2002 to December 2009. The 734 patients were divided into 2 treatment groups: TRAM flap reconstruction immediately after MRM (MRM-TRAM group, n = 226) and MRM alone (MRM group, n = 508). Subsequently, the patients were assigned to a poor conformity group if they met any of the following criteria (against the practice guideline for breast cancer treatment in our institution): (1) tumor size > 1 cm, but the patient refused chemotherapy following mastectomy; (2) positive estrogen receptor status, but the patient refused hormone therapy after mastectomy; and (3) metastases in ≥ 3 axillary lymph nodes, but the patient refused radiotherapy. The remaining patients were assigned to a good conformity group, and the survival and local recurrence rates of the 2 groups were then compared. The collected data comprised age, histology, tumor grade, cancer stage, estrogen receptor status, progesterone receptor status, and further adjuvant therapies (radiation therapy, chemotherapy, hormone therapy). Results: The conformity rate of the MRM-TRAM group (82.3%) was significantly better than that of the MRM group (74.4%) (P=.019). Compared with the poor conformity group, the good conformity group exhibited significantly higher breast cancer-specific survival (P<.001). The 5-year breast-cancer-specific survival rate of the good conformity group (87.0%) was significantly higher than that of the poor conformity group (75.3%) (P<.001). The 5-year survival rates of good conformity and poor conformity group in each cancer stage were: stage I, 94.1% and 97.6%, p=.502; stage II, 87.8% and 86.1%, p=.401; stage III, 74.5% and 51.6%, p=.001, respectively. A multivriate analysis revealed that good conformity, MRM with immediate breast reconstruction, and earlier TNM stage are accurate independent predictors of survival. Compared with the MRM group, the MRM-TRAM group exhibited a significantly lower mortality (hazard ratio; HR, .495; 95% confidence interval; CI, .276–0.886; P = .018). The poor conformity group exhibited a 73.4% increase in the risk of cancer-related death (HR, 1.734; 95% CI, 1.136-2.645; p = .011) in comparison with the good conformity group. The 5-year local recurrence rate of the poor conformity group (25.3%) was significantly higher than that of the good conformity group (14.7%) (P<.001). The multivariate analysis results indicated that good conformity and earlier TNM stage are accurate independent predictors of a reduced the rate of local recurrence. Conclusion: Recent studies and a previous research by our institution have demonstrated an improved breast cancer-specific survival in patients undergoing immediate breast reconstruction after mastectomy. This study points out that patients who undergo TRAM flap breast reconstruction immediately following MRM have better conformity with the practice guideline than those who undergo MRM alone. Furthermore, multivariate analytical model results indicate that good conformity and MRM with TRAM flap reconstruction are accurate independent predictors of survival. All these evidences prove that patients in MRM-TRAM group possess both factors of better conformity with the practice guideline and breast reconstruction can have better survival than non-reconstructed patients. |
本系統中英文摘要資訊取自各篇刊載內容。