MROC研究：即刻乳房重建术后1年患者报告结局

编译：郭瑢 述评：杨犇龙 吴炅

目的

乳房全切术后即刻乳房重建旨在减少乳房术后畸形，提高患者生活质量。本研究为MROC子研究，前瞻性地评估了植入物或自体皮瓣即刻乳房重建的患者报告结局。

方法

纳入MROC研究中乳腺癌术后即刻重建的患者1632例，包括即刻假体重建1139例，自体皮瓣重建493例， 1183例（72.5%）患者完成基线及术后1年患者报告结局量表。其中，69.8%为植入物重建，包括87例（5.3%）即刻置入假体（direct to implant , DTI）以及1052例（64.5%）扩张器-假体两步法（tissue expander/implant , TE/I）；30.2%为自体皮瓣重建，包括75 例（4.6%）带蒂横行腹直肌肌皮瓣（pedicle transverse rectus abdominis muscle,  PTRAM）、69 例（4.2%）游离横行腹直肌肌皮瓣（free transverse rectus abdominis muscle,  FTRAM）、294例（18.0%）游离腹壁下动脉穿支皮瓣（deep inferior epigastric perforator, DIEP）以及55例（3.4%）腹部浅动脉皮瓣（superficial inferior epigastric artery, SIEA）。使用的患者报告结局量表包括BREAST-Q和PROMIS-29。

结果

自体皮瓣重建术后1年与术前基线满意度相比，乳房满意度(差值, 6.3; P＜.001)，性健康满意度(差值, 4.5; P = .003)以及心理社会健康满意度(差值, 3.7; P = .02)均有所提高。而植入物重建术后1年与术前基线满意度相似。植入物组(差值, -3.8; P = .001) 及自体皮瓣组(-2.2; P = .04）术后1年胸部健康评分均低于术前，自体皮瓣组腹部健康评分远也不如术前(-13.4; P ＜ .001)。然而，两组患者术后1年焦虑和抑郁都有所减轻。同时，与基线相比，植入物重建患者1年后疲惫感减轻(差值, -1.4; P = .035)，但自体皮瓣患者疼痛干预增加(差值, 2.0; P = .006)。自体皮瓣重建与植入物重建相比，有较高的乳房满意度(差值, 6.3; P＜ .001)，性健康满意度(差值, 4.5; P= .003)以及心理社会健康满意度(差值, 3.7; P = .02)。

结论

即刻重建术后1年，自体皮瓣乳房重建患者乳房满意度、性健康满意度以及心理社会健康满意度均高于植入物重建组。尽管两组患者的重建乳房满意度与基线水平持平或稍有提高，然而在心里社会健康满意度方面并未得到彻底改善。

述评

MROC研究（Mastectomy Reconstruction Outcomes Consortium，MROC）是一个历时5年 ，旨在探讨乳房重建结局的多中心研究，所有数据均为前瞻性收集、录入。该研究有美国和加拿大的11个中心参与，包括：纪念斯隆-凯特林癌症中心，安德森癌症中心，西北纪念医院，乔治城大学，俄亥俄州立大学，圣约瑟夫-仁慈健康系统，乔治亚整形外科学会，布里格姆妇女医院，曼尼托巴大学以及普罗维登斯健康与服务中心。多中心研究、前瞻性实验设计、获得术前基线以及术后1年患者报告结局，以及较高的问卷响应率都是该研究能发表高质量文章的原因。

该研究发现自体皮瓣乳房重建患者乳房满意度、性健康满意度以及心理社会健康满意度均高于植入物重建组。这是一个大样本研究，可以较为容易的达到统计学上的意义，因此重要的不仅是考虑其统计学意义，同时需考虑这些其差异程度及临床意义。自体皮瓣与植物乳重建相比最为显著的是改善了患者术后乳房满意度，中度改善了性健康满意度，而心里社会健康满意度仅有较小差别。然而，自体皮瓣乳房重建组术后腹部健康评分远不如术前，疼痛干预也增加。

因此，该研究这并不意味着建议所有患者都选择自体皮瓣重建，而是再次为我们证实了自体皮瓣重建可获得更加自然、柔软的乳房，患者满意度高于植入物。但也有患者可能由于较短的手术时间，术后恢复时间以及没有供区的损伤而选择植入物重建；另外，部分术者并不能提供自体皮瓣重建的选择，也是植入物重建占比较高的原因之一。即便如此，该报道中，自体皮瓣乳房重建的比例仍达到30%，主要原因在于其联盟医疗机构均为北美卓越的医疗中心，有强大的整形外科团队参与乳腺癌多学科诊疗活动，并且承担住院医师和专科医生的教学任务。此研究结果可帮助乳腺专科和患者更好地理解重建手术的预期结果，并指导针对重建结局的临床革新。

Patient-Reported Outcomes 1 Year After Immediate Breast Reconstruction: Results of the Mastectomy Reconstruction Outcomes Consortium Study

【J CLIN ONCOL. 2017 AUG 1;35(22):2499-2506】

Andrea L. Pusic, Evan Matros, Neil Fine, Edward Buchel, Gayle M. Gordillo, Jennifer B. Hamill, Hyungjin M. Kim, Ji Qi, Claudia Albornoz, Anne F. Klassen, and Edwin G. Wilkins

Author affiliations and support information (if applicable) appear at the end of this article.

Published at jco.org on March 27, 2017.

The BREAST-Q is owned by Memorial Sloan Kettering Cancer Center and the University of British Columbia. A.L.P. is a co-developer of the BREAST-Q and receives royalties when it is used in for- profit industry-sponsored clinical trials.

Clinical trial information: NCT01723423.

Corresponding author: Andrea L. Pusic, MD, Memorial Sloan Kettering Cancer Center, 417 E 68th St, New York, NY 10065; e-mail: [e-mail].

Purpose

The goals of immediate postmastectomy breast reconstruction are to minimize deformity and optimize quality of life as perceived by patients. We prospectively evaluated patient-reported outcomes (PROs) in women undergoing immediate implant-based or autolgous reconstruction.

Methods

Women undergoing immediate postmastectomy reconstruction for invasive cancer and/or carci- noma in situ were enrolled at 11 sites. Women underwent implant-based or autologous tissue reconstruction. Patients completed the BREAST-Q, a condition-specific PRO measure for breast surgery patients, and Patient-Reported Outcomes Measurement Information System–29, a generic PRO measure, before and 1 year after surgery. Mean changes in PRO scores were summarized. Mixed-effects regression models were used to compare PRO scores across procedure types.

Results

In total, 1,632 patients (n = 1,139 implant, n = 493 autologous) were included; 1,183 (72.5%) responded to 1-year questionnaires. After analysis was controlled for baseline values, patients who underwent autologous reconstruction had greater satisfaction with their breasts than those who underwent implant-based reconstruction (difference, 6.3; P , .001), greater sexual well-being (difference, 4.5; P = .003), and greater psychosocial well-being (difference, 3.7; P = .02) at 1 year. Patients in the autologous reconstruction group had improved satisfaction with breasts (difference, 8.0; P = .002) and psychosocial well-being (difference, 4.6; P = .047) compared with preoperative baseline. Physical well-being of the chest was not fully restored in either the implant group (difference, 23.8; P = .001) or autologous group (22.2; P = .04), nor was physical well-being of the abdomen in patients who underwent autologous reconstruction (213.4; P , .001). Anxiety and depression were mitigated at 1 year in both groups. Compared with their baseline reports, patients who underwent implant reconstruction had decreased fatigue (difference, 21.4; P = .035), whereas patients who underwent autologous reconstruction had increased pain interference (difference, 2.0; P = .006).

Conclusion

At 1 year after mastectomy, patients who underwent autologous reconstruction were more satisfied with their breasts and had greater psychosocial and sexual well-being than those who underwent implant reconstruction. Although satisfaction with breasts was equal to or greater than baseline levels, physical well-being was not fully restored. This information can help patients better un- derstand expected outcomes and may guide innovations to improve outcomes.