美国克利夫兰诊所Daniel I Sessler教授课题组联合北京协和医院黄宇光教授课题组比较了乳腺癌局部或全身麻醉术后的复发率。相关论文10月20日在线发表于《柳叶刀》。

在癌症手术中，有三个围手术期因素影响复发率：手术应激反应、使用挥发性麻醉剂和阿片类镇痛。而局部麻醉镇痛可改善上述因素。研究组对局部麻醉镇痛较于全身麻醉镇痛，是否会降低乳腺癌术后的复发率进行了验证。

研究人员在阿根廷、奥地利、中国、德国、爱尔兰、新西兰、新加坡和美国的13家医院进行了一项随机对照试验。 2007年1月30日至2018年1月18日，研究组共招募了2132名年龄低于85岁的原发性乳腺癌患者，这些患者经手术有望治愈。术前排除24名。随机将其分为两组，其中1043名接受局部麻醉镇痛，即椎旁阻滞和异丙酚；1065名接受全身麻醉，即七氟醚和阿片镇痛。两组患者的一般资料无显著差异。

中位随访36个月后，局麻镇痛组中有102例（10%）复发，全麻镇痛组中有111例（10%）。局麻镇痛组和全麻镇痛组术后6个月切口疼痛的发生率分别为52%和52%，术后12个月则分别为28%和27%；术后6个月神经性乳腺疼痛的发生率分别为10%，术后12个月则分别为7%，均无显著性差异。

研究结果表明，与挥发性麻醉剂和阿片类药物相比，局部麻醉镇痛并不能降低乳腺癌术后的复发率。术后持续性乳房切口疼痛的发生率和严重程度亦与麻醉方式无关。

附：英文原文

Title: Recurrence of breast cancer after regional or general anaesthesia: a randomised controlled trial

Author: Prof Daniel I Sessler, MD,Lijian Pei, MD,Prof Yuguang Huang, MD,Prof Edith Fleischmann, MD,Prof Peter Marhofer, MD,Prof Andrea Kurz, MD,Douglas B Mayers, MD,Tanja A Meyer-Treschan, MD,Martin Grady, MD,Ern Yu Tan, MD,Prof Sabry Ayad, MD,Edward J Mascha, PhD,Prof Donal J Buggy, MD,on behalf of the Breast Cancer Recurrence Collaboration *

Issue&Volume: 2019-10-20

Abstract: 

Background

Three perioperative factors impair host defence against recurrence during cancer surgery: the surgical stress response, use of volatile anaesthetic, and opioids for analgesia. All factors are ameliorated by regional anaesthesia-analgesia. We tested the primary hypothesis that breast cancer recurrence after potentially curative surgery is lower with regional anaesthesia-analgesia using paravertebral blocks and the anaesthetic propofol than with general anaesthesia with the volatile anaesthetic sevoflurane and opioid analgesia. A second hypothesis was that regional anaesthesia-analgesia reduces persistent incisional pain.

Methods

We did a randomised controlled trial at 13 hospitals in Argentina, Austria, China, Germany, Ireland, New Zealand, Singapore, and the USA. Women (age <85 years) having potentially curative primary breast cancer resections were randomised by computer to either regional anaesthesia-analgesia (paravertebral blocks and propofol) or general anaesthesia (sevoflurane) and opioid analgesia. The primary outcome was local or metastatic breast cancer recurrence. The secondary outcome was incisional pain at 6 months and 12 months. Primary analyses were done under intention-to-treat principles. This trial is registered with ClinicalTrials.gov, NCT00418457. The study was stopped after a preplanned futility boundary was crossed.

Findings

Between Jan 30, 2007, and Jan 18, 2018, 2132 women were enrolled to the study, of whom 24 were excluded before surgery. 1043 were assigned to regional anaesthesia-analgesia and 1065 were allocated to general anaesthesia. Baseline characteristics were well balanced between study groups. Median follow-up was 36 (IQR 24–49) months. Among women assigned regional anaesthesia-analgesia, 102 (10%) recurrences were reported, compared with 111 (10%) recurrences among those allocated general anaesthesia (hazard ratio 0·97, 95% CI 0·74–1·28; p=0·84). Incisional pain was reported by 442 (52%) of 856 patients assigned to regional anaesthesia-analgesia and 456 (52%) of 872 patients allocated to general anaesthesia at 6 months, and by 239 (28%) of 854 patients and 232 (27%) of 852 patients, respectively, at 12 months (overall interim-adjusted odds ratio 1·00, 95% CI 0·85–1·17; p=0·99). Neuropathic breast pain did not differ by anaesthetic technique and was reported by 87 (10%) of 859 patients assigned to regional anaesthesia-analgesia and 89 (10%) of 870 patients allocated to general anaesthesia at 6 months, and by 57 (7%) of 857 patients and 57 (7%) of 854 patients, respectively, at 12 months.

Interpretation

In our study population, regional anaesthesia-analgesia (paravertebral block and propofol) did not reduce breast cancer recurrence after potentially curative surgery compared with volatile anaesthesia (sevoflurane) and opioids. The frequency and severity of persistent incisional breast pain was unaffected by anaesthetic technique. Clinicians can use regional or general anaesthesia with respect to breast cancer recurrence and persistent incisional pain.

DOI: 10.1016/S0140-6736(19)32313-X

Source: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)32313-X/fulltext