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中华乳腺病杂志(电子版) ›› 2019, Vol. 13 ›› Issue (01) : 16 -23. doi: 10.3877/cma.j.issn.1674-0807.2019.01.003

所属专题： 文献；

论著

自体脂肪移植在乳腺癌术后乳房重建中肿瘤学安全性的Meta分析
刘欢欢1, 林珣珣2, 许澍洽2, 许扬滨2,†()   
  1. 1. 510120　广州，孙逸仙纪念医院整形外科
    2. 510080　广州，中山大学附属第一医院整形外科
  • 收稿日期:2018-10-30 出版日期:2019-02-01
  • 通信作者: 许扬滨

Oncological safety of autologous fat grafting for breast reconstruction after mastectomy: a meta-analysis

Huanhuan Liu1, Xunxun Lin2, Shuqia Xu2, Yangbin Xu2,†()   

  1. 1. Department of Plastic Surgery, Sun Yat-Sen Memorial Hospital, Guangzhou 510120, China
    2. Department of Plastic Surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510080, China
  • Received:2018-10-30 Published:2019-02-01
  • Corresponding author: Yangbin Xu
  • About author:
    Corresponding author: Xu Yangbin, Email:
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引用本文：

刘欢欢, 林珣珣, 许澍洽, 许扬滨. 自体脂肪移植在乳腺癌术后乳房重建中肿瘤学安全性的Meta分析[J]. 中华乳腺病杂志(电子版), 2019, 13(01): 16-23.

Huanhuan Liu, Xunxun Lin, Shuqia Xu, Yangbin Xu. Oncological safety of autologous fat grafting for breast reconstruction after mastectomy: a meta-analysis[J]. Chinese Journal of Breast Disease(Electronic Edition), 2019, 13(01): 16-23.

目的

评价乳腺癌术后乳房重建患者行自体脂肪移植的肿瘤学安全性。

方法

检索PubMed、Embase、Cochrane、中国知网、万方及维普数据库，收集截止至2018年5月所有已发表的队列研究，由2位评价员独立完成文献筛选和数据提取，并运用改良纽卡斯尔-渥太华量表(NOS)系统评价文献质量。采用比值比(OR)及95%置信区间(CI)为效应量，使用RevMan 5.3软件进行Meta分析。

结果

最终纳入符合标准的文献13篇，总样本量8 466例患者，其中乳房重建过程应用脂肪移植者(AFG组)1 963例，未应用脂肪移植者(NFG组)6 503例。NOS评价结果显示，所有纳入文献质量均较高(评分为6～9分)。Meta分析显示：AFG组总复发病例数为88例(4.5%，88/1 963)，NFG组总复发病例数为455例(7.0%，455/6 503)，AFG组乳腺癌复发率明显低于NFG组(OR＝0.73，95%CI：0.57～0.95，P＝0.02)；脂肪移植对乳腺癌的局部复发率、区域复发率及远处复发率均无显著影响(OR＝1.06，95%CI：0.60～1.88，P＝0.84；OR＝0.89，95%CI：0.32～2.48，P＝0.83；OR＝0.36，95%CI：0.10～1.28，P＝0.11)。亚组分析显示：在DCIS或浸润性癌患者中，脂肪移植对乳腺癌复发率无显著影响(OR＝1.16，95%CI：0.05～26.91，P＝0.93；OR＝0.68，95%CI：0.40～1.16，P＝0.16)；在行保留乳房术或乳房全切手术的患者中，脂肪移植对乳腺癌复发率亦无显著影响(OR＝0.36，95%CI：0.08～1.66，P＝0.19；OR＝0.64，95%CI：0.33～1.26，P＝0.19)。

结论

基于1965年1月至2018年5月相关临床队列研究的综合分析，自体脂肪移植是安全的，且其乳腺癌复发风险较低。

关键词: Meta分析, 乳腺肿瘤, 乳房成形术, 自体脂肪移植, 肿瘤学安全性
Objective

To investigate the oncological safety of autologous fat grafting for breast reconstruction after mastectomy in breast cancer patients.

Methods

The PubMed, Embase, Cochrane, CNKI, Wanfang and VIP databases were searched for all published relevant cohort studies up to May 2018. According to the Newcastle Ottawa Scale (NOS), the literature screening, data extraction and systematic evaluation were performed by two reviewers independently. A meta-analysis was performed using the RevMan 5.3 software, with odds ratio (OR) and 95% confidence interval (CI) as the effect size.

Results

Thirteen studies were included, with a sample size of 8 466 patients including 1 963 patients in autologous fat grafting group (AFG group) and 6 503 patients in non-fat grafting group (NFG group). The NOS scores were 6 to 9, indicating high methodological quality. The meta-analysis showed that 455 patients (7.0%, 455/6 503) in NFG group had recurrence, while 88 patients (4.5%, 88/1 963) in AFG group had recurrence, indicating that the recurrence rate of AFG group was significantly lower than that of NFG group (OR=0.73, 95%CI: 0.57-0.95, P=0.02). Fat grafting had no significant effect on the local recurrence rate, regional recurrence rate and distant recurrence rate (OR=1.06, 95%CI: 0.60-1.88, P=0.84; OR=0.89, 95%CI: 0.32-2.48, P=0.83; OR=0.36, 95%CI: 0.10-1.28, P=0.11). Subgroup analysis showed that fat grafting had no significant effect on the recurrence rate of breast cancer in patients with carcinoma in situ or invasive carcinoma (OR=1.16, 95%CI: 0.05-26.91, P=0.93; OR=0.68, 95%CI: 0.40-1.16, P=0.16). The fat grafting still had no significant effect on the recurrence rate of breast cancer in the patients undergoing breast-conserving surgery or total mastectomy (OR=0.36, 95%CI: 0.08-1.66, P=0.19; OR=0.64, 95%CI: 0.33-1.26, P=0.19).

Conclusion

Based on our meta-analysis of the cohort studies from January 1965 to May 2018, autologous fat grafting is feasible, with low risk of recurrence.

Key words: Meta-analysis, Breast neoplasms, Mammaplasty, Autologous fat grafting, Oncological safety
表1 Meta分析的文献纳入标准
项目 内容
患者 确诊乳腺癌并手术的患者，乳房重建方式包含自体脂肪移植重建、自体皮瓣重建、假体/扩张器重建或混合重建
干预 利用Colman方法、改良Colman方法对乳腺癌术后的患者行自体脂肪移植
比较 比较自体脂肪移植组与非自体脂肪移植组患者的乳腺癌复发率
结局 术后随访12个月以上，乳腺癌复发为结局指标
研究设计 已发表的回顾性队列研究、前瞻性队列研究，一次文献(无语言限制)
表2 纳入文献的质量评价
文献作者 出版年 研究类型 研究对象选择(分) 组间可比性(分) 结果测量(分) NOS总分
Bennett等[10] 2017 PCS 4 2 2 8
Cohen等[11] 2017 RCS 3 2 2 7
Khan等[12] 2017 RCS 3 2 1 6
Kronowitz等[13] 2016 PCS 4 2 3 9
Masia等[14] 2015 RCS 3 2 3 8
Mestak等[15] 2016 PCS 4 2 2 8
Myckatyn等[16] 2017 RCS 3 1 2 6
Petit等[17] 2012 RCS 4 2 2 8
Petit等[18] 2013 RCS 3 2 2 7
Seth等[19] 2012 RCS 3 2 2 7
Fertsch等[20] 2017 RCS 3 2 3 8
Stumpf等[21] 2017 RCS 3 1 2 6
Weichman等[22] 2013 RCS 3 1 2 6
表3 纳入文献的基本特征
文献作者 出版年 病例数 随访时间(月) 平均年龄(岁) 手术类型 重建方式 证据等级
AFG组 NFG组
Bennett等[10] 2017 150 1 682 未说明 48 乳房全切 假体皮瓣 Ⅱ
Cohen等[11] 2017 162 414 45.6 50 乳房全切 假体皮瓣 Ⅲ
Khan等[12] 2017 32 39 36.0 52 保留乳房 未说明 Ⅲ
Kronowitz等[13] 2016 719 670 59.6 47 乳房全切(639) 假体皮瓣 Ⅱ
? ? ? ? ? ? 保留乳房(79) ? ?
Masia等[14] 2015 107 107 89.0 49 乳房全切 皮瓣 Ⅲ
Mestak等[15] 2016 32 45 77.0 56 保留乳房 未说明 Ⅲ
Myckatyn等[16] 2017 64 1 133 未说明 47 乳房全切 皮瓣 Ⅲ
Petit等[17] 2012 321 642 56.0 45 乳房全切(196) 假体皮瓣 Ⅲ
? ? ? ? ? ? 保留乳房(125) ? ?
Petit等[18] 2013 59 118 63.0 47 乳房全切(47) 未说明 Ⅲ
? ? ? ? ? ? 保留乳房(12) ? ?
Seth等[19] 2012 90 1 112 44.6 48 乳房全切 扩张器 Ⅲ
Fertsch等[20] 2017 100 100 72.5 50 乳房全切 皮瓣 Ⅱ
Stumpf等[21] 2017 27 167 36.0 54 保留乳房 未说明 Ⅲ
Weichman等[22] 2013 100 274 18.0 49 乳房全切 皮瓣 Ⅲ
图1 文献筛选流程图
图2 自体脂肪移植(AFG)组与非自体脂肪移植(NFG)组乳腺癌患者术后复发的森林图及异质性检验结果
图3 13篇文献发表偏倚检验结果　a图所示13篇文献发表偏倚漏斗图；b图所示Egger回归图(t＝0.25，P＝0.80，95%CI: －1.04～1.31，包含0)；c图所示Begg漏斗图(Z<0.01时，P>0.05)；d图所示剪补法校正后的漏斗图(与剪补法校正前一致)
图4 自体脂肪移植(AFG)组与非自体脂肪移植(NFG)组乳腺癌患者复发类型分层分析的森林图及异质性检验结果　a图所示，采用固定效应模型分析AFG组与NFG组患者局部复发和区域复发的差异；b图所示，采用随机效应模型分析AFG组与NFG组患者远处复发的差异
图5 按乳腺癌患者疾病特征分类的分层分析森林图及异质性检验结果　a图所示，采用随机效应模型分析导管原位癌亚组中，自体脂肪移植(AFG)组与非自体脂肪移植(NFG)组患者复发率的差异；b图所示，采用固定效应模型分析浸润性癌以及保留乳房、全乳切除亚组中，AFG组与NFG组患者复发率的差异
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