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癌症围手术期的三个因素（手术应激反应、挥发性麻醉剂、阿片类药物镇痛）可能削弱人体对癌症复发的防御能力，区域麻醉镇痛可能改善这些因素。有学者推测：一、椎旁阻滞和丙泊酚（异丙酚）区域麻醉镇痛，与挥发性麻醉剂七氟烷（七氟醚）全身麻醉和阿片类药物镇痛相比，乳腺癌根治手术后复发较少；二、区域麻醉镇痛可以减少切口持续疼痛。 2019年10月20日，国际四大医学期刊之一、英国《柳叶刀》正刊在线发表美国克利夫兰医学中心、中国医学科学院北京协和医院、奥地利维也纳医科大学、德国杜塞尔多夫大学、新加坡南洋理工大学陈笃生医院、爱尔兰都柏林大学的随机对照研究报告，对乳腺癌区域或全身麻醉手术后的长期复发和切口疼痛进行了比较。 该国际多中心随机对照研究于2007年1月30日～2018年1月18日从阿根廷、奥地利、中国、德国、爱尔兰、新西兰、新加坡、美国的13家医院，入组年龄<85岁的原发乳腺癌根治切除女性，通过计算机随机分组，接受区域麻醉镇痛（椎旁阻滞和丙泊酚）或者全身麻醉（七氟醚）和阿片类药物镇痛。主要结局为乳腺癌局部或远处转移复发，次要结局为6个月和12个月时的切口疼痛。初步分析按照意向治疗原则进行。超过预设无效临界值后，该研究停止。 NCT00418457: Regional Anesthesia and Breast Cancer Recurrence 结果，该研究入组2132例女性，其中24例由于不符合条件、患者或医师决定、手术取消，而未接受手术和麻醉镇痛，其余1043例接受区域麻醉镇痛、1065例接受全身麻醉镇痛。两组患者入组时特征相似。中位随访36个月（四分位24～49）。 区域麻醉镇痛与全身麻醉镇痛相比：
因此，该研究结果表明，对于该乳腺癌手术人群，区域麻醉镇痛（椎旁阻滞和丙泊酚）与挥发性麻醉药（七氟烷）和阿片类药物相比，根治手术后乳腺癌复发并未减少，乳房切口持续疼痛比例和严重程度相似。临床医师既可以选择区域麻醉镇痛，也可以选择全身麻醉镇痛，并不影响乳腺癌复发和切口持续疼痛。 对此，加拿大渥太华大学、多伦多大学和圣米迦勒医院发表同期评论：麻醉干预与长期肿瘤复发。 Lancet. 2019 Oct 20. [Epub ahead of print] Recurrence of breast cancer after regional or general anaesthesia: a randomised controlled trial. Daniel I Sessler, Lijian Pei, Yuguang Huang, Edith Fleischmann, Peter Marhofer, Andrea Kurz, Douglas B Mayers, Tanja A Meyer-Treschan, Martin Grady, Ern Yu Tan, Sabry Ayad, Edward J Mascha, Donal J Buggy; Breast Cancer Recurrence Collaboration. Cleveland Clinic, Cleveland, OH, USA; Peking Union Medical College Hospital, Beijing, China; Medical University of Vienna, Vienna, Austria; University of Düsseldorf, Düsseldorf, Germany; Tan Tock Seng Hospital, Singapore, Singapore; University College Dublin, Dublin, Ireland. 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. FUNDING: Sisk Healthcare Foundation (Ireland), Eccles Breast Cancer Research Fund, British Journal of Anaesthesia International, College of Anaesthetists of Ireland, Peking Union Medical College Hospital, Science Fund for Junior Faculty 2016, Central Bank of Austria, and National Healthcare Group. DOI: 10.1016/S0140-6736(19)32313-X Lancet. 2019 Oct 20. [Epub ahead of print] Anaesthetic interventions and long-term tumour recurrence. Faraj W Abdallah, Duminda N Wijeysundera. University of Ottawa, Ottawa, ON, Canada; University of Toronto, Toronto, ON, Canada; St Michael's Hospital, Toronto, ON, Canada. Surgery is a major component of the treatment plan for patients with potentially curable solid tumours. The efficacy of surgery in preventing tumour recurrence is affected by several factors, including disease stage, adequacy of surgical tumour resection, and intrinsic antitumour immunity. 1 Although adequate intraoperative and postoperative pain control is an important component of optimum recovery after surgery, pain might also be another factor affecting the risk of long-term recurrence after cancer surgery. Specifically, pain has both direct and indirect (ie, mediated via the surgical stress response) immunosuppressive effects, as do some commonly used pain-control drugs (eg, inhaled general anaesthetics and opioids). DOI: 10.1016/S0140-6736(19)32314-1
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