Application of endoscopic surgery for breast cancer treatment

Endoscopic breast surgery has the advantage that it can be performed from a small, inconspicuous incision remote from the lesion. The cosmetic outcome is an important factor in the selection of the surgical technique as in addition to the oncologic effect on breast cancer. From this point of view, endoscopic partial mastectomy should be performed in patients with small tumors, especially those located in the upper quadrants. The approach should be selected for each case considering the size and location of the tumor. For patients with multiple tumors or with tumors accompanied by extended intraductal components, endoscopic total glandectomy or subcutaneous mastectomy with breast reconstruction is a good choice. Patients with a tumor located near the skin or invading the skin are not candidates for endoscopic surgery. Endoscopic axillary dissection is still controversial in its advantages compared with conventional surgery. To avoid surgical complications and an increase in the local failure rate of breast cancer, selection of patients and the surgical technique must be considered carefully.     

Endoscopic-assisted subcutaneous mastectomy and axillary dissection with immediate mammary prosthesis reconstruction for early breast cancer

BACKGROUND: Endoscopic surgery has been applied successfully in breast lump excision, breast augmentation, subcutaneous mastectomy for gynecomastia, and axillary dissection. Since subcutaneous mastectomy has been proven to be oncologically safe for early breast cancer, we have sought to develop a reproducible minimally invasive endoscopic-assisted technique to address this condition. METHODS: Between December 1998 and May 1999, endoscopic-assisted subcutaneous mastectomy and axillary dissection with immediate reconstruction using a mammary prosthesis was performed in nine patients with early breast cancer at the Prince of Wales Hospital, Hong Kong. A 5-cm skin incision was made along the line of the lowest axillary skin crease. Dissection was continued down to the lateral border of the pectoralis major muscle. A subpectoral pocket was gently created by an endoscopic breast dissector. The endoscopic breast retractor and 10-mm/30 degrees scope were introduced into the subpectoral pocket, and further dissection was carried out using a 7-in harmonic scalpel under endoscopic vision down to a level 1 cm caudal to the inframammary fold. This subpectoral space was used for the insertion of the mammary prosthesis later on. Endoscopic-assisted subcutaneous mastectomy was performed afterward. Combined level I and level II axillary dissection was carried out via the same incision under direct vision. RESULTS: Apart from minor skin flap bruises in our first two patients, there were no major complications. Histological examination of all the specimens showed clear margins. Postoperative radiotherapy and chemotherapy were given in the usual manner. All patients were satisfied with the reconstructive outcome. CONCLUSIONS: We have described a novel endoscopic technique for subcutaneous mastectomy with immediate mammary prosthesis reconstruction in treating early breast cancer patient. This technique can minimize skin incision, reduce blood loss, and improve reconstructive outcome. It is easy to learn and well accepted by patients.     

腔镜腋窝淋巴结清扫在早期乳腺癌保乳手术中的应用

目的:探讨腔镜腋窝淋巴结清扫治疗早期乳腺癌保乳手术的可行性及临床效果。方法:回顾分析98例早期乳腺癌行保乳手术的临床资料,其中41例行腔镜腋窝淋巴结清扫术(腔镜组),57例行常规腋窝淋巴结清扫术(常规组),比较两组手术时间、出血量、清扫淋巴结个数、阳性淋巴结数及并发症、预后等。结果:两组均完成手术。腔镜组与常规组平均手术时间分别为99.5 min与61.5 min(P<0.05),平均清扫出腋窝淋巴结数分别为17.6枚与18.6枚(P>0.05),平均阳性淋巴结数分别为2.1枚与2.4枚(P>0.05),平均手术出血量分别为35.4 mL与61.5 mL(P<0.05)。随访1～4年,腔镜组无复发及转移病例,未出现术后并发症。常规组1例出现患侧上肢水肿,1例乳房皮肤瘢痕愈合不良;1例乳房局部复发,1例肺转移,1例胫骨转移。两组均无死亡病例。结论:腔镜腋窝淋巴结清扫术与开放腋窝淋巴结清扫术同样能彻底完成腋窝淋巴结清扫,具有并发症少,美学效果好的优势。     

Video-assisted axillary surgery for cancer: non-randomized comparison with conventional techniques

Endoscopic techniques have been introduced in most of surgical disciplines including surgery for breast cancer. However, there is shortage of evidence-based guidelines and oncological outcome data. We present a controlled trial of endoscopic axillary surgery for breast cancer with mid-term oncologic results. Fifty cases of axilloscopy for sentinel node biopsy, axillary sampling or full axillary dissection were included. Sentinel node biopsy was accomplished with the blue dye technique. Full axillary dissection was performed with a three-port approach with gas insufflation without liposuction. Endoscopic axillary dissection significantly lowered duration of drainage and operative blood loss. Lymph node harvest with endoscopic approach was significantly lower than with open procedure. One case developed axillary recurrence. Endoscopic sentinel node biopsy yielded identification rate of 80%. Current data do not justify the oncological safety of resectional endoscopic procedures. Endoscopically assisted axillary cancer surgery is technically feasible. The technique is valuable to maximize utility of blue dye method for sentinel lymphadenectomy in areas with no access to radio-guided surgery.     

Endoscopic breast surgery for breast cancer

Since 1995, endoscopic breast surgery (EBS) has been gradually established in Japan. Establishment of EBS was inextricably linked to explosive development of instruments for endoscopic surgery and profound theoretical understanding, how to perform broad & stable dissection of the compact connective tissue thorough small incisions. EBS consisted chiefly of two procedures added to breast and axilla and procedures to breast is classified into three methods according to incisions, axillar, periareolar and combined incisions. With EBS technique, any kind breast surgery, sentinel node biopsy, reconstruction, augmentation, and benign tumor excision, could be performed through same skin incisions. Curability of breast cancer EBS is same as that with conventional method and local recurrence rate after total and partial mastectomy. All breast cancer without skin involvement of cancer would be candidate for EBS. To minimize invasiveness of treatment and maintain cosmetic outcome of breast, combination treatment of ablation treatment, EBS and evolution of radiation therapy would be important.     

Transaxillary retromammary route approach of video-assisted breast surgery enables the inner-side breast cancer to be resected for breast conserving surgery

BACKGROUND: Endoscopic surgery for inner-side breast cancer usually is performed by periareolar approach, but leaves deformation or malposition, and sensory disturbance. We devised an approach of retromammary route without subcutaneous removal, from an axillary skin incision, to treat distant cancers and also to preserve sensation to skin touch. METHODS: We have performed video-assisted breast surgery on 230 patients. The transaxillary retromammary-route approach was performed on 20 patients with early breast cancer. From a 2.5-cm axillary incision, we dissected the major pectoral muscle fascia to detach retromammary tissue. We cut the proximal side of the gland vertically, and dissected the skin flap over the tumor by the tunnel method. Then we cut each side of the gland vertically and removed it through the axillary port. RESULTS: All surgical margins were negative. The surgical time was 45 minutes longer than the conventional video-assisted breast surgery. The postoperative esthetic results were good. CONCLUSIONS: The transaxillary retromammary-route approach leaves no injury on whole breast, and can become a single standard method for breast-conserving surgery wherever a cancer is situated.     

Endoscopy-assisted Breast-Conserving Surgery for Early Breast Cancer

Purpose Breast-conserving surgery is now accepted as one of the standard therapeutic options for stages I and II breast cancers. Although breast-conserving surgery can help retain a good breast shape, a long marked scar would be a disadvantage. Endoscopic surgery can be performed via a small and remote incision that becomes inconspicuous after surgery. To improve the cosmetic outcome, endoscopic breast-conserving surgery, which can be performed through minimal axillary and periareolar semicircular incisions, was undertaken. Methods and materials From October 2002 to October 2004, 20 breast cancer patients whose tumor sizes were less than 3 cm and who were clinically node negative without invasion to the skin and pectoralis major muscle underwent endoscopic breast-conserving surgery. First, endoscopic dye-guided sentinel node biopsy was done through a low transverse axillary incision lateral to the pectoralis major muscle. The subpectoral pocket was gently created by Vein Harvest under the view of endoscopic monitor. We made the periareolar semicircular incision to create the skin flap and to resect the tumor-containing quadrant by using Visiport and PowerStar scissors. Frozen-section biopsies were done to rule out tumor invasion to the resection margin. Patient characteristics, tumor characteristics, operation time, and amount of bleedings were all evaluated. Results The mean age of patients was 45 (range: 25–64). The mean tumor size was 2.2 cm (range: 0.2–4.0 cm). The average operation time of the early 9 cases, except the 3 cases that underwent axillary-node dissection, was 178 minutes, and that of the later 8 cases was 130 minutes (P < 0.001). The mean amount of operative bleeding was 184 ± 130 ml. There were no major complications. Conclusion Endoscopic breast-conserving surgery is a new technique that can minimize the long operation scar of classic breast-conserving surgery. In properly selected cases, our results showed the maximized cosmetic satisfaction of the breast cancer patients and a shortened operation time after the learning period, promising it could be an alternative to the classic breast-conserving surgery. This article contains a supplementary video. This paper is to be presented as a video-mode presentation for the 41st World Congress of Surgery at the International Surgical Society/Societe Internationale de Chirurgie (August 21–25, 2005, Durban, South Africa)     

腔镜技术在乳腺疾病中的应用

目的 探讨腔镜技术在乳腺疾病的诊断和治疗方面的安全性和可行性。方法 对近年来有关文献进行复习。结果 微创腔镜手术可以通过小切口完成，从而最大限度地减少术后疼痛，缩短恢复时间，而且切口位于隐蔽部位，具有较好的美容效果。通过乳腺腔镜可以进行细微的止血和解剖，并安全地完成乳房切除术和乳房即时重建、哨兵淋巴结活检以及腋窝淋巴结清扫手术；还可用于乳腺良性肿瘤的诊断和治疗，以及男性乳房肥大症患者的手术治疗；纤维乳管镜可用于乳头溢液患者的诊断。通过腔镜手术既可使乳腺疾病有满意的治疗效果，又保持术后良好的乳房外形与功能，而不遗留明显的瘢痕，从而可以增强患者的自信心，提高生活质量。结论 乳腺外科是腔镜技术一个很好的应用领域。     

Laparoscopic-assisted axillary dissection in breast cancer surgery

BACKGROUND: Significant morbidity such as pain, paresthesia, and arm stiffness has often been associated with axillary dissection for breast cancer. We report our experience of 30 patients with stage I and II invasive ductal carcinoma of the breast who underwent laparoscopic-assisted axillary dissection together with segmental mastectomy. METHODS: Tumours were situated in the upper or lower lateral quadrants only. In all cases, initial exposure for axillary dissection was performed through the breast periareolar incision. A 10-mm 30 degrees laparoscope was introduced through the breast incision to gain entry to the axilla. A separate stab incision in the lower aspect of the axilla was used for introduction of the 5-mm Harmonic shears (Ethicon Endo-Surgery, Inc, Cincinnati, OH). A grasping forceps was introduced through the main incision alongside the endoscope. Subsequent axillary dissection was performed laparoscopically, and the axillary content was removed through the breast incision. RESULTS: Average yield of lymph nodes was 15 (range 7 to 25). There were no intraoperative complications. Immediately postsurgery, all patients were able to fully mobilize the upper limb, facilitated by absence of an axillary scar. Patients also reported minimal pain, paresthesia, with no stiffness or frozen shoulder. CONCLUSION: Laparoscopic-assisted axillary dissection offers a safe and improved approach to the axilla, which can be incorporated into breast cancer surgery.     

非溶脂腔镜腋窝淋巴结清扫术在乳腺癌治疗中的临床研究

目的:探讨非溶脂腔镜腋窝淋巴结清扫术治疗乳腺癌的临床疗效、安全性、优势、手术规范与技巧。方法:前瞻性纳入2016年10月至2019年10月收治的96例乳腺癌患者。根据腋窝手术方式随机分为腔镜组(n=48,行非溶脂腔镜腋窝淋巴结清扫术)与对照组(n=48,行传统开放腋窝淋巴结清扫术)。对比分析两组临床资料及治疗结果。结果:两组手术时间、淋巴结清扫数量、淋巴结阳性率差异无统计学意义(P>0.05)。腔镜组手术切口、术中出血量、术后引流量、手术并发症发生率优于对照组,住院费用高于对照组,差异有统计学意义(P<0.05)。术后6个月,腔镜组肩关节活动度、生活质量评分均优于对照组,差异有统计学意义(P<0.05)。术后随访14~50个月,中位随访37个月,两组均未出现切口种植、局部复发及远处转移。结论:非溶脂腔镜腋窝淋巴结清扫术在保证腋窝淋巴结清扫效果的同时具有美容效果好、创伤小、并发症少等优势,改善了患者的术后生活质量,值得临床推广应用,但术者需要具备一定的腔镜下乳腺手术技术与技巧。     

Breast conservation treatment of early breast cancer--eight-year experience]

In the period between 1983 and 1991, we experienced 80 cases of early breast cancer treated by conservative surgery and postoperative radiotherapy. Our indications for breast conservation treatment are the size of tumor (less than 2 cm), the location (more than 3 cm away from the nipple) and no palpable axillary nodes. Our surgical procedures of quadrantectomy and level I and II axillary dissection are presented. The shape of the skin incision should be elliptical with the major axis radial from the nipple for good cosmetic results. The entire quadrant of the breast containing the primary carcinoma is radically removed with the superficial pectoralis fascia. At present, one breast recurrence and two distant metastases have developed. A further follow up study is needed to prove the safety of breast conservation treatment.     

Immediate reconstruction in breast cancer surgery requires intensive post-operative pain treatment but the effects of axillary dissection may be more predictive of chronic pain

The aim of this study was to investigate post-operative pain intensity, analgesic consumption and the incidence of chronic pain in women after different types of breast cancer surgery. Patients were randomized to either patient-controlled analgesia or nurse-administered analgesia. Opioid-consumption was registered for 24 h. A division of the patient-material into four subgroups was performed: (1) mastectomy; (2) mastectomy and axillary lymph node dissection; (3) mastectomy and reconstruction; and (4) mastectomy, reconstruction and axillary lymph node dissection. Visual analogue scale was used to measure pain intensity. Four years after surgery, a questionnaire regarding persistent pain was completed. Patients undergoing reconstruction scored higher pain levels than the others. Patient-controlled analgesia provided better pain relief but also considerably higher consumption of opioids by the women who underwent breast reconstruction. The incidence of remaining pain was 25% after 3-4 years. Immediate breast reconstruction causes severe post-operative pain that can respond poorly to opioids. Chronic pain after breast cancer surgery is common and should be further analysed aiming at better prevention and treatment options.     

注射溶脂剂在乳腺癌腋窝淋巴结清扫术中的应用价值

目的:探讨腋窝皮下注射溶脂剂在乳腺癌腋窝淋巴结清扫术中的应用价值.方法:将2012年3月-2012年7月收治的26例乳腺癌患者分为常规组(行常规腋窝淋巴结清扫术)与溶脂剂组(皮下注射溶脂液后行腋窝淋巴结清扫术),每组13例.比较两组的手术时间、术中出血量、肋间臂神经的保留情况及术后并发腋窝积液等.结果:溶脂剂组肋间臂神经全部完整保留,且术中出血较少,与常规组比较差异均有统计学意义(均P＜0.05);两组的手术时间及术后并发腋窝积液的几率差异无统计学意义(均P＞0.05).结论:注射溶脂剂后行腋窝淋巴结清扫术有利于分离和保留肋间臂神经,且术中出血少,对于乳腺癌腋窝淋巴结清扫术具有实际的应用价值.     

A randomized trial comparing axillary dissection to no axillary dissection in older patients with T1N0 breast cancer: results after 5 years of follow-up

SUMMARY BACKGROUND DATA: Axillary dissection, an invasive procedure that may adversely affect quality of life, used to obtain prognostic information in breast cancer, is being supplanted by sentinel node biopsy. In older women with early breast cancer and no palpable axillary nodes, it may be safe to give no axillary treatment. We addressed this issue in a randomized trial comparing axillary dissection with no axillary dissection in older patients with T1N0 breast cancer. METHODS: From 1996 to 2000, 219 women, 65 to 80 years of age, with early breast cancer and clinically negative axillary nodes were randomized to conservative breast surgery with or without axillary dissection. Tamoxifen was prescribed to all patients for 5 years. The primary endpoints were axillary events in the no axillary dissection arm, comparison of overall mortality (by log rank test), breast cancer mortality, and breast events (by Gray test). RESULTS: Considering a follow-up of 60 months, there were no significant differences in overall or breast cancer mortality, or crude cumulative incidence of breast events, between the 2 groups. Only 2 patients in the no axillary dissection arm (8 and 40 months after surgery) developed overt axillary involvement during follow-up. CONCLUSIONS: Older patients with T1N0 breast cancer can be treated by conservative breast surgery and no axillary dissection without adversely affecting breast cancer mortality or overall survival. The very low cumulative incidence of axillary events suggests that even sentinel node biopsy is unnecessary in these patients. Axillary dissection should be reserved for the small proportion of patients who later develop overt axillary disease.     

探讨手术切口在保乳术外观的影响

目的探讨手术切口对保乳术的外观的影响。方法对我院2003．9-2009．2期间早期乳腺癌通过不同的切口来完成保乳术的63病人进行总结。肿瘤切除选择梭形横切口43例,梭形放射状切口20例。腋SLN取出选择皮纹横切口47例,与肿瘤切除同一个切12113例．弧形切口3例。全部病人均因术中冰冻切片证实肿瘤四周切缘阴性而完成保乳术。结果全部病人治愈出院,切口均无发生感染及积液等并发症,随访2～65个月,切口愈合良好,梭形横切口及腋窝皮纹切口的疤痕相对较小。结论当施行保乳术时,肿瘤切除术时选择梭形横切口,而SLN取出时应选择皮纹横切口愈合较为美观。     

吸脂法腔镜腋窝淋巴结清扫手术的技术探讨

目的探讨吸脂法腔镜腋窝淋巴结清扫的手术技术.方法分析采用吸脂法进行完全腔镜腋窝淋巴结清扫手术的45例患者的临床资料,并与传统开放手术进行比较.结果完全腔镜腋窝淋巴结清扫手术组清扫淋巴结8～34枚,平均18枚;腔镜腋窝淋巴结清扫手术时间为60～190min,平均108 min,较传统手术时间长（P＜0.05）.腔镜手术组出血量为80～220 ml,平均152.82 ml,明显少于常规手术组280.29 ml（P＜0.01）.腔镜手术组术后腋窝引流量为60～180 ml,平均140.38ml,拔引流管时间6～15 d,平均6.91 d.术后皮下积液7例,皮肤表皮水疱5例,胸壁和上臂内侧蜂窝织炎2例.腔镜手术组在清扫腋窝淋巴结数目、术后引流量、引流时间、术后并发症等方面与常规开放性手术相比较无明显差异（P＞0.05）.结论腔镜手术组手术切口相对较小,美容效果较好,患者比较满意.吸脂法腔镜腋窝淋巴结清扫可以达到常规手术的清扫范围,但技术有待进一步规范.     

Sentinel Node Biopsy Interpretation: The Milan Experience

From March 1996 to December 1999 we performed 1,266 sentinel node biopsies (SNBs) in patients with small breast cancers. The technique is to inject technetium 99m-labeled albumin particles close to the tumor, locate the sentinel node (SN) scintigraphically, and use a handheld gamma-detecting probe to guide its removal via a small incision during breast surgery. Our experience was divided into three phases. In the first phase, complete axillary dissection was performed to assess the accuracy of SNB in predicting axillary status. We also assessed safety, perfected tracer injection technique, determined optimal particle size and radioactivity levels, optimized lymphoscintigraphic scanning, and perfected the surgical technique. The SN was identified and removed in 98.7% of cases. Comparison with complete axillary dissection showed that the SN predicted axillary status in 96.8% of cases. However, use of an intraoperative frozen section method predicted axillary status in only 86.5% of cases. In the second phase we developed a new method for intraoperative histologic analysis. Extensive sampling (up to 60 sections/SN) and an experienced pathologist proved more important than use of antikeratin immunostaining in identifying tumor cells, and the new method has the accuracy of a definitive histologic examination. The third phase, a randomized trial, closed at the end of 1999. Trial objectives were to confirm that the SN predicts axillary status, to determine the number of axillary relapses, and to assess overall and disease-free survival. Patients were randomized in the operating room to complete axillary dissection or SNB. If the SN was positive, complete axillary dissection was performed; if the SN was negative, no further axillary treatment was given. We expect the trial to confirm our clinical experience that SNB is a safe and accurate procedure for staging patients with early breast cancer and a clinically negative axilla.     

Periareolar subcutaneous quadrantectomy: a new approach in breast cancer surgery

Plastic and oncological breast surgery are becoming more and more closer as one surgical treatment. The term "oncoplastic surgery" refers to the use of plastic surgery techniques in breast cancer surgery, in order to avoid and to correct the adverse aesthetic findings. The care of cosmetic sequelae of breast cancer surgery has reached an important therapeutic role for psychological consequences of disease and because of the higher patients expectations of a good aesthetic result. Considering the concept of oncoplastic surgery, since 1999 the Authors began to use a periareloar approach in the breast conserving therapy (BCT), associated to axillary dissection performed through the same periareolar incision. This technique, original from the oncological point of view, is not different from the traditional quadrantectomy in the extension of the glandular resection, while the skin may be preserved in according to the conventional protocols of BCT. Oncological and aesthetic results have proved to be safe and satisfactory.     

Endoscopic thyroidectomy and sentinel lymph node biopsy via an anterior chest approach for papillary thyroid cancer

The clinical role of endoscopic thyroidectomy and sentinel lymph node biopsy (SLNB) for differentiated thyroid cancer remains open to debate. Conventional thyroidectomy requires a cervical incision and often leaves an unsightly scar on the anterior neck. Endoscopic thyroidectomy is technically feasible and safe, with much better cosmetic results. The prognostic importance of lymph node metastasis in thyroid cancer makes central lymph node dissection a crucial option in thyroid cancer surgery. However, it is associated with an increased risk of complications such as recurrent laryngeal nerve injury or hypoparathyroidism, even in expert hands. Thus, the feasibility and future role of SLNB in thyroid cancer remains controversial. We describe our technique of performing endoscopic thyroidectomy with SLNB and central lymph node dissection via a gasless anterior chest approach for thyroid cancer.