经乳晕保乳手术联合常规腋窝淋巴结清扫治疗乳腺癌

目的探讨经乳晕或乳腔镜辅助保乳手术联合常规腋窝淋巴结清扫治疗乳腺癌的效果. 方法 2001年8月～2003年11月,对19例直径<2 cm、距离乳头>2 cm的乳腺癌经乳晕或乳腔镜辅助行保乳手术,腋窝脂肪溶解抽吸后常规开放性腋窝淋巴结清扫. 结果 1例术中冰冻病理报告一侧切缘镜下癌残留,经扩大切除后转阴.术后2例乳房创面皮下积液,抽洗加压包扎消失.保留的乳房形态良好,伤口小而隐蔽,所有患者对手术效果满意.术后随访2～19个月,平均10.6月,未见乳腺和腋窝肿瘤复发. 结论经乳晕或乳腔镜辅助下,借助乳腔镜器械可以方便地完成乳腺癌保乳手术,联合常规腋窝淋巴结清扫,手术效果肯定.     

微创技术在乳腺外科的应用

微创技术是21世纪外科发展的主流，凡能够减少组织手术损伤、有利于机体功能恢复的治疗措施都属于微创技术的范畴。目前，微创技术在乳腺外科的应用可总结为一枪（穿刺活检枪）、一仪（前哨淋巴结探测仪）、二镜（乳管镜和乳腔镜）、二保（保乳手术和保腋窝手术），以及乳腺肿瘤的消融和靶向放疗，主要用于乳腺肿瘤的诊断和治疗。     

乳腺癌微创治疗的研究进展

近20年来,乳腺癌的诊断和治疗正向微创(minimally invasive)方向发展,因为它能够达到甚至优于标准外科手术,且并发症少[1-3].乳腺疾病微创诊断和治疗的进展主要有以下几方面[4-10]:①影像引导的经皮活组织检查技术,可提供准确的组织学诊断,代替手术活组织检查;②乳腔镜(mastoscopy)下微创手术,乳腺保留手术已成为早期乳腺癌的标准治疗;③前哨淋巴结活检(sentinel lymph node biopsy,SLNB)代替腋窝淋巴结清扫(axillary lymph node dissection,ALND)成为能够预测腋窝淋巴结状况的一种新方法;④各种消融治疗(ablation treatment)能够破坏原位乳腺癌,不手术治疗原发性肿瘤,现主要将乳腺癌微创治疗的乳腔镜下手术、麦默通(mammotome,MMT)和消融治疗的研究进展介绍如下.     

腔镜技术在乳腺癌治疗应用及评价

传统乳腺癌手术存在的一些固有缺陷激发了外科医生对微创手术的探索,乳腔镜开创了乳腺癌微创外科新领域。乳腔镜辅助保乳手术,改善了常规保乳手术的功能和美容效果。乳腔镜皮下乳腺腺体切除一期假体植入术治疗乳腺癌已显示明显优势。乳腔镜辅助小切口改良根治术可以避免常规手术中对肿瘤的挤压,摆脱胸壁巨大、丑陋切口瘢痕。乳腔镜腋窝淋巴结清扫体现了微创和功能效果。乳腔镜手术还解决和改善了乳腺外科的部分临床难题,如内乳淋巴结清扫、注射式隆乳术后出现的并发症处理。此外,乳腔镜辅助下乳房切除后的即时乳房重建在技术上已日臻成熟。     

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目的 探讨乳腔镜在乳腺癌保留乳房腋窝淋巴结清扫术中的手术方法及可行性.方法 2001年8月至2007年8月首都医科大学附属北京复兴医院普外科行保乳乳腔镜腋窝淋巴结清扫术治疗乳腺癌276例,同期行乳腺癌改良根治术142例.对比分析其治疗效果.结果 276例经乳腔镜完成腋窝淋巴结清扫,手术时间由2h缩短至40min以内,术后发生并发症2例;改良根治术组142例发生术后并发症27例,手术时间55～160min.结论 乳腺癌保留乳房手术使用乳腔镜进行腋窝淋巴结清扫术可以缩短手术时间、简化手术;在保证腋窝淋巴结清扫质量的同时降低了手术并发症发生率,达到了生理、心理的微创化,提高了病人的生活质量.乳腔镜腋窝淋巴结清扫术是可行的.     

经乳腺癌病灶切口腔镜辅助腋窝淋巴结清扫术

保乳手术中腋窝淋巴结清扫（ axillary lymph node dissection ,ALND）通常采用腋窝或腋下切口,术后对上肢活动有一定的影响［1］。我们在腔镜辅助乳腺手术（video-assisted breast surgery ,VABS）［2,3］治疗乳腺良性病变的基础上,于2014年4月为1例病灶位于外下象限的乳腺癌实施经病灶切口腔镜辅助腋窝淋巴结清扫术（ video-assisted axillary lymph node dissection ,VAALND）,手术效果满意,现报道如下。     

乳腺腔镜经腋下小切口施行乳腺癌保乳手术

目的　探索腔镜经腋下隐蔽小切口对早期乳腺癌行保乳手术的可行性及效果。方法　全麻下使用乳腺腔镜经腋下小切口入路 ,结合腋窝脂肪溶解抽吸技术 ,进行保乳手术 2 1例。结果　术中冷冻病理切片报告所有标本各切缘均无癌残留。 3例腋窝淋巴结有转移。平均手术时间 81.6min。术后 1例出现皮下积液 ,经抽液加压包扎后消失。所有病例乳房形态保持良好 ,患者满意。均获随访 3 .1～ 15 .6个月 ,未见复发和远处转移。结论　乳腺腔镜经腋下入路行早期乳腺癌保乳手术切口微小隐蔽 ,可提高患者的生活质量 ;改变了早期乳腺癌常规保乳手术的观念。腋窝脂肪抽吸后 ,腋窝淋巴清扫变得容易。     

乳腔镜腋窝淋巴结清扫术的初期应用分析

目的：探讨乳腔镜腋窝淋巴结清扫术的疗效,并与传统腋窝淋巴结清扫术的早期结果进行对比。方法：选取2012年1月至2013年4月收治的54例临床Ⅰ、Ⅱ期乳腺癌患者,其中腔镜组12例,传统手术组42例,对比分析两组患者临床资料及手术指标。结果：两组手术均顺利完成。两组患者创面引流液量、引流时间、术后住院时间、淋巴水肿、创面积液及清除淋巴结数量差异无统计学意义（P〉0．05）,腔镜组在术后患侧上肢疼痛、麻木及肩部活动受限率方面优于传统手术组（P〈0．05）,尽管腔镜组手术时间稍长于传统手术组（P=0．001）,但腔镜组术中出血量明显少于传统手术组（P=0．004）。结论：掌握精细的腔镜操作技术,熟悉腋窝结构,术中细致解剖,手术流程正确,早期开展乳腔镜腋窝淋巴结清扫术是可行的,显著改善了腋窝淋巴结清扫手术的预后,达到了生理微创与心理微创的双重目的,与传统手术相比优势明显。     

乳腔镜辅助下早期乳腺癌的保乳治疗

目的 探讨乳腔镜辅助下早期乳腺癌保乳治疗的优越性.方法 乳腔镜辅助下行保乳术37例,术后均行乳腺和病灶区放射治疗,并按病理及受体情况给予相应的辅助化疗及内分泌治疗.结果 乳腔镜辅助下保乳术成功35例,2例术中因腋窝出血量多而转开放性手术.患者无明显手术并发症, 且美容效果良好.术后随访时间最长27个月, 中位随访时间为18 个月,无一例局部复发、远处转移和死亡.术后乳腺美容效果评估: 优、良者术后6个月为68.2%,术后1年为83.4%.结论 乳腔镜辅助下早期乳腺癌保乳术以不降低生存率、不增加复发率为原则,联合多学科有机配合及综合治疗为保证,具有创伤小、并发症少、外形美观、生存质量高等优点.     

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。     

Treatment of invasive breast carcinoma with ultrasound-guided radiofrequency ablation

BACKGROUND: Radiofrequency ablation (RFA) is a minimally invasive thermal ablation technique. This study reports the safety and efficacy of RFA as a minimally invasive strategy for breast cancers <3 cm diameter in postmenopausal women. METHODS: Twenty-two postmenopausal women (aged 60 years or older) with clinical T-1N0 core biopsy proven breast cancers were studied. Thermocoagulation was undertaken using a sonographically guided RF probe under local anesthesia and sedation. The ablated tumor was resected between 1 and 2 weeks later. Endpoints were technical success, completeness of tumor kill, marginal clearance, skin damage, and patient reports of pain and procedural acceptability. RESULTS: The procedure was well tolerated and cosmesis was excellent. Pathology revealed a central ablation zone surrounded by hyperemia. Coagulative necrosis was complete in 19 of 22 patients. Disease at the ablation zone margin was found in 3 patients and 5 patients had disease distant to the ablation zone consisting of multifocal tumors (2), in-transit metastasis (1), and extensive ductal carcinoma in situ with microinvasive carcinoma (2). Ninety-five percent of patients would be willing to have RFA again. CONCLUSIONS: Radiofrequency ablation can be safely applied in an outpatient setting with acceptable patient tolerance. By itself, RFA cannot be considered effective local therapy. Trials to evaluate RFA complemented with breast irradiation are justified.     

Caveolin-1在乳腺癌中的表达及其意义

目的 探讨caveolin-1在乳腺癌中的表达及其意义.方法 采用免疫组化二步法,检测105例乳腺癌和50例非癌乳腺组织中caveolin-1的表达情况,同时检测组织中CK5/6、EGFR、E-cadherin表达情况,研究其与eaveolin-1表达的关系,并对105例乳腺癌患者的临床病理资料进行回顾性分析.结果 105例乳腺癌按基因分型分为基底细胞样乳腺癌20例,腔上皮A型乳腺癌22例,腔上皮B型乳腺癌23例,HER2高表达型乳腺癌23例,正常乳腺表型乳腺癌17例.Caveolin-1蛋白在乳腺癌和非癌乳腺组织的表达率分别为24.8％ (26/105),88％ (44/50).Caveolin-1在基底细胞样型,腔上皮A型,腔上皮B型,HER2高表达型,正常乳腺表型乳腺癌的表达率分别为75.0％ (15/20)、4.8％ (1/22)、17.4％ (4/23),17.4％ (4/23)、11.8％ (2/17),Caveolin-1蛋白在基底细胞样型的表达水平强于腔上皮A、腔上皮B型、HER2高表达型和正常乳腺表型(P＜0.01).基底细胞样型caveolin-1蛋白表达与CK5/6、EGFR水平正相关(P＜0.01),与E-cadherin水平无关(P＞0.05).乳腺癌中表达caveolin-1蛋白者淋巴结转移率亦高(69.2％ vs.46.8％,P=0.047).乳腺癌患者中caveolin-1(±)5年无瘤生存率(10/26,38.46％)显著低于caveolin-1(一)患者(59/79,74.68％,P=0.0004).但多因素分析未证明caveolin-1为乳腺癌患者无瘤生存的预后因素(P＞0.05).结论 Caveolin-1可作为基底细胞样乳腺癌的一个筛选标记,可能促进癌细胞的转移,但不是影响乳腺癌患者预后的独立因素.     

单发直径≤3 cm肝肿瘤No-touch射频消融治疗的安全性及近期疗效分析(附50例报告)

目的探讨No-touch射频消融术(radiofrequency ablation,RFA)治疗直径≤3 cm单发肝肿瘤的安全性和疗效。方法 2015年9月至2017年6月采用cooltip电极对直径小于3 cm单发肝肿瘤50例病人进行No-touch RFA治疗。其中,治疗原发性肝癌49例(初发31例、复发18例),转移性肝癌1例。肿瘤平均直径1.8 cm,治疗前、后检查肝功能、增强CT扫描、磁共振检查、超声造影以及细针肝穿刺活检。观察RFA治疗时间、次数和术后住院时间,RFA治疗后的并发症以及肿瘤完全毁损率,并随访病人的生存情况。结果 50例病人共行No-touch RFA治疗51次,其中1例病人1个月内连续治疗2次。每例平均为1.02次;每次治疗时间平均为8.2 min;术后平均住院时间为3.2 d。Notouch RFA治疗后1个月内复查CT或磁共振,单次治疗后的肿瘤完全毁损率为98.0%,甲胎蛋白(AFP)阳性的22例病人在No-touch RFA治疗后6~12个月内有14例转阴,5例明显下降。50例病人随访时间从2015年9月开始至2017年6月止,其总体生存率为100%,术后总体无瘤生存率为90.0%(45/50)。结论 No-touch RFA对直径小于3 cm的单发肝肿瘤的治疗是一种微创、安全有效的方法。     

Utility of ultrasound and fine-needle aspiration biopsy of the axilla in the assessment of invasive lobular carcinoma of the breast

BACKGROUND: The unique growth pattern of invasive lobular carcinoma (ILC) poses a challenge for preoperative assessment of disease extent within the breast. Whether it similarly limits lymph node staging by ultrasound (US) and fine-needle aspiration (FNA) biopsy was the subject of the current study. METHODS: A total of 217 patients with ILC who underwent axillary US were reviewed. FNA biopsy was performed when US findings were suspicious or indeterminate. Findings were compared to literature reports of US in invasive ductal carcinoma (IDC) patients. RESULTS: Axillary US was negative in 137 patients (63%) and suspicious or indeterminate in 80 patients (37%). FNA biopsy was positive in 62% (47/76 patients). Preoperative US and FNA biopsy identified 43 of 111 (39%) node-positive patients. Sensitivity of US with FNA biopsy correlated with primary tumor and nodal metastasis size. Similar results were seen in IDC populations. CONCLUSION: US with FNA biopsy appears to be similarly useful in axillary staging of ILC and IDC patients.     

Breast conservation for male breast carcinoma

Male breast cancer in general is treated by modified radical mastectomy. Data have emerged supporting the replacement of the axillary lymph node dissection by a sentinel lymph node biopsy in the male patient with breast carcinoma. Local therapy in the breast continues to be primarily mastectomy. The reasons suggested for this include the central location of many of the male breast tumors and the paucity of breast tissue. Our experience with breast conservation over the last decade in male breast carcinoma and a review of the literature is outlined here. Between 1996 and 2006, seven men underwent breast conservation for breast carcinoma and to date with a median follow-up of 67 months, there have been no local recurrences. Breast carcinoma in males can be treated with breast conservation with acceptable local recurrence. Breast-conserving surgery in male breast cancer patients should be considered an option in patients without overt nipple/areolar involvement.     

Success of sentinel lymph node mapping after breast cancer ablation with focused microwave phased array thermotherapy

BACKGROUND: Breast cancer tumor ablation as part of a multimodality approach in the treatment of breast cancer is the subject of recent interest. This study was conducted to determine if the ability to perform sentinel node biopsy was impaired after thermal-induced ablation of breast cancer. METHODS: We studied patients who had sentinel node biopsy after preoperative focused microwave phased array for breast cancer ablation. RESULTS: Twenty-one patients with T1-T2 breast cancer and clinically negative axilla underwent wide local excision and sentinel node biopsy guided by blue dye and sulfur colloid. Surgery was done an average of 17 days after microwave ablation. Fifteen of 22 patients (68%) had histologic evidence of tumor necrosis. Sentinel lymph node mapping was successful in 19 of 21 patients (91%). Axillary metastases were detected in 42% of cases. CONCLUSIONS: This study documents successful sentinel lymph node mapping for patients treated with antecedent local tumor ablation using focused microwave phased array ablation.     

乳腺微小钙化灶定位切除的临床应用

目的探讨应用乳腺摄片结合立体定位系统对乳腺微小钙化灶进行细针定位外科切除术及B超定位金属“倒钩”选择切口的价值。方法对2000年5月至2006年11月收治的178例乳腺微小钙化灶患者行X线引导下细针定位外科切除活检术,其中62例经B超定位金属“倒钩”选择切口。结果全组178例患者中,发现乳腺癌58例（32．6％）,其中导管内癌32例（55．1％）,导管内癌伴间质浸润11例（19．0％）,浸润性导管癌15例（25．9％）,伴有淋巴结转移者4例。5年生存率100％。经B超定位选择切口患者较沿针道切除选择切口患者对术后乳腺外形的改变满意度高（P=0．022）。结论对乳腺微小钙化灶实施X线立体定位、B超定位选择切口的外科切除术是一种可靠安全的诊断方法。     

Diagnosis of breast tumors after breast reduction

We conducted a retrospective study to evaluate the diagnosability of breast tumors after breast reductions as this is a frequent surgical procedure. The data should shed light on the hypothesis that routine screening methods concerning the diagnosis of breast tumors prove more difficult after breast operations. All women who had undergone breast reduction at our department between January 1989 and December 1994 were examined. During this period we counted 166 patients; the majority of them (n = 144) had undergone a bilateral breast reduction and the rest of them (n = 22) a unilateral breast reduction for various reasons. After the operation, all patients were checked in standardized intervals. Those who developed any kind of breast mass (n = 6) were recorded and examined by ultrasound and mammography, and occasionally by an additional fine-needle biopsy. In case any doubt about the dignity had remained, an excisional biopsy was carried out. In none of our patients was it possible to get a precise diagnosis of an ill-defined mass with ultrasound. With mammography, some of the existing masses, which were really scars, mimicked different kinds of tumors, and once a carcinoma was initially interpreted as scar tissue with oil cysts. The diagnosis of breast masses after breast reductions with routinely used screening methods has proved to be more difficult as breast reductions lead to architectural alterations of the remaining breast parenchyma. Such alterations can and should be documented shortly after the operation so that later occurring tumors are distinguished more easily. Therefore, a basic mammography 3 months after each breast reduction has to be claimed in order to facilitate further breast tumor diagnosis.     

Radiofrequency ablation of breast cancer

Radiofrequency ablation (RFA) is currently under study as a candidate for nonsurgical removal or destruction of breast tumors. RFA of solid tumors is produced by frictional heating caused when ions in the tissue attempt to follow the changing directions of a high-frequency alternating current. The radiofrequency probe is typically placed into the tumor under ultrasound guidance, and the ablation is performed with real-time ultrasound monitoring. Preliminary studies in which RFA was followed by standard surgical resection have indicated that this technique is effective for the surgical ablation of small (< or = 2 cm) primary breast tumors. A new study at the University of Texas M.D. Anderson Cancer Center will use RFA as the sole local treatment of breast tumors < or = 1.5 cm in size to determine whether this technique is oncologically and cosmetically appropriate for the local treatment of primary breast cancer. Twenty patients with small tumors that are clearly identifiable and measurable by ultrasound will be enrolled in the study. Local control will be assessed by core and fine-needle biopsies, and long-term outcomes will be assessed using imaging studies and quality-of-life measurement scales for 5 years after treatment.     

乳腺乳头状癌17例的诊断与治疗

目的 探讨乳腺乳头状癌的临床特征、病理和诊治.方法 回顾性分析温州医学院附属第一医院收治的17例乳腺乳头状癌的临床资料.结果 乳腺乳头状癌发病率占同期收治所有乳腺癌的0.64％.患者均可触及肿块.12例患者行乳腺癌改良根治术,2例行单纯乳房切除术,2例行保乳手术,1例行乳房单纯切除+前哨淋巴结活检术.术后15例行辅助化疗,其中5例另行放射治疗.术后随访时间1个月～8年,中位随访时间为32.5个月.1例发生骨转移于术后2年死亡,1例发生多器官转移于术后7年死亡.结论 乳腺乳头状癌患者的治疗及预后与其病理类型密切相关.对导管内乳头状癌的治疗宜选择低创伤的手段,对浸润性乳头状癌及浸润性微乳头状癌须按浸润性导管癌治疗原则处理.