全数字化乳腺X线立体定位及切除技术对触诊阴性乳腺病灶的应用

目的：探讨全数字化乳腺X线立体定位及切除技术对触诊阴性乳腺病灶的应用价值。方法对146例乳腺触诊阴性病灶行X线检查确定病灶位置,采用导丝立体定位乳腺病灶,根据定位导丝指引完整切除病灶及定位导丝,切除标本行X线检查,证实预定病灶已完整切除,标本做病理检查,确定病灶的病理类型。结果146例乳腺病灶中乳腺癌21例,占14.38%（21/146）,癌前病变（非典型增生17例,导管内乳头状瘤病6例）共23例,占15.75%（23/146）,良性病变102例,占（69.86%,102/146）。结论立体定位切除活检对触诊阴性乳腺病灶定位准确,可以早期发现乳腺癌及癌前病变,对提高乳腺癌的早期诊断率、提高乳腺癌的二级预防具有一定的临床应用价值。     

Goal-directed fluid therapy for microvascular free flap reconstruction following mastectomy: A pilot study

BACKGROUND:

Fluid management of the surgical patient has undergone a paradigm shift over the past decade. A change from ‘wet’ to ‘dry’ to a ‘goal-directed’ approach has been witnessed. The fluid management of patients undergoing free flap reconstruction is particularly challenging. This is typically a long operation with minimal surgical stimulation, and hypotension often ensues. The use of vasopressors in these cases is contraindicated to maintain adequate flow to the flap. Hypotension is often treated with intravenous fluid boluses. However, aggressive fluid administration to maintain adequate blood pressure can result in flap edema, venous engorgement and, ultimately, flap loss.

OBJECTIVE:

The primary objective of the present study was to determine whether goal-directed fluid therapy, titrated to maintain stroke volume variation ≤13%, with the use of an arterial pulse contour device results in improved postoperative cardiac index (CI) and stroke volume index (SVI) with reduced amounts of intravenous fluid. The primary end points studied were CI, SVI and cumulative crystalloid/colloid administration.

METHODS:

Twenty female patients undergoing simultaneous microvascular free flap reconstruction immediately following mastectomy were studied. Preoperative and intraoperative care were standardized. Each patient received intra-arterial blood pressure monitoring. In all patients, cardiac output measurement occurred throughout the intraoperative period using the arterial pulse contour device. Control patients had their fluid administered at the discretion of the anesthesiologist (blinded to results from the cardiac output device). Patients in the intervention group had a baseline crystalloid infusion of 5 mL/kg/h, with intravenous colloid boluses to maintain a stroke volume variation ≤13%.

RESULTS:

There was no difference in heart rate or mean arterial pressure between groups at the end of the operation. However, at the end of the operation, the intervention group had significantly higher mean (± SD) CI (3.8±0.8 L/min/m² versus 3.0±0.5 L/min/m²; P=0.02) and SVI (51.4±2.4 mL/m² versus 43.3±2.3 mL/m²; P=0.03). This improved CI and SVI was achieved with similar amounts of administered intraoperative fluid (5.8±0.5 mL/kg/h versus 5.0±0.7 mL/kg/h, control versus intervention). The intervention group required less postoperative fluid resuscitation during the early postoperative period (total fluid administered from end of operation to midnight of the operative day, 6.4±1.9 mL/kg/h versus 10.2±3.3 mL/kg/h, intervention versus control, respectively, P<0.01).

DISCUSSION:

Goal-directed fluid therapy using minimally invasive cardiac output monitoring resulted in improved end-operative hemodynamics, with less ‘rescue’ fluid administration during the perioperative period.     

Nipple-sparing Mastectomy in Breast Cancer: From an Oncologic Safety Perspective

Objective:

To evaluate the oncologic safety of nipple-sparing mastectomy (NSM) for breast cancer patients based on current literature.

Data Sources:

A comprehensive literature search of Medline, Embase databases was conducted for studies published through March 2014.

Study Selection:

Our search criteria included English-language studies that focused on NSM at nipple-areola complex (NAC) involvement, patient selection, and recurrence. Prophylaxis NSM, case series or reports that based on very small population were excluded. In the end, 42 studies concerning NSM and oncological safety were included into the review.

Results:

NSM is a surgical procedure that allows the preservation of the skin and NAC in breast cancer patients or in patients with prophylactic mastectomy. However, the oncologic safety and patient selection criteria associated with NSM are still under debate. The incidence of NAC involvement of breast cancer in recent studies ranges from 9.5% to 24.6%, which can be decreased through careful patient selection. Tumour-nipple distance, tumour size, lymph node involvement and molecular characteristics can be evaluated preoperatively by clinical examinations, imaging studies and biopsies to predict the risk of NAC involvement. Currently, there is no available standard protocol for surgical approaches to NSM or pathological examination of NSM specimens. The local recurrence (ranges from 0% to 24%) of NSM is not significantly higher than that of traditional mastectomy in selected patients based on long-term follow-up. The role of radiotherapy in NSM is still controversial and is not universally accepted.

Conclusions:

NSM appears to be oncologically safe following careful patient selection and assessment of margins.     

Effects of dextran-40 on flap viability after modified radical mastectomy

BACKGROUND:

Postoperative management of patients after modified radical mastectomy has evolved over the past decades. In the early postoperative period, wound complication rates were reported to be as high as 60%. Flap necrosis after modified radical mastectomy is a common problem encountered by surgeons. Various treatment strategies have been proposed in the literature but none have addressed the use of dextran-40.

OBJECTIVE:

To determine whether dextran-40 infusion improves skin flap viability after modified radical mastectomy.

METHODS:

Twenty-eight patients who underwent modified radical mastectomy were randomly assigned to receive dextran-40 or no dextran-40 intraoperatively after flap dissection. Patients were followed prospectively over a five-year period in a community hospital. The incidence of postmastectomy skin flap necrosis and prognosis of the necrotic area after dextran-40 infusion was observed.

RESULTS:

Flap necrosis was observed in five (17.8%) patients. Hypertension and diabetes mellitus were found to be risk factors for the development of flap necrosis (P<0.05). Flap thickness and tension on the flaps were found to be related to flap necrosis. Six of seven patients with flap perfusion problems (ecchymosis or necrosis) underwent dextran-40 treatment and healed without graft replacement.

CONCLUSIONS:

Dextran-40 treatment did not affect development of flap necrosis. However, if necrosis had already developed, the necrotic area of the skin flaps improved with dextran-40 treatment.     

早期乳腺癌患者保乳手术的临床疗效的分析

目的探讨在治疗早期乳腺癌时保乳手术的临床疗效。方法回顾性分析2010至2012年间进行治疗的300例早期乳腺癌患者病历,其中148例患者进行常规的改良根治术,152例患者进行保乳手术,用统计学软件SPSS 17.0分析数据。对手术时间、手术出血量、生活质量评分等计量资料数据用(±s)表示,用t检验;术后3年生存率、手术并发症等计数资料比较用χ2检验。P0.05具有统计学意义。结果进行保乳手术的患者的生活质量评分显著高于改良根治术组患者,其具体的差异表现在心理因素和身体因素(体能、身体疼痛、健康变化)方面,差异有统计学意义(P0.05);两组患者的手术时间、手术出血量、术后的生存率和并发症发生率差异无统计学意义,P0.05。结论保乳手术在治疗早期乳腺癌的临床疗效相对于传统的改良根治术的临床疗效更佳,能够更大程度的保证人体的美观,是一种适于推广的治疗方式。     

乳腺癌术后乳糜漏的诊治分析

目的探讨乳腺癌术后乳糜漏的诊断及治疗方法,为该病提供有效治疗方法。方法回顾性分析1997年6月至2013年8月收治6例乳腺癌术后并发乳糜漏的诊治经过。结果 1例保守治疗治愈。5例行手术治疗,1例治愈,4例术后仍有乳糜漏,采用碘仿纱填塞漏口加压包扎、负压引流治愈。结论术中熟悉腋窝的解剖关系、彻底结扎淋巴管可以减少乳糜漏发生。禁食营养支持治疗、局部加压包扎、碘仿纱填塞和负压引流是治愈乳腺癌术后乳糜漏的有效方法。     

乳腔镜乳腺癌保乳术及腋窝淋巴结清扫50例临床分析

目的探讨乳腺癌保乳手术行腔镜腋窝淋巴结清扫治疗效果及应用价值。方法回顾性分析2010年3月至2015年3月以来50例腔镜腋窝淋巴结清扫术(腔镜组)及50例既往行传统根治术患者(传统组)的临床资料。采用SPSS 13.0软件进行分析,患者术中、术后情况计量数据以x珋±s表示,采用t检验;肿瘤部位、临床分期及术后并发症的发生率采用χ~2检验,P0.05有统计学意义。结果两组术中清扫淋巴结数目及术后病理学检查淋巴结转移数目差异无统计学意义(P0.05),腔镜组平均手术时间为(160.5±30.6)min,较传统组时间显著延长(t=24.459),但术中出血量少(t=2.103),术后并发症发生率低(χ~2=2.214),住院时间短(t=16.466),差异均有统计学意义(P0.05)。结论乳腔镜腋窝淋巴结清扫术具有手术创伤小、术后并发症少、住院时间短、微创美容效果好等优点,是一种值得推广的手术方法,但腔镜操作延长了手术时间,其手术技巧有待进一步提高。     

Postmastectomy Pain: A Cross-sectional Study of Prevalence,Pain Characteristics,and Effects on Quality of Life

Background:

Postmastectomy pain syndrome (PMPS) is defined as a chronic (continuing for 3 or more months) neuropathic pain affecting the axilla, medial arm, breast, and chest wall after breast cancer surgery. The prevalence of PMPS has been reported to range from 20% to 68%. In this study, we aimed to determine the prevalence of PMPS among mastectomy patients, the severity of neuropathic pain in these patients, risk factors that contribute to pain becoming chronic, and the effect of PMPS on life quality.

Methods:

This cross-sectional study was approved by the Sakarya University, Medical Faculty Ethical Council and included 146 patients ranging in age from 18 to 85 years who visited the pain clinic, general surgery clinic, and oncology clinic and had breast surgery between 2012 and 2014. Patients were divided into two groups according to whether they met PMPS criteria: pain at axilla, arm, shoulder, chest wall, scar tissue, or breast at least 3 months after breast surgery. All patients gave informed consent prior to entry into the study. Patient medical records were collected, and pain and quality of life were evaluated by the visual analog scale (VAS) for pain, a short form of the McGill Pain Questionnaire (SF-MPQ), douleur neuropathique-4 (DN-4), and SF-36.

Results:

Patient mean age was 55.2 ± 11.8 years (33.0–83.0 years). PMPS prevalence was 36%. Mean scores on the VAS, SF-MPQ, and DN-4 in PMPS patients were 1.76 ± 2.38 (0–10), 1.73 ± 1.54 (0–5), and 1.64 ± 2.31 (0–8), respectively. Of these patients, 31 (23.7%) had neuropathic pain characteristics, and 12 (9.2%) had phantom pain according to the DN-4 survey. Patients who had modified radical mastectomy were significantly more likely to develop PMPS than patients who had breast-protective surgery (P = 0.028). Only 2 (2.4%) of PMPS patients had received proper treatment (anticonvulsants or opioids).

Conclusions:

PMPS seriously impacts patients’ emotional situation, daily activities, and social relationships and is a major economic burden for health systems. We conclude that the rate of PMPS among patients receiving breast cancer surgery in Turkey is 64.1% and that challenges to the proper treatment of these patients deserve further investigation.