乳腺癌的保留乳房手术及哨兵淋巴结活检103例报告

目的 总结乳腺癌保留乳房手术及哨兵淋巴结活检的临床经验。方法 103例乳腺癌患者，肿块局部扩大切除23例，乳腺区段切除加腋淋巴结清扫80例。全部病例均行哨兵淋巴结活检。结果 活检与术后病理对照，准确性95．8％，假阴性率14．1％，假阳性率0。随访10个月至7年，2例4年内复发，7例5年内复发，10例7年内复发。复发者均改行乳腺癌改良根治术。结论 早期乳腺癌中。行保留乳房的乳腺癌手术可行。术后应进行根治性放疗及全身化疗，可获得满意效果。     

早期乳腺癌的保乳综合治疗疗效分析

目的　评价早期乳腺癌保乳综合治疗的疗效。方法　保乳组 92例 ,行保留乳房的肿瘤切除加腋窝淋巴结清扫术 ;对照组 60例 ,行乳癌改良根治术。术后给予放疗、全身化疗和 /或内分泌治疗。结果　平均随访 5 7个月 ,保乳组中无局部复发病例 ,3年生存率为 97.2 % ,5年生存率为 89.3 % ,远隔脏器转移率为 6.5 % ;对照组局部复发 2例 ,3年生存率为 97.5 % ,5年生存率为90 .1% ,远隔脏器转移率为 5 .0 % ,两组各指标对比无明显差异 (P >0 .0 5 )。结论　早期乳腺癌采用保乳综合疗法 ,可以达到与根治术相似的治疗效果 ,可作为首选方法     

保留乳头的乳腺癌根治术即乳房重建术

目的：探讨早期乳腺癌行保留乳头的改良根治、即期硅胶假体植入乳房重建术的可行性.方法：利用早期乳腺癌极少侵犯乳头、乳晕及皮肤的特点，切除病灶及其上方部分皮肤后行皮下乳房切除＋腋淋巴结清扫术，并与硅胶假体植入术有机结合，达到一期重建乳房的目的.结果：对18例早期乳腺癌患者采用上述术式重建乳房后客观评价效果优良和尚好者达94.4%，主观评价效果优良和尚好者达100%，术后随访12～36个月，所有病例均无局部复发及远处转移.结论：保留乳头的非定型式乳腺癌根治与即期硅胶假体植入乳房重建术是治疗Ⅰ期及部分Ⅱ期乳腺癌安全可行的方法。     

经胸大肌清扫Ⅲ组淋巴结在乳腺癌改良根治术中的应用

目的探讨经胸大肌间隙入路清扫Ⅲ组淋巴结在乳腺癌改良根治术中的应用及其临床意义。方法观察组采用保留胸大小肌的乳腺癌改良根治术（Auchincloss手术）,同时沿胸大肌肌问沟切开胸大肌,彻底清除Ⅲ组淋巴结（锁骨下淋巴结）。对照组采用仅保留胸大肌、切除胸小肌的乳腺癌改良根治术（Patey手术）。结果与对照组比较,观察组能彻底清扫腋淋巴结,明显减少胸大肌萎缩率,提高术后生活质量。结论经胸大肌清扫Ⅲ组淋巴结既保留胸大肌功能,又彻底清扫腋淋巴结,值得临床推广。     

保留皮肤的乳腺癌改良根治术后即时乳房再造

目的介绍保留皮肤的乳腺癌改良根治术后即时乳房再造的经验.方法对早期乳腺癌,保留乳房皮肤,切除乳腺组织和腋窝淋巴结,应用下腹部横行腹直肌肌皮瓣或扩大背阔肌肌皮瓣即时乳房再造.结果应用该方法治疗37例,再造乳房形态良好.结论保留皮肤乳腺癌根治术后即时乳房再造,切口隐蔽,再造乳房形态效果好,对早期乳腺癌患者值得推广应用.     

早期乳腺癌保乳手术疗效分析

目的探讨早期乳腺癌保乳综合治疗的疗效。方法行保留乳房的肿瘤切除及腋窝淋巴结清扫术52例,术后给予放化疗和内分泌治疗。结果平均随访56个月,无局部复发病例,3年和5年生存率分别为96.2%和92.3%,远隔脏器转移率为3.8%。结论早期乳腺癌采用保乳综合疗法,可以达到与根治术相似的治疗效果,且提高了患者生存质量,可作为首选治疗方法。     

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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.     

乳腺癌保乳综合治疗的疗效分析

目的　评价I ,IIa期乳腺癌保乳综合治疗的疗效。方法　将 14 1例I ,IIa期乳腺癌 (肿块距乳头≥ 3cm )前瞻性非随机分为两组 :(1)保乳治疗组 68例 ,行保留乳房的肿瘤局部广泛切除加腋窝淋巴结清扫术 ;(2 )对照组 46例 ,行乳癌改良根治术。术后均给予化疗、放疗和 /或内分泌治疗。结果　中位随访 46个月 ,两组病例均无局部复发。保乳治疗组 3a生存率为 98.0 % ,5年生存率为93 .3 % ,远隔脏器转移率为 7.4% ;改良根治组 3年生存率为 97.1% ,5年生存率为 91.3 % ,远隔脏器转移率为 8.7 ,两组各指标比较无明显差异 (P >0 .0 5 )。结论　对癌肿距乳头≥ 3cm的I ,IIa期乳腺癌采用保乳综合疗法 ,可以达到与根治术相似的治疗效果 ,可能逐渐成为治疗I ,IIa期乳腺癌患者的首选术式     

保留乳房的乳腺癌手术

保留乳房的乳腺癌手术是近30年来乳腺癌外科治疗的主要进展,它包括乳腺肿瘤局部扩大切除或象限切除,腋淋巴结 清扫(ALND),术后辅助放化疗、内分泌治疗。资料证明保乳手 术能获得与根治性全乳切除术一样的治疗效果,又保留了乳房 的形态,给女性患者带来了实在的益处。由“切乳”转向“保乳” 被称作革命性变化,说明乳腺癌外科治疗理念已从局部解剖为 基础、单一追求手术根治性转向以肿瘤生物学现象为指导的综 合治疗时代,这更充分地体现人类对生命质量的重视。 一、保乳手术的背景 1894年Halsted提出乳腺癌…     

乳腺癌改良根治术保留肩胛下肌群筋膜的腋窝淋巴结清扫对腋窝积液的影响

目的 探讨乳腺癌改良根治术腋窝淋巴结清扫保留肩胛下肌群筋膜的方法对腋窝积液的影响.方法 将我院2010年1月～2010年12月确诊乳腺癌并需行乳腺癌改良根治术的患者共178例随机分为保留肩胛下肌群筋膜腋窝淋巴结清扫组（治疗组,n＝98）及切除全部肩胛下肌群筋膜腋淋巴结清扫组（对照组,n＝80）,比较两组在切除淋巴结平均数目、拔引流管时间,腋窝皮下积液发生率及患侧上肢水肿发生率的情况.结果 治疗组切除腋窝淋巴结平均数、腋窝皮下积液例数（发生率）、拔管时间、拔管时间超过14天例数及发生患侧上肢水肿例数依次为：15.1个/例,6例（6.1%）、7±0.5天、4例及3例,对照组为14.8个/例、9例（11.3%）、9±0.5天、12例及7例.两组均未发生严重水肿.治疗组与对照组在切除淋巴结平均数目无显著差异,但前者拔管时间较后者短,腋窝皮下积液发生率及患侧上肢水肿发生率均较对照组低,两组差异具有统计学意义.结论 保留肩胛下肌群筋膜腋窝淋巴结清扫的方法较常规方法损伤更小,发生腋窝皮下积液及患侧上肢水肿的几率低,不影响肿瘤分期.     

乳房体积测量方法的比较研究

目的：比较各类乳房体积测量方法,为临床应用提供参考。方法以“breast volume”、“breast measurement”和“breast volumetry”为关键词,检索Pubmed和万方数据库,筛选出以乳房体积测量为主题的文献。回顾、整理各类乳房体积测量方法,并分析其原理,比较其准确性、经济性和操作可行性。结果自1970年7月至2013年5月,总共有46篇以乳房体积测量的文章符合入选标准。目前已被报道的乳房体积测量方法共有9种,可以根据其测量原理分为三类：影像法,包括MRI、超声和CT测量;自然法,包括3D建模、排水体积法和胸模法;几何法,包括Grossman-Roudner、人体测量计算和X线摄片。结论9种测量方法中,3D建模和MRI测量法,因准确性较高,又没有明显的副作用,可以用来为术前计划提供参考;Grossman-Roudner模具测量法和人体测量法虽可靠性有所降低,但经济简便,可以使用在较大样本量的临床研究中。     

Routine Operative Breast Endoscopy During Lumpectomy

Background: Lumpectomy for the management of breast cancer is commonly directed by mammography or ultrasound. We hypothesized that fluid-producing ducts would likely connect to the site of the known cancerous or precancerous lesion and that endoscopic evaluation might reveal unsuspected additional disease.Methods: All women undergoing lumpectomy in a single surgeon practice from January 2000 to August 2001 were evaluated for fluid production from the nipple at the time of lumpectomy. All fluid-producing ducts were cannulated and endoscoped with a 0.9-mm Acueity microendoscope.Results: Of the 201 patients (16 with atypical ductal hyperplasia, 52 with ductal carcinoma-in-situ, and 133 with stage 1 or 2 breast cancers), 150 (74.6%) could be successfully dilated and scoped. Additional lesions outside the anticipated lumpectomy were identified in 41% (n = 83) of cases. If successful, the chances for a positive margin for cancer decreased from 23.5% to only 5.0%. Endoscopy proved to be a useful adjunct in this series of patients because it identified all cases of extensive intraductal component in early-stage breast cancer.Conclusions: Routine operative breast endoscopy can reduce the need for re-excision lumpectomy. It also finds substantially more cancerous and precancerous disease than anticipated by routine preoperative mammography and ultrasound.     

Contribution of breast density to the volume of the augmented breast: A preliminary study

BACKGROUND:

Prediction of soft tissue contribution to the shape, volume and texture of the augmented breast proves to be an ever-challenging, uncontrollable variable. Similarly, the understanding of the contribution of breast density in breast augmentation has been elusive and, generally, not well studied.

OBJECTIVE:

With the aid of three-dimensional photographic analysis, the present preliminary study examined the contribution of differing breast densities to the overall volume of the augmented breast.

METHODS:

All patients undergoing primary augmentation over a six-month period were included in the study. To standardize technique and implant type, all patients received saline-filled moderate-profile implants, which were placed partially underneath the pectoralis muscle through a lower pole approach. Photographic analysis of the breast volume was completed preoperatively and, subsequently, at a minimum of six months postoperatively. Preoperatively, each breast was also assigned to one of four classes of increasing mammographic density, as judged by the mammographic radiologist (fatty, moderately dense, heterogeneously dense and extremely dense). Postoperative breast volumes were, subsequently, correlated to mammographic densities.

RESULTS:

Thirty-eight augmented breasts in 21 patients were examined. The average volume gain based on the implant size used was 92.7%. Heterogeneously dense breasts comprised 68% of the total breasts and showed an average volume gain of 100.67%, extremely dense breasts comprised 26% of the total breasts and showed an average volume gain of 97.3%, and moderately dense breasts comprised 5% of the total breasts with an average gain of 100.04%. There was no significant difference between the augmented breast volumes and the respective expected volumes (combined preaugmented breast volumes and implant volumes; P=0.3483). Additionally, no statistical difference was found between the density classes and the expected augmented volumes.

CONCLUSION:

No statistical difference was found between expected and actual augmented breast volumes among or between four different breast density classes. Thus, one would expect that the soft tissue compression or the response of the impression of the implant on the parenchyma, would not be statistically different among classes. Additionally, compressive atrophy, as seen with atrophy of the breasts over time, would be expected to be multifactorial and not uniquely independent to breast density. However, longitudinal analysis is needed to study the durability of breast shape relative to breast density.     

Virtual 3-dimensional modeling as a valuable adjunct to aesthetic and reconstructive breast surgery

Three-dimensional (3D) imaging technology currently is used by various commercial industries as a method for analyzing objects and shapes. Recent work from our group and others offer data to support the use of 3D imaging as a valuable tool in aesthetic and reconstructive breast surgery. We have developed a system for creating 3D breast models that provides clinical data that can help guide surgical management. With 3D breast models, surgeons are able to visually assess the size, shape, contour, and symmetry of the breast, as well as obtain quantitative breast measurements and volumetric calculations. Three-dimensional imaging may be applied to various plastic surgery procedures including breast reconstruction with implant/tissue expanders, local flap reconstruction, free-flap reconstruction, breast augmentation, and breast reduction surgery. The novel application of 3D imaging in these settings represents a significant advance from traditional approaches to aesthetic and reconstructive breast surgery in which surgical procedures are based on 2-dimensional photographs and visual size estimates.     

Occult breast carcinoma in patients undergoing reduction mammaplasty

Seven patients who had breast reduction surgery and whose preoperative physical examinations were unremarkable were found to have brest carcinoma. In the five in whom mastectomy was performed, most closures were difficult, and in one patient bilateral mastectomy was complicated by wound dehiscence. In only one of these seven was it possible to obtain information regarding the hormonal binding status of the tumor cells. These and other sequelae would not have occured had the tumors been diagnosed before operation. Because physical examination alone is not sufficiently sensitive for the diagnosis of breast cancer, we suggest that mammography be included in the evaluation of patients consulting surgeons for breast reduction.     

Case report of a definitive autologous reconstruction in a patient requiring immediate postoperative anticoagulation and reduced operative time

IntroductionThe available options for post-mastectomy reconstruction in a patient requiring abbreviated operative times and immediate and sustained post-operative anticoagulation are limited.Presentation of caseA 50 year old woman with a history of multiple deep venous thromboses (DVTs) and pulmonary embolisms (PEs) requested a bilateral prophylactic mastectomy and immediate reconstruction. She had a history of multiple breast biopsies demonstrating atypia and two sisters with premenopausal breast cancer. Her hematologist requested that her anticoagulation be held for the minimal amount of time and that her theater times be kept as short as possible. As such, we felt that she was not a candidate for traditional implant-based reconstruction nor autologous flap surgery. Instead, we made use of a recently described single-stage autologous modified Goldilocks procedure to complete her bilateral mastectomy and reconstruction in 150 min. She was anticoagulated in the operating room and was restarted on her preoperative regimen twelve hours after surgery. She suffered no post-operative complications.DiscussionThere is minimal published literature discussing immediate post-mastectomy reconstruction in the anticoagulated patient. Most reconstructive surgeons find these patients unsuitable for traditional reconstructive techniques. In the current case, we utilized a recently described single-stage autologous technique which allowed us to avoid the bleeding complications associated with the muscular dissection required with implant and flap-based reconstructive surgery. The extirpation and reconstruction was completed in 150 min which is significantly quicker than traditional reconstructions.ConclusionThe modified Goldilocks procedure is an excellent option in the patient who requires immediate postoperative anticoagulation and abbreviated operative times.     

Predicting breast reduction weight using the mass of breast ptosis

BACKGROUND:

The preoperative prediction of therapeutic breast reduction weights, to achieve both relief of breast weight symptoms and yet achieve excellent breast shape, remains a challenge.

OBJECTIVES:

To design a simple clinical method to preoperatively predict and quantify therapeutic breast reduction weights.

METHODS:

In 31 women who underwent therapeutic bilateral reduction mammaplasty, the mass of the hypertrophic breast hanging below the inframammary fold was preoperatively weighed and then compared with the mass of the reduction specimen. Thirty patients underwent breast reduction using a superomedial nipple-areolar pedicle. Postoperative breast weight-related symptoms and breast shape findings were then noted. Statistical analysis relied on mean, SD, sample size, Mann-Whitney test for medians, Levene’s test for variances and regression analysis.

RESULTS:

The average clinical follow-up was 160 days, with all patients achieving satisfactory breast size and shape from both the patient and surgeon’s perspectives. All patients reported improvement of back pain, shoulder pain and lower neck pain. Two breasts developed delayed healing of the lateral skin flap, necessitating debridement and reclosure, followed by uneventful ongoing healing. There was no significant difference in preoperative ptotic breast mass and resectional breast mass (all P>0.05).

CONCLUSIONS:

Simple preoperative weighing of the ptotic portion of the hypertrophic breast can serve as a goal for the reduction weight, while creating pleasing breast proportions and improving breast weight-related symptoms. Preoperative quantification of the ptotic breast mass may guide the reduction technique and assist insurance precertification efforts.     

三平面法隆乳术在乳房萎缩伴下垂矫正术中的应用

目的 探讨应用胸大肌后放置假体,并于胸大肌中央部位切开,形成假体表面胸肌-腺体-胸肌三平面覆盖的方法,矫正乳房萎缩伴下垂的效果.方法 选择环乳晕切口,进行乳房上象限腺体表面分离及真皮帽折叠固定.再由乳腺外下象限边缘进入乳房后间隙,于新的乳头、乳晕水平将胸大肌横行及纵行部分离断,将假体植入胸大肌后.于术前及术后对乳房各解剖径线进行标准化测量.结果 2011年6 ～12月,应用上述方法行乳房上提联合隆乳手术14例,患者术后乳房上极形态、乳房凸度及乳头、乳晕位置均得到了明显改善,且无严重并发症发生.术后随访6～12个月,乳房形态良好.结论 三平面法能够在不离断胸大肌起点及止点的情况下,保证假体在乳头、乳晕水平良好的凸度,避免了乳房下垂联合隆乳手术时易发生的双泡畸形或阶梯现象,且损伤较小.     

乳癌术后不同乳房再造术式的临床应用

目的探讨适合乳癌术后各种乳房再造术式的适应证。方法对我院2003至2005年收治的44例、45只乳癌术后乳房再造的患者,根据不同情况分别采用扩张器/假体置入(5只)、背阔肌肌皮瓣 假体置入(13只)、背阔肌肌皮瓣(3只)、DIEP皮瓣(6只)、单蒂TRAM瓣(10只)及劈开的双蒂TRAM瓣(8只)等方法进行乳房再造,分析各手术方法的适应证。结果应用皮瓣乳房再造40只,皮瓣全部成活;1只应用扩张器/假体乳房再造术后,注射壶部表皮坏死;1只应用背阔肌 假体乳房再造术后半年出现假体破裂伴局部感染;1只应用DIEP乳房再造术后,出现皮瓣下积液;2只部分皮瓣坏死。术后随访3个月至半年,医生及患者对乳房形态均较满意。所有应用腹部皮瓣的患者均无腹壁疝发生。结论6种乳房再造技术基本满足了我国女性乳癌术后各个时期各种条件再造乳房的要求,整形外科技术的改进以及新材料的应用扩大了乳房再造的适应证。     

80例乳房再造术后并发症临床分析

目的　对应用不同术式行乳房再造术的 80例患者进行分析讨论。方法　从皮瓣坏死率、腹壁疝发生率、腹壁张力、感觉等分析了应用假体 ,背阔肌肌皮瓣 (latissimusdorsimusculocutaneousflap ,LDFM瓣 )、带蒂横行腹直肌肌皮瓣 (transverserectusabdominismusculocutaneousflap ,TRAM瓣 )、臀大肌肌皮瓣 (gluteusmaximmusculocutaneousflap ,GMM瓣 )、腹壁下动脉穿支皮瓣 (deepinferiorepigastricarteryperforatorflap ,DIEP瓣 )等方法并发症产生的原因及预防措施。结果　LDFM瓣最主要的并发症是血清肿 (12 5 % )。LDFM、TRAM、DIEP三者中TRAM瓣坏死率最高 (2 6 % ) ,1例GMM瓣再造后皮瓣部分坏死 ,19例应用假体者包膜挛缩率为 2 1%。结论　乳房再造的并发症与选择的术式有关 ,术者应熟悉乳房再造的各种皮瓣的解剖 ,尽量应用自体组织再造乳房。