关于预防性乳腺切除术的几个问题

迄今为止 ,还没有明显有效的方法可以用来对乳癌进行早期预防。预防性乳房切除术对高危患者提供了一种可供选择的治疗方法。施行预防性手术的理论基础和惟一理由便是对具有潜在发病因素的人群进行预防 ,以减少这种致命疾病的发生率。目前 ,乳腺预防性切除术的标准如下 :①组织学上的发现证明患者具有乳癌的发病危险 ;②具有乳癌基因的个体 ;③能使用自体组织行乳房重建术。在 2 0世纪 70年代 ,预防性乳腺切除术的指征包括 :乳房疼痛、查体发现的乳房结节、恐癌症患者、乳癌的家族史以及乳房小叶的原位癌等。一部分医生采用上述指征作为施行…     

三阴性乳腺癌术后对侧转移1例

<正>患者女,51岁。2014年1月因左乳肿物就诊我院,并于我科行"左乳腺空芯针穿刺活检术",穿刺病理提示浸润性癌,结合免疫组化考虑浸润性导管癌。免疫组化结果显示ER(-),PR(-),HER-2(+)。先予"AT"方案新辅助化疗2个周期。2014年3月在我院行左侧乳腺癌改良根治术。术后病理结果为:(左侧)乳腺浸润性导管癌II级;肿物大小3 cm×2 cm×2 cm,肿物间及肿物周围乳腺组织胶原组织增生,淋巴细胞浸润,区域淋巴结可见癌转移(腋窝淋巴结19/24),淋     

乳腺癌保乳手术治疗研究进展

随着对乳腺癌生物学特性的进一步认识及诊疗水平的提高，保乳手术终将逐步取代改良根治术而成为主要术式。笔者就乳腺癌治疗观念的改变、保乳手术及其适应证、保乳治疗的技术保障等方面进行综述。     

IA期乳腺癌临床病理特征及预后相关因素分析

目的：探讨IA期乳腺癌患者的临床病理特征与预后因素。 方法：回顾性分析2004年1月—2009年12月天津医科大学肿瘤医院收治的156例IA期（T1N0M0,）乳腺癌患者的临床病理资料。 结果：156例患者均为女性;病理类型以浸润性导管癌为主（115例,73.7%）;原发肿瘤大小以T1c居多 （77例,49.4%）;组织学分级以II级（79例,50.6%）及III级（58例,37.2%）为主。5年无进展生存（PFS）为93.3%,5年总生存（OS）为99.1%。单因素分析结果显示,组织学分级、Ki-67表达及淋巴脉管侵犯与患者的PFS有关（均P<0.05）;多因素分析显示,组织学分级及Ki-67表达情况是影响患者PFS的独立预后因素（均P<0.05）。 结论：IA期乳腺癌患者虽然总体预后较好,但对于某些亚组患者而言,预后较差,该类患者的复发转移风险较大。     

乳腺癌正规治疗后对侧乳腺癌发生的危险因素分析

目的 探讨女性初发乳腺癌治疗后再发对侧乳腺癌(contralateral breast cancer, CBC)的危险因素.方法 回顾性分析我院1997年1月至2002年12月期间收治的340例女性初发乳腺癌患者的临床资料,包括患者的年龄、病理结果、手术方式、化疗、放疗、激素治疗具体方案和执行情况等.采用Kaplan-Meier法评估CBC的发生率,Cox部分相关回归评估CBC的相关危险因素.结果 14例诊断为CBC,总发病率为4.1%.10年CBC发生率(2.7%)高于5年CBC发生率(1.4%),随着随访时间的延长发生率逐年升高.单因素分析提示,患者年龄≤45岁、乳腺癌家族史、病理学分型为髓样癌及未采取内分泌治疗为5年和10年CBC发生的危险因素(P＜0.05),而化疗和放疗与否为CBC发生的非危险相关因素(P＞0.05).多因素分析表明,其中年龄≤45岁及乳腺内放疗为5年和10年CBC发生的独立危险因素(P＜0.05).结论 对于≤45岁、髓样癌、有乳腺癌家族史的初发乳腺癌患者应警惕CBC的发生; 初发乳腺癌患者应采取内分泌治疗,避免乳腺内放疗以降低CBC的发生率.     

乳腺癌分期与术式选择

乳腺癌严重威胁女性的健康,外科治疗在乳腺癌治疗中占据了极其重要的地位。起初,乳腺癌根治术占据着主要地位,随后经历了到扩大根治术和改良根治术的转变。后来,乳腺癌的外科治疗完成了从最大的可耐受的治疗向最小的有效的治疗的转变,随着保乳手术和前哨淋巴结活检术的产生和发展,个体化保守治疗成为乳腺癌外科治疗的发展方向。     

保留皮肤的乳房切除术研究进展

传统的乳腺癌根治术要求至少切除肿瘤周围5 cm的皮肤,而且在术中切除乳头-乳晕复合体,这些都大大增加患者的残缺感[1].为减少这方面的负面心理影响,人们希望能有一种新的外科治疗乳腺癌的方法,即保留皮肤的乳房切除术(skin-sparingmastectomy,SSM).本文就SSM的研究进展做一综述.     

发病年龄对乳腺癌保留乳房治疗后长期生存的影响

目的探讨年龄对乳腺癌患者保留乳房治疗后长期复发及生存结局的影响。方法从北京大学肿瘤医院乳腺癌预防治疗中心数据库中回顾性收集1999年12月至2014年12月2778例原发性乳腺癌保留乳房治疗病例的资料,中位年龄47岁(范围:21~91岁)。根据发病年龄将患者分为≤40岁组(677例)与>40岁组(2101例),比较两组患者的临床特征。采用Kaplan-Meier法绘制生存曲线,并用Log-rank法比较两组局部复发率、无远处转移动生存(DDFS)、无病生存(DFS)及乳腺癌特异性生存(BCSS),采用Cox比例风险模型分析复发及生存的预后因素。结果≤40岁组和>40岁组的激素受体阳性比例(490/677比1581/2101,χ²=6.981,P=0.030)、腋窝淋巴结阳性比例(314/677比713/2101,χ²=34.966,P<0.01)、T1期比例(301/677比1160/2101,χ²=37.660,P<0.01)、接受新辅助化疗比例(413/677比1010/2101,χ²=34.272,P<0.01)的差异均有统计学意义。中位随访102个月。≤40岁组和>40岁组10年局部复发率差异无统计学意义(2.5%比1.6%,P=0.147)。≤40岁组和>40岁组10年DDFS率分别为90.6%和95.3%(P<0.01),10年DFS率分别为86.5%和91.1%(P=0.001),10年BCSS率分别为91.0%和93.7%(P=0.105)。年龄不是局部复发的独立预后因素(P>0.05);淋巴结状态(阳性比阴性,HR=2.73,95%CI:1.94~3.84,P<0.01)、年龄(≤40岁比>40岁,HR=1.73,95%CI:1.24~2.42,P=0.001)、肿瘤最大径(>2 cm比≤2 cm,HR=1.61,95%CI:1.14~2.28,P=0.001)是DDFS和DFS的独立预后因素;激素受体状态(阳性比阴性,HR=0.54,95%CI:0.39~0.74,P<0.01)、淋巴结状态(阳性比阴性,HR=2.94,95%CI:2.12~4.07,P<0.01)、肿瘤最大径(>2 cm比≤2 cm,HR=1.45,95%CI:1.05~2.01,P=0.025)是BCSS的独立预后因素。结论≤40岁与>40岁乳腺癌患者保留乳房治疗后局部复发风险相似,前者长期生存劣于后者。     

208例T1-2N1M0期乳腺癌改良根治术患者无病生存情况的危险因素分析

目的探究行改良根治术的T1-2N1M0期乳腺癌患者无病生存的影响因素。 方法回顾性分析2011年1月至2014年11月经改良根治术治疗208例T1-2N1M0期乳腺癌患者资料,统计术后截止2019年11月患者随访情况,并记录患者术后5年肿瘤转移、复发情况,以SPSS 22.00统计学软件进行数据处理。计数资料用[例(%)]表示,组间比较采用χ²检验;乳腺癌患者预后的相关因素行单因素和Cox多因素回归模型分析,P<0.05差异有统计学意义。 结果本次研究中208例患者均获得确切随访,无失访病例。其中复发、转移28例(13.5%),无转移复发180例(86.5%),患者5年无病生存率为86.5%;将单因素分析结果具有统计学意义的变量纳入Cox多因素回归模型。结果显示,年龄<45岁、组织学分级为III级、术后放疗、Ki-6 ≥30%为行改良根治术T1-2N1M0期乳腺癌患者复发转移的独立预后因素(P<0.05)。 结论年龄<45岁、组织学分级为III级、术后放疗、Ki-67≥30%是T1-2N1M0期乳腺癌患者行改良根治术后复发转移的独立危险因素,增加患者预后风险。     

隐匿性乳腺癌的诊治(附30例报告)

目的 总结隐匿性乳腺确（occult breast cancer，OBC）的诊治经验。方法 回顾性分析30例OBC的临床资料，均以腋下肿块为首发症状，并行手术治疗。结果 本组行乳腺癌根治术16例，改良根治术9例，腋下肿块切除加单纯乳房切除3例，腋下肿块切除术2例。术后14例予辅助化疗加放疗，10例予化疗。随访27例，平均6．8（0．5～12）年，5、10年生存率分别为75．5％和56．8％。结论 对女性腋窝肿块同时排除全身其他部位癌转移者应高度考虑OBC的可能。腋下肿块病检对诊断较有帮助，治疗可采用手术辅以放疗和（／或）化疗及内分泌治疗等综合手段。     

Contralateral prophylactic mastectomy in breast cancer patients who test negative for BRCA mutations

Background

Determination of BRCA1 and 2 mutation carrier status is important. Although BRCA carriers are offered bilateral mastectomy and oophorectomy, most who test negative decline. Some women choose contralateral prophylactic mastectomy (CPM) at the time of their breast cancer diagnosis despite testing negative.

Methods

A total of 110 women with breast cancer received genetic testing before surgical treatment. Patient demographics, tumor characteristics, surgical treatment, and magnetic resonance imaging use were recorded.

Results

Results revealed BRCA1/2 mutation in 33%, variant of unknown significance in 6%, and no mutation in 61% of women. In BRCA-negative women, 37% chose CPM. Marital status was significant for CPM (P = .03). Race, age, stage of presentation, and biomarker status were not associated with choice of CPM. Ninety-six percent of CPM recipients underwent breast reconstruction. Magnetic resonance imaging use did not affect CPM rates (P = .99).

Conclusions

Increased rates of CPM have been observed. In our study married women were more likely to choose CPM. We recommend genetic genotyping before surgery. These findings warrant further investigation.     

Development and pilot testing of a Decision Aid (DA) for women with early-stage breast cancer considering contralateral prophylactic mastectomy

ObjectiveDescribe the development, acceptability and feasibility of a Decision Aid (DA) for women with early-stage breast cancer (BC) at average contralateral breast cancer (CBC) risk considering contralateral prophylactic mastectomy (CPM).MethodsThe DA was developed using the International Patient Decision Aid Standards (IPDAS) and the Ottawa Decision Support Framework. It provides evidence-based information about CPM in a booklet format combining text, graphs and images of surgical options. Twenty-three women with a history of early-stage breast cancer were interviewed in person or over the phone using a ‘think aloud approach’. Framework analysis was used to code and analyse data.ResultsTwenty-three women participated in the study. Mean age of participants was 58.6 years and time since diagnosis ranged from 14 months to 21 years. Five women had CPM and eighteen had not. Women strongly endorsed the DA. Many felt validated by a section on appearance and found information on average risk of recurrence and metastases helpful, however, noted the importance of discussing personal risk with their surgeon. Many requested more information on surgery details (time taken, recovery) and costs of the different options.ConclusionThe DA was acceptable to women, including the format, content and proposed implementation strategies. Practical and financial issues are important to women in considering treatment options.Practice implicationsWomen appreciate information about CPM at diagnosis and emphasised the importance of discussing potential downsides of the procedure in addition to benefits. The DA was considered acceptable to facilitate such discussions.     

An exploration of Australian psychologists' role in assessing women considering risk-reducing or contralateral prophylactic mastectomy

ObjectivesGiven increasing rates of risk-reducing mastectomies (RRM) and contralateral prophylactic mastectomies (CPM), and the potentially significant psychological sequelae of this irreversible procedure, health professionals (HPs) regularly refer patients to psychologists for pre-operative assessment and support. This is the first study to provide qualitative insights from HPs into the role of psychologists who are working with women considering RRM or CPM.Materials and methods24 HPs (psychologists, surgeons, breast care nurses and genetic counsellors) experienced in treating patients before or after RRM/CPM completed semi-structured interviews (n = 15) or participated in a focus group (n = 10). Interviews were qualitatively analysed using Framework methods.ResultsQualitative analysis revealed four interconnected themes: (1) perceived patient motivation to undergo RRM/CPM; (2) HP reasons for psychologist referral; (3) role of the psychologist; and (4) value of psychologist involvement. The reported psychologist role included: mental health assessment, checking understanding of information, ensuring informed decision-making, preparation for the procedure, and management of post-surgical challenges.ConclusionPsychologists are perceived by HPs to have a key role in the multi-disciplinary care of patients considering RRM or CPM.     

Contralateral prophylactic mastectomy: A narrative review of the evidence and acceptability

The uptake of contralateral prophylactic mastectomy (CPM) has increased steadily over the last twenty years in women of all age groups and breast cancer stages. Since contralateral breast cancer is relatively rare and the breast cancer guidelines only recommend CPM in a small subset of patients with breast cancer, the drivers of this trend are unknown. This review aims to evaluate the evidence for and acceptability of CPM, data on patient rationales for choosing CPM, and some of the factors that might impact patient preferences. Based on the evidence, future recommendations will be provided. First, data on contralateral breast cancer risk and CPM rates and trends are addressed. After that, the evidence is structured around four main patient rationales for CPM formulated as questions that patients might ask their surgeon: Will CPM reduce mortality risk? Will CPM reduce the risk of contralateral breast cancer? Can I avoid future screening with CPM? Will I have better breast symmetry after CPM? Also, three different guidelines regarding CPM will be reviewed. Studies indicate a large gap between patient preferences for radical risk reduction with CPM and the current approaches recommended by important guidelines. We suggest a strategy including shared decision-making to enhance surgeons’ communication with patients about contralateral breast cancer and treatment options, to empower patients in order to optimize the use of CPM incorporating accurate risk assessment and individual patient preferences.     

Incidence and outcomes of contralateral breast cancers

BACKGROUND: The significance of a contralateral breast cancer is largely unknown, making prophylactic mastectomy controversial. METHODS: Differences between stages of initial and contralateral cancers were determined by t test. Survival distributions were compared by log-rank analyses and compared with Surveillance Epidemiology and End Results data for unilateral cancers. RESULTS: Metachronous contralateral cancers occurred at a rate of .13% per year and were of significantly lower stage. Metachronous cancers adversely impacted survival for patients with low-stage initial cancers, but the interval between cancers was less than 36 months. Synchronous tumors occurred in 2.3% of patients; survival was worse than for patients with metachronous cancers. CONCLUSIONS: Prophylactic mastectomy is unlikely to be beneficial because of the lower stages and low incidence of second cancers, even for patients with initial low-stage cancers.     

Axillary metastatic disease as presentation of occult or contralateral breast cancer

IntroductionAtypical axillary metastasis may arise from an occult ipsilateral or contralateral breast cancer or from primary non-breast tumour. The treatment of this entity is challenging and presents various options. We present our experience with a brief review of the literature.ResultsA study of atypical axillary metastasis done at St Mary's hospital, from 1998 to 2008, identified six cases. Radiological investigations and immunohistochemistry excluded non-breast primary tumour. Three patients had occult breast cancer on presentation, two patients had previously treated contralateral breast cancer and one patient developed a primary metachronous contralateral breast cancer, which had a completely different histological profile from the involved lymph nodes on the same side. Axillary nodal clearance was done for all patients except for the patient with lymphoedema. Four patients were alive with no evidence of disease and two patients died of the disease at a median follow-up of 23 months.ConclusionAtypical axillary metastasis from ipsilateral occult or contralateral breast cancer should be treated with axillary node clearance and further endocrine or chemotherapy. Radiation treatment or a watchful policy to the ipsilateral breast should be validated by further studies.     

Review of risk factors for the development of contralateral breast cancer

Background

Women treated for breast cancer have an increased risk for developing metachronous contralateral breast cancer (CBC). Patient perception of this risk is often overestimated and has been found to contribute to the decision to undergo contralateral prophylactic mastectomy. An individual's risk is dependent on both patient and tumor characteristics. This review examines and summarizes the current literature on the factors that affect CBC risk.

Data Sources

English-language publications with the keyword “contralateral breast cancer” were identified through a MEDLINE literature search.

Conclusions

The global incidence of CBC is decreasing, a trend that is attributed to more effective adjuvant therapies. Patients with BRCA germ-line mutations demonstrate the highest risk for CBC. In the absence of known genetic mutations, patients with strong family histories who are diagnosed at young ages (<35 years) with estrogen receptor–negative index tumors appear to have a higher incidence of CBC.