双侧乳腺切除加假体植入一期乳房重建治疗青年早期乳腺癌患者

目的探讨保留皮肤和乳头乳晕复合体的双侧乳腺切除及假体植入一期乳房重建在青年早期乳腺癌治疗中的临床应用。方法回顾性分析2006年1月至2011年3月接受保留皮肤及乳头乳晕复合体双侧乳腺切除加假体植入一期乳房重建术的21例青年早期乳腺癌患者临床资料。结果21例患者手术成功,术后美容效果优良。随访12—72个月（中位随访期为34个月）,无局部复发和远处转移。结论对青年早期乳腺癌患者,在切除患乳同时预防性切除对侧乳房,即行保留皮肤和乳头乳晕复合体的双侧乳腺切除加一期假体植入重建乳房,美容效果好,临床疗效满意。     

乳腔镜下行乳腺癌皮下腺体切除Ⅰ期假体植入术

 目的　探讨应用乳腔镜技术行乳腺癌皮下腺体切除，Ⅰ期假体植入的可行性。方法　2006年12月至2007年10月收集经TE方案（紫杉醇+表柔比星）新辅助化疗2～6次后的乳腺癌患者9例，Ⅰ期3例、Ⅱ期5例，Ⅲ期1例，其中5例Ⅱ期患者3例降为Ⅰ期，1例Ⅲ期降为Ⅱ期。乳腔镜下行保留乳头乳晕区的皮下腺体切除，Ⅰ期将假体植入胸大肌、胸小肌之间。根据术中冷冻决定是否保留乳头乳晕复合体。结果　9例中2例行双侧乳腺皮下切除，7例行单侧乳腺皮下切除术，均保留乳头乳晕复合体。8例行前哨淋巴结活检，腋窝淋巴结清扫7例，保腋窝2例。8例患者效果满意，1例效果一般。1例发生皮下积液、1例乳头表皮坏死、1例乳房皮瓣出血，经压迫好转。随访1～10个月，未见局部复发。结论　应用乳腔镜技术行乳腺癌皮下腺体切除，Ⅰ期假体植入安全可行，具有微创、美容效果。双侧乳房皮下腺体切除、Ⅰ期假体植入效果更佳。     

皮下乳腺癌改良根治术后Ⅰ期假体乳房再造术的探讨

目的 探讨早期乳腺癌改良根治术后Ⅰ期假体乳房再造.方法 1998年3月至2005年9月,对26例早期乳腺癌在行保留乳头乳晕复合体的皮下乳腺癌改良根治术后以国产硅凝胶假体植入胸大肌后Ⅰ期进行乳房再造,术后常规综合治疗.结果 26例手术均获成功,但5例乳头乳晕部分皮肤发生缺血坏死,通过换药愈合,1例出现皮下积液,通畅引流后消除.随访1～90个月,无一例复发和远处转移.乳房美容效果良好占69.2%,一般占19.2%,较差占11.5%.结论 保留乳头乳晕复合体的皮下乳腺癌改良根治术后Ⅰ期假体乳房再造术,手术操作简单易行,创伤小,恢复快,美容效果满意,是适合早期乳腺癌患者的一种安全有效的手术方式.     

乳腺癌改良根治术同期假体植入重建乳房

目的探讨乳腺癌行改良根治术后，同期硅胶假体植入重建乳房的可行性。方法2005年6月至2006年9月，对20例Ⅰ、Ⅱ期乳腺癌患者行保留皮肤的乳腺癌改良根治术后，同期于胸大、小肌间植入硅胶假体重建乳房，并根据冰冻切片检查结果决定是否保留乳头乳晕复合体。结果20例患者客观评价效果优良和尚好者达95％，主观评价效果优良和尚好者达100％。其中有6例保留乳头乳晕复合体。术后随访3～18个月，所有病例均无局部复发和远处转移，无明显术后并发症。结论保留皮肤的乳腺癌改良根治术后用硅胶假体行一期乳房重建，能达到满意的乳房美容效果，是治疗早期乳腺癌安全可行的方法。     

即刻乳房再造在乳腺癌手术中的应用与探讨

目的探讨即刻乳房再造在乳腺癌手术中的应用价值。方法自2005年10月至2009年2月共完成了26例乳腺癌改良根治即刻乳房再造手术,其中10例为局部晚期乳腺癌。即刻腹直肌肌皮瓣乳房再造术12例,背阔肌肌皮瓣乳房再造术8例,保留乳头乳晕复合体皮下乳腺全切假体植入乳房再造术5例,保留乳头乳晕复合体皮下乳腺全切背阔肌肌皮瓣结合假体植入乳房再造术1例。结果全组手术切缘病理均达到阴性,皮瓣全部成活,无假体相关并发症,亦无腹壁疝发生。再造乳房形态满意,肌皮瓣再造乳房可以安全地耐受术后放疗,随访1～40个月无局部复发病例。结论即刻乳房再造手术从根本上改善了乳腺癌患者术后的生活质量,在局部晚期乳腺癌手术中,肌皮瓣乳房再造还可以为足够的切除范围提供安全保障,颇具临床应用价值。     

乳腔镜辅助下行乳腺癌皮下腺体切除Ⅰ期假体植入术20例报告

目的:探讨乳腔镜辅助下行乳腺癌皮下腺体切除、Ⅰ期假体植入术的可行性.方法:2005年12月～2007年10月经TE或CEX方案新辅助化疗2～6周期后的乳腺癌患者20例,Ⅰ期8例,Ⅱ期10例,Ⅲ期2例,其中10例Ⅱ期患者4例降为Ⅰ期,2例Ⅲ期降为Ⅱ期.在乳腔镜辅助下行保留乳头乳晕区的皮下腺体切除,Ⅰ期将假体植入胸大肌、胸小肌之间.根据术中冰冻决定是否保留乳头乳晕复合体.结果:20例中1例行双侧乳腺皮下切除,19例行单侧乳腺皮下切除术,均保留乳头乳晕复合体,Ⅰ期假体植入.腋窝淋巴结清扫17例,9例行前哨淋巴结活检,保腋窝3例.17例患者效果满意,2例效果一般,1例感觉差.1例皮瓣坏死,2例发生皮下积液,1例乳头皮肤部分坏死.随访3～22.5个月,中位随访12.6个月,未见局部复发及远处转移.结论:应用乳腔镜辅助下行乳腺癌皮下腺体切除、Ⅰ期假体植入具有微创、美容效果.双侧乳房皮下腺体切除、Ⅰ期假体植入效果更佳.     

乳头乳晕区乳腺癌术后即刻乳房重建的临床探讨

目的 探讨乳头乳晕区乳腺癌术后即刻乳房重建的方法及临床应用。方法 回顾性分析天津医科大学肿瘤医院乳腺一科2004年1月至2007年12月共15例乳头乳晕区乳腺癌患者，其中0期乳腺癌3例，Ⅰ期乳腺癌7例，Ⅱ期乳腺癌5例。15例患者中13例行乳头乳晕区圆形切ISI的保乳手术（标本切缘阴性）后即刻背阔肌皮瓣重建术，2例拟行乳头乳晕区圆形切口的保乳手术，因标本切缘阳性，改行仿根治术，术后行即刻背阔肌皮瓣加假体植入乳房重建术。15例患者中即刻乳头乳晕重建术9例，延期乳头乳晕重建术2例，拒绝乳头乳晕重建4例。结果 13例保乳加背阔肌皮瓣重建患者中12例外形满意，满意率为92．31％，1例缝合后中央区内陷，外形不满意，但大小与健侧对称。2例背阔肌皮瓣联合假体重建乳房外形满意。9例即刻重建乳头乳晕7例成活，2例发生重建乳头部分坏死；3例乳头位置略高于健侧。2例延期乳头乳晕重建均成活，且位置对称。15例中6例发生背部皮下积液，1例背部切口裂开。随访10～48个月，中位随访时间25个月，1例患者出现切口局部复发，复发率为7．69％，无远处转移发生。结论 对乳头乳晕中央区乳腺癌进行保乳手术加即刻背阔肌皮瓣重建术可以提高术后乳房外形满意率，且可行即刻乳头乳晕重建术。保乳手术后局部复发率和远处转移率与根治术无差异。     

20例保留皮肤的乳腺癌全乳切除和即刻乳房再造

选择早期乳腺癌患者20例,行保留皮肤的乳腺癌改良根治术后即刻植入假体(14例)或背阔肌肌皮瓣(2例),或联合乳房再造(4例),部分保留乳头乳晕复合体.20例患者中,保留乳房皮肤及部分保留乳头乳晕,均未见局部复发.再造效果优6例,良12例,尚可2例,无严重变形病例.无严重并发症,均按时进行辅助治疗.保留乳房皮肤及乳头乳晕的乳腺癌全乳切除术局部复发率低,术中即刻假体、背阔肌肌皮瓣或联合乳房再造手术效果好,并发症少.     

保留乳头乳晕的全乳切除术的研究进展

乳腺癌已成为全球癌症发病率最高的恶性肿瘤。乳腺癌治疗主要采用以手术为主的综合治疗方案，保留乳头乳晕的全乳切除术（nipple-sparing mastectomy，NSM）作为乳腺外科的一种术式，保留了全部乳房皮肤和乳头乳晕复合体（nipple-areolar complex，NAC），术后乳房再造可获得良好的美学效果，具有显著优势。NSM在保证肿瘤学安全性的同时，提升了患者的生存质量，得到临床上越来越多的重视。本文将就NSM的适应证、禁忌证、肿瘤学安全性、美学效果、并发症及复发后的处理进行综述。      

保留乳头乳晕复合体乳房切除术后复合体坏死的研究

随着乳腺外科技术的不断发展,保留乳头乳晕复合体（nipple areola complex,NAC）的乳房切除术（nipple-sparing mastectomy,NSM）在乳腺癌患者中已经得到了越来越多的应用。近年研究发现在选择适合的乳腺癌患者的前提下,NSM术后局部复发及远处转移率都很低。NSM联合乳房再造术可以达到良好的美学效果,提高乳腺癌患者术后的生活质量。但术后并发症仍是一个不容忽视的问题,特别是NAC坏死,严重影响了手术效果,失去了保留乳头手术的意义,甚至会造成乳房重建的失败。     

Preoperative breast MRI in early-stage breast cancer

Rapid uptake of new imaging technology is a major contributor to rising healthcare costs. Preoperative breast magnetic resonance imaging (MRI) for patients with early-stage breast cancer has dramatically increased in use without the evidence of improved outcomes compared to standard assessment and is associated with higher rates of mastectomy. A decision analytic model was developed to evaluate the impact of adding breast MRI to the preoperative evaluation of women with early-stage breast cancer who were candidates for breast-conserving therapy on patient outcomes measured in quality-adjusted life years (QALYs). Model inputs, including survival, recurrence rates, and health utilities, were obtained from a comprehensive literature review. One-way sensitivity analyses were performed to estimate threshold values for key parameters at which adding MRI would become the optimal imaging strategy over standard assessment. Preoperative MRI resulted in 17.77 QALYs compared to 17.86 QALYs with standard assessment, a decrease of 0.09 QALYs or 34?days. In sensitivity analyses, standard assessment was associated with better patient outcomes than preoperative breast MRI across all plausible probabilities for mastectomy, local recurrence, and health utilities. For routine preoperative breast MRI to become the optimal strategy, the conversion rate to mastectomy after preoperative MRI would need to be <1?% (versus the range of 3.6-33?% reported in the literature). Routine preoperative breast MRI appears to confer no advantage over the standard diagnostic evaluations for early-stage breast cancer and may lead to worse patient outcomes.     

Glycolytic enzymes in breast cancer, benign breast disease and normal breast tissue

The activities of hexokinase, phosphofructokinase, aldolase, enolase and pyruvate kinase were studied in breast cancer tissues, in comparison to benign breast disease and normal breast tissues. The enzyme activities in breast cancer were significantly increased compared to normal and benign breast tissues (p less than 0.001). Also the increase in activity in benign disease compared to normal was statistically significant (p less than 0.001). Within the group of benign diseases, fibroadenomas could be distinguished from fibrocystic disease, the former generally showing higher activities compared to the latter (p less than or equal to 0.05). Carcinoma subgroups, classified according to their histology, could not be recognized enzymologically. In addition, isozyme composition of pyruvate kinase and enolase was studied. We did not find a significant shift towards K type pyruvate kinase expression in benign disease compared to normal breast tissues. Also fibroadenomas did not differ from fibrocystic disease. However, the amount of K type pyruvate kinase in carcinomas proved to be significantly higher in comparison to benign disease and normal breast tissues (p less than 0.001). Expression of alpha gamma-enolase in normal breast tissue was virtually absent. In benign disease only a minority of specimens did show the hybrid alpha gamma-enolase. Nearly all carcinomas had alpha gamma-enolase expression and in 20% of the carcinomas gamma gamma-enolase could be detected (so-called neuron-specific enolase). By discriminant analysis, the function giving the best discrimination compared to the histological data was based on natural logarithm aldolase and the total of gamma-enolase subunits. Contrary to expectation, the regulator enzymes of glycolysis; i.e., hexokinase, phosphofructokinase and pyruvate kinase were not included in this discriminant function. The best fit produced a 90% correct classification in both benign and malignant disease. If these findings are confirmed to a larger series, the discrimination is sufficiently strong to form the basis of a clinically useful tool.     

倒T形切口缩乳术在乳房肥大或合并乳腺癌患者中的应用

目的探讨倒T形切口缩乳术在乳房肥大患者，特别是合并乳腺癌的患者手术中的应用及其临床意义。 方法本回顾性研究共纳入2007年10月到2017年10月分别在同济大学附属东方医院及附属同济医院乳腺外科行缩乳术的39例乳房肥大女性患者，均采用倒T形切口(内侧蒂25例，垂直蒂5例，外侧蒂9例)。其中，包括18例符合保留乳房手术指征的乳腺癌患者(内侧蒂10例，垂直蒂4例，外侧蒂4例)。术后6、12个月评价美容效果(乳腺癌患者待放射治疗结束后进行评价)。评估患者的术后并发症、满意度以及复发转移情况。 结果39例患者术后乳房外形自然、对称，明显缩小上提，乳头、乳晕血供和感觉良好，瘢痕不明显，患者满意度高。1例术后2周出现一侧乳房的乳头乳晕区坏死，经过清创换药后愈合。5例术后双侧乳头乳晕感觉减退，其中4例在术后6个月左右恢复正常感觉，1例在术后12个月恢复。5例出现术后局部乳房组织硬结，其中3例为接受过放射治疗的乳腺癌患者，二次手术切除硬结后无再次发生。3例出现瘢痕处猫耳畸形，再次局部麻醉手术修整后效果良好，3例瘢痕增粗，其余患者瘢痕正常。乳腺癌患者中有3例出现放射治疗后患侧乳房皮肤水肿，术后12个月消退。术后6个月进行了美容效果评价，极好25例，良好10例，中等4例，差0例(18例乳腺癌患者中，极好9例，良好6例，中等3例，差0例)。术后12个月的美容效果评价显示：极好25例，良好13例，中等1例，差0例(18例乳腺癌患者中，极好9例，良好8例，中等1例，差0例)。随访时间最长的1例患者(双侧乳房单纯性重度肥大)术后观察了10年，乳房外形无明显变化。全部患者术后随访15～120个月，中位随访61个月，18例乳腺癌患者均无局部复发转移。 结论对于乳房肥大，特别是合并乳腺癌的患者，采用倒T形切口缩乳术，既可切除病变，又可缩小并悬吊乳房。     

保乳术和延迟即刻再造术对乳腺癌患者生活质量的影响

目的探讨保乳术和延迟即刻再造术对乳腺癌患者手术后生活质量(QOL)的影响。方法选取2010年1月至2015年6月北京协和医院行保乳术和延迟即刻再造术后于2016年3月至2016年4月在医院乳腺外科门诊随访的64例患者,其中保乳手术30例(保乳组),延迟即刻再造术34例(乳房再造组)。应用肿瘤治疗功能评价系统(FACT-B)量表对两组患者进行生活质量测评比较。结果两组患者生理状况、社会/家庭状况、情感状况、功能状况、总体生活质量评价FACT-G和FACT-B条目状况比较,差异无统计学意义(P>0.05);乳房再造组患者附加关注(乳腺癌特异模块)方面QOL优于保乳术组,差异有统计学意义(29.37±2.72vs 24.05±7.01,P<0.05)。结论乳腺癌保乳术和延迟即刻再造术后患者生活质量无明显差异。     

早期乳腺癌保乳手术后加速部分乳腺照射与全乳照射剂量学的比较

目的比较早期乳腺癌患者保乳手术后加速部分乳腺照射(APBI)与全乳照射(WBI)剂量学的差异。方法选取2013年1月至2013年12月间收治的26例保乳术后采用APBI治疗的乳腺癌患者作为观察组,另选取同期保乳术后采用WBI治疗的28例乳腺癌患者作为对照组。采用剂量体积直方图(DVH)比较两组患者剂量学差异,总结两组患者的短期疗效;比较观察组患者在有无图像指导下的位移差异。结果观察组患者的平均剂量(Dmean)、照射体积百分比(V103、V105、V110)和靶区剂量不均匀指数(IHI)均显著低于对照组,各项危及器官(OARS)照射剂量均显著低于对照组,且心脏和肺的照射体积也显著低于对照组,差异均有统计学意义(均P<0.05)。观察组患者美容满意率为96.2%(25/26),对照组患者为67.9%(19/28),两组间差异有统计学意义(P<0.05)。观察组患者在有无图像引导下的位移差异均有统计学意义(均P<0.05)。结论早期乳腺癌患者保乳手术后APBI照射剂量低于WBI,改善靶区剂量分布,降低心肺等组织高剂量受照体积,结合图像引导,可以增加准确性。     

保留乳房天然结构的乳腺癌改良根治术后即刻乳房成形术的临床应用

目的探讨保留乳房天然结构的乳腺癌改良根治术后即刻自体组织乳房成形术在临床中的运用价值。方法乳腺癌患者12例,其中DCIS 6例,浸润性导管癌3例,小管癌1例,髓样癌1例,黏液癌1例;保留乳房皮肤的乳腺癌改良根治术9例,保留乳头乳晕复合体的乳腺癌改良根治术3例。全组均保留或重建乳房下皱襞,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背阔肌肌皮瓣即刻乳房成形。结果横行腹直肌肌皮瓣乳房成形术3例,背阔肌肌皮瓣乳房成形术9例,术后皮瓣均存活,皮瓣血管通畅,成形乳房外观良好。结论对早期乳腺癌患者行保留乳房天然结构的乳腺癌改良根治术后即刻自体组织乳房成形,切口隐蔽,成形乳房形态效果良好,可以获得较好的美容效果。     

Controversies in breast conservation treatment for breast cancer

Breast conservation treatment has become the standard treatment for early breast cancer patients, after the equivalence of mastectomy and breast conservation treatment was demonstrated in prospective, randomized trials and large retrospective studies. New questions, such as the feasibility of neoadjuvant chemotherapy in improving breast conserving rate, the appropriateness of breast conservation treatment in ductal carcinoma in situ, the effectiveness of radiation therapy in patients treated by breast conservation, and patient selection for breast conservation without radiation, are now being raised. Future work that needs to be done to answer these questions is discussed in this review.     

Prostate specific antigen in breast cancer,benign breast disease and normal breast tissue

Prostate specific antigen (PSA) is a tumor marker used widely for the diagnosis and monitoring of prostatic adenocarcinoma. Recently, we provided evidence that PSA may also be produced by breast tumors. In this report we examined quantitatively the PSA levels in 199 breast tumors, 48 tissues with benign breast disease (BBD, 34 fibroadenomas), and 36 normal breast tissues. Significant amounts of PSA (≥ 0.030 ng of PSA per mg of total protein) were found in 28% of breast tumors, 65% of BBD tissues, and 33% of normal breast tissues. PSA positivity in breast tumors was highest in stage I disease (34%) and decreased with disease stage (24% in stage II and 18% in stage III–IV). Using polymerase chain reaction amplification we have shown PSA mRNA presence in patients with PSA protein-positive tissues (benign and malignant) but not in patients with PSA protein-negative tissues. Our data suggest that PSA is expressed frequently by normal breast tissue, by tissue of benign breast diseases, and by breast cancer tissue. Highest expression is seen in benign breast disease and lowest expression in advanced stage cancerous tissue. As PSA production is mediated by steroid hormones and their receptors, we propose that PSA may be a new marker of steroid hormone action in the normal or diseased female breast. The role of this enzyme in the development of breast diseases including breast cancer is currently unknown.     

早期乳腺癌部分乳腺加速放疗

随着乳腺癌术后复发模式的研究进展,部分乳腺照射方法 成为乳腺癌放疗的热点.组织间插植、球囊近距离治疗、术中放疗及三维适形放疗和调强放疗等部分乳腺加速放疗已进入临床研究.其局部控制率和安全性与全乳腺照射比较相当,同时具有治疗周期短、方便患者等优势.部分乳腺加速放疗在部分患者有望代替全乳腺放疗,成为早期乳腺癌保乳术后放疗的标准治疗之一.

Abstract：

With a view to patterns of local recurrence after breast conserving surgery, whole breast irradiation(WBI) after surgery is controversial and partial-breast irradiation(PBI) came up. Many clinical trials related with accelerated partial-breast irradiation using a variety of radiotherapeutic techniques such as interstitial brachytherapy (IBT), MammoSite Radiation Therapy System, intraoperative radiotherapy(IORT), threedimensional conformal radiotherapy(3-DCRT)and intensity modulated radiation therapy(IMRT) in selected patients have been carried out. Accelerated partial-breast irradiation that provides faster, more convenient treat-ment demonstrates local control rate and safety comparable to that of whole breast irradiation. Partial breast irradiation may be an alternative way to whole breast radiotherapy and will be one of the standard treatments in women with early breast cancer seeking breast conservation.