乳房整形技术在乳腺癌保乳手术中的应用

目的总结乳房整形技术在乳腺癌保乳手术中的可行性及其对美容效果的影响。方法回顾性分析150例乳腺癌保乳手术患者的临床资料,根据保乳手术中应用乳房整形技术与否分为乳房整形技术保乳组(A组,70例)和传统手术保乳组(B组,80例),比较两组患者术后并发症、复发转移率、生存率及术后乳房美容效果,采用SPSS16.0软件对数据进行统计分析。结果平均随访时间为30.5个月(6~62个月),随访率为93.3%(140/150)。两组患者术后并发症、局部复发、远处转移、总生存和无病生存率均无统计学差异(P0.05)。A组主观满意率、乳房美容客观评分均优于B组。结论对早期乳腺癌患者采用乳房整形技术进行保乳手术治疗安全性好,而且术后乳房美容效果佳,是一项值得推荐的技术。     

Patient evaluation of cosmetic outcome after conserving surgery for treatment of primary breast cancer.

AIMS: To investigate patient self-assessment of and satisfaction with cosmetic outcome following breast-conserving treatment. METHODS: A total of 254 patients with primary breast cancer who had been treated by wide local excision (WLE) were assessed objectively for cosmesis. Patients then self-rated their own cosmetic outcome and satisfaction via a questionnaire. RESULTS: Seventy-two per cent of the patients stated that there was little or no difference between the treated and untreated breast. Patient satisfaction was high with 90.5% being or with their cosmetic result. There were very good correlations between the objective assessment and the patient self-assessment of the cosmetic result (chi(2)=77.98 P<0.001) and between the patient satisfaction and the patient self-assessment (chi(2)=122.65 P<0.001). CONCLUSION: This study shows very good cosmetic outcome with high patient satisfaction. These cosmetic results combined with a low local recurrence rate following wide local excision validate the operative method used.     

Simultaneous integrated boost by Intensity Modulated Radiotherapy (SIB-IMRT) in patients undergoing breast conserving surgery – A clinical and dosimetric perspective

Aim

To study feasibility of simultaneous integrated boost by intensity modulated radiotherapy (SIB-IMRT) in patients undergoing breast conserving surgery and its impact on cosmesis and dosimetry.

Immediate nipple-areola-sparing mastectomy reconstruction: An update on oncological and reconstruction techniques

Nipple-sparing mastectomy (NSM) is a safe technique in patients who are candidates for conservation breast surgery. However, there is worry concerning its oncological safety and surgical outcome in terms of postoperative complications. The authors reviewed the literature to evaluate the oncological safety, patient selection, surgical techniques, and also to identify the factors influencing postoperative outcome and complication rates. Patient selection and safety related to NSM are based on oncological and anatomical parameters. Among the main criteria, the oncological aspects include the clinical stage of breast cancer, tumor characteristics and location including small, peripherally located tumors, without multicentricity, or for prophylactic mastectomy. Surgical success depends on coordinated planning with the oncological surgeon and careful preoperative and intraoperative management. In general, the NSM reconstruction is related to autologous and alloplastic techniques and sometimes include contra-lateral breast surgery. Choice of reconstructive technique following NSM requires accurate consideration of various patient related factors, including: breast volume, degree of ptosis, areola size, clinical factors, and surgeon’s experience. In addition, tumor related factors include dimension, location and proximity to the nipple-areola complex. Regardless of the fact that there is no unanimity concerning the appropriate technique, the criteria are determined by the surgeon’s experience and the anatomical aspects of the breast. The positive aspects of the technique utilized should include low interference with the oncological treatment, reproducibility, and long-term results. Selected patients can have safe outcomes and therefore this may be a feasible option for early breast cancer management. However, available data demonstrates that NSM can be safely performed for breast cancer treatment in selected cases. Additional studies and longer follow-up are necessary to define consistent selection criteria for NSM.     

Repeat breast-conserving therapy for ipsilateral breast cancer recurrence: A systematic review

The standard of care for patients with an ipsilateral breast tumour recurrence (IBTR) after breast-conserving therapy (BCT) is a salvage mastectomy. However, there is growing interest in the feasibility of repeat BCT for these patients. This systematic review contains the latest insights on BCT options for patients with an IBTR after initial BCT.A PubMed literature search was performed for articles on BCT options for IBTR after primary lumpectomy followed by radiotherapy. Weighted estimates were calculated for 5- and 10-year local control, distant metastasis-free and overall survival rates. Secondary outcomes were toxicity, cosmesis and quality of life.In total, 34 studies were eligible for analysis, of which 5 reported on repeat breast-conserving surgery (BCS) alone, 10 with mixed populations (BCS ± RT and/or mastectomy), 18 on repeat BCS followed by re-irradiation (whole-breast or partial) and one on quality of life. The weighted estimates for 5-year overall survival for repeat BCS and repeat BCS followed by reirradiation were 77% and 87%, respectively. Five-year local control was 76% for repeat BCS alone and 89% for repeat BCS followed by re-irradiation. Grade III-IV toxicity rates after re-irradiation varied from 0 to 21%, whereas the cosmesis was excellent-good in 29–100% of patients and unacceptable in 0–18%.Repeat BCS followed by re-irradiation, with either whole breast or partial breast re-irradiation, seems a feasible alternative to mastectomy in case of IBTR, in selected patients. Toxicity rates are low and the cosmetic outcome is good, but the size and follow-up of the published patient series is limited.     

Accelerated partial breast irradiation: Past,present, and future

Accelerated partial breast irradiation (APBI) focuses higher doses of radiation during a shorter interval to the lumpectomy cavity, in the setting of breast conserving therapy for early stage breast cancer. The utilization of APBI has increased in the past decade because of the shorter treatment schedule and a growing body of outcome data showing positive cosmetic outcomes and high local control rates in selected patients undergoing breast conserving therapy. Technological advances in various APBI modalities, including intracavitary and interstitial brachytherapy, intraoperative radiation therapy, and external beam radiation therapy, have made APBI more accessible in the community. Results of early APBI trials served as the basis for the current consensus guidelines, and multiple prospective randomized clinical trials are currently ongoing. The pending long term results of these trials will help us identify optimal candidates that can benefit from ABPI. Here we provide an overview of the clinical and cosmetic outcomes of various APBI techniques and review the current guidelines for selecting suitable breast cancer patients. We also discuss the impact of APBI on the economics of cancer care and patient reported quality of life.     

Oncoplastic surgical techniques for personalized breast conserving surgery in breast cancer patient with small to moderate sized breast

Oncoplastic surgery has revolutionized the field of breast conserving surgery (BCS). The final aims of this technique are to obtain an adequate resection margin that will reduce the rate of local recurrence while simultaneously improving cosmetic outcomes. To obtain successful results after oncoplastic surgery, it is imperative that patients be risk-stratified based on risk factors associated with positive margins, that relevant imaging studies be reviewed, and that the confirmation of negative margins be confirmed during the initial operation. Patients who had small- to moderate-sized breasts are the most likely to be dissatisfied with the cosmetic outcome of surgery, even if the defect is small; therefore, oncoplastic surgery in this population is warranted. Reconstruction of the remaining breast tissue is divided into volume displacement and volume replacement techniques. The use of the various oncoplastic surgeries is based on tumor location and excised breast volume. If the excised volume is less than 100 g, the tumor location is used to determine which technique should be used, with the most commonly used technique being volume displacement. However, if the excised volume is greater than 100 g, the volume replacement method is generally used, and in cases where more than 150 g is excised, the latissimus dorsi myocutaneous flap may be used to obtain a pleasing cosmetic result. The local recurrence rate after oncoplastic surgery was lower than that of conventional BCS, as oncoplastic surgery reduced the rate of positive resection margins by resecting a wider section of glandular tissue. If the surgeon understands the advantages and disadvantages of oncoplastic surgery, and the multidisciplinary breast team is able to successfully collaborate, then the success rate of BCS with partial breast reconstruction can be increased while also yielding a cosmetically appealing outcome.     

How safe is oncoplastic breast conservation?: Comparative analysis with standard breast conserving surgery

Aim

Oncoplastic techniques are increasingly used to facilitate breast conservation and maintain breast aesthetics but evidence with regards to the oncological safety of oncoplastic breast conservation surgery (oBCS) remains limited. The aim of this study was to compare re-excision and local recurrence rates for oBCS with standard breast conserving surgery (sBCS).

Methods

From June 2003 to Feb 2010 data was obtained from contemporaneously recorded electronic patient records on patients who had oBCS and sBCS within a single breast cancer centre. Re-excision rates and local recurrence rates were compared.

Results

A total of 440 sBCS and 150 oBCS (in 146 women) were included in this study. Median tumour size and specimen weight was 21 mm and 67 g for oBCS and 18 mm and 40 g in the sBCS group (p < 0.001). Re-excision was 2.7% (4/150) and 13.4% (59/440) for oBCS and sBCS respectively (p < 0.001). At a median follow-up of 28 months, local relapse was 2.7% (4) and 2.2% (10) and distant relapse 1.3% (2) and 7.5% (33) for oBCS and sBCS respectively.

Conclusions

Oncoplastic breast conserving techniques decrease re-excision rates. Early follow up data suggests oncological outcomes of oncoplastic breast conservation surgery are similar to standard breast conservation.     

Endoscopic breast surgery: where are we now and what might the future hold for video-assisted breast surgery?

Endoscopic surgery has been extensively used for many surgical conditions and has gained acceptance as an alternative and less invasive approach to open surgery. However, minimal access endoscopic techniques have yet to be translated into mainstream clinical practice in breast surgery. More recently, technical innovations have made it feasible to conduct endoscopic breast cancer resection, with or without breast reconstruction, through wounds inconspicuously hidden in the axilla and periareolar region. Several clinical trials have now been conducted to demonstrate technical feasibility, assess safety and provide follow up data regarding oncological success of endoscopic breast surgery. This primary aim was to critically evaluate the literature in order to determine the oncological and cosmetic efficacy of endoscopic breast surgery. A systematic review was conducted using Medline, Ovid and Embase to identify original data from studies of endoscopic breast surgery. Initial results have demonstrated that endoscopic breast surgery is safe and technically feasible. Early data suggests that it is possible to achieve disease control with high rates of overall survival and low rates of local relapse recurrence and/or distant metastases. However, the absence of level I randomised clinical evidence currently precludes a recommendation that endoscopic breast cancer surgery is capable of achieving equivalent oncological outcomes to open surgery.     

Repeat breast-conserving surgery for in-breast local breast carcinoma recurrence: the potential role of partial breast irradiation

Mastectomy is the current standard of care for in-breast local recurrence of breast carcinoma. The objective of the current study was to critically review the rationale for and the theoretic and actual risks and benefits of repeat breast-conserving surgery followed by partial breast irradiation (PBI) for in-breast local recurrence of breast carcinoma. The main outcomes of interest were local control and survival after in-breast local recurrence and side effects, complications, and cosmesis after reirradiation of the breast. The risk of local recurrence was not found to be eliminated with mastectomy; approximately 2-32% of patients treated with mastectomy develop a chest wall recurrence. The interpretation of local control rates in evaluating repeat breast-conserving surgery studies is difficult because of the lack of information regarding preoperative diagnostic mammography to rule out concurrent multicentric disease and microscopic margin status after surgery. Rates of subsequent local recurrence in these studies appeared to be between 19-50%, similar to reported rates of in-breast local recurrence in patients with a first diagnosis of breast carcinoma who were treated with conservative surgery without irradiation. Early follow-up studies of breast reirradiation suggest that catheter-based interstitial brachytherapy and standard external beam radiation therapy can be delivered to the breast more than once without significant side effects in most patients and with acceptable cosmesis in some patients. Mastectomy may not be necessary in all patients with an in-breast local recurrence of breast carcinoma. Recent advances in conformal radiation delivery and single-center published reports concerning repeat breast-conserving therapy support well designed prospective trials to formally test this hypothesis.     

Intraoperative radiation therapy delivered prior to lumpectomy for early-stage breast cancer: a single institution study

Objective: To evaluate the safety, cosmesis, and clinical outcome of intraoperative electron radiation therapy (IOERT) delivered prior to lumpectomy for early-stage breast cancer. Methods: From December 2008 to March 2012, 75 breast cancer patients (ages 34-66 years) were treated with IOERT during breast conservative surgery. IOERT was delivered using a mobile linear accelerator. Suitable energy and applicator size were chosen to ensure coverage of the tumor with anterior and posterior margins of 1 cm and lateral margins of 2 cm. Patients with sentinel node metastases or younger than 40 years received 8 Gy as boost followed by post-operative external beam radiation therapy of 50 Gy/25F; the others had 15 Gy, prescribed to the 90% isodose depth. Adjuvant treatment consisted of chemotherapy (55 patients), hormonal therapy (59 patients), or combined chemotherapy and hormonal therapy (41 patients). The safety, cosmesis, and short-term outcome were evaluated. Results: Median follow-up was 54 months (range: 30-66 months). Two (2.7%) patients developed post-surgical hematoma. Six (8.0%) patients developed mild breast fibrosis. Eight (10.7%) patients suffered from local pain. One (1.2%) patient experienced a post-operative infection. Sixteen (21.3%) patients developed Grade 1 pulmonary fibrosis. Forty-three (57.3%) patients had an excellent cosmetic result and 23 (30.7%) had a good cosmetic result. Three patients had an ipsilateral breast recurrence, with an actual 3-year local recurrence rate of 4.0%. One patient had an ipsilateral axillary recurrence, resulting in a 3-year regional recurrence rate of 1.3%. No distant metastases or deaths were observed. The 3-year disease free survival was 94.6%. Conclusions: Intraoperative electron radiation therapy delivered prior to lumpectomy is safe and feasible for selected patients with early-stage breast cancer. Early side effects, cosmesis and short-term efficacy are acceptable, but a longer follow-up is needed for evaluation of late side effects and long-term outcome.     

The outcome of patients with breast cancer who underwent breast conserving treatment with or without immediate volume replacement with autogenous tissue

Background  Breast conserving treatment (BCT) is accepted as an appropriate therapy for most patients with stage I and stage II breast cancer. However, BCT is associated with a relatively high incidence of local recurrence, and aesthetically unacceptable results occur in some patients. A novel method of immediate volume replacement using autogenous tissue has been developed to strike a balance between adequate excision and cosmesis. We determined the oncological outcome in patients with breast cancer treated with wide excision, immediate volume replacement with autogenous tissue, and axillary dissection followed by radiotherapy. Methods  One hundred fifty-three patients with TIS, stage I, II, or III breast cancer underwent wide excision and axillary dissection. The surgical margin of excised breast tissue was examined histologically during surgery. If involved, the breast tissue adjacent to the primary site was excised. When the margin of re-excision was positive, patients underwent modified radical mastectomy with or without breast reconstruction. After wide excision, immediate volume replacement with autogenous tissue was performed, unless the deformity was corrected by undermining and conization of the residual breast tissue. Postoperatively, all patients received breast irradiation. Results  Eighteen patients underwent modified radical mastectomy. The surgical margin was negative in 132 of the 135 patients who underwent BCT. The crude local recurrence rate was 0.7% (1/135). Estimated overall and disease-free 5-year survival rates were 96% and 94%, respectively. Conclusions  Wide excision with tumor-free margins and axillary dissection followed by breast irradiation provides adequate local control in many patients with breast cancer. Immediate breast volume replacement with autogenous tissue may avoid some unpleasant cosmetic results associated with extensive local resection. Our technique eliminates the need for mastectomy in selected patients.     

Oncoplastic breast surgery: Current status and best candidates for treatment

The term oncoplastic surgery was coined to describe an evolving area of breast surgery that applies the principles of surgical oncology and plastic and reconstructive surgery to the management of women with breast cancer. Oncoplastic surgery does not describe a particular surgical procedure; it represents a comprehensive approach to surgical planning intended to achieve 1) widened surgical margins; 2) reduced local recurrence risk; 3) optimized cosmetic outcome; and 4) breast volume reduction when patients with macromastia develop breast cancer. This specialized field of cancer surgery, once confined to surgeons practicing in Europe, has gained popularity and attention in the United States, with surgeons anxious to achieve these goals for patients. Multiple factors have combined to allow surgeons to use innovative surgical solutions to simultaneously improve oncologic outcome and surgical cosmesis. This article explores current aspects of oncoplastic surgery, summarizes how various methods are applied in clinical practice, and discusses future directions in the emerging field of oncoplastic breast cancer surgery.     

Impact of boost technique on outcome in early-stage breast cancer patients treated with breast-conserving therapy

We reviewed our institution's experience treating early-stage breast cancer patients with breast-conserving therapy (BCT) to determine the impact of boost technique on outcome. A total of 552 patients with stage I and II breast cancer were managed with BCT. All patients were treated with a partial mastectomy and radiation therapy (RT). RT consisted of 45 Gy to 50 Gy external beam irradiation to the whole breast followed by a boost to the tumor bed using either electrons (232 patients), photons (15 patients), or an interstitial implant (316 patients). Local control and cosmetic outcome was compared among three patient groups based on the type of boost used. Forty-one patients had a recurrence of cancer in the treated breast for 5-, 10-, and 13-year actuarial local recurrence rates of 2.8%, 7.5%, and 11.2%, respectively. There were no significant differences in the local recurrence rates or cosmetic outcome using electrons, photons, or an interstitial implant. On multivariate analysis, only young age and margin status were associated with local recurrence. Stage I and II breast cancer patients undergoing BCT can be effectively managed with electron, photon, or interstitial implant boost techniques. Long-term local control and cosmetic outcome are excellent regardless of which boost technique is used.     

Cosmetic and functional outcomes of breast conserving treatment for early stage breast cancer. 2. Relationship with psychosocial functioning.

The relationship between cosmetic and functional results of breast conserving therapy and psychosocial functioning was examined in a sample of 76 patients with early stage breast cancer, who received treatment between 1975 and 1985. The patients were interviewed at their homes regarding breast cosmesis, arm functioning and psychosocial health, and subsequently attended the hospital for independent assessment of cosmetic and functional outcomes by clinical observers. High levels of psychological distress, disturbance of body image, and decreased sexual functioning were noted in approximately one-quarter of the study sample. About half of the patients expressed heightened concern with disease recurrence and their future health. Psychosocial problems were only modestly associated with treatment-related cosmetic and functional outcomes, as determined by clinical ratings and objective assessments. The patients' own ratings of breast cosmesis and arm functioning exhibited somewhat higher correlations with self-reported psychosocial functioning. In particular, a significant association was noted between the patients' ratings of overall cosmesis and arm edema and their body image (r = 0.48 and r = 0.43, respectively). The association between cosmetic and functional results and self-reported psychosocial health was strongest among those patients younger in age and treated longer ago. These findings suggest that, in order to evaluate the impact of breast conserving therapy on the patients' quality of life, the patients' own assessments of cosmetic and functional outcomes should be used as a primary source of information.     

The role of oncoplastic therapeutic mammoplasty in breast cancer surgery--a review

BackgroundReduction mammoplasty is an established technique for symptom relief in women with breast hypertrophy. Therapeutic mammoplasty and radiotherapy may allow cancers to be surgically treated whilst maintaining oncological safety and improving cosmetic outcome. This article aims to review the evidence upon which therapeutic mammoplasty is based and to outline an approach for surgical planning and selection.MethodsA systematic PubMed and Medline literature search was carried out. All abstracts were studied and papers that dealt primarily with breast conservation using plastic surgery techniques were reviewed.Results and conclusionTherapeutic mammoplasty is a useful procedure for breast conserving cancer surgery in women with large breasts, conferring a good cosmetic and functional outcome. This article proposes that breast surgeons experienced in oncological surgery can safely resect tumours from all aspects of the breast with a minimal number of variations in standard mammoplasty technique.     

Cosmetic outcome of breast conservative treatment for early stage breast cancer

Purpose To evaluate the cosmetic outcome of breast conservative therapy and to examine the degree of agreement between the patients’ and oncologists’ ratings. We also analyze the influence of several factors on cosmesis. Methods and materials We retrospectively evaluated 145 patients with primary breast cancer treated by local excision and radiotherapy between January 2000 and May 2001. Cosmetic outcome was evaluated by doctors and patients and was scored as excellent, good, fair or poor. Results 73% of patients rated cosmesis as excellent or good while the percentage was 71% when rated by radiation oncologists. The degree of cosmesis concordance evaluated by oncologists and patients was low (kappa=0.3). In our study the variables which significantly influence on the cosmetic outcome were concomitant adjuvant chemotherapy (p=0.04) and radiation therapy boost, either by electron beam or brachytherapy (p=0.013). Conclusion The cosmetic outcome of breast conserving therapy was good. There was a similar rating by the patient and radiation oncologist, but the level of concordance between patients and doctors was low. Factors that significantly influence the cosmesis appear to be concomitant adjuvant chemotherapy and radiation therapy boost.     

保乳术治疗早期乳腺癌疗效观察

目的 观察早期乳腺癌保乳术的疗效.方法 入组保乳术治疗的早期乳腺癌30例,其中Ⅰ期21例,Ⅱ期9例,均行象限切除加腋窝淋巴结清扫,术后均进行辅助化疗、放疗和内分泌治疗等综合治疗.结果 30例全部得到随访,随访时间6～96个月,未发现局部复发或远处转移.5年总生存率90.6%,乳房美容优良率93.3%.结论 保乳手术配合...