乳腺癌术后患者支持性照护需求的纵向研究

目的 了解乳腺癌患者手术后不同阶段支持性照护需求现状及影响因素,为制定不同阶段支持性照护干预方案提供依据。方法 采用癌症患者支持性需求简明问卷对初次确诊的126例乳腺癌患者分别在手术后第3天、第14天、1个月、3个月、6个月进行调查。结果 乳腺癌术后患者支持性照护需求在术后第14天得分最高,自术后1个月后逐渐下降。不同特征乳腺癌患者术后6个月支持性照护需求比较,差异无统计学意义（均P>0.05）。不同阶段乳腺癌手术后患者支持性照护需求的主要影响因素包括医疗服务满意度、包块部位、主要照顾人员、职业、对疾病了解程度、获取疾病知识的主要途径、业余爱好、肿瘤类型(P<0.05,P<0.01)。结论 初次诊断乳腺癌患者手术后各阶段均存在支持性照护需求,且各维度随着时间的推移呈动态变化,建议医务人员进一步加强对患者的健康信息及支持照护指导,并针对主要影响因素与照顾者共同制订有效的干预措施,满足患者不同阶段的支持性照护需求。     

Concepts of seroma formation and prevention in breast cancer surgery

BACKGROUND: Seroma formation is the commonest early sequel to breast cancer surgery especially when axillary dissection is undertaken. It is associated with significant morbidity and financial burden. The main pathophysiology of seroma is still poorly understood and remains controversial. The optimal ways to reduce the incidence of seroma formation are unknown. The aim of this paper is to review the concepts of pathophysiology of seroma formation following mastectomy and breast-conserving surgery for cancer. The various techniques in practice to reduce its incidence and treatment are outlined. METHOD: MEDLINE search of published work on the subject with respect to its pathophysiology, prevention and treatment was carried out. Manual retrieval of relevant articles in the reference lists of the original papers from the MEDLINE was then carried out. RESULT: The pathophysiology and mechanism of seroma formation in breast cancer surgery remains controversial and not fully understood. Methods of prevention and treatment of seroma remain varied and inconclusive. CONCLUSION: Evidence suggests an increase in the incidence of seroma because of thermal trauma from electrocautery dissection, but this is indispensable for surgical haemostasis. Obliteration of dead space by various flap apposition techniques has been shown to be advantageous in reducing incidence and volume of seroma. Low-pressure suction drainage reduces seroma volume and duration of drainage leading to earlier drain removal. Preventive measures have to be tailored according to individual patient and operative factors.     

Results of a controlled study of CO2 laser vs conventional technique in breast cancer

In order to assess the therapeutic potential of CO₂ laser in breast cancer, a randomized study was performed. One hundred and thirty-nine women were randomly assigned to laser or conventional technique (scalpel and electrocautery) groups. Age, clinical tumour stage and pre- or post-menopausal state were set up as criteria of randomization. A radical mastectomy with axillary lymph node dissection was performed in our patients. Statistical analysis showed no difference between the two therapy groups regarding blood loss, post-operative drainage, operating time and hospital stay. All patients were examined on a regular basis—median follow-up time was 5.5 years. Recurrence was equal in both groups (four in each group). Kaplan-Meier evaluation of survival demonstrated no difference between the groups. Evaluation of prognostic factors by the proportional hazards regression model demonstrated an increased risk for the advanced clinical tumour stage (relative risk 2.37,p=0.05) and for patients who did not receive hormone therapy (relative risk 4.85,p=0.0001). The mode of surgical therapy did not affect prognosis. An interaction between treatment and clinical stage was found (ratio of relative risks, 5.87,p=0.01). Thus a differential effect of laser treatment on survival depending on tumour size could be demonstrated. According to our study CO₂ laser treatment does not in general offer significant advantage over conventional technique. However, due to the study design, our findings are preliminary; definite results have to be awaited. The therapeutic potential of laser in breast conserving surgery remains to be investigated.     

An efficient technique for drainage of seromas after breast cancer surgery

Seroma formation is a frequent sequelae following breast cancer surgery. Current methods for seroma drainage often involve repeated needle aspiration that requires multiple passes, and is time consuming. We describe a technique that uses a needle attached to a high vacuum wound drainage system. We believe that this technique is aseptic, relatively cheap, and efficient. It can easily and safely be adopted in the outpatient setting.     

邻近扩张皮瓣在局部晚期乳腺癌手术中应用的临床研究

目的探讨邻近扩张皮瓣在局部晚期乳腺癌（LABC）手术中临床应用效果分析。方法选取我院从2006年1月～2013年12月收治的34例局部晚期乳腺癌手术患者作为研究对象。按照人院顺序分为治疗组与对照组,A组试验组16例,B组对照组18例。对照组即行乳腺癌根治术,同时予全厚皮或背阔肌皮瓣转移修补皮肤缺损,治疗组应用邻近扩张皮瓣配合乳腺癌根治术治疗。对比两组患者围手术期的各项临床数据、术后胸壁外观与感觉、局部复发情况。结果两组患者各项临床指标对比,试验组优于对照组,差异具统计学意义（P〈0．05）。试验组患者的术后胸壁外观与感觉显著优于对照组,差异具统计学意义（P〈0．05）。试验组患者的复发率低于对照组,差异具统计学意义（P〈0．05）。结论应用邻近扩张皮瓣在局部晚期乳腺癌手术中临床效果好,对局部晚期乳腺癌来说是一种安全、有效的治疗方法,值得临床推广应用。     

Modern surgical treatment of breast cancer

Since the 1950's the treatment of breast cancer has changed substantially. This related surgery has become less disfiguring without either impairing survival or increasing recurrences. Adjuvant chemotherapy has also contributed.     

Skin-sparing mastectomy and immediate breast reconstruction: a prospective cohort study for the treatment of advanced stages of breast carcinoma

Background Recent published series demonstrate the safety and effectiveness of skin-sparing mastectomy (SSM) with immediate reconstruction for the treatment of early-stage breast carcinoma. Although several reports have retrospectively evaluated outcomes after breast reconstruction for locally advanced disease (stages IIB and III), no study has specifically considered immediate breast reconstruction after SSM for locally advanced disease. Methods From 1996 to 1998, 67 consecutive patients with breast carcinoma underwent SSM with immediate reconstruction and were prospectively observed. From this group of patients, those with locally advanced disease (stage IIB, n=12; stage III, n=13) were analyzed separately. Tumor characteristics, adjuvant therapy, type of reconstruction, operative time, complications, hospital stay, and incidence of local recurrence and distant metastasis were noted. Results Breast reconstruction consisted of a transverse rectus abdominis myocutaneous flap (n=22) or a latissimus flap plus an implant (n=4). The median operative time was 5.5 hours; the average hospital stay was 5.2 days. Complications required reoperation in three patients (12%): partial skin flap necrosis in two and partial abdominal skin necrosis in one. Surgery on the opposite breast for symmetry was required in one patient (4%). Postoperative adjuvant therapy was not significantly delayed (median interval, 32 days). With a median length of follow-up of 49.2 months (range, 33–64 months), local recurrence was present in only one patient (4%), with successful local salvage treatment, and distant metastasis was present in four patients (16%). Conclusions SSM with immediate reconstruction seems safe and effective and has a low morbidity for patients with advanced stages of breast carcinoma. Local recurrence rates and the incidence of distant metastasis are not increased compared with those of patients who have had modified radical mastectomies without reconstruction.     

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     

A new method of modified radical mastectomy for breast cancer

We have developed a new type of modified radical mastectomy, the method and clinical results of which are reported herein. In this operation, axillary dissection is performed by the following two approaches. Firstly, the axillary contents are dissected from the highest possible subclavicular point to the pectoralis minor muscle, after partially cutting the sternocostal origin of the pectoralis major muscle. The second approach is from the posterior aspect of the pectoralis minor muscle to the lateral portion of the latissimus dorsi muscle. Parasternal dissection can also be performed for stage II and IIIa cancers with a central or medial tumor. After lymph node dissection, the detached edge of the sternocostal origin of the pectoralis major muscle is resutured to cover the parasternal region. Thus, complete dissection of the axillary nodes is performed whilst preserving the pectoralis major and pectoralis minor muscles. Good clinical results were achieved with respect to radicality, cosmetic effects and function in 28 patients with stage I, II and IIIa breast cancers who were followed up for between 5 to 8 years. This new operation may therefore be adopted for the majority of patients with Stage I, II, or IIIa cancers, unless massive infiltration into the pectoralis major muscle has occurred. Preservation of both the pectoralis major and pectoralis minor muscles results in a good cosmetic appearance, good functioning of the arm and easy reconstruction of the breast following mastectomy.     

Trends in immediate breast reconstruction and radiation after mastectomy: A population study

In the last decade, there has been an increase in women undergoing immediate breast reconstruction (IBR) at the time of mastectomy. Recent literature suggests a shift in practice: Surgeons are becoming more comfortable with IBR in the setting of possible postoperative adjuvant radiotherapy, despite the known complications. This study sought to investigate, at a population level, the patient and surgeon characteristics associated with the use of IBR and which of these factors were predictive of adjuvant radiotherapy. This retrospective population‐based cohort study included all adult women who underwent mastectomy in the province of Ontario from 2007 to 2014. The Canadian Institute for Health Information (CIHI) administrative data base was used to generate patient demographic and clinical data. The Ontario Health Insurance Plan (OHIP) data base was used to elicit surgeon characteristics including clinical experience and volume of practice dedicated to breast surgery. Outcome variables included reconstruction concurrent with mastectomy, alloplastic vs autologous reconstruction, and use of radiation. A total of 25 861 patients underwent mastectomy and 2972 had IBR (11.5%). The rate of IBR after mastectomy increased over time from 7.2% in 2007 to 17.2% in 2014 (P < .001). There was also an increase in the proportion of patients with IBR who received radiation over the time period, from 19.4% in 2007 to 28.2% in 2014 (P = .003). In the first regression analysis, IBR was associated with younger patient age, residing in closer proximity to cancer clinics, absence of malignant breast disease (ie, prophylactic mastectomy), having a younger surgeon performing the mastectomy, and receiving care at a teaching hospital. A second analysis showed that patient variables predictive of radiation after IBR were a younger age and a more advanced cancer stage and no variables specific to surgeon or institution were predictive of radiation in patients with IBR. A significant increase in the rate of IBR as well as the use of radiation occurred over the 7‐year study period. Multiple patient and surgeon factors were associated with IBR. Variables associated with radiation in IBR were harder to predict. Given the increase in the use of radiation in IBR, further research is needed to look at long‐term outcomes in these patients at the population level.     

Surgical techniques in breast cancer: an overview

With advancements in oncology and oncoplastic training, the options for treating breast cancer have expanded exponentially over the past two decades. In particular, surgical techniques have advanced to the point where oncological safety and aesthetic outcomes are now the pillars of contemporary breast surgery. Studies have demonstrated that by using oncoplastic techniques, breast conservation has become an alternative for many patients who would otherwise undergo mastectomy. Nonetheless, a considerable cohort of patients will still require, or request, a mastectomy. Surgical options range from a simple wide local excision, therapeutic mammoplasty or volume replacement techniques with a local flap, to mastectomy with whole breast reconstruction using autologous tissue or a prosthetic implant. Deciding between surgical options involves careful consideration of tumour characteristics, patient comorbidities and the potential effects of neoadjuvant and adjuvant treatments. The key message for surgeons is to ensure the chosen surgery does not compromise oncological outcomes and provides an excellent aesthetic outcome with timely healing to prevent delays in commencing adjuvant oncology treatments. In this article, we discuss techniques for breast conservation surgery and reconstructive options after mastectomy. In addition, we detail the safety and influence of neo-adjuvant and adjuvant treatments on surgery.     

隐匿性乳腺癌12例临床分析

目的 探讨隐匿性乳腺癌(occult breast cancer,OBC)的诊断、治疗和愈后.方法 回顾分析首都医科大学附属大兴区人民医院与首都医科大学附属北京同仁医院1995年6月～2006年6月共12例OBC临床资料.结果 本组OBC共12例女性患者,平均年龄52.7岁,均单侧发病,绝经前4例,绝经后8例;左侧病变1O例,右侧病变2例,占同期诊治各型乳腺癌患者0.5%(12/2385);12例均以腋下肿块为首发症状;10例行腋下肿块切除活检证实淋巴结转移性腺癌,2例术前行细针穿刺检查为淋巴结转移性腺癌;12例中3例行淋巴结转移性腺癌的雌激素受体(estrogen receptor,ER)测定,均为阳性;10例术前行乳腺X线钼靶照相检查,2例可见有细小钙化灶,不除外乳腺癌;11例行乳腺B超检查、10例行近红外线扫描,均未发现乳腺内病灶;10例术前胸片、腹部B超,5例胸腹部CT及全身骨扫描和2例胃镜检查未发现全身其他部位病变;10例行乳腺癌改良根治术,1例行乳腺癌根治术,1例患者行姑息手术;9例术后病理检查发现乳腺原发病灶,浸润性导管癌6例、导管内癌3例;术后均予以放射治疗和化疗;3例雌激素受体阳性患者化疗后接受口服三苯氧胺内分泌治疗;随访3～10年,11例均生存且未见复发或转移,1例死亡,其中5例已生存5年以上,5年生存率为41.66%(5/12).结论 OBC是临床较为少见的特殊类型乳腺癌之一;左侧乳腺多见,比一般原发癌浸润能力强,早期即出现腋窝淋巴结肿大或远处转移;对肿大淋巴结进行细针穿刺细胞学检查或切除行组织学检查有助于诊断;乳腺癌改良根治术为常用治疗方法.     

Characteristics of male triple negative breast cancer: A population‐based study

Male triple negative breast cancer (TNBC), which lacks expression of the estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2), is a very rare entity, comprising only a very small percentage of all male breast cancer cases. Management strategies are typically based off research conducted in female TNBC patients; however, there is still much that remains unknown in the male cohort, such as risk factors for developing these malignancies, the optimal treatment approach, and both short‐term and long‐term outcome data. In this retrospective cohort study, we aimed to address these concerns by assessing both the characteristics of male patients who develop TNBC as well as their outcomes. We harnessed data from the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) Program and identified 66 male patients diagnosed with TNBC between 2010 and 2016. Patients were stratified by several variables including age, insurance status, time period of diagnosis, histology, nodal status, tumor grade, tumor stage at diagnosis, and treatment strategy employed for the assessment of overall survival (OS) differences. Our analysis demonstrated that stage remains the most important prognostic factor for OS, with higher stage corresponding to worse OS. A significant OS benefit was also identified in men undergoing a total mastectomy, compared to partial mastectomy or no surgery at all. We also identified that male patients are more likely to present with more advanced disease stages compared to their female counterparts and, therefore, have worse outcomes on average. This may be due to various factors, including the rarity of male TNBC cases and less clear screening guidelines for male breast cancer in general. Trends toward poorer OS with higher tumor grade, higher tumor T stage, advanced age, earlier time period of diagnosis, and ductal histology were also identified, but did not achieve statistical significance. The remaining variables did not appear to influence outcomes in a meaningful manner. In summary, our study suggests, similar to population studies of women with TNBC, that tumor stage is a major prognostic factor of OS in men with TNBC. The data also suggest that the surgical treatment strategy employed is also likely of significance, with improved OS being seen with total mastectomies over partial mastectomies. Other variables such as tumor grade and T stage also likely play a role, but did not achieve statistical significance owing to the small population size. Owing to the rarity of cases, further studies of male TNBC are needed to better understand this rare entity and guide future management strategies.     

保乳治疗和乳房全切除对不同管腔亚型早期乳腺癌患者预后影响的meta分析

目的评价保乳治疗(BCT)和乳房切除(Mast)对早期管腔乳腺癌患者预后的影响。方法通过检索Pub Med、Embase、Web of Science、CNKI、万方、维普等数据库,对符合纳入标准的文献进行meta分析。采用Review Manager 5.3和Stata 12.0统计软件对数据进行分析。结果共纳入25篇文献13032例患者,其中BCT8419例,Mast 4613例。meta分析结果显示:(1)对于总体早期管腔型乳腺癌患者,采用BCT和Mast治疗后的局部区域复发率比较差异无统计学意义[OR=0.84,95%CI(0.43,1.64),P=0.61]。(2)采用BCT治疗管腔A型患者后的局部复发率[OR=0.61,95%CI(0.46,0.81),P=0.0007]、远处转移率[OR=0.53,95%CI(0.41,0.69),P<0.00001]、无病生存率[OR=0.59,95%CI(0.36,0.96),P=0.03]和总生存率[OR=0.65,95%CI(0.42,0.99),P=0.05]方面明显优于管腔B型患者;同样采用BCT治疗管腔A/B型患者后的远处转移率[OR=0.56,95%CI(0.35,0.90),P=0.02]和无病生存率[OR=0.47,95%CI(0.27,0.83),P=0.009]方面明显优于管腔HER2型。(3)采用Mast治疗管腔A型乳腺癌患者后的局部区域复发率[OR=0.58,95%CI(0.36,0.92),P=0.02]、局部复发率[OR=0.56,95%CI(0.38,0.83),P=0.004]、远处转移率[OR=0.58,95%CI(0.40,0.84),P=0.004]和总生存率[OR=0.62,95%CI(0.43,0.89),P=0.009]方面均明显优于管腔B型;同样采用Mast治疗管腔A/B型患者后的局部区域复发率[OR=0.43,95%CI(0.25,0.76),P=0.004]明显优于管腔HER2型。结论对于早期管腔型乳腺癌患者,接受BCT和Mast治疗后的局部区域复发率相近;无论选择何种手术策略,管腔A型早期乳腺癌患者更易获得相对理想的临床预后效果;对于接受BCT治疗的早期管腔亚型乳腺癌患者中管腔HER2型乳腺癌患者的预后最差。