Management of skin-sparing mastectomy: results of a survey of German hospitals

BACKGROUND: The aim of this study was to evaluate the current management of skin-sparing mastectomy in German hospitals and to determine its oncologic safety. For this purpose, 100 surgeons were surveyed regarding their use of skin-sparing mastectomy. RESULTS: Almost all surveyed hospitals performed skin-sparing mastectomy. Most of them believe that the recurrence rate is equal to that of conventional mastectomy. 95% regard inflammatory cancer as a contraindication to skin-sparing surgery. Most of the hospitals thin out the skin without leaving any macroscopic glandular tissue behind, and 73% leave the nipple-areola complex (NAC) on the basis of frozen sections. Volume replacement is most commonly done with latissimus dorsi muscle flaps and pedicled TRAM flaps. In 76% of the surveyed hospitals, reconstruction after mastectomy is performed by the gynecological department. CONCLUSION: Skin-sparing mastectomy is considered to be the best cosmetic option for breast reconstruction in selected breast cancer patients. At present, statistical proof of its oncologic safety is lacking. The surgical techniques used for skin-sparing mastectomy have not yet been standardized. In order to achieve standardization, careful discussion-making and evaluation remain important.     

乳腺癌术后即时扩展型背阔肌肌皮瓣乳房重建27例分析

目的探讨乳腺癌改良根治术后应用扩展型背阔肌肌皮瓣即时乳房重建的疗效。方法对27例乳腺癌患者施行乳腺癌改良根治术（其中6例行保留皮肤的乳腺癌改良根治术,21例行保留乳头、乳晕的乳腺癌改良根治术）,术后即时切取包括背阔肌及其表面的脂肪和岛状皮肤、髂嵴上方脂肪、背阔肌前沿侧胸部脂肪和肩胛区脂肪构成扩展型背阔肌肌皮瓣,转移至胸壁重建乳房。结果27例即时乳房重建全部获得成功。切除乳房的组织量为180-330ml（平均215ml）,移植重建乳房的扩展型背阔肌肌皮瓣组织量为210-380ml（平均245ml）。24例术后辅助化疗,5例辅助放射治疗。随访6～24个月（中位随访12个月）,所有患者均生存,术后无一例局部复发、转移。美容效果：优17例,良6例,一般3例,差1例。结论乳腺癌患者行保留皮肤或乳头乳晕改良根治术后应用扩展型背阔肌肌皮瓣即时乳房重建形态良好,不影响术后辅助治疗和远期疗效,作为目前乳腺肿瘤治疗的一种有效补充手段,值得临床推广。     

保留皮肤的乳腺癌改良根治术后即刻乳房再造的临床应用

目的探讨保留皮肤的乳腺癌改良根治术后即刻再造乳房的适应证、方法、效果及可行性。方法2002年1月至2007年11月本院对94例乳腺癌患者行保留乳房皮肤皮下乳腺组织切除加腋窝淋巴结清扫术后，应用下腹部横行腹直肌肌皮瓣（transverse rectus abdominis myocutaneous flap，TRAM）、背阔肌肌皮瓣（latissimus dorsi myocutaneous flap，LDM）联合或不联合假体、单纯乳房假体植入4种方式即刻再造乳房。结果再造手术均取得成功。带蒂TRAM再造47例，LDM再造共42例（其中联合假体28例），单纯乳房假体植入5例。4例出现轻微术后并发症（4．25％）。经过3～67个月随访，局部区域复发率为0，再造乳房形态自然，效果满意，术后外观评价优良率97．87％。结论合理选择病例行保留皮肤或保留乳头乳晕乳腺癌改良根治术后即刻乳房再造是安全可靠的，切口隐蔽并能够保留原有乳房皮肤的感觉，从而获得最佳美容效果，值得广泛推广和应用。     

保留皮肤的青年乳腺癌改良根治术后即刻乳房再造与改良根治术的比较分析

目的:比较保留皮肤的乳腺癌改良根治术后即刻乳房再造与改良根治术对青年患者的疗效,并对乳房再造患者的预后因素进行分析。方法:回顾性分析柳州市人民医院2008年7 月至2014年6 月收治并行保留皮肤的乳腺癌改良根治术后即刻乳房再造组（60例）与改良根治术组（68例）的青年乳腺癌患者临床病理资料,比较两组间局部复发、无瘤生存及总生存,并分析年龄、肿瘤大小、是否保留乳头乳晕等因素对乳房再造患者生存的影响。结果:所有病例随访15～88个月,中位时间51个月。即刻乳房再造组局部复发3 例,远处转移8 例,死亡5 例,3 年无瘤生存率91.7% ,5 年无瘤生存率81.7% ,总生存率91.7%;改良根治术组局部复发2 例,远处转移9 例,死亡5 例,3 年无瘤生存率94.1 % ,5 年无瘤生存率83.8% ,总生存率92.6% ,两组比较均差异无统计学意义（均P > 0.05）。 即刻乳房再造组患者预后分析显示,淋巴结转移及雌孕激素受体阴性与无瘤生存率、总生存率相关（均P <0.05）。 结论:青年乳腺癌患者保留皮肤的改良根治术后即刻乳房再造组与改良根治术组在局部复发及远期生存方面无显著性差异,对于早期青年乳腺癌患者是安全的,保留乳头乳晕并未增加肿瘤复发风险,淋巴结转移及雌孕激素受体阴性是影响预后的主要因素。      

Skin-sparing mastectomy and immediate reconstruction with a deep inferior epigastric perforator flap

BACKGROUND: It is important for breast reconstruction after mastectomy to recreate immediately good breast symmetry with an adequate amount of soft tissue. METHODS: Eight patients with breast cancer underwent skin-sparing mastectomy and immediate reconstruction with a deep inferior epigastric perforator flap. This operative technique, and the results, advantages, and disadvantages of the technique were assessed. RESULTS: Seven patients had stage IIA disease, and one patient had stage I disease. An arc-shaped incision was made just at the lateral border of the breast in all patients. Three patients had a separate periareolar incision, and one had a circumferential nipple incision. There was 100% flap survival, and good breast symmetry was achieved in all patients. No major perioperative complications occurred in this series. A small amount of fat necrosis occurred in one flap. One patient had slight abdominal bulging. Minor wound-healing problems at the lateral breast skin envelope occurred in two patients. CONCLUSION: These data indicate that skin-sparing mastectomy and immediate reconstruction with a DIEP flap is a reliable and safe technique. This method is a potentially useful surgical technique, which has achieved very promising results.     

Skin-sparing radiation using intensity-modulated radiotherapy after conservative surgery in early-stage breast cancer: a planning study

PURPOSE: To evaluate the feasibility of skin-sparing by configuring it as an organ-at-risk (OAR) while delivering whole-breast intensity-modulated radiotherapy (IMRT) in early breast cancer. METHODS AND MATERIALS: Archival computed tomography scan images of 14 left-sided early-breast tumor patients who had undergone lumpectomy were selected for this study. Skin was contoured as a 4- to 5-mm strip extending from the patient outline to anterior margin of the breast planning target volume (PTV). Two IMRT plans were generated by the helical tomotherapy approach to deliver 50 Gy in 25 fractions to the breast alone: one with skin dose constraints (skin-sparing plan) and the other without (non-skin-sparing plan). Comparison of the plans was done using a two-sided paired Student t test. RESULTS: The mean skin dose and volume of skin receiving 50 Gy were significantly less with the skin-sparing plan compared with non-skin-sparing plan (42.3 Gy vs. 47.7 Gy and 12.2% vs. 57.8% respectively; p < 0.001). The reduction in skin dose was confirmed by TLD measurements in anthropomorphic phantom using the same plans. Dose-volume analyses for other OARs were similar in both plans. CONCLUSIONS: By configuring the skin as an OAR, it is possible to achieve skin dose reduction while delivering whole-breast IMRT without compromising dose profiles to PTV and OARs.     

Nipple-sparing mastectomy--is it worth the risk?

Nipple-sparing mastectomy (NSM) is a surgical protocol designed to reduce the disabling psychological effects of radical or skin-sparing mastectomy. The preservation of the nipple-areola complex produces a more-natural result of the breast reconstruction, but this preservation is suspected of increasing tumor local recurrence. To reduce this risk, different approaches have been proposed: restrict the inclusion criteria and/or add localized radiation therapy. The local recurrence rate in recent series of patients receiving NSM is comparable with the local recurrence rate in modified radical or skin-sparing mastectomies. Today, the quality of the subcutaneous mastectomy technique allows for a more radical glandular removal, especially in the retroareolar area; therefore, local recurrence is observed in 3-6% of patients at 5 years, consistent with traditional mastectomy.     

24例保留乳头乳晕乳腺癌术后即刻乳房重建的临床经验

目的:探讨保留乳头、乳晕及部分乳房皮肤的乳腺癌改良根治术后即刻采用不同的方法乳房重建的可行性。方法:筛选出病理符合要求的24例早期乳腺癌患者,行保留乳头、乳晕及部分皮肤的改良根治术,根据患者的要求,结合其身体、心理、经济等状况,特别是乳房的大小和需要切除的尺寸,选择适合该患者的手术方式即刻行乳房重建,采用硅胶充填假体置入乳房重建9 例,腹直肌肌皮瓣乳房重建3 例,背阔肌肌皮瓣和硅胶填充假体联合重建12例。术后根据客观标准和主观标准评价重建效果。结果:24例乳腺癌患者术后即刻乳房再造术后外观良好,双侧乳房基本对称。客观评价效果优良和尚好者23例（95.83%）,主观评价优良和尚好者24例（100%）,1 例术后部分乳头坏死、脱落。1 例术后出现血肿,于术后3 个月消失。术后给予常规化疗,随访5～48个月,除1 例患者术后2 年死于原发性肝癌,均无局部复发或远处转移。结论:对于早期乳腺癌行保留乳头、乳晕及部分乳房皮肤的乳腺癌改良根治术后即刻采用不同方法乳房再造,具有经济、整形效果好、显著减少患者乳房缺失造成的心理影响、提高生存质量等优点。术后不影响乳腺癌的辅助治疗和远期疗效,能同时满足肿瘤治疗和形体美容两个方面的要求,正逐渐被广大乳腺癌患者所接受。      

Does post-mastectomy radiotherapy represent a contraindication to skin-sparing mastectomy and immediate reconstruction: an update

The use of skin-sparing mastectomy (SSM) to facilitate breast reconstruction is increasing due to a wide acceptance of improved cosmetic outcomes and evidence of equivalence in oncologic outcomes. The rates of patients undergoing mastectomy for whom post-mastectomy radiotherapy (PMRT) will be recommended is increasing as evidence of decreased loco-regional recurrence and increased survival mounts. PMRT may adversely effect complication rates and cosmetic outcomes for patients undergoing immediate breast reconstruction and PMRT--although the evidence for this is methodologically flawed. This article summarises the above evidence and highlights a reconstructive algorithm that may be used to mitigate the possible deleterious effects of PMRT on results.     

Update on the indications for nipple-sparing mastectomy

There is renewed interest in the use of nipple-sparing mastectomy (NSM), which combines skin-sparing mastectomy with preservation of the nipple-areola complex. NSM may be an oncologically safe treatment in a subgroup of patients who are candidates for breast-conserving surgery but still prefer to undergo mastectomy. A combination of newer techniques and good coordination between plastic and oncologic surgeons can achieve excellent cosmetic results and a low incidence of postoperative complications. However, major concerns about NSM include the persistent risk for breast cancer development when it is used for prophylaxis as well as the potential failure of local control when it is used for treatment. The reported experience with these newer techniques lacks the power to generate a consensus for its indications because of limited reported series with small populations. Although the current role of NSM seems to be more defined as a prophylactic procedure in high-risk patients, prospective studies and reports are needed to better define its indications.     

Nipple-Sparing Skin-Sparing Mastectomy and Vertical Latissimus Dorsi Flap Reconstruction for Bilateral Fibromatosis of the Breast

Fibromatosis of the breast results in aggressive, infiltrative lesions with a tendency for local recurrence. A case of bilateral fibromatosis of the breast treated with nipple-sparing skin-sparing mastectomy and vertical latissimus dorsi flap reconstruction occurring in 22-year-old woman is described herein.     

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。     

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。     

保留皮肤的乳腺癌改良根治术后即时乳房再造15例

目的探讨一种既达到肿瘤根治性切除,又保留乳房美观外形的乳房再造的手术方法。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。结果应用下腹部横行腹直肌肌皮瓣乳房再造10例,扩大背阔肌肌皮瓣再造5例。优11例（73．3％）,良4例（26．7％）。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。对早期乳腺癌患者是一种安全可行的治疗方法。     

Skin-sparing mastectomy and immediate breast reconstruction

Skin-sparing mastectomy is a new surgical approach that allows a mastectomy while preserving the natural envelope of the breast. Skin-sparing mastectomy followed by immediate reconstruction can be used for prophylaxis for high- risk patients or BRCA carriers. It represents an effective treatment option for patients with extensive DCIS or early invasive breast cancer, but is contraindicated for inflammatory breast cancer and extensive skin involvement by the tumor. Skin-sparing mastectomy had similar surgical outcomes compared to non- skin- sparing mastectomy, but skin flap ischemia and necrosis is more common and is associated with a range of risk factors, including smoking. Skin-sparing mastectomy seems to be an oncologically safe technique and does not increase in particular the risk of local, regional or systemic recurrences. It facilitates immediate breast reconstruction using implants or myocutaneous flaps, resulting in excellent cosmesis and high level of patient satisfaction. This article reviews the published data on skin-sparing mastectomy and immediate reconstruction and aim to establish its current role in clinical practice, as there is a lack of prospective data.     

乳腺切除术后即刻乳房再造术式的选择

乳腺切除术后即刻乳房再造与二期再造相比在术后效果、患者心理、住院时间以及所需费用等方面均具有明显优势.为乳腺癌术后患者选择一个合适的即刻乳房再造方式十分必要.本文对TRAM皮瓣、双蒂TRAM皮瓣、DIEP皮瓣、背阔肌肌皮瓣、扩张器/假体置入以及背阔肌肌皮瓣联合假体置入等各种即刻乳房再造术式的适应证与禁忌症进行综述.并从肿瘤学角度针对各种乳腺癌根治术如改良根治术、保留乳头、乳晕的乳腺切除术，以及保留皮肤的乳腺切除术、保乳手术后即刻乳房再造等术式的选择策略进行讨论.     

HHLA2在肝细胞癌组织中的表达及其临床意义

目的:探讨人内源性逆转录病毒-H长末端重复关联蛋白2(human endogenous retrovirus subfamily H long terminal repeat associating protein 2,HHLA2)在肝细胞癌(hepatocellular carcinoma,HCC)组织中的表达及其与...     

Pneumoendoscopic single port approach to breast cancer. How we do it?

Endoscopic procedures have not become the gold standard in breast surgery. In order to improve today's outcomes we have developed a pilot study in the Breast Pathology Unit of Hospital Germans Trias i Pujol. A surgical procedure was performed creating a pneumoendoscopic cavity by using a Single Incision Laparoscopic Surgery (Single port) approach with a follow up of four years.Four patients underwent pneumoendoscopic single-port breast surgery receiving skin-sparing quadrantectomy and axillary surgery requiring lymphadenectomy in all of them. All patients had immediate reconstruction with a Latisimus Dorsi flap. No perioperative complications appeared. Mean operative time was 290 min (range 240–315 min) and mean hospital stay was 3,2 days. Surgical margins of all cases were pathologically negative and all patients were disease free after four years of monitoring. All patients were satisfied with the cosmetic outcome in the immediate postoperative and during the follow up.Although all innovative techniques generate hesitation on their beginnings and are liable to improve, we believe that pneumoendoscopic single-port breast surgery can be suitable for breast cancer, offering better cosmetic outcomes with oncological safety.     

PAX2在早期子宫内膜癌组织中的表达及与其手术预后的相关性

目的 观察配对盒基因2(paried-box gene 2,PAX2)在早期子宫内膜癌组织中的表达,并分析其与子宫内膜癌手术预后的相关性.方法 以60例早期子宫内膜癌的患者作为研究对象,患者均实施常规开腹手术,免疫组化(SP法)检测患者癌组织及癌旁组织中PAX2的表达差异,Spearman分析其与患者手术预后相关性.结...     

Incidence of the superficial fascia and its relevance in skin-sparing mastectomy

BACKGROUND: With the move away from classical radical mastectomy to ever more skin-sparing procedures, there has been an ongoing discussion about how much skin and subcutaneous tissue should be resected to perform an adequate mastectomy while leaving viable skin flaps. One of the common recommendations is to dissect just superficial to the superficial layer (SL) of the superficial fascia of the breast. This, in turn, has revived the old, unsolved controversy about the existence or absence of the SL, a fascia that reportedly encloses the mammary gland ventrally. In skin-sparing mastectomies (SSM), which combine tumor resection with immediate breast reconstruction, the ideal would be to create skin flaps that are thin enough to remove all breast tissue but at the same time are thick enough to preserve flap circulation. The feasibility of meeting these two goals simultaneously and the possible role and relevance of the SL as a guide to dissection in SSM was examined in this study. METHODS: Sixty-two breast resection specimens from 31 women who underwent breast reduction were examined histologically to determine whether the SL was present, whether breast tissue could be detected within or beyond this SL, the measured distance between the caudal border of the dermis and the SL or the breast tissue, and whether the thickness of the subcutaneous fat layer was correlated with the patients' physical data, such as body weight or body mass index (BMI). RESULTS: The SL was absent in 44% of resection specimens. When the SL was present, 42% of specimens contained several islands of breast tissue within the SL. No breast tissue was found beyond the SL. The minimal distance between the SL and the dermis varied from 0.2 mm to 4.0 mm; the minimal distance between the breast tissue and the dermis was 0.4 mm. In 50% of specimens, the minimal distance between the dermis and the SL or breast tissue was < 1.1 mm. A distance of > or = 5 mm was encountered in only 17% of specimens, and a distance of > or = 10 mm was encountered in only 5% of specimens. No significant correlation between the right and left breast was found with any of the parameters examined. A weak negative correlation was seen between the BMI and the mean thickness of the subcutaneous fat (P = 0.049; correlation coefficient [r] = -0.39; Spearman rank correlation). CONCLUSIONS: Histologic evaluation revealed that the SL is not present in all breasts and, thus, cannot serve as a reliable plane of dissection. Furthermore, if the SL is present microscopically, then it often is too thin and delicate to be detectable macroscopically. Finally, even if the SL is present and visible macroscopically, the distance to the overlying skin is so small in the majority of patients that a dissection superficial to the SL would not leave viable skin flaps in skin-sparing mastectomies.