隐匿性乳腺癌36例诊治分析

目的探讨隐匿性乳腺癌的诊断和治疗方法。方法对36例隐匿性乳腺癌患者分别采用乳房X线、MRI检查,对肿块切除活检病理免疫组化检查;治疗采用乳腺癌根治术、改良根治术或保乳术后加放疗。结果乳腺钼靶的阳性率45．8％（11／24）,MRI的阳性率70％（7／10）;免疫组化检查阳性率62％（18／29）;乳腺癌根治术、改良根治术和保乳术后加放疗的5年生存率分别73．9％、77．8％（P〉0．05）。结论乳腺钼靶和MRI有重要诊断价值,切检和免疫组化检查有助于确诊;乳腺癌根治术或改良根治和保乳术后放疗的5年生存率相同。     

Problems with the use of breast conservation therapy for breast cancer in a patient with neurofibromatosis type 1: a case report

Abstract:  Patients with Neurofibromatosis type I and breast cancer represent a subset of people who may be considered at high risk for secondary cancers after conventional whole breast radiation therapy and breast conservation surgery. A case of a 49-year-old woman with neurofibromatosis type I is presented. She was diagnosed with a 1.1-cm right breast infiltrating ductal carcinoma. Clinical, diagnostic imaging, and pathologic features are discussed. Her initial treatment plan of breast conserving therapy was thwarted when her sentinel node biopsy was positive for micrometastatic disease in 1/14 lymph nodes. She elected to have a bilateral simple mastectomy. This case addresses the rare dilemma of offering breast conservation therapy as a viable option for patients with neurofibromatosis type I. Current data on radiation-induced secondary cancers such as sarcoma after treatment for breast and other cancers are reviewed.     

微创确诊乳腺癌后保乳手术的选择

【摘要】 目的 探讨微创手术（Mammotome）确诊乳腺癌后保乳手术的特点和可行性。方法 对我院2008.4~2012.2期间654例乳腺微创手术后确诊的8例乳腺癌进行总结,探讨其保乳手术的特点。结果 7例完成保乳手术,1例完成保留乳头的根治术。保乳手术者术后均进行了化放疗及内分泌治疗,随访至今均无复发。结论 微创手术确诊的乳腺癌一般为早期乳腺癌,选择保乳手术是可行的。     

Radiation-induced angiosarcoma of the breast: case report and self-criticism of therapeutic approach

Angiosarcoma (AS) of the breast is a rare and highly aggressive vascular cancer. It presents as a primitive or radioinduced form. The case of a 46-year-old woman who underwent quadrantectomy of the breast plus axillary lymph node dissection and radiotherapy postoperatively (QUART) for ductal infiltrant carcinoma is reported in the following. Ten years later, the patient underwent mastectomy with immediate reconstruction, for local recurrence that was diagnosed as an AS of the breast at final pathological examination. She did not receive any adjuvant treatment due to local post-operative complications related to breast reconstruction. We criticize our therapeutic approach and we recommend more attention about local recurrence suggesting that tru-cut needle biopsy of local recurrence of the breast after QUART, should be the correct diagnostic approach.     

Treatment of Recurrent Breast Cancer Following Breast Conserving Surgery

Patients with isolated ipsilateral breast cancer recurrence face completion mastectomy in the majority of cases. Selected patients may derive good outcomes from repeat breast conservation surgery and indeed repeat irradiation may be employed using one of many different modalities. Tumor biology rather than salvage surgery method is likely to influence outcome. Patients with isolated breast tumor recurrence are treated in the majority of cases with completion mastectomy, when for selected patients there exists little evidence that more radical surgery provides better outcomes in terms of further recurrence and overall survival, than repeated breast conserving surgery. Literature search identifying articles addressing the issue of repeat breast conserving surgery for ipsilateral breast tumor recurrence, and repeat radiotherapy (search terms include: repeat breast conserving surgery, salvage mastectomy, salvage breast conserving surgery, salvage radiotherapy, reirradiation). Thirty‐five articles discussed the outcomes of repeat breast conserving surgery versus salvage mastectomy, methods of repeat breast irradiation, repeat sentinel lymph node biopsy and related factors. Repeat breast conserving surgery may represent a safe and feasible treatment method for isolated ipsilateral breast tumor recurrence.     

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目的 探讨乳腺癌保乳手术后发生延迟性蜂窝织炎(DBC)的高危因素.方法 回顾性分析2001年1月至2006年12月北京大学第一医院乳腺疾病中心诊治的152例保乳手术病人,根据诊断标准对14例确诊保乳术后DBC病人的临床资料进行哂顾性分析,采用Pearson相关性检验分析影响DBC发生的因素.结果 DBC的发生率为9.2%(14/152),平均发生于术后6.2个月.肿瘤T分期、原发肿瘤部位、腋窝淋巴结清扫数目＞15个、术后乳腺血肿/血清肿形成与DBC的发生有相关性.而年龄、糖尿病、新辅助化疗、腋窝淋巴结转移与DBC的发生无关.结论 手术及放疗造成乳腺淋巴通路回流障碍可能是保乳术后发生DBC的重要因素,对这一并发症的认识和治疗水平的提高,可以改善乳腺癌保乳术后病人的生活质量.     

乳腺癌新辅助化疗后行保乳手术值得关注的问题

新辅助化疗的目的从初始的局部晚期乳腺癌降期,逐渐扩展到肿瘤药物敏感性检测和根据临床试验短期疗效加快药物的审批。其降期的目的之一是为局部晚期乳腺癌的病人提供接受保乳手术可能性。根据肿瘤分期、分子分型等因素所选取的个体化新辅助化疗方案使疗效逐渐提高,近年来化疗药物与靶向药物或免疫治疗的组合使更多的人类表皮生长因子受体-2（HER-2）阳性和三阴性乳腺癌获得满意的降期疗效,使新辅助化疗后保乳手术成为可能。鉴于新辅助化疗降期后的保乳手术与未行新辅助化疗的保乳手术相比仍存在诸多不同之处,新辅助化疗后保乳手术能否成功通常取决于新辅助治疗前获得准确的影像学信息、临床和病理特征、肿瘤的精准定位和标记,以及通过术前复习新辅助化疗前资料了解肿瘤退缩模式和预期切除病灶的再次精准定位。在保证病灶R0切除、术后放疗和良好美容效果的必要前提下,给予新辅助化疗后降期的病人实施保乳手术是安全可行的。     

Metaplastic squamous cell breast cancer: A case report and treatment strategy during covid-19 pandemic

IntroductionSquamous carcinoma is a very rare breast cancer resulting from a differentiated squamous metaplasia. Its diagnosis is late due to the absence of specific clinical and radiological features.Presentation of caseThe authors present the case of a 39-year-old patient with the clinical onset of an inflammatory cyst diagnosed with mammography and cytological examination. After segmentectomy, on histological examination was defined as: “squamous keratinizing aspect”. In light of this report she was subjected to quadrantectomy with lymphadenectomy. She did not undergo radiotherapy treatment, which was delayed due to the ongoing pandemic. After a few months developed a local recurrence and underwent a mastectomy with multidisciplinary treatment.DiscussionSquamously-differentiated metaplastic carcinoma of the breast is one of the rarest forms of breast cancer. Its etiopathogenesis is still unclear but some authors suggest that it originates from a squamous metaplasia deriving from the epithelium of cysts. This is a very aggressive and fast-growing tumour especially in young women, in fact the patient had a recurrence after a few months. She came to our attention 6 months after the initial surgery with a relapse at a local-regional level for which she was subjected to radical treatment and with a metastatic spread for which she was given the first-line chemotherapy treatment.ConclusionThere are no well-defined guidelines for the treatment of this rare form of cancer. The case illustrates how the rapid aggressiveness of the disease requires adequate and immediate multidisciplinary treatment from the very beginning.     

针对性护理在早期乳腺癌保乳术后调强放疗患者中的应用效果

探讨给予早期乳腺癌保乳术后调强放疗患者针对性护理的效果。方法 选取2022年2月- 12月于我院行早期乳腺癌保乳术后调强放疗的102例患者为研究对象,采用随机数字表法分为对照组和观 察组,每组51例。对照组给予常规护理,观察组在对照组基础上给予针对性护理,比较两组生命质量及护 理满意度。结果 观察组干预后身体健康、社会/家庭状况、情感状况、功能状况、附加关注评分均高于对 照组（P ＜0.05）;观察组护理满意度为88.24%,高于对照组的66.67%（P ＜0.05）。结论 针对性护理在早 期乳腺癌保乳术后调强放疗患者中的应用效果确切,可有效提升乳腺癌患者的生命质量,有利于提高护理 满意度。     

Finding the balance between over- and under-treatment of ductal carcinoma in situ (DCIS)

With the widespread adoption of population-based breast cancer screening, ductal carcinoma in situ (DCIS) has come to represent 20–25% of all breast neoplastic lesions diagnosed. Current treatment aims at preventing invasive breast cancer, but the majority of DCIS lesions will never progress to invasive disease. Still, DCIS is treated by surgical excision, followed by radiotherapy as part of breast conserving treatment, and/or endocrine therapy. This implies over-treatment of the majority of DCIS, as less than 1% of DCIS patients will go on to develop invasive breast cancer annually. If we are able to identify which DCIS is likely to progress or recur as invasive breast cancer and which DCIS would remain indolent, we can treat the first group intensively, while sparing the second group from such unnecessary treatment (surgery, radiotherapy, endocrine therapy) preserving the quality of life of these women. This review summarizes our current knowledge on DCIS and the risks involved regarding progression into invasive breast cancer. It also shows current knowledge gaps, areas where profound research is highly necessary for women with DCIS to prevent their over-treatment in case of a harmless DCIS, but provide optimal treatment for potentially hazardous DCIS.     

Rates for mastectomy are lower in women attending a breast-screening programme

Background: Mammographic screening for breast cancer facilitates earlier recognition of lesions, thus potentially allowing for breast‐conserving surgery. Few studies have compared the final surgical outcomes of women presenting through breast screening programmes with those presenting via other sources. Are breast cancer patients presenting through BreastScreen more likely to undergo breast‐conserving surgery than those presenting from other sources? Methods: Using the Royal Perth Hospital (RPH) Multidisciplinary Breast Service Database, the final surgical outcomes were reviewed for 723 women treated for breast cancer at RPH between January 2000 and August 2002. During this period, 397 patients were referred to the RPH Multidisciplinary Breast Clinic from BreastScreen WA, and 326 were referred from other sources. Results: Of all patients undergoing surgery for breast cancer, 58% in the screen group and 36% in the non‐screen group had breast‐conserving surgery (P < 0.0001). When surgical outcomes for women in the BreastScreen target age range of 50?69 years were analysed, 59.5% in the screen group and 42.3% in the non‐screen group had breast‐conserving surgery (P < 0.001). Patient choice was second only to disease extent as a factor determining the outcome of mastectomy. In both cohorts, more than 40% of patients who underwent re‐excisional surgery for positive margins, after initial breast‐conserving surgery, had residual invasive or in situ disease present. Conclusions: At RPH, BreastScreen patients were more likely to undergo breast‐conserving surgery than those who presented from other sources. A significant proportion of women with positive margins after initial breast‐conserving surgery had residual in situ or invasive disease. Re‐excision for positive margins was thus warranted.     

保乳术、改良根治术和改良根治术联合放疗治疗三阴性乳腺癌术后局部复发情况比较

目的探讨保乳术、改良根治术和保乳术联合放疗治疗三阴性乳腺癌的术后局部复发情况。 方法回顾性分析2009年1月至2014年12月间接受治疗的320例三阴乳腺癌患者资料,根据手术方案分为保乳术(BCT组)132例、改良根治术(MRM组)120例、保乳术联合放疗(联合组)68例。采用SPSS19.0软件进行统计分析。术中术后等计量资料采用( ±s)描述,组间比较采用单因素方差分析。采用COX生存回归分析术后3年的局部复发风险。P<0.05为差异有统计学意义。 结果三组的手术时间差异无统计学意义(P>0.05),BCT组和联合组的切口长度、术中出血量和住院时间显著优于MRM(P<0.05);术后3年,BCT组、MRM组的局部复发风险分别是联合组的2.37倍、2.24倍(P<0.05);胸壁转移风险是联合组的3.14倍、3.85倍(P<0.05);BCT组的淋巴结转移风险是联合组的2.65倍(P<0.05),MRM组的淋巴结转移风险和联合组差异无统计学意义(P>0.05)。 结论相较于改良根治术,保乳术联合放疗治疗乳腺癌不仅能术后恢复快、降低局部复发风险,还能保证相对正常的乳房外形,有利于患者术后生存质量提高,具有临床价值。     

Radiation-induced leiomyosarcoma following mastectomy: a case report

Adjuvant radiotherapy following mastectomy for breast carcinoma is the current standard of care; however, this has its own associated complications. One of the rare but documented long-term sequelae is the development of a radiation-induced soft tissue sarcoma. We present the case of a 76-year-old Caucasian female with a non-healing axillary ulcer several years post-radiotherapy for a right-sided breast carcinoma. She was referred to the plastic surgery unit for excision and reconstruction which involved a range of techniques including skin grafting and pedicled tissue transfer. Postoperative histology confirmed the rare diagnosis of radiation-induced leiomyosarcoma. This report describes the presentation, diagnosis and management options for a case of soft tissue sarcoma following radiotherapy. Although uncommon, this diagnosis should be considered in the presence of uncharacteristic skin changes after radiotherapy treatment.     

Trend towards conservative surgery for intraductal carcinomas of the breast. (Retrospective study of 165 cases)]

One hundred and sixty-five intraductal, non invasive breast carcinomas in 162 patients were reviewed. The mean follow-up was 75 months. Recurrence rates seem to be influenced by the therapeutic approach: 4.8% following mastectomy (4 cases out of 83); 16% following breast conserving surgery associated with radiotherapy (4 cases of 25); 22.8% following subcutaneous mastectomy (8 cases out of 35); 50% following breast conserving surgery alone (11 cases out of 35). When considering the clinical and radiological sizes of the tumor in the group of tumor excision and breast irradiation, additional information is gained. When the size is less than 25 mm the recurrence rate drops to 6.6% (1 case out of 15). When the lesions are extensive a subcutaneous mastectomy followed by irradiation (with or without a breast implant) might be an interesting alternative to modified radical mastectomy.     

Bilateral orbital metastases from breast cancer: a case report of successful palliation using stereotactic radiotherapy

Of ophthalmic involvement from metastatic breast cancer, extraocular/intraorbital metastases are extremely rare. External beam radiotherapy has been a mainstay palliation for symptomatic orbital metastases. We present a case of bilateral orbital metastases from breast cancer successfully treated with stereotactic radiotherapy (SRT). A 38-year-old woman presented with decreased vision in the right eye for 3 weeks. Eight months previously, she underwent whole-brain radiotherapy for multiple brain metastases from breast cancer. Visual acuity was hand motion, and the eyelid closed incompletely in the affected eye. Computed tomography scans showed a 3-cm extraconal mass in the right orbit. She underwent temporary tarsorrhaphy followed by SRT. A total dose of 39 Gy was delivered to the right orbital mass in three daily fractions. Four months later, her visual function was normal in both eyes and the right orbital mass disappeared. A new lesion was detected in the left orbit. She underwent SRT for the left orbital lesion using the same dose-fractionation schedule. No radiation-related toxicities were observed. She died 19 months after the first SRT. Our case suggests that SRT may be an effective and safe treatment option in patients with orbital metastases from breast cancer.     

Pyogenic vertebral osteomyelitis in a breast cancer patient: report of a case

We herein report a rare case of pyogenic vertebral osteomyelitis (PVO) coexisting with breast carcinoma. A 71-year-old female presented with neck pain without fever. Magnetic resonance imaging (MRI) showed suspected metastatic lesions in her neck (C7 and Th1). Fluorine-18 fluorodeoxyglucose positron emission tomography (FDG-PET) showed increased FDG uptake in the neck spines and in the left breast. A core needle biopsy of the left breast revealed the presence of invasive ductal carcinoma. Our first tentative diagnosis of the patient was left breast carcinoma with bone metastases, and first-line endocrine therapy was started. However, surgical intervention for the spines had to be considered, because her neurological symptoms progressed. A repeated MRI scan showed a narrowing of the disc space and fluid accumulation around the vertebrae. This suggested the presence of PVO rather than metastases. Surgery confirmed the presence of PVO in C7 and Th1, and a culture of the abscess yielded Escherichia coli. The patient’s neurological symptoms dramatically improved after surgery. Breast conserving surgery was performed 3 months after the surgery for PVO. The patient is well and has no clinical evidence of disease 18 months after the breast conserving surgery. PVO is rare, but should be included in the differential diagnosis in patients presenting with early breast carcinoma.     

Results of breast conserving surgery in clinical stage I–II breast carcinoma

Background  

The role of breast conserving surgery with radiotherapy is well established and has become a widely used procedure in breast cancer. Patient selection, a multidisciplinary approach, and expert surgical technique are important factors to avoid locoregional recurrence. The aim of this study was to analyse the outcomes of patients treated with breast conserving surgery in stage I–II breast cancer.     

BRCA1/2基因突变对乳腺癌保乳术后局部复发的影响及相关预后模型的构建

背景与目的 保乳手术现已成为乳腺癌的标准手术方式之一,保乳手术能够保留患者的乳房外形,极大地改善患者术后的心理状态和生活质量。BRCA1/2基因是与乳腺癌密切相关的易感基因,BRCA1/2基因突变对保乳术后乳腺癌患者局部复发的影响目前尚有争议。因此,本研究分析BRCA1/2基因突变与乳腺癌保乳术后局部复发的关系,并构建相关预测模型,预测保乳术后乳腺癌患者的无局部复发生存（LRFS）率,为乳腺癌患者保乳手术适应证的选择提供可靠的依据。方法 回顾性分析2014年6月—2016年6月于中国人民解放军空军军医大学第一附属医院进行保乳手术的189例乳腺癌患者临床资料,并比较不同临床病理特征下患者BRCA1/2基因突变的差异,通过单因素及多因素Cox等比例回归模型分析BRCA1/2基因突变及其它临床病理因素对乳腺癌患者保乳术后局部复发的影响,并构建列线图来预测患者的LRFS率。通过一致性指数（C-index）、受试者工作特征（ROC）曲线及曲线下面积（AUC）对模型进行内部验证,通过校准曲线评估模型的准确性,并通过临床决策曲线分析（DCA）评价模型的临床获益和应用价值。结果 BRCA1/2基因突变组和未突变组的年龄和分子分型进行差异有统计学意义（均P<0.05）。单因素Cox等比例回归模型分析结果显示,BRCA1/2突变、肿瘤分级、肿瘤大小、N分期及分子分型是保乳术后乳腺癌患者LRFS率的影响因素（均P<0.1）。多因素Cox等比例回归模型分析结果显示,BRCA1/2基因突变、肿瘤大小、N分期及分子分型是保乳术后乳腺癌患者局部复发的独立影响因素（P<0.05）。将这些因素纳入并建立LRFS率的列线图预测模型。模型的C-index为0.86,内部验证C-index为0.81。ROC曲线分析结果显示,模型的3、5年LRFS率预测的AUC分别为0.89、0.85;校准曲线显示列线图预测的LRFS率与实际LRFS率接近;DCA分析显示模型的临床获益及应用价值较高。结论 BRCA1/2基因突变与保乳术后乳腺癌患者的局部复发相关,基于BRCA1/2基因突变列线图模型能够准确地预测保乳术后乳腺癌患者的LRFS率,并为乳腺癌患者手术方式的选择提供有效的科学依据。     

Incidence of intramammary nodes in completion mastectomy specimens after axillary node sampling: implications for breast conserving surgery

BACKGROUND: Axillary node sampling (ANS) is widely used in conjunction with breast conserving surgery in the treatment of primary breast cancers in the UK. Some evidence suggests that axillary staging techniques can miss intramammary nodes contained within the axillary tail of the breast. This study aims to assess the incidence of such nodes in completion mastectomy specimens in women who have had previous breast conserving surgery and ANS. METHODS: One hundred and fifty-seven completion mastectomy specimens were obtained from women who had previous breast conserving surgery and ANS, at the Nottingham Breast Institute over a 3-year period. The pathology samples underwent detailed histological examination to identify lymph nodes, and determine their disease status. RESULTS: Seventy-six (48%) of completion mastectomy specimens contained intramammary lymph nodes. Fifteen patients were upstaged (lymph node stage) because of the histological findings at completion mastectomy. One patient from the study population received additional systemic treatment, as a result of the upstaging. CONCLUSION: The incidence of intramammary nodes in this series correlates with previous data. This study shows that in breast cancer patients who undergo ANS, intramammary nodes, if present and more so positive, are unlikely to change systemic treatment decisions, but may increase the number of patients needing radiotherapy and or further axillary dissection.     

Rapidly progressive multifocal phyllodes tumour of the breast: A case report and review of the literature

INTRODUCTIONMalignant transformation of a phyllodes tumour is a rare form of breast cancer, accounting for just 0.5% of all breast cancer cases.¹PRESENTATION OF CASEWe report a case of a 49 year old female with rapidly progressive, multifocal disease. She initially presented with two giant fibroadenomas which were excised. She represented eight months post surgery with two new lesions in the same breast, one suspicious, one suggestive of fibroadenoma. Biopsy was borderline. Surgery was therefore scheduled for wide local excision. At localisation two weeks later, at least eight lesions were seen on ultrasound scan. Three were removed as histology was at this point unknown to conserve the breast. Histology revealed intermediate grade DCIS, benign Phyllodes and borderline/malignant phyllodes. She was scheduled for mastectomy and immediate Strattice reconstruction. An MRI was performed pre-operatively to ascertain extent of disease. Two weeks post localisation, 13 lesions were identified. The right breast was entirely unaffected. Surgery interval was three weeks and final histology revealed 18 lesions, ranging from fibroadenoma through to borderline/malignant phyllodes with an incidental papilloma.DISCUSSIONThis is the first report of such rapid progression of disease, with 16 new lesions, of varied histology, developing in just an eight week period.CONCLUSIONThis case highlights the difficulty of forming a clear diagnostic and therapeutic pathway in this highly variable disease. Arguments for over and under treating these patients remain but those with any borderline/malignant potential have to be removed as recurrence is both common and aggressive, with a clear surgical margin the only proven protective factor.