乳腺癌保乳手术的进展与评述

保乳治疗是乳腺癌多学科综合治疗模式的体现和结晶。保乳手术联合术后放疗可以使乳腺癌患者达到与根治性手术相同的生存率,因同时具备良好的美容效果,从而有更高的生活质量。选择合适的早期乳腺癌患者给予保乳治疗是安全可行并值得推荐的治疗策略。临床医师需要清晰地掌握保乳手术的适应证和禁忌证等,掌握病理切缘评估的方式、方法和规范,掌握具体的手术技巧等,切实提高我国乳腺癌患者的保乳率和保乳成功率。     

乳腺癌Intrabeam系统术中放射治疗临床操作指南

正目前乳腺癌已成为中国女性发病率最高的恶性肿瘤~([1])。随着诊疗技术的提高,能行保留乳房(简称保乳)手术的早期乳腺癌患者也越来越多,经过综合治疗的保乳手术可以取得与乳房切除相同的临床疗效~([2])。保乳手术辅以放射治疗已成为早期乳癌患者的首选标准化治疗方式~([3-4])。研究表明,乳腺癌保乳手术治疗后85%～90%的复发位于原发灶附     

早期乳腺癌保乳综合治疗模式

由中国医学科学院肿瘤医院承担、联合北京、上海、广州、浙江、辽宁、解放军等全国10家三级甲等医院参加的"早期乳腺癌规范化保乳综合治疗的临床研究"课题,已被批准为国家"十五"科技攻关项目. 国外早期乳腺癌采用保乳的综合治疗已经获得肯定的疗效.美、法、意、丹麦等发达国家经过6至10年的前瞻性、随机分组研究证明,早期乳腺癌保乳综合治疗与乳腺癌根治术(包括肿瘤在内的全部乳腺、胸肌切除及区域淋巴结清扫)的疗效相同.因而被认为是乳腺癌外科治疗中的一次革命.加坡乳腺癌患者做保乳治疗的在70%以上,美国也在50%以上.而我国除少数教学医院和有条件的大、中型医院外,尚未普遍开展早期乳腺癌保乳综合治疗,做保乳治疗的约占10%左右.究其原因,一是医生和病人对保乳综合治疗的疗效心存疑虑;二是多数医生对根治手术比较熟;三是不少医院内质量可靠的放疗设备不具备,影响了综合治疗的开展. "早期乳腺癌规范化保乳综合治疗的临床研究"课题在总结国内外乳腺癌治疗经验的基础上,从病人的需求出发,开展适合我国特点的早期乳腺癌规范化保乳手术,结合规范化的最佳的放、化疗及内分泌综合治疗.总例数将超过1200例,其中保乳手术达到600例.预期5年生存率>90%,达到国际先进水平. 据该课题负责人、中国医学科学院肿瘤医院张保宁教授介绍,在统一的诊断标准、统一的手术术式、统一的术后放疗、化疗及内分泌治疗原则的基础上,对早期乳腺癌开展多中心、大样本、有对照的前瞻性研究,通过统一的标准进行评估总结,提出我国早期乳腺癌保乳综合治疗模式,以便推广,与国际接轨,提高我国乳腺癌治疗的整体水平.郭力     

保乳手术治疗早期乳腺癌96例

目的 探讨保乳手术治疗早期乳腺癌的疗效.方法 选取96例行保乳手术的早期乳腺癌患者,与同期行乳腺癌改良根治术的患者进行对比分析,比较两组的复发率、转移率和生存率.结果 保乳手术组和改良根治术组的1、3、5年局部复发率、生存率及远处转移方面差异均无统计学意义(P>0.05).结论 保乳手术+放疗可获得与改良根治术相同的疗效,且术后采用常规温和化疗与内分泌治疗等综合治疗方案,能够进一步保证治疗效果.     

早期乳腺癌保乳手术近期疗效评价

目的 分析临床早期乳腺癌保乳综合治疗的近期疗效,为普及临床早期乳腺癌保乳综合治疗提供参考.方法 2002年9月至2006年1月对122例临床早期乳腺癌患者施行保乳手术,对肿瘤采取局部扩大切除或乳房象限切除,所有患者均行腋窝淋巴结清除;术后辅以放疗、化疗或内分泌治疗.结果 122例患者均获随访,随访时间8～49个月,无局部复发、远处转移和死亡病例.保乳治疗乳房美容效果评估优、良者占90.16%(110/122).结论 临床早期乳腺癌保乳综合治疗创伤小、美容效果良好、疗效满意,可显著提高患者生活质量,值得广泛推广应用,但必须严格掌握手术适应证.     

老年人早期乳腺癌保乳手术的临床研究

目的探讨保乳手术在老年人早期乳腺癌治疗中的临床应用。方法回顾性分析2002年1月至2007年12月间在克拉玛依市中心医院和新疆医科大学第二附属医院接受保乳手术的46例老年早期乳腺癌患者的临床资料。手术方式为乳腺部分切除加腋窝淋巴清扫,术后辅助放射治疗、化疗和（或）内分泌治疗。结果46例患者手术成功,术后无严重并发症,标本石蜡病理切片显示各切缘均无癌细胞残留,随访9～68个月,2例局部复发,均无远处转移。结论保乳手术创伤小、术后并发症少,是老年人早期乳腺癌安全有效的治疗方法。掌握适应证及禁忌证,以及规范化和个体化治疗是保乳手术成功的关键。     

216例女性乳腺癌保乳手术及综合治疗的临床分析

目的:探讨Ⅰ、Ⅱ期乳腺癌保乳综合治疗的疗效及相关技术,为普及早期乳腺癌保乳综合治疗提供参考。方法:回顾性分析我院1993年12月～2004年10月间216例行保乳手术治疗的乳腺癌患者的相关资料,对肿瘤采取局部扩大切除或乳房象限切除,有209例行腋窝淋巴结清扫。术后辅以放疗、化疗或内分泌治疗。结果:无手术并发症。随访3～147个月,死亡2例,其中1例与本病无关;局部复发率1.85%。按照国家“十五”攻关课题“早期乳腺癌规范化保乳综合治疗的临床研究”采用的乳房美容评定标准进行评价,符合优良标准的有199例(92.13%),不满意者17例(7.87%)。结论:早期乳腺癌保乳综合治疗创伤小、疗效确切、形体改变少、能提高生存质量,但须合理的掌握手术适应证及保乳综合治疗的相关技术。     

早期乳腺癌保乳手术加放化疗15例临床分析

近年来，人们对乳腺癌生物学行为认识不断提高，保乳手术加放化疗的综合治疗模式逐渐成为早期乳腺癌治疗的新方法。我院自2003年5月-2005年8月对15例早期乳腺癌实施保乳手术加放化疗的综合治疗，取得满意的效果，现报告如下。     

早期乳腺癌保乳治疗的临床研究(附86例报告)

目的观察早期乳腺癌保乳治疗效果，探讨乳腺癌保乳治疗的禁忌证及技术要求。方法回顾性分析1995～2002年行保乳治疗的86例Ⅰ、ⅡA期早期乳腺癌的临床特点及疗效。结果保乳治疗手术的并发症为8．14％。术后乳房外形效果良好为59．3％，局部再发率为6．15％，3年和5年总生存率分别为95．38％和92．31％。结论选择早期乳腺癌中部分病例积极推行保乳治疗不影响总生存率，手术并发症少，局部复发率低，在生理和心理上均改善了患者的生存质量；但残乳再发癌的发病机理及预防有待进一步研究。     

早期乳腺癌保乳手术的相关问题

早期乳腺癌大样本多中心对照表明我国开展保乳治疗是可行的、有效的。文章就早期乳腺癌保乳手术的适应证、禁忌证,肿瘤切缘的安全性、腋窝淋巴结清扫范围及切口设计、术后综合治疗等作一分析。     

Local control by breast-conserving surgery with nipple resection

Local control was compared between patients who had undergone breast-conserving therapy with and without nipple resection. We explored whether there was any difference in local control between the two treatment methods for patients with early breast cancer. A total of 333 women with breast cancer, who had undergone breast-conserving therapy between 1991 and 2002, were included in this study. Surgery consisted of a wide local excision of the primary tumor with a 2-cm free margin as the minimum distance. When the tumor was located under the nipple or close to the nipple, breast-conserving surgery with nipple resection was selected. A total of 320 patients received breast-conserving surgery without nipple resection and radiation therapy (BCT) and 13 patients breast-conserving surgery with nipple resection and radiation therapy (BCT-NR). There were no significant differences in age, tumor size, nodal status, clinical stage, ER status, histological type or surgical margin status between the two groups. The surgical margin was positive in 55 (17.2%) out of 320 patients in the BCT group and in one (7.7%) out of 13 patients in the BCT-NR group. There was no significant difference in the breast-free survival between the two groups. In conclusion, breast-conserving surgery with nipple resection and radiation therapy may be the treatment of choice for early breast cancer patients with the tumor located under the nipple or very close to the areola.     

Bilateral breast-conserving therapy for bilateral breast cancer: Results and consideration of radiation technique

BACKGROUND: Although breast-conserving surgery followed by definitive irradiation is an established treatment for patients with early breast cancer, the role of breast-conserving therapy (BCT) for patients with bilateral breast cancer has not been well studied and the radiation therapy technique is still under investigation. We examined the feasibility of breast-conserving therapy for bilateral breast cancer and present here our radiation therapy technique with CT simulator. METHODS: Between July 1990 and December 1998, we treated 17 patients with bilateral breast cancer who underwent bilateral breast-conserving surgery followed by definitive irradiation. Seven patients had synchronous bilateral breast cancer and ten had metachronous bilateral breast cancer. Radiation therapy consisted of 50 Gy to the bilateral whole breast in all patients but one. A CT simulator was used to plan a tangential radiation field to the breast in all patients. Boost irradiation of 10 Gy was administered to 8 tumors with close or positive margins. RESULTS: With a median follow-up periods of 95 months from each operation, no patients showed loco-regional recurrence on either side, and none suffered distant metastasis. Furthermore no serious late adverse effects were observed. CONCLUSION: This study demonstrated that BCT is feasible for bilateral breast cancer and the CT simulator is useful for determining the radiation field, especially when lesions are metachronous.     

Factors predicting the use of breast-conserving therapy in stage I and II breast carcinoma.

PURPOSE: To define patterns of care for the local therapy of stage I and II breast cancer and to identify factors used to select patients for breast-conserving therapy (BCT). PATIENTS AND METHODS: A convenience sample of 16,643 patients with stage I and II breast cancer treated in 1994 was obtained from hospital-based tumor registries. Histologic variables were determined from original pathology reports. RESULTS: BCT was performed in 42.6% of patients. Multivariate analysis demonstrated that living in the Northeast United States (odds ratio [OR], 2.48; 95% confidence interval [CI], 2.16 to 2.84), having a clinical T1 tumor (OR, 2.51; 95% CI, 2.27 to 2.78), and having a tumor without an extensive intraductal component (OR, 2.07; 95% CI, 1.81 to 2.37) were the strongest predictors of breast-conserving surgery. Radiation therapy was given to 86% of patients who had breast-conserving surgery. Age less than 70 years was the most significant predictor of receiving radiation (OR, 2.11; 95% CI, 1.77 to 2.25). Tumor variables did not correlate with the use of radiation, but favorable tumor characteristics were associated with the use of breast-conserving surgery. CONCLUSION: Despite strong evidence supporting the use of BCT, the majority of women continue to be treated with mastectomy. Predictors of the use of BCT do not correspond to those suggested in guidelines.     

Breast-conserving therapy in patients with bilateral breast cancer: Do today’s treatment choices burn bridges for tomorrow?

PURPOSE: To determine how often initial treatment choices limit treatment options for subsequent breast cancer management in patients undergoing breast-conserving therapy (BCT), in particular with treatment of internal mammary nodes. METHODS AND MATERIALS: Between January 1985 and June 2001, 464 women with pathologic Stage 0, I, and II (T0-2, N0-1) breast cancer underwent BCT at our institution. All 464 patients had computed tomography-based treatment planning. In patients with bilateral breast cancer, the planning computed tomography scans were used to determine the impact initial radiation therapy fields had on treatment options for subsequent contralateral breast cancer. RESULTS: There were 500 breast cancers diagnosed in 464 patients. Thirty-six patients (8%) had bilateral breast cancer with 9 (2%) synchronous and 27 (6%) metachronous primaries. In 80 patients, the ipsilateral internal mammary nodes were explicitly treated. Initial breast cancer treatment choices impacted subsequent treatment decisions for the contralateral breast in only 2 of 464 patients (0.4%) in the study: 2 of 80 patients (2.5%) whose internal mammary nodes were treated, and 2 of 27 patients (7.4%) who developed metachronous bilateral breast cancer. CONCLUSIONS: Initial BCT, including internal mammary node irradiation, rarely compromised future contralateral breast-conserving therapy.     

The prognosis of patients with local recurrence more than five years after breast conservation therapy for invasive breast carcinoma.

AIMS: The increasing use of breast-conserving therapy (BCT) and the rising incidence and improved prognosis of early breast are causing a substantial increase in the absolute number of patients with a late local recurrence following BCT. This study examined the characteristics and the prognosis of patients with a local recurrence occurring more than 5 years after BCT. METHODS: In the period 1982-1997, 3280 patients with invasive breast cancer underwent breast-conserving therapy in one of the eight community hospitals in the South-eastern part of The Netherlands. Of these patients, 98 developed a local recurrence in the breast more than 5 years after BCT. RESULTS: Eighty-five of the 98 recurrences were invasive, 12 were purely in situ and for one patient this information was not available. The 5 years distant recurrence-free survival rate of 85 patients with a late invasive local recurrence was 68% (95% confidence interval [CI], 56-80) and significantly better than the rate of 41% (95% CI, 33-48) in an existing cohort of 173 patients with invasive recurrence within 5 years after BCT (p=0.007). Local excision of the recurrence was followed by a significantly lower local control rate than salvage mastectomy (50 vs 89%; p=0.004). CONCLUSION: The prognosis of patients with a local recurrence more than 5 years after BCT is significantly better than of patients with local recurrence within 5 years after BCT.     

Determinants of Breast-Conserving Therapy in Early-Stage Breast Cancer Patients: A Nationwide Study

IntroductionEvidence from previous studies and treatment guidelines suggested that breast-conserving therapy (BCT) is the treatment of choice for early-stage breast cancer. However, in the last decades, surgeons have noticed a high percentage of mastectomies done in this population. The aim of this study is to explore the factors associated with not choosing BCT among eligible patients with early-stage breast cancer.Materials and MethodsThis study uses a retrospective cohort design. Demographic and clinical characteristics derived from The Taiwan Cancer Registry Database, the National Health Insurance Database and the Death File Database from January 1, 2004 to December 31, 2014. Patients were followed until December 31, 2015. To explore the associated factors related to BCT, we used univariate and multivariate logistic regression analysis.ResultsA total sample of 25,967 stage I breast cancer patients was included. Among them, 12,191 underwent BCT and 13,776 underwent mastectomy as their primary treatment. The logistic regression analysis reveals that age, pay-for-performance (P4P) program participation, number of affected lymph nodes, tumor size and location, were determinants of BCT. Interestingly enough, histological type did not reach the significance level.ConclusionThis study shows that personal and clinical characteristics influence the treatment choice in stage 1 breast cancer patients.     

中国乳腺癌保乳治疗的前瞻性多中心研究

目的 探讨早期乳腺癌保乳治疗的可行性,以及我国开展保乳综合治疗的模式。方法 中国医学科学院中国协和医科大学肿瘤医院等全国共10家三级甲等医院协作,进行早期乳腺癌保乳治疗与切除乳房治疗的大样本前瞻性多中心对照研究。结果 完成保乳手术872例,占符合保乳治疗条件乳腺癌患者的19．5％,占同期全部可手术乳腺癌患者的9．0％。保乳治疗组复发9例（1．0％）,远处转移11例（1．3％）,死亡1例（0．1％）;切除乳房组复发18例（0．5％）,远处转移49例（1．4％）,死亡4例（0．1％）。两组术后局部复发率、远处转移率与死亡率差异无统计学意义（P均〉0．05）。保乳治疗乳房美容效果评估优、良者术后6个月占89．7％,术后1年占91．1％,术后2年占86．6％。结论 保乳治疗在中国是可行的,对早期乳腺癌患者的生存率、复发率无负面影响,提高了患者的生活质量。保乳治疗必须严格把握手术适应证,需要多学科的有机配合,综合治疗是保乳治疗成功的保证。     

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.     

Cost comparison of mastectomy versus breast-conserving therapy for early-stage breast cancer

BACKGROUND: Choice of treatment for early-stage breast cancer depends on many factors, including the size and stage of the cancer, the woman's age, comorbid conditions, and perhaps the costs of treatment. We compared the costs of all medical care for women with early-stage breast cancer cases treated by breast-conserving therapy (BCT) or mastectomy. METHODS: A total of 1675 women 35 years old or older with incident early-stage breast cancer were identified in a large regional nonprofit health maintenance organization in the period 1990 through 1997. The women were treated with mastectomy only (n = 183), mastectomy with adjuvant hormonal therapy or chemotherapy (n = 417), BCT with radiation therapy (n = 405), or BCT with radiation therapy and adjuvant hormonal therapy or chemotherapy (n = 670). The costs of all medical care for the period 1990 through 1998 were computed for each woman, and monthly costs were analyzed by treatment, adjusting for age and cancer stage. All statistical tests were two-sided. RESULTS: At 6 months after diagnosis, the mean total medical care costs for the four groups differed statistically significantly (P:<.001), with BCT being more expensive than mastectomy. The adjusted mean costs were $12 987, $14 309, $14 963, and $15 779 for mastectomy alone, mastectomy with adjuvant therapy, BCT plus radiation therapy, and BCT plus radiation therapy with adjuvant therapy, respectively. At 1 year, the difference in costs was still statistically significant (P:<.001), but costs were influenced more by the use of adjuvant therapy than by type of surgery. The 1-year adjusted mean costs were $16 704, $18 856, $17 344, and $19 081, respectively, for the four groups. By 5 years, BCT was less expensive than mastectomy (P:<.001), with 5-year adjusted mean costs of $41 930, $45 670, $35 787, and $39 926, respectively. Costs also varied by age, with women under 65 years having higher treatment costs than older women. CONCLUSIONS: BCT may have higher short-term costs but lower long-term costs than mastectomy.     

早期乳腺癌保乳治疗的临床研究

目的：探讨早期乳腺癌保乳术后综合治疗的效果。方法：对１０８例早期乳腺癌行保乳治疗,并与同期行改良根治术治疗的１２１例早期乳腺癌行对比研究。保乳治疗患者年龄３１～６１岁,中位年龄４４.５岁。保乳术后行全乳腺放疗和瘤床加量,处方剂量５０Ｇｙ／５周,瘤床追加６～９ＭｅＶ电子线１０～１５Ｇｙ／７～１０天。改良根治术患者年龄３４～６８岁,中位年龄４７.６岁。改良根治术后放疗的范围根据肿块大小和淋巴结转移情况决定,处方剂量５０Ｇｙ／５周。两组均采用ＣＡＦ或ＣＭＦ方案化疗,ＥＲ或ＰＲ阳性的患者给予内分泌治疗。结果：１０８例保乳治疗患者中３例复发,５例出现远处转移（２例为骨转移,１例为骨、肝、肺多发转移,２例为肺转移）。术后６个月美容效果评估优、良者为９１.７％,术后１年为９２.６％。１２１例改良根治术患者中３例复发,７例出现远处转移（３例为骨转移,３例为肺转移,１例为多发脏器转移）。两组的近期疗效差异均无统计学意义（Ｐ＞０.０５）。结论：早期乳腺癌采用保乳术及术后综合治疗的疗效不低于改良根治术,且美容效果更优。