乳腺癌乳头乳晕复合体受侵犯的相关临床病理因素

保留乳头乳晕复合体(nipple areola complex,NAC)的乳房切除术(nipple-areola complexsparing mastectomy,NSM)是传统的乳腺切除手术的一种改进术式,能完整切除肿瘤并最大限度保持乳房外形美观。目前有关NSM仍存在许多尚待解决的问题,其中一个重要问题就是如何在术前选择合适的患者。许多肿瘤的临床病理特征,如肿瘤到乳头的距离(tumor-to-nipple distance,TND)和肿瘤位置、肿瘤大小、多中心性肿瘤、淋巴结转移和脉管侵犯、组织学分级、HER-2表达情况等与NAC隐匿性的肿瘤累及率密切相关,但如何在NSM术前对这些指标进行精确评估仍需进一步探索。临床评估NAC有无异常,NAC后方乳腺组织的病理评估,并综合分析与NAC累及相关的临床病理因素是目前用于判断乳腺癌患者是否可行NSM的主要方法。更多的大规模临床研究仍需进行,以利于制定统一的NSM患者选择标准。     

保留乳头乳晕复合体的乳房切除术中乳头乳晕的血供特点及其评估

保留乳头乳晕复合体(nipple-areola complex,NAC)的乳房切除术(nipple-areola complexsparing mastectomy,NSM)在乳腺肿瘤领域的治疗已得到认可,其更好的美容效果也使得这种手术方式的应用日益普及。在手术技巧方面需要着重考虑术后乳头缺血、坏死造成的并发症。患者因素、重建方法以及切口的位置等的选择可以降低这种缺血坏死并发症的发生,而且NSM术中判断NAC的血供更为重要。首先,着重阐述了NAC血供的解剖特点及临床意义;其次,讨论了乳腺MRI检查明确NAC血流灌注分类的方法,包括动脉充盈期、静脉引流期及三维重建最大密度投影(maximal intensity projection,MIP)图像,可以在术前评估NAC的血管解剖并提供有价值的信息;最后,阐述了基于吲哚氰绿(indocyanine green,ICG)荧光成像在术中影像导航的应用,为外科医生提供了术中实时评估乳房皮肤和NAC血流灌注的方法,可以帮助医生检测缺血的情况并及时调整手术方案,降低NSM术后乳头缺血坏死的发生。     

保留乳头乳晕复合体乳房切除术的手术切口设计

随着外科技术的不断发展,保留乳头乳晕复合体(nipple-areola complex,NAC)的乳房切除术(nipple-areola complex-sparing mastectomy,NSM)在乳腺癌患者中得到了越来越多的应用。在保证肿瘤患者安全性的基础上,术后的美观也是临床医生和患者十分关注的问题。切口的选择不但会对手术的可操作性产生影响,还与术后的效果密切相关。目前,关于NSM术中手术切口选择并无共识。就NSM术中手术切口选择的问题,回顾性分析相关临床研究,旨在为临床工作提供借鉴及参考。     

保留乳头乳晕的全乳切除术的研究进展

乳腺癌已成为全球癌症发病率最高的恶性肿瘤。乳腺癌治疗主要采用以手术为主的综合治疗方案,保留乳头乳晕的全乳切除术（nipple-sparing mastectomy,NSM）作为乳腺外科的一种术式,保留了全部乳房皮肤和乳头乳晕复合体（nipple-areolar complex,NAC）,术后乳房再造可获得良好的美学效果,具有显著优势。NSM在保证肿瘤学安全性的同时,提升了患者的生存质量,得到临床上越来越多的重视。本文将就NSM的适应证、禁忌证、肿瘤学安全性、美学效果、并发症及复发后的处理进行综述。      

保留乳头乳晕复合体乳房切除术后复合体坏死的研究

随着乳腺外科技术的不断发展,保留乳头乳晕复合体（nipple areola complex,NAC）的乳房切除术（nipple-sparing mastectomy,NSM）在乳腺癌患者中已经得到了越来越多的应用。近年研究发现在选择适合的乳腺癌患者的前提下,NSM术后局部复发及远处转移率都很低。NSM联合乳房再造术可以达到良好的美学效果,提高乳腺癌患者术后的生活质量。但术后并发症仍是一个不容忽视的问题,特别是NAC坏死,严重影响了手术效果,失去了保留乳头手术的意义,甚至会造成乳房重建的失败。     

保留乳头乳晕复合体乳腺癌根治术的肿瘤学风险及适应证

保留乳头乳晕复合体(nipple-areola complex,NAC)的乳腺癌改良根治术是在保留胸肌的改良根治术的基础上,进一步保留乳头、乳晕,其具有保乳手术良好的效果,同时又达到改良根治术的较低的复发率,可望作为Ⅰ、Ⅱ期乳腺癌手术治疗的常规选择术式。该术式的缺陷在于保留NAC带来的残留癌的风险,因此术前结合NAC浸润相关因素,准确预测NAC受累风险,从而制定恰当的手术适应证是关键。本文就保留NAC的乳腺癌改良根治术的肿瘤学风险及适应证进行综述。     

保留乳头乳晕复合体乳房切除加一期假体植入术的应用

目的研究保留乳头乳晕复合体乳房切除加一期假体植入术（NSM—IBRWI）应用于早期乳腺癌的安全性与有效性。方法1999年6月至2006年10月，对13例患者的14只乳房实施NSM-IBRWI手术，主要采用沿乳晕上或下的180。弧形切口，完整切除乳房，保留乳头乳晕复合体，在胸大肌下或皮下植入硅凝胶假体，同时乳腺癌患者另取胸大肌外缘切口行腋窝淋巴结清扫术。结果13例患者共植入14只假体，其中1例患者（单侧）因假体植入皮下后引流液2个月以上不减少而导致伤口无法愈合，被迫取出假体。手术成功率为92．9％（13／14）。术后6个月自我满意度良好者9例，一般者3例（其中不对称2例，疼痛1例），较差者1例（假体取出者）。13例中有原位癌1例，浸润性导管癌10例。所有患者的中位随访时间为27个月。1例患者（T1N1M0）术后9个月出现肺、骨转移，继而出现脑转移，术后15个月死亡，其余10例患者均无病生存至今。术后主要问题是伤口不愈合、不对称和疼痛。结论NSM—IBRWI是一种安全有效治疗早期乳腺癌的新方式，它可与保乳手术取长补短。     

保留乳头乳晕复合体的改良根治术对早期乳腺癌的疗效研究

目的探讨保留乳头乳晕复合体(nipple-areolar complex,NAC)的乳腺癌改良根治术对早期乳腺癌的临床疗效。方法选取40例行保留NAC改良根治术和40例行传统改良根治术的早期乳腺癌患者,按1∶1比例进行配对回顾性研究。结果保留NAC组中位随访时间为48个月,传统改良根治组为50个月。保留NAC组5年局部区域复发率为5.0%,传统改良根治组为7.5%,两者比较差异无统计学意义(P=0.673)。保留NAC组5年远处转移率为10.0%,传统改良根治组为7.5%,两者比较差异无统计学意义(P=0.557)。保留NAC组和传统改良根治组5年总生存率分别为96.0%和98.2%,差异无统计学意义(P=0.589);两组5年无瘤生存率分别为91.7%和92.3%,差异无统计学意义(P=0.612)。结论严格把握适应症基础上,保留NAC改良根治术对早期乳腺癌的疗效与传统改良根治术疗效相近,但可达到患者乳房重建的美容效果和提高患者术后生活质量。     

乳腺癌患者乳头乳晕复合体癌细胞浸的概率及其保留的可行性

背景与目的:传统的乳腺癌外科治疗切除的范围包括乳头乳晕复合体,因为普遍认为保留它有残留癌的可能性.本研究旨在分析乳腺癌乳头乳晕复合体(nipple-Areola complex,NAC)癌细胞浸润的概率,分析保留NAC的可行性.方法:168例乳腺癌患者,保留乳头乳晕后方5mm软组织取材行病理检查,分别了解乳头、乳晕及深部软组织受累情况.结果:168例乳腺癌中3例乳头、乳晕及深部软组织浸润,10例累及乳晕及乳晕后组织,13例仅乳晕后方软组织受累.乳头以及乳晕受累的癌肿位于中央区且位置表浅.乳头乳晕复合体受累与肿瘤位置(X2=9.672,P=0.002)、乳头乳晕区皮肤改变及肿瘤大小(X2=7.141,P=0.008)、淋巴结状况(X2=6.081,P=0.014)、临床病理分期(X2=10.142,P=0.006)差异均有显著性.结论:如果无乳头以及乳晕临床表现异常,肿瘤距离乳晕边缘2.5 cm以上,肿瘤≤5 cm,保留NAC是安全的.     

保留乳头乳晕的乳腺癌改良根治术治疗乳腺癌的安全性

保留乳头乳晕的乳腺癌改良根治术（NSM）作为乳腺外科的一种术式,因其保留了患者的乳头乳晕复合体（NAC）,对患者术后的美容效果或者术后重建外观美容有极为重要的意义。然而,其临床应用仍存在一些值得探讨的争议点。近年来国内外出现了一些与NSM安全性相关的热点问题,如NSM术前筛选标准、NAC受侵情况、NSM术后并发症及处理方法等。     

The incidence of arm edema in women with breast cancer randomized on the National Surgical Adjuvant Breast and Bowel Project study B-04 to radical mastectomy versus total mastectomy and radiotherapy versus total mastectomy alone

PURPOSE: To determine the incidence and factors associated with the development of arm edema in women who participated in the National Surgical Adjuvant Breast and Bowel Project (NSABP) study B-04. METHODS AND MATERIALS: Between 1971 and 1974, the NSABP protocol B-04 randomized 1,665 eligible patients with resectable breast cancer to either (1) the Halstead-type radical mastectomy; (2) total mastectomy and radiotherapy to the chest wall, axilla, supraclavicular region, and internal mammary nodes if by clinical examination axillary nodes were involved by tumor; and (3) for patients with a clinically uninvolved axilla, a third arm, total mastectomy alone. Measurements of the ipsilateral and contralateral arm circumferences were to be performed every 3 months. RESULTS: There was at least one recorded measurement of arm circumferences for 1,457 patients (87.5% of eligible patients). There were 674 women (46.3%) who experienced arm edema at some point during the period of follow-up until February 1976. For radical mastectomy patients, total mastectomy and radiotherapy patients, and total mastectomy patients alone, arm edema was recorded at least once in 58.1%, 38.2%, and 39.1% of patients, respectively (p<.001) and at last recorded measurement in 30.7%, 14.8%, and 15.5%, respectively (p=or<.001). Increasing body mass index (BMI) also showed a statistically significant correlation with arm edema at any time (p=.001) and at last assessment (p=.005). CONCLUSIONS: Patients who undergo mastectomy, including those whose treatment plans do not include axillary dissection or postoperative radiotherapy, suffer an appreciable incidence of arm edema.     

Preventing relapses of breast cancer with modified radical mastectomy

Better prevention and early detection have improved the percentage of early cancers among all the treated breast tumors to about 40%. After the first demonstration in Milan in 1981 that even conservative surgery can effectively prevent tumor relapses, radical and modified radical mastectomy was compared in 136 and 127 women, respectively. The groups were well stratified as regards age, menopause, T- and N-status. No difference was found in 10-yr survival (58.8 and 59.8%, respectively) or local relapses (9.5 and 10%, respectively) or general relapses. The median disease-free survival was 10 yr in both groups. The results suggest that in Tl-T2a, N0-Nlb M0 unilateral breast cancer relapses are prevented as effectively with modified radical as with radical mastectomy.     

Clinical investigation: regional nodal failure patterns in breast cancer patients treated with mastectomy without radiotherapy

PURPOSE: The purpose of this study was to describe regional nodal failure patterns in patients who had undergone mastectomy with axillary dissection to define subgroups of patients who might benefit from supplemental regional nodal radiation to the axilla or supraclavicular fossa/axillary apex. METHODS AND MATERIALS: The cohort consisted of 1031 patients treated with mastectomy (including a level I-II axillary dissection) and doxorubicin-based systemic therapy without radiation on five clinical trials at M.D. Anderson Cancer Center. Patient records, including pathology reports, were retrospectively reviewed. All regional recurrences (with or without distant metastasis) were recorded. Median follow-up was 116 months (range, 6-262 months). RESULTS: Twenty-one patients recurred within the low-mid axilla (10-year actuarial rate 3%). Of these, 16 were isolated regional failures (no chest wall failure). The risk of failure in the low-mid axilla was not significantly higher for patients with increasing numbers of involved nodes, increasing percentage of involved nodes, larger nodal size or gross extranodal extension. Only 3 of 100 patients with <10 nodes examined recurred in the low-mid axilla. Seventy-seven patients had a recurrence in the supraclavicular fossa/axillary apex (10-year actuarial rate 8%). Forty-nine were isolated regional recurrences. Significant predictors of failures in this region included > or = 4 involved axillary lymph nodes, >20% involved axillary nodes, and the presence of gross extranodal extension (10-year actuarial rates 15%, 14%, and 19%, respectively, p < 0.0005). The extent of axillary dissection and the size of the largest involved node were not predictive of failure within the supraclavicular fossa/axillary apex. CONCLUSIONS: These results suggest that failure in the level I-II axilla is an uncommon occurrence after modified radical mastectomy and chemotherapy. Therefore, supplemental radiotherapy to the dissected axilla is not warranted for most patients. However, patients with > or = 4 involved axillary lymph nodes, >20% involved axillary nodes, or gross extranodal extension are at increased risk of failure in the supraclavicular fossa/axillary apex and should receive radiation to undissected regions in addition to the chest wall.     

The outcome of treatment by tumorectory and radiotherapy of patients with operable breast cancer

We performed a retrospective study on 314 patients treated for a localized breast cancer by tumorectomy and radiotherapy to determine the overall survival, incidence of loco-regional failure and outcome of salvage surgery. All patients were followed for at least three years. Two hundred and fourteen patients had tumors ≤ 3 cm and 74 had tumors ≤ 6 cm. The three and five years absolute survival, free of disease (NED), is 88% ($\text{276}\text{314}$) and 84% ($\text{190}\text{225}$). The incidence of loco-regional failures was not dependent on tumor size and did not exceed 10% for the entire group. Recurrences were common (35%) in young patients (≤ 30). No patient older than 50 had recurrences. Eighty-one percent of failures appeared within three years. Salvage surgery was performed on 78% ($\text{14}\text{18}$) of patients with recurrences; 57% ($\text{8}\text{14}$) were free of disease (NED). Local failure in this group was not necessarily associated with disseminated cancer. Tumorectomy followed by radiotherapy is an acceptable alternative to mastectomy, particularly since salvage surgery can usually be successfully performed for recurrences.     

乳腺癌根治术或改良根治术后辅助性放疗

近年来关于影响乳腺癌术后辅助性放疗预后及效果的因素逐渐成为研究热点,乳腺癌的不同分期、不同亚型、激素水平以及患者的身体质量指数等均与其密切相关.此外,从三维适形放疗到螺旋断层放疗,放疗技术的发展也有了质的突破,使得疾病的治疗更加精确化、合理化.