乳腺癌手术治疗回顾和进展

几个世纪以来,外科手术一直是治疗乳腺癌的主要手段。从1882年Halsted首创的根治性乳房切除术到现在的保乳手术,乳腺癌的外科手术方式在不断演变,然而治疗乳腺癌的最佳术式一直是外科医生争议的热点。本文从最初的根治性乳房切除术、扩大根治术、改良根治术、保乳术、前哨淋巴结活检术及乳腺癌腔镜手术五个方面对乳腺癌手术的变迁进行综述分析,总结不同时代乳腺癌手术治疗的特点,探寻了新的发展趋势。     

乳腺癌保乳治疗48例临床疗效分析及诊疗体会

目的：总结乳腺癌保乳治疗的临床疗效及诊疗经验。方法：2001年3月-2010年3月间,对我科收治的具有保乳治疗指征及保乳意愿的48例乳腺癌患者实施了保乳治疗,包括新辅助化疗、保乳手术、辅助化疗、辅助放疗、辅助内分泌治疗及分子靶向治疗。随访始计时间为手术日,做新辅助化疗者自开始化疗之日计。结果：48例全部随访至2011年7月,随访时间最短28个月,最长124个月,平均45个月。现无病生存47例,死亡1例,2例术后局部复发,其中1例二次保乳治疗,另1例乳腺全切现仍无病生存。美容效果满意者达97.1%（47/48）。结论：乳腺癌保乳治疗临床近远期效果良好,美容效果满意,可提高生活质量。     

乳腺癌保乳治疗48例临床疗效分析及诊疗体会

目的:总结乳腺癌保乳治疗的临床疗效及诊疗经验.方法:2001年3月-2010年3月间,对我科收治的具有保乳治疗指征及保乳意愿的48例乳腺癌患者实施了保乳治疗,包括新辅助化疗、保乳手术、辅助化疗、辅助放疗、辅助内分泌治疗及分子靶向治疗.随访始计时间为手术日,做新辅助化疗者自开始化疗之日计.结果:48例全部随访至2011年7月,随访时间最短28个月,最长124个月,平均45个月.现无病生存47例,死亡1例,2例术后局部复发,其中1例二次保乳治疗,另1例乳腺全切现仍无病生存.美容效果满意者达97.1%(47/48).结论:乳腺癌保乳治疗临床近远期效果良好,美容效果满意,可提高生活质量.     

乳腺癌的保乳治疗(附76例报告)

目的 探讨乳腺癌保乳治疗的相关问题及保乳治疗成功率的影响因素.方法 总结我科2003年-2007年对76例乳腺癌采用外科保乳治疗病例及随访资料,对70例(失访6例)患者的术后乳房外形进行评估,评价乳房美容效果的影响因素.结果 Ⅰ、Ⅱ期乳腺癌保乳治疗67例,9例Ⅲ期乳腺癌经新辅助化疗2周期后,肿块缩小至3 cm以下,行保乳治疗;手术方法的选择:行肿块局部扩大切除21例,区段切除45例,象限切除10例,均行同期腋下淋巴结清扫术;其中,9例行乳腔镜下腋窝淋巴结清扫术.即时局部乳房缺损修复36例,其中胶原蛋白海绵填塞8例,带蒂背阔肌肌(皮)瓣修复缺损28例.术后乳房美容效果评价,"良好"76﹪,"一般"16﹪,"差"8﹪.所有病例术后均给予6周期的化疗、乳房术后根治性辅助放疗及内分泌治疗.随访最长58月,平均32月,2例局部复发,3例发生远处转移,其中1例死亡.结论 对于Ⅰ、Ⅱ期乳腺癌外科治疗,保乳根治术具有美观效果、提高了生活质量;对于Ⅲ期乳腺癌,采用新辅助化疗为主的综合治疗后仍可成功保乳;带蒂背阔肌肌(皮)瓣修复乳房缺损是保乳手术Ⅰ期乳房成形的理想方法;乳腔镜行腋窝淋巴结清扫术具有美观、微创的优势;加强医患沟通、提高保乳意识势在必行.     

乳腺癌保乳治疗的现状和展望

本文介绍早期乳腺癌保乳治疗的现状和进展,主要从乳腺癌病理生理特点、保乳治疗与根治性手术的等效性、保乳手术的技术要求、前哨淋巴结活检、局部复发的相关风险因素和术后放疗等几个方面加以探讨。随着乳腺癌早期发现比例的逐渐提高和医患观念的更新,乳腺癌保乳治疗的应用前景将更加广阔。     

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。     

乳腺癌保乳术后复发及转移的分子生物学相关因素

随着人们对乳腺癌认识的深入及诊断、治疗技术的成熟,使得保乳手术逐渐得到推广.研究显示,对于Ⅰ、Ⅱ期乳腺癌,保乳手术加放疗与根治性手术有相似的局部控制率和长期生存率[1,2],而保乳术后患者生存质量明显改善.但保乳术后局部复发和远处转移还未能有效控制,迄今一直是人们普遍关心的问题.近年来,国内外对保乳手术预后影响因素的研究,多涉及临床病理学及辅助治疗方面,较少从反映肿瘤生物学特征的分子生物学角度入手.本文复习了近年来国内外文献,着重从分子生物学角度分析影响保乳手术预后的相关因素.     

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。     

早期乳腺癌保乳治疗12例临床治疗体会

目的:总结早期乳腺癌保乳治疗的临床治疗体会.方法:回顾性分析1999年1月至2004年12月保乳治疗的12例早期乳腺癌患者的手术资料、术后近期并发症及随访情况.结果:12例手术均顺利,无术后并发症,11例坚持完成术后放疗及化疗,随访至今未见局部复发与远处转移,1例失访.除1例乳房过小者外,其余10例对术后乳房外形及生活质量满意.结论:保乳治疗是早期乳腺癌很好的治疗方法,不仅同样可以根治肿瘤,而且能够提高生存质量.     

早期乳腺癌保乳治疗12例临床治疗体会

目的：总结早期乳腺癌保乳治疗的临床治疗体会。方法：回顾性分析1999年1月至2004年12月保乳治疗的12例早期乳腺癌患者的手术资料、术后近期并发症及随访情况。结果：12例手术均顺利，无术后并发症，11例坚持完成术后放疗及化疗，随访至今未见局部复发与远处转移，1例失访。除1例乳房过小者外，其余10例对术后乳房外形及生活质量满意。结论：保乳治疗是早期乳腺癌很好的治疗方法，不仅同样可以根治肿瘤，而且能够提高生存质量。     

President’s Address

In breast cancer surgery, there has been a major shift toward less invasive local treatment: from extended or radical mastectomy to modified radical mastectomy, from modified radical mastectomy to breast conserving therapy, and from routine axillary lymph node dissection to sentinel lymph node biopsy. Many breast surgeons have experienced an evolutionary progression of surgical management of breast cancer. However, there is an increasing demand for minimally invasive and non-surgical treatment methods for patients with small breast cancer. Radiofrequency (RF) ablation is the most promising among non-surgical ablation techniques in the treatment of breast cancer, although it is still in the investigative stage. Nevertheless, surgery still plays an integral role in the treatment of breast cancer, because local therapy is important for enhancing survival in the presence of systemic therapy. In clinical practice, surgical oncologists must individualize treatments, selecting a surgical or non-surgical procedure that provides the best local control, does not compromise the chances of cure, and achieves the best cosmetic results.     

Radiation therapy for early breast cancer

In women with early-stage breast cancer treated with surgery alone, microscopic residual disease may not be eliminated and can eventually cause life-threatening metastatic recurrence. Radiation therapy has been widely recommended for local control after breast-conserving surgery (BCS) and after a complete mastectomy in women at high risk of recurrence. However, even with widespread support for these recommendations within the medical community, they are not always heeded. Because local recurrence, when detected early, can often be treated with additional surgery alone, some physicians and patients still elect to avoid radiation therapy. It was felt, based upon individual trial data, that radiation therapy did not affect overall survival, but just decreased local relapse. The meta-analysis, published in the December 17/2005 Lancet, analysed individual data from 42,000 women, collected during 78 different randomised trials conducted since 1985. The availability of extensive 15-year survival data allowed the investigators to quantify the relationship between successful local control and long-term survivorship. Moreover, individual trials all show a benefit in local control and some trends toward survival advantages. The pooled meta-analysis of breast conservative surgery with or without radiation therapy Vinh Hung (2004) demonstrates a significant impact on local relapse and a small but significant impact on survival. It is considered that after BCS and in certain cases after mastectomy, radiation therapy is the standard treatment for improved local control and long-term survival.     

新辅助化疗后保留乳房手术治疗进展期乳腺癌可行性分析

目的 对新辅助化疗后保留乳房手术治疗进展期乳腺癌行可行性分析。方法 收集2010年6月—2011年6月间进展期乳腺癌患者60例,根据患者意愿分为新辅助化疗后保乳手术组和改良根治术组,每组30例,分别给予新辅助化疗后保乳手术及改良根治手术,随访3年。比较两组的治疗效果,并分析两组乳腺癌循环肿瘤细胞(CTCs)阳性情况,记录两组患者随访后期局部复发率、远处转移率、总生存率和无瘤生存率。结果 新辅助化疗后保乳手术组与改良根治术组相比,两组CTCs检出率没有统计学差异(P＞0.05),两组患者在临床完全缓解率、部分缓解率、疾病稳定率以及局部复发率、远处转移率、总生存率和无瘤生存率方面均无统计学差异(P＞0.05)。结论 对进展期乳腺癌患者应用新辅助化疗合并保乳手术治疗,能达到与改良根治术类似的治疗效果,可作为治疗进展期乳腺癌的一种选择。     

早期乳腺癌保乳术后联合全乳腺放射治疗的疗效分析

目的评价早期乳腺癌保乳手术联合放射治疗的疗效及美容效果。方法对26例早期乳腺癌患者采取保乳手术加术后全乳腺放射治疗,并与19例同期早期乳腺癌行改良根治术加术后放射治疗的患者进行对比分析。结果所有的患者均完成治疗,均无切口感染、切口不愈合及放射性皮肤坏死等不良反应,均有不同程度的近期皮肤反应,但均没有明显纤维化。保乳组的3年、5年生存率分别为96.2%(25/26)、92.3%(24/26),与对照组的3年、5年生存率100.0%(19/19)、94.7%(18/19)相似。保乳组22例(84.6%)美容效果良好。结论乳腺癌保乳手术美容效果良好,放射治疗对乳房外形无明显影响,两者联合应用可显著提高乳腺癌患者的生活质量。     

不同治疗方法对年轻乳腺癌患者的生存情况及生活质量的影响

目的 观察年轻乳腺癌患者(年龄≤35岁)保乳手术及改良根治术后的疗效.方法 临床纳入年轻乳腺癌患者90例.其中,保乳手术患者45例,进行改良根治术患者45例.观察两组患者3年生存情况、手术情况、生活质量等.结果 保乳组3年生存率、局部复发率、远处转移率分别为95.56%、2.22%、2.22%,根治组3年生存率、局部复发率、远处转移率分别为91.11%、4.44%、6.67%,均无显著差异性(P>0.05);保乳组手术时间、出血量、引流量及住院时间均优于改良组,差异有统计学意义(P<0.05);且保乳组生理机能(PF)、生理职能(RP)、躯体疼痛(BP)、社会功能(SF)以及精神健康(MH)评分均明显优于改良组,差异有显著性(P<0.05).结论 年轻乳腺癌患者进行保乳手术以及改良根治术均能够起到较好的临床治疗效果,对患者的生存率及复发率均没有明显的影响.但保乳手术具有创伤小、临床恢复快且能够提高生活质量优点,值得推广.     

Present status of endoscopic mastectomy for breast cancer

Endoscopy is now being used for breast cancer surgery. Though it is used for mastectomy, lymph node dissection, and breast reconstruction, its prime use is for mastectomy. Because an incision can be placed inconspicuously in the axillary site, a relatively large incision can be created. A retractor with an endoscope, CO₂, and an abrasion device with the endoscope are used for operation space security. It is extremely rare that an endoscope is used for lymph node dissection. For breast reconstruction, it may be used for latissimus muscle flap making, but an endoscope is rarely used for other reconstructions. Endoscopic mastectomy is limited to certain institutions and practiced hands, and it has not been significantly developed in breast cancer surgery. On the other hand, endoscopic surgery may be used widely in breast reconstruction. With respect to the spread of robotic surgery, many factors remain uncertain.     

The evolution of the locoregional therapy of breast cancer

Breast-conserving therapy (BCT) and mastectomy have equal survival outcomes. Rates of local recurrence after BCT have declined steadily, largely as a result of the widespread use of systemic therapy. Sentinel node biopsy has replaced axillary dissection for staging the axilla, and in women undergoing BCT with whole-breast irradiation (WBI), axillary dissection is not needed for local control or survival in those with fewer than three involved sentinel nodes. Alternatives to 6 weeks of WBI have been shown to be safe and effective for subsets of breast cancer patients, and the use of preoperative chemotherapy allows BCT in some women who require mastectomy if surgery is the initial step in treatment. The combination of the smaller cancers detected with screening and the routine use of multimodality therapy has resulted in a decrease in the morbidity of local therapy and improved cancer treatment outcomes.     

局部区域复发乳腺癌的治疗进展

和初治的乳腺癌相比,局部区域复发性患者的预后分析和挽救治疗策略选择存在更多的不确定性。本文首先分析了影响保乳手术和乳房切除术后局部-区域复发的高危因素以及相应的复发模式。以再次手术和包括完整复发灶及相应亚临床病灶的放射治疗为主要形式的局部治疗是综合治疗策略的基础,合理的局部治疗可以达到有效的局部疾病控制率并降低二次局部区域复发。虽然既往的前瞻性或回顾性资料对于全身治疗在局部-区域复发乳腺癌治疗中的价值始终没有确认,由多个国际乳腺癌研究组织联合发起的CALOR研究结果的公布第一次证实,在保留合理的内分泌治疗和靶向治疗的前提下,手术+放射治疗联合后续的全身化疗可以进一步提高无病生存率和总生存率,尤其在激素受体阴性的患者中获益更显著。所以结合原发病灶和复发灶的肿瘤标志物给予合理的全身治疗将成为局部区域复发患者综合治疗重要的组成部分。     

Early-stage bilateral breast cancer treated with breast-conserving surgery and definitive irradiation: The university of pennsylvania experience

: To determine whether patients with early-stage bilateral breast cancer can be treated with definitive irradiation following breast-conserving surgery with acceptable survival, local control, complications, and cosmesis.

: During the period 1977–1992, 55 women with State 0, I, or II concurrent (n = 12) or sequential (n = 43) bilateral breast cancer were treated with definitive irradiation following breast-conserving surgery. The records of these 55 patients with 110 treated breasts were reviewed for tumor size, histology, pathologic axillary lymph node status, first and overall site(s) of failure, and adjuvant chemotherapy or hormonal therapy. Curves for survival, local control, and regional control were determined. Cosmetic outcome, complication rates, and matching technique were analyzed. The median total radiation dose delivered was 64 Gy *range 42–72) using tangential whole-breast irradiation followed by an electron or iridium implant boost. The tangential fields were matched with no overlap in 40 patients (73%); there was overlap on skin of up to 4 cm in 14 patients. (25%); and the matching technique was unknown in 1 patient (2%). The median follow-up for the 12 women with concurrent bilateral breast cancer was 4.0 years. The median follow-up for the other 43 women with sequential cancer was 9.3 and 4.9 years, respectively, after the first and second cancers.

: For the overall group of 55 patients, the 5- and 10-year overall survival rates were 96% and 94%, respectively, after treatment of the first cancer, and 96% and 92%, respectively, after treatment of the second cancer. The 5- and 10-year actuarial relapse-free survival rates were 90% and 75%, respectively, after treatment of the first cancer, and 83% and 72%, respectively, after treatment of the second cancer. For the 110 treated breast cancers, th 5- and 10-year actuarial local failure rates were 5% and 15%, respectively. Complication rates were: 28% breast edema, 8% arm edema, 4% pneumonitis, 3% cellulitis, 1% rib fracture, and 1% brachial plexopathy; no patients developed matchline fibrosis. For patients with a minimum of 3 years of relapse-free follow-up, the rate of excellent or good cosmetic outcome for 104 treated beasts was 85%.

: Definitive irradiation after breast-consercing surgery is technically feasible for selected patients with concurrent or sequential early-stage bilateral breast cancer. Survival, local control, complication rates, and cosmetic outcomes appear comparable to historical reports of breast conservation treatment for unilateral disease. Bilateral definitive breast irradiation after breast-conservation surgery should be considered an acceptable alternative treatment to bilatera; mastectomy for selected patients with concurrent or sequential early-stage bilateral breast cancer.     

Advances in Local-Regional Treatment for Patients With Early-Stage Breast Cancer: A Review of the Field

This review highlights advances in the field of the local-regional treatment for patients with early-stage breast cancer. Through the years, the surgical treatment for early-stage breast cancer has evolved into more conservative treatment, with breast-conserving measures replacing the mastectomy as the most common procedure performed to treat the primary tumor. Likewise, nodal staging has evolved so that the lymphatic mapping procedures have replaced axillary dissection, resulting in a less morbid procedure and better staging information. Advances in radiation treatment have resulted in increasingly tailored approaches to adding radiation treatment after breast-conserving surgery or mastectomy. These improvements in local-regional treatment have benefitted patients through increased breast conservation treatment, improved local control, increased survival, and improved quality of life.