乳腺癌微创治疗研究进展

良好的手术效果不仅要彻底地切除肿瘤,同时也要保证患者的生活质量.因此,迫切要求外科医生改变理念,不断改进手术方式.随着现代科技的深入发展,微创治疗,即以最小的损伤达到最佳效果,已成为21世纪肿瘤学者追求的目标.今天外科手术已进入一个微创与功能保存时代,人们已不再满足乳房肿瘤的单纯医治,而且更要求在形体、功能和心理得到康复,对于临床早期的乳腺癌,常规的乳腺手术范围严重影响患者的生存质量.因此,人们正在探索各种替代常规手术的微创手术,其中包括射频消融、高强度聚焦超声、冷冻治疗、激光治疗、电化学治疗、前哨淋巴结活检代替腋窝淋巴结清除术和腋腔镜治疗等.     

腋下微创小切口治疗胸部肿瘤的临床研究

目的 :应用腋下微创切口治疗常见的胸部肿瘤 ,在保证与经典胸部切口治疗效果相同的情况下 ,减小手术创伤 ,达到微创的目的。方法 :34例患者均采用患侧腋下小切口 ,保留背阔肌 ,沿肌纤维方向分离前锯肌 ,不切断肋骨 ,沿肋骨上缘切开肋间肌进胸完成常见胸部肿瘤的手术治疗。结果 :全组均顺利地完成了手术治疗 ,手术损伤小、术后恢复快、患者痛苦小、遗留疤痕较小 ,基本上不影响肌肉和关节功能 ,有利于患者术后早期活动及生活自理 ,并明显减轻了患者的心理负担。术后并发症的情况与经典的胸部切口基本相同。结论 :大部分胸部肿瘤手术可以应用腋下微创切口来完成 ,不仅手术损伤较小 ,术后恢复快 ,而且疗效也与经典胸部切口相当 ,符合微创手术的原则 ,可以作为治疗胸部肿瘤的常规手术切口     

早期非小细胞肺癌电视胸腔镜微创手术与常规手术淋巴结清扫的效果比较

目的:探讨早期非小细胞肺癌电视胸腔镜微创手术与常规手术淋巴结清扫的差异。方法:选择2015年1月至2017年2月之间在儋州市人民医院进行治疗的肺癌患者123例,按照患者的治疗方法分为对照组和观察组,对照组患者69例使用常规开胸的手术方法,观察组患者54例使用电视胸腔镜介导下的微创手术和淋巴结清扫,对淋巴结清扫的效果进行对比。结果:两组患者的清扫淋巴结组数、清扫淋巴结个数、N1期淋巴结个数、N1期阳性个数、N2期淋巴结个数、N2期阳性个数数据差异均不具有统计学意义（P＞0.05）,观察组患者的淋巴结清扫时间高于对照组患者,手术后引流时间、失血量、住院时间低于对照组患者,数据差异均具有统计学意义（P＜0.05）,两组患者在手术后1年之中均未出现肿瘤的局部复发、纵隔淋巴结转移和其他的远处转移。结论:利用电视胸腔镜微创手术对早期非小细胞肺癌患者进行淋巴结清扫,各项指标基本等同于常规开胸手术的效果,但是对患者的创伤更小,值得在临床范围内进行推广。     

乳腺癌微创治疗研究的现状

对于早期乳腺癌 ,尤其是扫描发现的乳腺癌 ,常规保留乳房手术的范围可能相对过大 ,不能满足人们的美容要求 ,某些不适合手术的患者也不能采用。因此 ,人们正在探索各种替代常规手术的微创疗法 ,其中包括 :射频消融、激光组织间照射凝固、高强度聚焦超声、冷冻治疗、组织间放疗和聚焦微波热疗等。这些治疗方法具有技术上的可行性 ,但多处于基础研究阶段 ,临床治疗的病例极少 ,治疗效果未能大规模地和常规治疗作比较 ,仍存在许多需要解决的问题。简要综述它们的技术原理、治疗方法、存在问题等     

头颈肿瘤外科的发展与展望

头颈外部是一门比较年青的学科,半个世纪以来,头颈外科有了长足的进步,治疗的观念从单纯牺牲患病器官为求得生存,转变成为不但考虑患者的生存率,而且要重视患者的生存质量,高度重视综合治疗与功能保留。为了达到这个目标,我们应积极开展头颈肿瘤的微创手术与前哨淋巴结活检,开展头颈部恶性肿瘤的基因治疗和生物学技术在头颈肿瘤研究中的应用。     

射频消融治疗恶性肿瘤现状

目前,恶性肿瘤的治疗多强调以手术切除为主的多学科综合治疗,而对于一些不能手术切除的肿瘤患者,微创介入疗法是一种较好的肿瘤姑息治疗手段。射频消融(radiofrequency ablation,RFA)是一种针对肿瘤局部的微创介入性疗法,已被证实是一种有效、安全、并发症少、定位准确的治疗恶性实体肿瘤的微创技术。近年来,此项技术已被广泛应用于多种恶性肿瘤,如肝癌、肺癌、乳腺癌等。随着RFA治疗原理研究的不断深入、射频消融技术的不断改进,局部肿瘤治疗的疗效将进一步提高,但仍需要随机化的研究和长期的随访来证实RFA在肿瘤治疗中的重要意义。     

乳腺肿瘤被迫修复重建9例报告北大核心CSCD

引言随着手术技术的提高,乳腺肿瘤手术逐渐向微创及美容方面发展,整形外科技术也不断应用于乳腺肿瘤手术,但是由于地区发展不平衡以及人们对乳腺肿瘤认识不足,一部分患者就诊时已出现巨大肿块,甚至溃烂、恶臭,对手术治疗造成很大难度,并且影响患者生活质量。本文对巨大乳腺肿瘤手术切除术后被迫重建及修复进行探讨及思考,目的为延长患者生命,改善生存质量。     

胃癌微创治疗之路

外科手术是目前唯一可能治愈胃癌的手段,但传统的开腹手术通常伴随较高的并发症率和死亡率,还会对患者术后的生活质量产生较大影响。而微创外科技术由于可有效减少手术创伤,加快术后恢复,因此对于医生和患者均具有很大的吸引力,今后或将替代传统的开腹手术。目前,胃癌微创外科技术主要向着两个不同的方向发展,即内镜下肿瘤切除和腹腔镜手术。不久的将来,前哨淋巴结导航技术和机器人手术也将为胃癌治疗提供更多选择。随着各种微创技术的不断发展,胃癌患者术后的生活质量将显著改善。目前,许多有关各种微创技术的高水平临床研究正在进行当中,胃癌微创外科必将在世界范围内广为接受,并快速发展。      

腋下微创小切口治疗胸部肿瘤的临床研究

目的：应用腋下微创切口治疗常见的胸部肿瘤，在保证与经典胸部切口治疗效果相同的情况下，减小手术创伤，达到微创的目的，方法：34例患者均采用患侧腋下小切口，保留背阔肌，沿肌纤维方向分离前锯肌，不切断肋骨，沿肋骨上缘切开肋间肌进胸完成常见胸部肿瘤的手术治疗。结果：全组均顺利地完成了手术治疗，手术损伤小，术后恢复快，患者痛苦小，遗留疤痕较小，基本上不影响肌肉和关节功能。有利于患者术后早期活动及生活自理，并明显减轻了患者的心理负担。术后并发症的情况与经典的胸部切口基本相同。结论：大部分胸部肿瘤手术可以应用腋下微创切口来完成，不仅手术损伤较小，术后恢复快，而且疗效也与经典胸部切口相当，符合微创手术的原则，可以作为治疗胸部肿瘤的常规手术切口。     

功能成像技术对局部晚期直肠癌新辅助治疗预测与评估价值

对于局部晚期直肠癌,新辅助放化疗后行手术切除,再行术后辅助化疗,已发展为标准治疗模式。新辅助治疗可使肿瘤病灶发生不同程度的退缩,部分患者术后病理证实达到完全缓解,有助于增加直肠癌患者根治性手术概率,并降低复发率,改善患者的远期预后。近年来,新辅助治疗疗效的预测和评估,成为临床医生关注的焦点。在影像学方面,常规的形态成像技术,不能够准确反映新辅助放化疗后肿瘤治疗效果,而DWI-MRI、DCE-MRI、PET-CT等功能成像技术不仅能够反映肿瘤退缩程度,还可以反映治疗前后肿瘤功能代谢方面的变化,因而更为准确。现对直肠癌新辅助放化疗影像学疗效评价方法的应用现状进行综述。     

乳腺癌前哨淋巴结规范化处理

前哨淋巴结活检术（sentinel lymph node biopsy, SLNB）标志着乳腺癌淋巴结手术进入微创时代,循证医学I类证据支持SLNB是临床腋窝淋巴结阴性早期乳腺癌患者安全、有效的腋窝诊断技术,前哨淋巴结阴性及低肿瘤负荷患者行SLNB替代腋窝淋巴结清扫术后,腋窝淋巴结复发风险和并发症极低。作为乳腺癌区域淋巴结微创诊断技术,SLNB安全有效替代腋窝淋巴结清扫术应建立在规范化操作前提下。目前SLNB在我国早期乳腺癌患者中逐渐趋于规范化和普及化,本文将对临床实践中SLNB的适应证、示踪剂应用、学习曲线掌握、手术规范操作和组织标本处理等问题进行综述。      

A prospective study of use of a clinicopathological score to select patients for the type of axillary surgery.

AIMS: The aim of this study was to prospectively assess a previously described and independently validated clinicopathological score for counselling and selecting patients for sentinel node biopsy or axillary clearance. The clinicopathological score is based on the size of primary tumour, grade of primary tumour, age of the patient, quadrant of the breast and lymphovascular invasion, which are all independent predictors of lymph node involvement. The clinicopathological score may assist patients to decide if they would benefit from sentinel node biopsy or axillary clearance as a primary procedure. METHODS: All patients with invasive breast cancer were counselled for the possible rate of lymph node positivity, need for a second operation and false negative rate for sentinel node biopsy. Based on a previously validated clinicopathological score (Table 1), patients with a score of 10 or below were classed as less likely to have positive lymph nodes and hence were offered for minimally invasive axillary surgery and patients with a score of 11 or above were regarded to have high risk of nodal involvement and were counselled for axillary clearance. RESULTS: Only 3 of 31 patients in the low score group had axillary metastasis and needed further axillary treatment. The node positivity rate in the low score group was 10% compared to 63% for the high score group. CONCLUSION: It is concluded that until pre-operative axillary staging becomes widely available, by using the clinicopathological score for patient's selection for minimally invasive axillary surgery, it may be possible to avoid a second axillary procedure in a large majority of patients.     

Minimally invasive approaches for diagnosis and treatment of early-stage breast cancer

Breast cancer management has been evolving toward minimally invasive approaches. Image-guided percutaneous biopsy techniques provide accurate histologic diagnosis without the need for surgical biopsy. Breast conservation therapy has become the treatment standard for early-stage breast cancer. Sentinel lymph node biopsy is a new procedure that can predict axillary lymph node status without the need of axillary lymph node dissection. The next challenge is to treat primary tumors without surgery. For this purpose, several new minimally invasive procedures, including radiofrequency ablation, interstitial laser ablation, focused ultrasound ablation, and cryotherapy, are currently under development and may offer effective tumor management and provide treatment options that are psychologically and cosmetically more acceptable to the patients than are traditional surgical therapies. In this review, we give an overview of minimally invasive approaches for the diagnostic and therapeutic management of early-stage breast cancer.     

Minimally invasive surgery for breast cancer

Breast conservation surgery has become a standard operation as a minimally invasive surgery for breast cancer in Japan. Now sentinel lymph node biopsy (SLNB), day surgery, and endoscopy assisted surgery are being introduced as more minimally invasive surgeries for breast cancer. When blue dye and/or isotope are injected into the peri-tumoral breast gland, the sentinel lymph nodes (SLN) can be detected easily, and node negative patients can be selected with certainty. When no metastasis is found in SLN by frozen section, T1N0 breast cancer patients can be treated without lymph node dissection. Using this technique, day surgery for patients who have clinically node-negative small breast cancer (less than 1.5 cm in diameter) is performed under local anesthesia. We have developed an endoscopy assisted conservation surgery for breast cancer. Using endoscopy, partial or total glandectomy with radical axillary lymph node dissection is performed via a 5 cm skin incision on the middle axillary line. When the amount of glandectomy is over one third, we perform immediate reconstruction using the latissimus dorsi. These minimally invasive surgeries for breast cancer will result in a better quality of life for breast cancer patients.     

Metachronous secondary primary occult breast cancer initially presenting with metastases to the contralateral axillary lymph nodes: report of a case

We report a rare case of a 64-year-old female with metachronous secondary primary left occult breast cancer initially presenting right axillary lymph node metastases. The patient, who had received breast-conserving therapy for left breast cancer at another hospital about 4.5 years ago, came to our hospital complaining of right axillary node swelling. After both breast and systemic examination, she received complete right axillary lymph node dissection. Just after the operation, she was diagnosed with right occult breast cancer by a review of the right axillary lymph nodes and previous left breast cancer. She was followed by radiation and systemic chemoendocrine therapies. One year after axillary lymph node dissection, mammography and ultrasonography showed a new lesion in her left breast. Core needle biopsy revealed similar findings to right axillary lymph node metastasis. After salvage surgery, the diagnosis was revised. We recommend that patients without clinical findings except for axillary lymph node metastasis, especially post-breast-conserving surgery followed by radiation therapy, should be considered not only as having ipsilateral but also contralateral occult breast cancer. If there is no evidence of a primary lesion, axillary lymph node dissection needs to be carried out, and the patient should be offered the choice of radiation therapy or mastectomy followed by proper systemic therapy.     

核素淋巴显像识别前哨淋巴结在乳腺癌治疗中的应用

目的评价核素淋巴显像和γ探针定位在乳腺癌中确定前哨淋巴结(SLN)的应用价值,验证前哨淋巴结活检替代腋窝淋巴结清除术用于乳腺癌治疗的安全性与价值。方法选择1999年6月至2009年11月本院住院的女性乳腺癌患者206例(体检时腋窝均未扪及肿块),应用99Tcm-DX37～74 MBq或99Tcm-SC74 MBq经皮下注射,行核素淋巴显像后,术中注射专利兰1 ml和(或)术中用γ探针定位并行前哨淋巴结活检,与术中冰冻病理检查结果对照。若术中冰冻发现有前哨淋巴结转移,则行腋窝淋巴结清除术,若前哨淋巴结阴性,则不做腋窝淋巴结清除,术后定期随访。结果 206例乳腺癌术中成功活检SLN204例,成功率为99.0%(204/206)。本组有64例仅行SLN切除,术后病理检查证实64例SLN均阴性,故未行腋窝淋巴结清除,其中仅1例于术后1年时出现腋窝淋巴结转移,其余63例患者在随访期间均未发现腋窝淋巴结转移,也未出现同侧上肢水肿、感觉及活动异常;另140例行腋窝淋巴结清除,其中6例经病理证实SLN阳性但腋窝淋巴结为阴性,134例经病理证实SLN阳性35例,阴性99例,腋窝淋巴结阳性37例,阴性97例。核素淋巴显像和γ探针定位法的灵敏度为94.6%(35/37例),准确率为98.5%(138/140),假阴性为5.4%(2/37)。结论核素淋巴显像和γ探针定位应用于乳腺癌是切实可行和可能的,对预测腋窝淋巴结转移有很大的临床实用价值。如技术方法规范,早期乳腺癌前哨淋巴结活检则能取代常规的腋窝淋巴结清除术,乳腺癌手术上肢并发症的发生率可大大降低。     

Detection of micrometastases in sentinel lymph nodes of the breast applying monoclonal antibodies AE1/AE3 to pancytokeratins

Sentinel lymph node excision in breast cancer is a minimally invasive diagnostic procedure for accurate staging of the axilla and for avoiding unnecessary axillary dissection. In patients with palpable breast cancer we injected microcolloidal particles of human serum albumin labelled with technetium-99m the day before surgery. The sentinel node was detected intraoperatively with a handheld gammaprobe and then removed. Complete axillary dissection was performed and the nodes inspected by routine histological examination. The axillary lymph node status was correctly predicted by the sentinel node technique in 32 of 33 breast cancer patients. Two cases of micrometastases escaped routine histopathological detection but were identified by immunohistochemical analysis applying the antibody AE1/AE3 to pancytokeratins. Immunohistochemical examination of the sentinel node improves the diagnostic security of patients with breast carcinoma by detection of micrometastases.     

乳腺癌内乳前哨淋巴结活检术的研究进展

乳腺癌内乳淋巴结作为仅次于腋窝淋巴结的重要淋巴转移途径之一,其转移情况在乳腺癌的准确分期及个体化治疗中具有重要意义.内乳前哨淋巴结活检术可以通过微创的方式评估内乳淋巴结的转移情况,本文就乳腺癌内乳前哨淋巴结活检术的研究进展进行综述.     

Lumpectomy and sentinel lymph node navigation surgery for breast cancer under local anesthesia

We studied and analyzed therapeutic outcomes of a radical surgery under local anesthesia for breast cancer in our department. Subjects were 42 patients with breast cancer whose diagnoses were definitely made before surgery. Indications were: localized DCIS diagnosed preoperatively; invasive carcinoma less than 3 cm in tumor diameter on ultrasound; and clinically tumors with negative axillary lymph nodes. Operative procedures included lumpectomy associated with sentinel lymph node navigation biopsy. We could perform the operation under local anesthesia in all of the 42 patients, and were not demanded to shift from local to general anesthesia. Two patients had sentinel lymph nodes metastasis. Surgical stumps were positive in 14 patients( 33.3%). None of serious complications were encountered. Today's radical operation under local anesthesia for breast cancer is a useful procedure as minimally invasive surgery as for the indications employed in this study.     

Sentinel node biopsy in breast cancer

Sentinel node biopsy is a promising surgical technique to avoid unnecessary axillary lymph node dissection for breast cancer patients with histologically negative nodes. Several randomized phase III trials in Western countries are underway to assess sentinel node biopsy in cases of breast cancer in comparison with conventional axillary lymph node dissection. Other investigators have also started observational studies in cases when sentinel lymph nodes are proven histologically negative. In Japan, many issues regarding this minimally invasive surgery remain unresolved: optimal procedure, pathologic work-up, radiation exposure, health insurance coverage, and indication for sentinel node biopsy. The current status and problems of sentinel node biopsy in breast cancer are discussed herein.