乳腺癌术后即刻乳房重建的相关问题探讨

 乳腺癌术后乳房重建显著提高了患者的生活质量,已成为乳腺癌综合治疗的一个重要部分,但也暴露出一些盲目重建的问题。乳腺癌术后乳房重建的选择应综合考虑,即刻重建与保乳手术相比选保乳,即刻重建与延期重建相比尽量即刻再造乳房,假体重建与自体重建的选择也因人而异。总之,乳房重建应遵循根治基础上兼顾美容的原则。     

1999—2008年中国大陆地区乳腺癌保乳术及术后放疗情况的临床流行病学研究

目的 了解中国大陆地区乳腺癌保乳治疗和放疗情况。方法 随机纳入7家医院在1999—2008年治疗的乳腺癌患者,分析其中230例保乳治疗者的一般临床病理因素和检查治疗情况,及术后放疗使用及部位情况。对结果采用Wilcoxon分析、Cochran-Armitage 趋势检验和χ²检验等。结果 198例(86.1%)接受腋窝淋巴结清扫术,16例(7.0%)行前哨淋巴结活检术,15例(6.5%)未行腋窝手术,1例不详(0.4%)。165例(71.7%)接受术后放疗,术后放疗的使用率随不同治疗年代变化不明显(P=0.212),不同医院之间有差别(P=0.000)。全乳放疗后134例(81.2%)瘤床补量。除导管内癌患者,152例放疗者中31.6%照射同侧锁骨上下区、7.9%照射同侧腋窝、5.3%照射同侧内乳。腋窝淋巴结阳性数为0、1~3和≥4个者接受锁骨上下区照射的比例分别为31.5%、54.2%和100%(P=0.000)。结论 国内地区乳腺癌保乳术的开展有待于进一步提高,前哨淋巴结活检的使用率低。保乳术后放疗范围选择较规范,但使用率需要提高。     

MammoSite在保乳治疗中的应用

乳腺癌是严重威胁广大妇女健康的疾病之一。近年来，由于普查技术的广泛开展，早期乳腺癌的病例数不断增加，保乳手术的开展也随之不断增多。保乳术后的乳房放疗已成为放疗的重要研究课题之一。特别是乳房部分放疗（APBI）是目前世界上研究的重点。MammoSite是目前乳房部分放疗的重要装置，国外已经开展3年，国内尚未开展，现将其有关应用的情况作一介绍。     

肿瘤整形外科在乳腺肿瘤治疗中的作用

坚持乳腺癌治疗原则的基础上,整形外科是提高病人生活质量的重要部分,包括有保乳手术,乳房切除后自体组织或乳房假体的乳房重建,对侧乳房修整以及局部晚期乳腺癌手术后胸壁缺损的修复等。良好的肿瘤整形外科医生应具备肿瘤外科医生的知识与技能。     

中国大陆地区乳腺癌保乳术后放疗现状调查分析

目的 通过调查全面了解中国大陆地区目前保乳术后放疗应用现状,进一步规范保乳术后放疗的临床实践。方法 2010年3月和8月分两轮向中国大陆地区开展放疗的医院邮寄乳腺癌保乳术后放疗调查表,内容包括 2009年度内医院基本信息、保乳综合治疗的一般情况、放疗靶区、适应证和技术细节等。调查内容通过电话或邮件确认。结果 952家医院接受调查,有回复的396家(41.6%),其中328家开展了保乳术后放疗(82.8%)。手术至放疗中位间隔时间9周。320家(97.6%)照射患侧乳腺,275家(83.8%)照射锁骨上下区,140家(42.7%)照射腋窝,86家(26.2%)照射内乳区。对原发肿瘤位于乳腺者,把患侧乳腺作为放疗指征的医院占97.5%(311/319);对腋窝淋巴结阳性和淋巴结阳性≥4个者,把锁骨上下区作为照射指征的医院分别占41.8%(114/273)和31.5%(86/273),把腋窝作为照射指征的医院比例分别占26.8%(37/138)和29.0%(40/138);对肿瘤位于内象限或中央区者,把内乳区作为照射指征的医院占72.9%(62/85)。所用放疗技术均为常规分割,51.8%医院还开展了三维适形放疗技术,所有靶区中位处方剂量均为50 Gy。结论 中国大陆地区保乳术后放疗目前较为规范,但仍需通过建立和推广保乳术后放疗指南进一步完善。     

早期乳腺癌保乳术中低能X线放疗安全及可行性初步研究

目的 探讨早期乳腺癌保乳手术中放疗的短期并发症及美容效果。方法 回顾分析2013—2015年间30例早期乳腺癌患者资料。全部患者均行乳腺癌保乳手术及低能X线术中放疗,术中予以适配器表面20 Gy处方剂量,术后观察手术区域并发症、放射性损伤、乳房美容效果。结果无严重3、4级不良反应;短期并发症为4例(13%)出现血清肿,其中2例需要外科抽吸处理;3例(10%)出现1—2级乳腺皮肤红斑;美容效果优秀率为50%。患者均未出现LR及远处转移。结论 低能X线术中放疗在乳腺癌保乳手术中安全可行,在部分早期低危乳腺癌患者中可作为瘤床补量的一种选择参考。     

乳腺癌处理新趋势——即时乳房重建时代正在发生改变

20世纪80年代以来，人们认识到乳房切除术后放疗并不会提高生存率，因此乳房切除术后进行放疗的数量也随之下降。随着越来越多的早期乳腺癌患者选择保乳手术，并且保乳手术效果得到了实践证实，使得整形外科医生开始进行即时乳房重建代替以前的延迟乳房重建。在此趋势中发展了即时自体游离皮瓣乳房重建手术，既有良好的重建效果也不增加手术次数和并发症。然而20世纪90年代以后，随机试验的结果证实术后放疗能提高腋窝淋巴结阳性患者的生存率。     

早期乳腺癌乳房保留治疗的疗效分析

目的 评价早期乳腺癌保乳术后伞乳放疗的生存率和局部.区域控制率,探讨影响局部控制的因素.方法 近10年收治的早期乳腺癌接受保乳术者335例,其中术后单纯放疗、序贯化放疗、同期放化疗、化放化疗分别为25、194、80、36例.312例接受腋窝淋巴结清扫,2例前哨淋巴结活榆.310例接受辅助化疗.256放疗范围为单纯乳房,79例包括区域淋巴结照射.全乳和区域淋巴结照射剂量为50 Gy分25次,中位瘤床剂量为60 Gy分30次.放疗和手术间隔时问<4、4～8、>8～20、>20周的比例分别为16.4%、23.6%、37.3%、22.7%.结果 中位随访期48.0个月(25.3～146.7个月).5年局部一区域控制率和同侧乳房控制率分别为94.5%和95.6%;5年无病生存率、无转移牛存牢和总生俘率分别为88.6%、93.2%和98.8%.单因素分析发现脉管受侵、神经受侵犯和Ⅱ期切除的5年局部控制率下降,手术与放疗间隔时间、化疗与放疗结合方式的局部榨制率均相似.多因素分析发现脉管侵犯和Ⅱ期切除是独立的预后因素.序贯化放疗+单纯放疗、同期放化疗、化放化疗≥3级皮肤反应(湿性脱皮)发生率分别为4.5%、80.0%、77.0%(χ2=226.00,P=0.000).结论 早期乳腺癌保乳术加术后伞乳放疗等可获得良好的局部控制率和牛存率.脉管受侵与否和Ⅱ期切除是影响局部控制率的独立预后因素.未发现手术与放疗间隔时间、放疗与化疗结合方式对局部控制率有影响,但同期放化疗或化放化疗者发生皮肤湿性脱皮的概率明显增高.     

自体组织即刻乳房重建和延迟乳房重建术后生活质量评价

目的评价自体组织即刻乳房重建和延迟乳房重建术后患者的生活质量。方法通过问卷和电话随访两种形式调查自体组织即刻乳房重建和延迟乳房重建的乳腺癌患者术后生活质量。生活质量问卷是欧洲癌症研究治疗组织制定的调查条例(EORTC QLQ-C30)及专用于乳腺癌的特异模块乳腺癌患者生命质量测定量表QLQ-BR23中文版。2005年1月-2009年10月,共随访到72例,即刻组31例,延迟组41例。结果即刻乳房重建对患者术后生活质量的影响在多方面优于延迟乳房重建。重建乳房对称性、角色功能、社会功能、情绪功能及上肢功能的评价即刻组显著高于延迟组（P<0.001和P<0.05）。结论自体组织即刻乳房重建患者术后生活质量优于延迟乳房重建患者,乳腺癌患者如果有乳房重建的要求,自体组织即刻乳房重建可以作为首选方法。     

乳腺癌术后可扩张假体与自体组织乳房重建的临床比较

目的:探讨并比较分析保留皮肤乳腺切除术后,应用即刻可扩张假体植入乳房重建与即刻自体组织乳房重建的手术方法、效果及并发症.方法:60例患者行保留皮肤的乳腺改良根治术后乳房重建,其中可扩张假体植入重建43例,即刻自体组织重建17例.根据乳房的体积、形状、与对侧乳房的对称性比较及患者满意度,评价两种手术的效果.结果:随访12个月,可扩张假体乳房重建组到达良好以上为93％,自体组织重建组为86％,两种重建方法治疗效果差异无统计学意义.可扩张假体植入乳房重建安全可靠,手术效果好,并发症少.结论:可扩张假体植入即刻乳房重建扩大了假体植入乳房重建的手术适应证,是一种值得推广的手术方式.     

Autologous tissue reconstruction after mastectomy–A cross-sectional survey of 110 hospitals in China

BackgroundAutologous reconstruction after mastectomy became more and more popular, so this study aimed to obtain up-to-date and comprehensive data on autologous reconstruction in China.MethodsAn electronic questionnaire was sent to 110 hospitals, which were chosen depending on geographical distribution and hospital types. The questionnaire investigated the demographics, characteristics, breast cancer treatment and reconstruction situation of these hospitals through different modules. We only focused on the autologous breast reconstruction module data.Results96 hospitals have performed breast reconstruction surgery. The proportion of the hospital performing latissimus dorsi flap (LDF, N = 91), pedicle transverse rectus abdominis myocutaneous flap (pTRAM, N = 62), free abdominal flap (N = 43) and other kinds of flap decreased in sequence. Of the overall reconstruction cases, only 34.3% were autologous reconstruction and LDF was still the most popular option for autologous reconstruction. Related factors of hospital performing different procedures included years of performing breast reconstruction, breast surgical volume, and establishment of an independent plastic surgery department. Compared with LDF, abdominal breast reconstruction was associated with a higher flap necrosis rate.ConclusionsThis cross-sectional survey offers real-life autologous reconstruction information on a large population and covers the national surgical landscape in China. Autologous reconstruction is still an important part of breast reconstruction. Nevertheless, its low proportion and lower proportion of abdominal flap reconstruction in each institution, demonstrates that special training should be developed for breast surgeons and multidisciplinary cooperation would be promoted in the future.     

Multi-center investigation of breast reconstruction after mastectomy from Chinese Society of Breast Surgery: A survey based on 31 tertiary hospitals (CSBrS-004)

Objective:Multi-center data on the current status and trends of breast reconstruction after mastectomy in China are lacking.Herein,we conducted a cross-sectional survey to investigate the current clinical practice pattern of postmastectomy breast reconstruction among Chinese female patients with breast cancer.Methods:A standardized questionnaire used to collect information on breast reconstruction among females diagnosed with breast cancer was distributed by 31 members of the Chinese Society of Breast Surgery between January 1,2018 and December 31,2018.Information was collected on tumor characteristics,treatment,mesh application,nipple-areola complex(NAC)preservation,postoperative complications,bilateral reconstruction,patient satisfaction and local recurrence.The overall rate of breast reconstruction was assessed,and the characteristics were compared across patient groups with different reconstruction approaches.Results:A total of 1,554 patients underwent breast reconstruction after total mastectomy,with a reconstruction rate of 9.6%.Among them,1,190 were implant-based,and 262 underwent autologous reconstructions,while 102 cases underwent a combination of both.Patients who underwent implant-based reconstruction were younger than those who received autologous reconstruction(40.1±4.6 vs.45.0±5.9,P=0.004).Compared to patients with autologous reconstruction,mesh application(25.5%vs.6.5%),NAC preservation(51.8%vs.40.5%)and reconstruction failure(1.8%vs.0)were more frequently reported among those with implant-based reconstruction.There was no significant difference in general satisfaction across three reconstruction approaches,though patients with autologous reconstruction reported the highest aesthetic satisfaction among the three groups(P=0.044).Conclusions:Implant-based breast reconstruction remains the dominant choice among patients,while autologous reconstruction was associated with higher aesthetic satisfaction.Our multi-center investigation based on the findings of the tertiary hospitals of Chinese Society of Breast Surgery may guide a future series of clinical studies on breast reconstruction in China.     

The impact of immediate breast reconstruction on the technical delivery of postmastectomy radiotherapy

PURPOSE: To quantify the impact of immediate breast reconstruction on postmastectomy radiation therapy (PMRT) planning. METHODS: A total of 110 patients (112 treatment plans) who had mastectomy with immediate reconstruction followed by radiotherapy were compared with contemporaneous stage-matched patients who had undergone mastectomy without intervening reconstruction. A scoring system was used to assess optimal radiotherapy planning using four parameters: breadth of chest wall coverage, treatment of the ipsilateral internal mammary chain, minimization of lung, and avoidance of heart. An "optimal" plan achieved all objectives or a minor 0.5 point deduction; "moderately" compromised treatment plans had 1.0 or 1.5 point deductions; and "major" compromised plans had > or =2.0 point deductions. RESULTS: Of the 112 PMRT plans scored after reconstruction, 52% had compromises compared with 7% of matched controls (p < 0.0001). Of the compromised plans after reconstruction, 33% were considered to be moderately compromised plans and 19% were major compromised treatment plans. Optimal chest wall coverage, treatment of the ipsilateral internal mammary chain, lung minimization, and heart avoidance was achieved in 79%, 45%, 84%, and 84% of the plans in the group undergoing immediate reconstruction, compared respectively with 100%, 93%, 97%, and 92% of the plans in the control group (p < 0.0001, p < 0.0001, p = 0.0015, and p = 0.1435). In patients with reconstructions, 67% of the "major" compromised radiotherapy plans were left-sided (p < 0.16). CONCLUSIONS: Radiation treatment planning after immediate breast reconstruction was compromised in more than half of the patients (52%), with the largest compromises observed in those with left-sided cancers. For patients with locally advanced breast cancer, the potential for compromised PMRT planning should be considered when deciding between immediate and delayed reconstruction.     

乳腺癌术后修复重建的临床经验

目的 探讨国人乳腺癌术后修复重建的经验。方法 回顾性分析2009年11月至2011年1月海南省农垦总医院收治的15例乳腺癌术后自体组织修复重建患者的临床资料。结果 15例手术患者中,即刻修复5例（4例为即刻修复临床Ⅳ期乳癌术后胸壁创面）,延期修复10例。单纯应用背阔肌肌皮瓣带蒂转移3例（2例为即刻修复保乳术后局部缺损）,背阔肌肌皮瓣带蒂转移加乳房假体3例,乳腺瓣修复保乳术后局部缺损1例,内窥镜辅助背阔肌肌瓣带蒂转移修复保乳术后乳腺局部缺损1例,组织扩张术行局部皮瓣转移2例。随访2～15个月,皮瓣全部成活,创面愈合良好,形态满意。结论 自体组织修复保乳术后的局部缺损对于乳房普遍较小的中国患者实用方便,设计灵活,可同时修复腋窝缺损,不影响放疗和化疗的及时进行,具有良好的应用前景。     

即刻乳房再造在乳腺癌手术中的应用与探讨

目的探讨即刻乳房再造在乳腺癌手术中的应用价值。方法自2005年10月至2009年2月共完成了26例乳腺癌改良根治即刻乳房再造手术,其中10例为局部晚期乳腺癌。即刻腹直肌肌皮瓣乳房再造术12例,背阔肌肌皮瓣乳房再造术8例,保留乳头乳晕复合体皮下乳腺全切假体植入乳房再造术5例,保留乳头乳晕复合体皮下乳腺全切背阔肌肌皮瓣结合假体植入乳房再造术1例。结果全组手术切缘病理均达到阴性,皮瓣全部成活,无假体相关并发症,亦无腹壁疝发生。再造乳房形态满意,肌皮瓣再造乳房可以安全地耐受术后放疗,随访1～40个月无局部复发病例。结论即刻乳房再造手术从根本上改善了乳腺癌患者术后的生活质量,在局部晚期乳腺癌手术中,肌皮瓣乳房再造还可以为足够的切除范围提供安全保障,颇具临床应用价值。     

乳腺癌放射治疗指南(中国医师协会2020版)

乳腺癌是严重影响女性身心健康的恶性肿瘤,发病率和死亡率分别居中国女性恶性肿瘤的第1位和第5位。手术、放射治疗(放疗)、化疗、靶向治疗和免疫治疗等多学科的综合治疗策略,大大改善了乳腺癌患者的预后。放疗是乳腺癌综合治疗的重要手段,是降低保乳手术和高危乳房切除手术患者复发并延长生存的重要措施,也是不可手术局部晚期和转移性乳腺癌患者的重要姑息治疗手段。当前,我国乳腺癌放疗领域暂没有统一的标准放疗指南。在中国医师协会放射肿瘤治疗医师分会的推动下,基于乳腺癌领域最新理论和实践知识,并结合我国国情,我们制定了《中国乳腺癌放射治疗指南》。该指南旨在指导乳腺癌放疗的实施,促进规范和标准化国内乳腺癌放疗实践,最终达到提高我国乳腺癌放疗水平,改善广大乳腺癌患者预后的目标。     

Analysis of complications and BREAST-Q score after radiotherapy in breast cancer patients treated with different reconstruction methods

Objective To compare the complications, degree of satisfaction and quality of life among breast cancer patients treated with different reconstruction methods after postoperative radiotherapy, aiming to explore the optimal combination of reconstruction and radiotherapy. Methods 105 breast cancer patients treated with postoperative radiotherapy after reconstruction surgery in Tumor Hospital from 2014 to 2019 were enrolled. According to the type of reconstruction, all patients were divided into group A (autologous reconstruction group, n=54) and group B (implant reconstruction group, n=51). Patients in group B were further divided into group B1(one-stage reconstruction group, n=30) and group B2(two-stage reconstruction group, n=21) according to the timing of reconstruction. The incidence of complications and BREAST-Q score were statistically compared between groups A and B, groups B1 and B2, respectively. The influencing factors of BREAST-Q score were identified by multiple linear regression analysis. Results The incidence of long-term complications and the total incidence of complications in group A were significantly lower than those in group B (1.9% vs. 37.3%, P<0.001 and 9.3% vs.43.1%, P<0.001), and the scores of psychosocial well-being and degree of satisfaction with breasts in group A were significantly higher than those in group B (71(15) vs. 66(22), P=0.027 and 53(8) vs. 53(8), P=0.032)). There was no significant difference in the incidence of complications and BREAST-Q scores between groups B1 and B2(both P>0.05). Breast volume and complications were the predictors of BREAST-Q score (both P<0.001). Conclusions Radiotherapy after autologous reconstruction of breast cancer yields fewer complications and better BREAST-Q score than the implantation reconstruction. The incidence of postoperative radiotherapy complications and BREAST-Q scores are equivalent between one-stage and two-stage reconstruction. The BREAST-Q score is lower in patients with large breasts or complications.     

乳腺癌不同重建方式术后放疗并发症及BREAST-Q评分分析

目的 对比乳腺癌不同重建方式术后放疗的并发症、满意度及生活质量,寻求重建与放疗的最佳结合方式。方法 收集2014-2019年肿瘤医院收治的105例乳腺癌重建术后放疗病例。根据重建类型不同分为A组(自体重建组,54例)及B组(假体重建组,51例),B组根据重建时机不同分为B1组(一步法重建组,30例)及B2组(二步法重建组,21例)。比较A与B组、B1与B2组的并发症发生率及BREAST-Q评分,采用多元线性回归分析BREAST-Q评分的影响因素。结果 A组远期并发症和总并发症发生率低于B组(1.9%∶37.3%,P<0.001和9.3%∶43.1%,P<0.001),A组社会心理健康和乳房满意度评分高于B组[71(15)∶66(22),P=0.027和53(8)∶53(8),P=0.032],B1与B2组并发症发生率和BREAST-Q评分均相近(均P>0.05)。乳房体积、并发症是BREAST-Q评分的预测因素(P<0.001、<0.001)。结论 乳腺癌自体重建术后放疗较假体重建而言并发症少,BREAST-Q评分部分较优;假体一步法与二步法重建术后放疗的并发症及BREAST-Q结果相当;乳房较大或有并发症的患者BREAST-Q评分较低。