乳房自体组织重建的研究进展

乳腺癌是全世界女性最常见的恶性肿瘤。这些患者必须面对手术治疗对其生活质量和身体外观的长期影响。因此,越来越多的患者亟需一种结合肿瘤治疗与乳房重建的方法来满足其对疾病的治疗和乳房外观的需求。在美国,20世纪80年代接受乳房切除术后即刻重建的患者只有不到20%。但近年来,越来越多的患者选择即刻重建。乳房自体组织重建因其美容效果好而成为了许多患者的首选方案,但其术前穿支血管的选择及术后并发症的发生仍是目前自体组织重建所面对的问题。本文就乳房重建技术中自体组织重建皮瓣的应用、相关并发症的发生及预防、皮瓣穿支血管的影像学评估及腔镜技术下乳房重建的研究进展进行了详细的总结。     

The oncological implications of immediate breast reconstruction.

AIMS: The timing of breast reconstruction following mastectomy has been an area of contention. The purpose of this study was to report the oncologic safety of mastectomy and immediate breast reconstruction, primarily with a tissue expander. METHODS: We offered 54 patients (58 reconstructions) an immediate breast reconstruction after a modified radical mastectomy was done for invasive breast cancer. RESULTS: Fifty-eight mastectomies were done for an invasive cancer. Thirteen out of 54 women suffered relapse of their cancer and nine patients died of their disease during the follow-up period. Only in one patient a local recurrence was detected at an early stage and treated without removal of the prosthesis. Disease free survival for all patients was 93% at 5 years. CONCLUSION: Immediate breast reconstruction after mastectomy is an oncologically safe approach and represents a clear improvement in the quality of life for patients with breast cancer. Thus this procedure can safely be offered to appropriately selected women.     

乳腺癌乳房整形外科应用现状与进展

 乳腺癌术后乳房重建已成为乳腺癌综合治疗不可或缺的一部分,旨在不影响乳腺癌预后的基础上,提高患者生活质量。虽然中国乳腺癌乳房整形外科起步较早,但近几年才逐渐进入快速发展时期,且与发达国家仍存在较大差距。乳腺癌术后乳房重建整形技术主要包括肿瘤保乳整形技术以及全乳切除术后乳房重建,而乳房重建又可分为自体皮瓣重建及植入物重建。同时,脂肪移植、生物材料等重建辅助技术也在快速发展。国内首个较为全面细致的乳房重建指南,乳腺肿瘤整形与乳房重建专家共识将于今年发布,对乳房整形重建问题进行全面探讨和分析。在遵循乳房重建共识和指南的基础上,积极完善专科医生培训体系,建立更广泛深入的学科合作,从而促进我国乳腺癌术后乳房整形与重建技术的发展。       

Autologous tissue breast reconstruction following the application of tissue expander

Breast reconstruction is usually performed with autologous tissue or mammary prostheses, and a single method is generally selected for the most reconstruction cases. We combined these two methods of breast reconstruction. In the first stage, a tissue expander was applied to maintain space for the breast, and in the next stage the space was replaced with autologous tissue. This combined method was performed in 7 cases with good results. Some advantages or this method became clear, especially in the case of immediate breast reconstruction: 1) the patient has time to objectively consider breast reconstruction using autologous tissue after the emotional trauma of mastectomy had subsided 2) no additional surgical scar remains on the chest wall 3) the exact site and the exact amount of autologous tissue can be ascertained by measuring the volume of the tissue expander 4) there is no breast-less period, and 5) the patient’s daily life is unaffected. We believe this combined procedure will contribute to a better quality of life for those who experience breast cancer and mastectomy as well as other conventional reconstructive procedures.     

Breast reconstruction with prosthetic implants

For patients who undergo mastectomy for the treatment of breast cancer, the restoration of a normal breast form through breast reconstruction is important to body image and quality of life. Implant-based reconstruction has the capability of producing excellent results in the well selected patient. In addition, compared with autogenous tissue reconstruction, implant reconstruction offers a shorter operative procedure with a quicker convalescence and no donor site morbidity. Reconstruction options for implant-based reconstruction include: single-stage reconstruction with a standard or adjustable implant, tissue expansion followed by placement of a permanent implant, or combined autologous tissue/implant reconstruction. Procedure selection is based on a range of patient variables, including: location and type of breast cancer, availability of local, regional and distant donor tissue, size and shape of the desired breast(s), surgical risk, and most importantly, patient preference. Although satisfactory results can be obtained with single-stage reconstruction, in most of patients, a more reliable approach involves two-stage expander/implant reconstruction. Individualizing selection of a reconstructive technique for each patient will be the predominant factor in achieving a reconstructive success.     

Oncoplastic and reconstructive breast surgeon performance and impact on breast reconstructions: Clinical outcomes,learning curve,and patients’ satisfaction

BackgroundCompared to mastectomy alone, the addition of breast reconstruction could improve quality of life and it is usually performed by two-team approach, which consisted of both breast surgeons and plastic surgeons. This study aims to illustrate the positive impacts of the dual-trained oncoplastic reconstructive breast surgeon (ORBS) and reveal the factors influencing reconstruction rates.MethodsThis retrospective study enrolled 542 breast cancer patients who undergone mastectomy with reconstruction performed by a particular ORBS between January 2011 and December 2021 at a single institution. Clinical and oncological outcomes, impact of case accumulation on performance and patient-reported aesthetic satisfactions were analyzed and reported. Furthermore, in this study 1851 breast cancer patients treated with mastectomy combined with or without breast reconstructions, which included 542 performed by ORBS, were reviewed to identify factors affecting breast reconstructions.ResultsAmong the 524 breast reconstructions performed by the ORBS, 73.6% were gel implant reconstructions, 2.7% were tissue expanders, 19.5% were transverse rectus abdominal myocutaneous (TRAM) flaps, 2.7% were latissimus dorsi (LD) flaps, 0.8% were omentum flaps, and 0.8% involved LD flaps and implants. There was no total flap loss in the 124 autologous reconstructions, and the implant loss rate was 1.2% (5/403). Patient-reported aesthetic evaluations showed that 95% of the patients were satisfied. As the ORBS's accumulated case experiences, the implant loss rate decreased, and the overall satisfaction rate increased. According to the cumulative sum plot learning curve analysis, it took 58 procedures for the ORBS to shorten the operative time. In multivariate analysis, younger age, MRI, nipple sparing mastectomy, ORBS, and high-volume surgeon were factors related to breast reconstruction.ConclusionThe current study demonstrated that a breast surgeon after adequate training could become an ORBS and perform mastectomies with various types of breast reconstruction with acceptable clinical and oncological outcomes for breast cancer patients. ORBSs could increase breast reconstruction rates, which remain low worldwide.     

Quality of life after immediate breast reconstruction and skin-sparing mastectomy – A comparison with patients undergoing breast conserving surgery

Background

Historically breast cancer surgery was associated with significant psychosocial morbidity and suboptimal cosmetic outcome. Recent emphasis on women’s quality of life following breast cancer treatment has drawn attention to the importance of aesthetic outcome and potential benefits of immediate breast reconstruction (IBR). Our primary aim was to assess patient’s quality of life after IBR, compared to a matched group undergoing breast conservation. We also investigated the oncological safety and morbidity associated with immediate reconstruction.

Methods

A prospectively collected database of all breast cancer patients who underwent IBR at a tertiary referral breast unit was reviewed. Patients were reviewed clinically, and administered two validated quality of life questionnaires, at least one year after completing their treatment.

Results

255 patients underwent IBR following mastectomy over a 55 month period. Reconstruction with ipsilateral latissimus dorsi flap was most commonly performed (88%). After mean follow-up of 36 months, IBR patients’ quality of life was comparable to a group of age-matched women (n = 160) who underwent breast conserving surgery (p = 0.89). No patient experienced local recurrence (0%), distant metastases developed in 4.8% and disease related mortality was 2.2%. Post-operative morbidities included wound infection (11.8%), chronic pain (2.0%), capsular contracture (11%; 36% of whom had radiotherapy) and fat necrosis (14.1%). No patient experienced flap loss.

Conclusions

IBR is a highly acceptable form of treatment for women requiring mastectomy. With high rates of patient satisfaction, low associated morbidity, and proven oncological safety, it is an appropriate recommendation for all women requiring mastectomy.     

Irradiation en situation postopératoire après reconstruction mammaire

Immediate breast reconstruction versus delayed breast reconstruction improves quality of life of breast cancer patients undergoing total mastectomy without impacting oncologic outcomes. Two types of immediate reconstruction are possible, implant-based reconstruction or autologous reconstruction. These reconstructions interpose a tissue in the operating bed, which modifies target volume definition compared to a wall without reconstruction Post mastectomy radiotherapy increases the rate of postoperative complications for both surgical procedures. Recent guidelines were published about target volume definition in the post mastectomy setting after implant-based reconstruction. Guidelines about target volume definition after autologous reconstruction are still awaited. The aim of our work is to present the different surgical procedures for immediate breast reconstruction, their complications, and the definition of the postmastectomy target volume.     

Microsurgical breast reconstruction

Breast cancer, the most common cancer diagnosed in American women, often necessitates mastectomy. Many studies have demonstrated improved quality of life and well-being after breast reconstruction. Numerous techniques are available for breast reconstruction including tissue expander implants and autologous tissues. Microsurgical tissue transfer involves the use of excess skin and fat (flaps) from a remote location to reconstruct the breast. Most often, tissues are transferred from the abdomen and buttocks. Less commonly, thigh flaps are used. These operations can provide durable, esthetic reconstructions. In addition, advances in microsurgical techniques have improved operative success rates to the range of 99%. The selection of an appropriate flap for microsurgical breast reconstruction is multifactorial and is based on patient and oncologic factors. These factors include patient comorbidities, body habitus/availability of donor tissues, cancer stage, and the need for postoperative adjuvant radiation therapy, as well as the risk of cancer in the contralateral breast. Appropriate choice of flap and surgical technique can minimize the risk of operative complications. Additionally, several large series have established that microsurgical breast reconstruction has no impact on survival, or locoregional/distant recurrence rates.     

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。     

Achieving autologous breast reconstruction for breast cancer patients in the setting of post-mastectomy radiotherapy

Introduction  

Breast cancer is now associated with long-term disease-free and overall survival, and in the setting of mastectomy, long term psycho-sexual health becomes an important consideration. To this end, breast reconstruction has been shown to significantly improve quality of life for mastectomy patients. With adjuvant radiotherapy often required in the setting of breast reconstruction, it is unclear what interaction the two can have.     

乳腺癌保留乳头乳晕切除即刻乳房重建术后患者生活质量的评价

目的:观察分析保留乳头乳晕乳腺切除术后即刻假体乳房重建术患者的美容效果和生活质量。方法:回顾性分析陕西省人民医院2015年5月至2016年9月收治并行保留乳头乳晕乳腺切除术后即刻假体乳房重建组（20例）与乳腺切除+前哨淋巴结活检术组（20例）的乳腺癌患者临床病理资料，术后就乳房重建的美容效果及随访1年生活质量等数据进行组间比较。结果:两组的平均年龄、TNM分期及文化程度等资料差异均无统计学意义（P＞0.05）；随访1年两组生活质量通过乳腺癌患者生命质量测定量表评价结果表明，重建组在社会/家庭状况、情感状况、功能状况、附加关注方面的得分均高于对照组，重建组显著优于对照组（P＜0.05）；而在生理状况评分方面无明显差异。结论:保留乳头乳晕乳腺切除术后即刻假体乳房重建术较乳腺切除+前哨淋巴结活检手术具有创伤小、效果良好、外形美观、生活质量高等优势，值得临床推广。     

我国乳腺肿瘤整形外科的临床研究进展

乳腺癌是我国女性发病率最高的恶性肿瘤。随着乳腺癌综合治疗技术的进步和患者生存期的延长,为提高乳腺癌患者的生存质量,乳腺肿瘤整形外科受到越来越多的重视。乳腺肿瘤整形外科主要包括保乳整形和乳房重建两个技术体系。相较于西方发达国家,我国乳腺肿瘤整形外科虽起步较晚,但发展迅速,在很多领域都取得长足的进步。本文将就植入物乳房重建、自体组织乳房重建、脂肪移植乳房成形、内窥镜辅助乳房重建、乳头乳晕重建、患者报告结局评价等亚专科领域,对我国乳腺肿瘤整形外科的研究进展、当前学科发展的不足之处,及未来发展方向进行综述。     

Positive psychological changes after breast cancer diagnosis and treatment: The role of trait resilience and coping styles

Abstract

Purpose: This study aimed to examine the relationships among trait resilience, coping styles, and perceived positive psychological changes in women’s lives after breast cancer diagnosis and treatment.

Design: The study adopted a cross-sectional design.

Sample/Method: A total of 201 participants diagnosed with stage I-IV breast cancer were recruited. The average time since diagnosis was 39.14 months. Four rating scales were used to assess the participants’ trait resilience, coping styles, perceived growth, and health-related quality of life. These are the Connor-Davidson Resilience Scale (CD-RISC), the Mini-Mental Adaptation to Cancer Scale (Mini-MAC), the Chinese Posttraumatic Growth Inventory (PTGI), and the Functional Assessment of Cancer Therapy Scale-Breast (FACT-B).

Findings: Hierarchical analysis showed that trait resilience significantly predicted high levels of perceived growth and health-related quality of life. This effect was moderated by Positive-Acceptance coping. The study also found that Negative-Affect coping had a direct effect on lowering health-related quality of life but had no influence on perceived growth.

Conclusions: These findings highlight the facilitating effect of trait resilience and Positive-Acceptance coping on the psychological well-being and perceived growth among breast cancer outpatients.

Implications: Trait resilience may be a protective, even facilitating factor of cancer adaptation. The knowledge that trait resilience offers a way to enhance wellness after cancer diagnosis and treatments may be useful in a clinical setting.     

State of the Art in Breast Reconstruction

In patients undergoing breast reconstruction after partial and total mastectomy, selecting the appropriate timing as well as the best method of reconstruction are essential to optimize the outcome. At M.D. Anderson Cancer Center, the timing of oncoplastic repair after partial mastectomy defects and breast reconstruction after mastectomy tends to dictate the technique for reconstruction. In patients undergoing repair of a partial mastectomy defect, immediate or delayed repair before radiation therapy allows for the use of the remaining breast tissue to perform the repair. Delayed repair after radiation therapy is usually performed with autologous fat grafting or a flap. Immediate breast reconstruction after mastectomy is preferable for patients with a low risk of requiring postmastectomy radiation therapy (XRT) (stage I breast cancer, some stage II). In patients who are deemed preoperatively to be at an increased risk of requiring XRT (stage II breast cancer), delayed-immediate breast reconstruction may provide an additional option. Delayed-delayed reconstruction may be a consideration in patients known preoperatively to require XRT (stage III breast cancer), to allow for a skin-preserving delayed reconstruction after XRT. Newer techniques for breast reconstruction after mastectomy include one-stage implant, implant-based reconstruction plus acellular dermal matrix, autologous fat grafting after negative suction applied to chest wall, and perforator-based autologous tissue flaps. Often, the decision to perform a partial or total mastectomy depends upon reconstructive issues, not oncology-related considerations. Whether to repair a partial mastectomy defect or perform a total breast reconstruction after mastectomy is one of the most critical decisions in breast reconstruction.     

游离腹部皮瓣乳房重建的应用及研究进展

乳腺癌发病率居女性新发恶性肿瘤的第一位,外科治疗是重要的治疗手段之一。全乳切除术后乳房重建能在不影响肿瘤学安全性的前提下,提高患者的生存质量,其中,自体组织乳房重建因其特有的优势成为乳房重建的重要方式之一,而游离腹部皮瓣是自体组织乳房重建中最理想的材料。该研究将对游离腹部皮瓣乳房重建手术的临床应用、手术时机及并发症进行综述,旨在探讨游离腹部皮瓣乳房重建的应用及研究进展。     

Objectively measured breast symmetry has no influence on quality of life in breast cancer patients

Aims

This study investigates how quality of life (QoL) of breast cancer patients is related to breast symmetry.

Methods

We objectively measured breast symmetry using the breast analyzing tool (BAT) in 101 patients after breast conserving surgery for breast cancer at different time points during follow up. We correlated the results with the quality of life measured at the same time using the breast image scale (BIS), the EORTC QLQ-BR23 scale and a not validated sexual score scale. Age, tumour size, tumour/breast relation and the use of oncoplastic surgery were also correlated with symmetry and quality of life scales. Using multivariate analyses, independent parameters for an improved quality of life were identified.

Results

Mean age was 56 (±11.6), and 75.2% of patients had T1 or T2 tumours. Patient age (p = 0.03) and tumour size (p = 0.01) significantly influenced objectively measured breast symmetry. The cosmetic result was important for 53% of patients while 48% found it not important. Independent from this, neither overall quality of life nor breast self esteem was influenced by breast symmetry in our patients.

Conclusions

After breast cancer surgery, breast symmetry is not a major factor for patients’ quality of life and breast self esteem. Cosmetic result seems to be less important than oncologic outcome in patients with breast cancer.     

Quality of life after breast cancer surgery: What have we learned and where should we go next?

Treatment options for women with newly diagnosed breast cancer include breast conservation therapy and mastectomy with or without reconstruction, which provide equivalent cancer outcomes in properly selected patients. Although multiple studies have evaluated breast surgery quality‐of‐life outcomes, the data are inconsistent. This factor is important to consider when counseling patients and defining surgical quality measures. J. Surg. Oncol. 2009;99:447–455. © 2009 Wiley‐Liss, Inc.