改良Auchincloss手术治疗乳腺癌50例效果分析

通过对50例乳腺癌患者行Auchincloss改良根治术,术中切断胸小肌喙突止点,但不切除胸小肌,必要时再加胸大肌内侧劈开,使腋窝淋巴结得以充分清扫。另取同期50例行传统乳腺癌改良根治术病例作为对照组。结果改良组淋巴结清扫术多于对照组,改良组术后健患侧胸大肌外缘厚度无统计学差异。     

乳腺癌Auchincloss术中保护肋间臂神经、胸肌神经的意义

目的:探讨在乳腺癌Auchincloss术中保护肋间臂神经、胸肌神经的临床意义.方法:对2008年9月-2010年10月间的38例乳腺癌患者,在Auchincloss术中行腋淋巴结清扫时,注意游离并保护肋间臂神经、胸肌神经,随访观察术前、术后患者胸大肌功能、胸大肌外缘厚度、上臂内侧及腋部皮肤感觉功能的变化;腋窝淋巴结清扫的数量,对术中保护肋间臂神经、胸肌神经的价值进行评估.结果:38例患者中患侧上臂内侧及腋部皮肤感觉正常32例,感觉异常仅2例,占5.6%,4例腋窝淋巴结明显肿大与之黏连,放弃保留肋间臂神经;38例患者均成功保留胸肌神经,经术后随访观察,胸大肌功能均为5级,术后6个月复查B超,胸大肌外缘厚度与术前比较无明显差异.结论:在乳腺癌Auchincloss术中注意保护肋间臂神经、胸肌神经可有效避免术后上臂内侧皮肤感觉障碍及胸大肌萎缩,能明显改善患者术后生存质量,对手术疗效并无影响.     

乳腺癌Auchincloss术中保护肋间臂神经、胸肌神经的意义

目的：探讨在乳腺癌Auchincloss术中保护肋间臂神经、胸肌神经的临床意义。方法：对2008年9月-2010年10月间的38例乳腺癌患者,在Auchincloss术中行腋淋巴结清扫时,注意游离并保护肋间臂神经、胸肌神经,随访观察术前、术后患者胸大肌功能、胸大肌外缘厚度、上臂内侧及腋部皮肤感觉功能的变化;腋窝淋巴结清扫的数量,对术中保护肋间臂神经、胸肌神经的价值进行评估。结果：38例患者中患侧上臂内侧及腋部皮肤感觉正常32例,感觉异常仅2例,占5.6%,4例腋窝淋巴结明显肿大与之黏连,放弃保留肋间臂神经;38例患者均成功保留胸肌神经,经术后随访观察,胸大肌功能均为5级,术后6个月复查B超,胸大肌外缘厚度与术前比较无明显差异。结论：在乳腺癌Auchincloss术中注意保护肋间臂神经、胸肌神经可有效避免术后上臂内侧皮肤感觉障碍及胸大肌萎缩,能明显改善患者术后生存质量,对手术疗效并无影响。     

保留肋间臂神经的改良乳腺癌根治术

目的:探讨改良乳腺癌根治术保留肋间臂神经的方法及临床意义。方法:选择Ⅰ、Ⅱ期乳腺癌患者82例,随机分成两组:A组(试验组)49例,经胸大肌入路清扫腋淋巴结,保留肋间臂神经;B组(对照组)33例,经胸大肌入路清扫腋淋巴结,切除肋间臂神经。观察随访两组术后情况。结果:A组49例中腋窝及上臂内侧皮肤感觉正常45例(91.8%),感觉障碍4例(8.2%);B组感觉障碍31例(93.9%)。两组比较,有显著差异(χ2=59.30,P<0.01)。结论:保留肋间臂神经的改良乳腺癌根治术能够有效地防止患侧腋窝及上肢皮肤感觉障碍的发生率。     

保留胸前神经的改良乳癌根治术——附3例报道

目的：探讨根治乳癌更为合理的术式。方法：对３例ⅡⅢ期的乳癌患者在行改良一式乳癌根治术的基础上，沿第２肋软骨上缘作胸大肌开窗清扫腋尖群淋巴结和胸肌间淋巴结。结果：本组术后经１年零３个月至２年零８个月的随访，均无肿瘤复发，术侧胸肌无萎缩，肩关节及上肢活动自如。结论：保留胸前神经的改良乳腺根治术既能彻底根治乳癌，又能使保留的胸肌有功能无萎缩，是一种比较理想的术式，适合于无胸大肌浸润的临床各期乳癌病例。     

保留中、下胸肌神经的Patey手术41例分析

目的 探讨保留中、下胸肌神经的乳腺癌改良根治术Ⅱ式（Patey术）的可行性,并观察手术效果.方法 回顾性分析2010年1月至2011年3月在第三军医大学西南医院乳腺外科行保留中、下胸肌神经Patey术治疗的41例乳腺癌患者的临床资料.结果 所有患者均顺利完成该手术.手术时间为72 ～107 min之间,平均时间为87 min；术中出血量在15 ～ 120ml之间,平均出血量为75 ml；腋窝淋巴结清扫数量在15～42枚之间,平均清扫23枚淋巴结；转移淋巴结数目在2～32枚之间,平均转移数为7.7枚.全组无皮瓣坏死、切口感染、术后出血等并发症,3例拔除引流管后出现皮下积液,再次置管行负压引流后痊愈.术后3个月随访,所有患者同侧胸大肌外形良好、患侧上肢活动自如.结论 保留中、下胸肌神经的Patey术对于术后胸大肌功能的恢复和胸廓形态的维持具有重要意义,是一种具有应用价值的手术方式.     

Kodama法改良根治术治疗进展期乳腺癌60例分析

目前，乳腺癌改良根治术（Auchincloss法）还是中国大多数医院治疗进展期乳腺癌的主要手术方式。虽然乳腺癌传统根治术（Halsted法）腋窝淋巴结清扫彻底，但术后并发症多且胸壁毁损严重，现已少用。Auchincloss法清扫Ⅲ组淋巴结困难，易使进展期乳腺癌腋窝淋巴结清扫不彻底，导致其病理结果不能真实反映腋窝淋巴结转移的情况，从而影响乳腺癌患者的综合治疗和预后判断。Kodama法改良根治术不仅能彻底清扫腋窝淋巴结，而且术后胸部外观和患侧上肢功能良好。现将近5年来本院采用Kodama法改良根治术治疗进展期乳腺癌印例总结报告如下。     

乳腔镜辅助保留乳头乳腺癌改良根治术的临床研究

目的:探讨乳腔镜辅助保留乳头乳腺癌改良根治术的近期疗效。方法:对46例肿块直径≤3 cm、距离乳晕≥3 cm的乳腺癌患者施行乳腔镜辅助保留乳头乳腺癌改良根治术。腋窝脂肪抽吸后经乳腔镜行腋窝淋巴清除。彩色多普勒(探头频率10 MHz)测量患者双侧胸大肌厚度。测量前臂屈曲至胸前上臂尽力内收的角度,以评价上肢功能。结果:手术时间120~156 min(平均125 min),术中出血量30~100 mL(平均58 mL),术后引流量10~200 mL(平均92 mL),引流时间3~7 d(平均4 d),清除腋窝淋巴结6~35枚(平均16.3枚)。17例患者腋窝淋巴结阳性,平均受累淋巴结数为2.6。保留的乳头形态良好,伤口小而隐蔽,术后双侧胸大肌厚度及上肢内收角度差别差异均无统计学意义,t=1.68,P>0.05。所有患者对手术效果满意。术后随访2~41个月,平均16.1个月,未见局部肿瘤复发及腋窝和远处转移。结论:乳腔镜辅助保留乳头乳腺癌改良根治术并发症少,具有微创、临床易行、功能保护和美容兼具的特点,还可以保护上肢功能,保持胸部良好的外观形状及提高患者的生存质量,是一种治疗Ⅰ、Ⅱ期乳腺癌合理有效的术式。     

Ⅰ期乳腺癌保乳手术并腋窝放疗的临床观察

目的 探讨Ⅰ期乳腺癌保乳手术时不行腋窝淋巴结清扫而术后根治性放疗的疗效.方法 回顾性分析我科136例Ⅰ期乳腺癌临床资料,其中58例行保乳手术,术中不行腋窝淋巴结清扫,术后第1天开始用CMF方案化疗6周期,术后3周开始根治性术后放疗.78例行改良根治术,术后常规放化疗.结果 保乳手术 腋窝放疗组与改良根治术组相比,二者在生存率及局部复发率上差异无统计学意义(P＞0.05),而上肢水肿及功能障碍发生率差异有统计学意义(P＜0.05).结论 Ⅰ期乳腺癌保乳手术并腋窝单纯放疗优于腋窝淋巴结清扫.     

经胸大肌清扫Ⅲ组淋巴结在乳腺癌改良根治术中的应用

目的 探讨经胸大肌间隙入路清扫Ⅲ组淋巴结在乳腺癌改良根治术中的应用及其临床意义.方法 观察组采用保留胸大小肌的乳腺癌改良根治术(Auchincloss手术),同时沿胸大肌肌间沟切开胸大肌,彻底清除Ⅲ组淋巴结(锁骨下淋巴结).对照组采用仅保留胸大肌、切除胸小肌的乳腺癌改良根治术(Patey手术).结果 与对照组比较,观察组能彻底清扫腋淋巴结,明显减少胸大肌萎缩率,提高术后生活质量.结论 经胸大肌清扫Ⅲ组淋巴结既保留胸大肌功能,又彻底清扫腋淋巴结,值得临床推广.     

Modified radical mastectomy and lymphocyte subsets of regional lymph nodes

Whether or not regional lymph nodes in tumor-bearing hosts possess special immunological properties, still remains an important problem in the management of breast cancer. Regional lymph node cells from 22 patients with breast cancer were immunologically studied using monoclonal antibodies, OKT-3, 4, 8, OK-M 1, Leu-7, and laser flow cytometry. Among these patients, 13 early cancer patients underwent modified radical mastectomy (Auchincloss operation or Patey operation) and 9 underwent standard radical mastectomy (resection of breast, pectoralis major muscle and axillary dissection). More helper T lymphocytes defined by OKT-4 were found in regional lymph nodes in modified radical mastectomy patients in comparison with standard radical mastectomy patients. In patients given the modified operations, NK activity defined by OK-M 1 or Leu-7 were significantly increased, especially in lateral axillary lymph nodes. Also, OK-M 1 lymphocytes and Leu-7 lymphocytes were increased in lymph nodes without metastasis rather than those with metastasis. These findings suggest that regional lymph nodes may have defence mechanisms against the spread of tumor cells in early cancer patients.     

Low risk of locoregional recurrence of primary breast carcinoma after treatment with a modification of the Halsted radical mastectomy and selective use of radiotherapy

BACKGROUND: The purpose of the current study was to evaluate the locoregional recurrence rate after treatment of patients with operable breast carcinoma with a modification of the Halsted radical mastectomy and the selective use of radiotherapy and to identify risk factors for locoregional recurrence. METHODS: Between 1979-1987, 691 consecutive patients underwent mastectomy after a negative biopsy of the axillary apical lymph nodes. The median age of the patients was 59 years (range, 26-89 years). The clinical tumor size was < 2 cm in 72 patients, 2-5 cm in 387 patients, and >5 cm in 169 patients; 16 patients had a T4 tumor. Surgery was comprised of a modification of the Halsted radical mastectomy, including at least part of the pectoralis major muscle and the entire pectoralis minor muscle, in 573 patients; 303 patients had positive axillary lymph nodes. Adjuvant radiotherapy to the chest wall and regional lymph nodes was given to 74 patients, whereas an additional 414 patients underwent irradiation to the internal mammary and medial supraclavicular lymph nodes. The median follow-up was 91 months. RESULTS: The actuarial overall survival rate was 82% at 5 years and 63% at 10 years. The 10-year chest wall and regional lymph node control rates, including patients with prior distant failures, were 95% and 94%, respectively. The only two significant prognostic factors for locoregional recurrence on multivariate analysis were lymph node status and pathologic tumor size. CONCLUSIONS: Excellent locoregional control can be achieved with a modified technique of radical mastectomy in patients with negative apical biopsy and the selective use of comprehensive radiotherapy. These results may serve as a reference outcome for comparison with other locoregional treatment strategies.     

Modification of muscle-preserving radical mastectomy.

A technical improvement of the muscle-preserving radical mastectomy for breast cancer is presented. In this procedure, the Sulcus interpectoralis, located between clavicular and sternocostal parts of the pectoralis major muscle, is split bluntly and spread apart. Then, the pectoralis minor muscle is severed near its attachment to the coracoid process and an axillary dissection is thereby easily and thoroughly accomplished. The effectiveness of lymph node dissection by this method was ascertained when the number of the lymph nodes removed by this procedure was compared with that removed by the conventional muscle preserving mastectomy (Madden's operation) and the radical mastectomy. Ninety-three patients treated by this operation have shown a satisfactory cosmetic appearance and a good prognosis when compared with patients treated by the standard radical mastectomy.     

乳腺癌改良根治术与Halsted根治术的疗效比较

本文复习了我院７２例改良根治术治疗的乳腺癌患者，与同时期Ｈａｌｓｔｅｄ根治术７３例作比较。ＭＲＭ组５年、１０年生存率分别为８１．０４％和５０．５９％，ＲＭ组分别为７５．５７％和５５．３３％。经统计学处理，两组无显著性差异（Ｐ＞０．０５）。同时对腋淋巴结清除数目与局部复发率分别进行比较，两组也无显著差异。作者认为对可手术的乳腺癌，除非肿瘤累及胸大肌或腋淋巴结转移较大而影响手术操作外，ＭＲＭ为可行术式。     

Complete axillary lymph node dissection for stage I-II carcinoma of the breast

We reviewed the complete axillary dissection specimens of 136 patients with stage I-II breast cancer to clarify the distribution of axillary lymph node metastases in this disease. Our series included 71 patients undergoing axillary dissection as part of a modified radical mastectomy (MRM) and 65 patients undergoing axillary dissection in conjunction with conservative surgery of the breast and definitive postoperative breast radiotherapy (CAD). These two groups of patients were comparable according to age, menopausal status, tumor size, and clinical stage. In all patients the pectoralis minor muscle was excised and all axillary tissue removed. Each specimen contained a median of 23 lymph nodes. The axillary levels (I, II, III) were determined according to the relationship of axillary tissue to the pectoralis minor muscle (lateral, inferior, medial). Thirty-nine percent of the lymph nodes were contained in level I, 41% in level II, and 20% in level III. There were no significant differences noted in the number of lymph nodes or in the distribution of lymph nodes according to axillary level between dissections performed as part of the MRM or those done as a single procedure (CAD). Sixty-five patients (47.8%) had one or more positive lymph nodes in their axillary specimen. The clinical and pathologic stage was determined and compared for all patients. Among patients judged to have a clinically negative axilla, 37.6% had histologically positive lymph nodes (clinical false-negative rate). For patients with a clinically positive axilla, 11.1% had, histologically, no evidence of metastatic disease (clinical false-positive rate). When the distribution of lymph node metastases according to axillary level was studied, it was found that 29.2% of lymph node-positive patients (or 14.0% of all patients) had metastases only to level II and/or III of the axilla, with level I being negative (skip metastases). This incidence of skip metastases was greater among clinically node-negative than among clinically node-positive patients, but was not related to the size or location of the primary tumor in the breast. In addition, it was found that 20.0% of lymph node-positive patients (or 9.6% of all patients) were converted from three or fewer to four or more positive nodes by analysis of lymph nodes contained in levels II and III. This conversion from three or fewer to four or more positive nodes was due primarily to information contained in level II, with level III contributing to a smaller degree.(ABSTRACT TRUNCATED AT 400 WORDS)     

Interpectoral nodes in carcinoma of the breast: Requiem or resurrection

Fifty-eight consecutive patients undergoing a modified radical mastectomy were subjected to complete dissection and pathological assessment of the interpectoral fascia and the group of lymph nodes it contains. The dissection was carried out in all patients, irrespective of whether they were palpable or not. Interpectoral nodes (IPNs) were anatomically present in 28 patients (48%) and were completely absent in 30 patients (52%). Ten patients were Stage I, 18 were Stage II, and 30 were Stage III. Of the 25% (15/58) of patients with microscopic metastasis, only 12/15 had palpable nodes; 66% (10/15) of patients had axillary and apical nodes positive. Significantly, two patients with negative nodes in the axillary and apical group had metastatic Rotter's nodes. Of the 15 patients with positive IPNs, nine had primary tumors located within the upper quadrants of the breast, whereas only five had tumors in lower quadrants and one had a centrally located tumor. The neurovascular bundle to the pectoralis major could be safely preserved in 93% (54/58) of patients. The incidence of impalpable nodes with microscopic metastasis and the evidence of exclusively metastatic interpectoral nodes with uninvolved axillary and apical nodes prompt the following conclusions: (1) interpectoral fascia and nodes should be mandatorily dissected in all patients irrespective of the nodes being palpable or not; (2) the dissection is anatomic and is associated with almost no additional morbidity; (3) the group of patients with IPNs positive and the axillary group negative, would benefit maximally from the IPN dissection. Similarly, this dissection in all other groups of patients would enable a more accurate staging and selection of therapeutic strategies. © 1996 Wiley-Liss, Inc.     

改良乳腺癌根治术保留胸前神经的方法及临床意义

目的：探讨在改良乳腺癌根治术中保留胸前神经的方法和临床意义.方法：将68例拟行改良乳腺癌根治术的患者随机分为两组,保留胸前神经组和不保留胸前神经组各34例.保留胸前神经组手术时分开胸大肌暴露并保留胸内、外侧神经,不保留胸前神经组则不保留胸内、外侧神经.其余手术操作相同.术后12个月用彩超测量胸大肌厚度,并与对侧比较.结果：保留胸前神经组无重度胸大肌萎缩,不保留胸前神经组重度萎缩26例（76.5%）.经统计学检验,保留胸前神经组重度胸大肌萎缩情况较不保留胸前神经组明显减少（P＜0.01）.结论：改良乳腺癌根治术中保留胸前神经能减少术后胸大肌萎缩.     

The pattern of lymphatic metastasis of breast cancer and its influence on the delineation of radiation fields

PURPOSE: The delineation of radiation fields should cover the clinical target volume (CTV) and minimally irradiate the surrounding normal tissues and organs. This study was designed to explore the pattern of lymphatic metastasis of breast cancer and indications for radiotherapy after radical or modified radical mastectomy and to discuss the rational delineation of radiation fields. METHODS AND MATERIALS: Between September 1980 and December 2003, 78 breast cancer patients receiving extended radical mastectomy in the Margottini model and 61 cases with complete data were analyzed to investigate the internal mammary lymphatic metastatic status. Between March 1988 and December 1988, 46 patients with clinical negative supraclavicular nodes received radical mastectomy plus supraclavicular lymph node dissection. The supraclavicular lymph nodes and axillary lymph nodes were labeled as S and levels I, II, or III, respectively, and examined pathologically. Between January 1996 and April 1999, 412 patients who had radical or modified radical mastectomy underwent the pathologic examination of axillary or levels I, II, or III nodes. RESULTS: The incidence of internal mammary lymph node metastasis was 24.6%. It was 36.7% for the patients with positive axillary lymph nodes and 12.9% for the patients with negative axillary lymph nodes. All the metastatic internal mammary lymph nodes were located at the first, second, and third intercostal spaces. Skipping metastasis of the supraclavicular and axillary lymph nodes was observed in 3.8% and 8.1% of patients, respectively. CONCLUSIONS: According to our data, we suggest that the radiation field for internal mammary lymph nodes should exclude the fourth and fifth intercostal spaces, which may help to reduce the radiation damage to heart. It is unnecessary to irradiate the supraclavicular lymph nodes for the patients with negative axillary level III nodes, even with positive level I and level II nodes.