具备保留乳房条件的早期乳腺癌治疗方式选择

目的探讨具备保留乳房条件的早期乳腺癌行保留乳房手术＋术中放疗＋前哨淋巴结活检（SLNB）的可行性及优点。方法回顾无锡市第四人民医院乳腺科2007年6月至2012年1月期间收治的136例保留乳房手术患者的临床资料。保留乳房手术＋术中放疗62例（术中放疗组），使用9MeV电子线21Gy一次照射，其中行腋窝淋巴结清扫（ALND）41例（ALND组），行SLNB21例（SLNB组）；保留乳房手术＋术后全乳照射74例（术后放疗组），照射剂量为50—60Gy（5～6周，照射25～30次）。比较术中放疗组与术后放疗组手术及伤口愈合时间、放疗费用和美容效果；并记录两组放射性损伤、肿瘤复发及死亡事件；记录SLNB组与ALND组肩关节功能、患肢水肿及感觉异常、皮下积液等并发症。计量资料和等级资料采用非参数检验。结果与术后放疗组相比，术中放疗组的手术时问和切口愈合时间延长[M（QR）：120（15）min比90（15）min，P=0．00；M（QR）：13（4）d比8（1）d，P=0．00]，放疗费用少[M（QQ）：3500（200）元比14100（1000）元，P=0．00]，美容效果优良率差异无统计学意义[95．2％（59／62）比86．5％（64／74），P=0．09]，并且放射性损伤轻。保留乳房手术＋术中放疗组有2例局部复发、2例远处转移、1例死亡；而保留乳房手术＋术后放疗组有1例局部复发、3例远处转移、无死亡病例；两组皆无对侧乳腺癌发生。ALND组有3例肩关节功能障碍、7例患肢水肿、10例患肢感觉异常、5例皮下积液；而SLNB组轻度肩关节功能障碍、Ⅰ度患肢水肿、皮下积液各1例。结论保留乳房手术＋术中放疗具有单次照射、部位剂量确切、费用低、美容效果佳、保护周围脏器等优点。同时，SLNB可避免肩关节功能障碍、患肢水肿及感觉异常、皮下积液等并发症。

Treatment choice in early breast cancer patients suitable for breast conservation

Objective To study the feasibility and the advantages of breast-conserving surgery plus intraoperative radiotherapy plus sentinel lymph node biopsy （SLNB） in early breast cancer patients who are suitable for breast conservation. Methods We retrospectively analyzed the clinical data of 136 early breast cancer patients with breast conservation in our hospital from June 2007 to January 2012. Among them, 62 received intraoperative radiotherapy at the dosage of 21 Gy with 9 MeV electrons （ intraoperative radiotherapy group）, including 41 with axillary lymph node dissection （ALND group） and 21 with SLNB （SLNB group） ; 74 received conventional postoperative whole-breast radiotherapy at the dosage of 50-60 Gy （5-6 weeks, 25- 30 times） after breast-conserving surgery （postoperative radiotherapy group）. The duration of operation and wound healing, cost of radiotherapy, and cosmetic results were compared between the intraoperative and postoperative radiotherapy group. The events of radiation injury, recurrence and death were recorded. The function of shoulder joint, edema and abnormal sensation of the affected limb, subcutaneous effusion were recorded in SLNB group and ALND group. The non-parametric test was used for quantitative data and ranked data. Results Compared with postoperative radiotherapy group, the intraoperative radiotherapy group had longer operation time [ M（ QR ） ： 120 （ 15 ） min vs 90 （ 15 ） min, P = 0. 00 ], more wound healing days [ M（ QR ） ： 13（4） d vs 8（1） d, P=0.00], less cost [M（QR） ：3500（200）RMB vs 14100（1000）RMB, P=0.00], and slighter radiation injury. No difference in cosmetic results was showed [ 95.2% （59/162） vs 86. 5 % （64/74） , P= 0.09 ]. There were 2 cases of local recurrences, 2 distant metastases and 1 death in the intraoperative group, while there was 1 local recurrence, 3 distant metastases and no death in the postoperative radiotherapy group. No contralateral breast cancer occurred in two groups. There were 3 cases of shoulder joint dysfunction, 7 edema of affected limb, 10 abnormal sensation of the affected limb, 5 subcutaneous effusion in ALND group, whereas we observed 1 case of shoulder joint dysfunction, 1 edema of affected limb of degree Ⅰ, and 1 subcutaneous effusion in SLNB group. Conclusions The breast-conserving surgery plus intraoperative radiotherapy have the advantages of single fraction irradiation, accurate location and dosage, less cost, better cosmetic results and protection of adjacent organs. Meanwhile the sentinel lymph node biopsy can avoid surgical complications such as shoulder joint dysfunction, limb swelling and abnormal cutaneous sensation, subcutaneous effusion.