转移背阔肌肌皮瓣在局部晚期乳腺癌手术.ppt

转移背阔肌肌皮瓣修复术在局部晚期乳腺癌手术中的应用汕头大学医学院附属肿瘤医院乳腺中心黄文河主任医师Contents局部晚期乳腺癌定义局部晚期乳腺癌定义局部晚期乳腺癌治疗现状局部晚期乳腺癌治疗现状背阔肌解剖学背阔肌解剖学背阔肌肌皮瓣修复术手术要点背阔肌肌皮瓣修复术手术要点注意事项及临床体会注意事项及临床体会局部晚期乳腺癌定义IIIA（T3N1M0除外）、除外）、IIIB或或IIIC期的非炎性乳腺癌期的非炎性乳腺癌Locallyadvancedbreastcancer(LABC)ischaracterizedbyvaryingclinicalpresentationssuchaspresenceofalargeprimarytumour(5cm),associatedwithorwithoutskinorchest-wallinvolvementorwithfixed(matted)axillarylymphnodesorwithdiseasespreadtotheipsilateralinternalmammaryorsupraclavicularnodesintheabsenceofanyevidenceofdistantmetastases.J Cancer Res Ther.2005 Jan-Mar;1(1):21-30 局部晚期乳腺癌局部晚期乳腺癌治疗现状治疗现状？发展中国家局部晚期乳腺癌治疗现状Locallyadvancedbreastcancer(LABC)accountsforasizeablenumber(30-60%)ofbreastcancercasesandisacommonclinicalscenarioindevelopingcountries.TreatmentofLABChasevolvedfromsinglemodalitytreatment,consistingofradicalmutilatingsurgeryorhigherdosesofradiotherapyininoperablediseasetomultimodalitymanagementconsistingofsurgery,radiationtherapy(RT),chemotherapywithorwithouthormonaltherapy.The5yearoverallsurvivalformastectomygroupwas67%and80%fortheBCTgroup.MultidisciplinarytherapyhasnowbecomethestandardforwomenwithLABC.2005|Volume:1|Issue:1|Page:21-30Managementoflocallyadvancedbreastcancer:EvolutionandcurrentpracticeAshishRustogi,AshwiniBudrukkar,KetayunDinshaw,RakeshJalaliDepartmentofRadiationOncology,TataMemorialHospital,Parel,Mumbai,IndiaImpact of progression during neoadjuvant chemotherapy on surgical management of breast cancer.METHODS:WereviewedclinicopathologicaldataonpatientswhoreceivedNCTforstageI-IIIbreast cancerfrom1994to2007.Chemotherapyregimenswereanthracycline-and/ortaxane-basedasdeterminedbythetreatingmedicaloncologist.RESULTS:Of1,928patientswhoreceivedNCT,1,762(91%)hadapartialorcompleteresponse,107(6%)hadstabledisease(SD),and59(3%)progressed(PD)whilereceivingatleastoneregimen.Ofthepatientswithprogressivedisease,40(68%)patientsunderwentmastectomy,12(20%)underwentBCT,and7(12%)didnotundergosurgery.Inpatientswhounderwentmastectomy,onlythree(8%)wereBCTcandidatesbeforeprogression.Overall,diseaseprogressionchangedtheoperativeplanin11(0.5%)patients:3developeddistantmetastasis,2developedclinicallymphadenopathy,3requiredmastectomyinsteadofBCT,2becameinoperable,and1requiredflapclosure.CONCLUSIONS:DiseaseprogressionwhilereceivingNCTisinfrequent(3%),butearlyidentificationmayallowforchangetoother,potentiallybeneficial,therapeuticinterventions.Patientswithbreast cancerwhoreceiveNCTshouldbeevaluatedfrequentlyforresponsetotherapy.Overall,progressionduringNCTchangesthesurgicalmanagementinasmallproportionofpatients.Caudle AS et al.Ann Surg Oncol.2011 Apr;18(4):932-8.转移背阔肌肌皮瓣修复术适应症及禁忌症适应症：乳房切除术后皮肤缺损乳腺癌根治术后自体组织乳房重建保乳术后局部畸形放疗后胸壁溃疡禁忌症开胸术后背阔肌被切断胸背血管受损者上胸壁大面积皮肤缺损者背阔肌的解剖学基础背阔肌解剖学位于肩胛骨下方，三角形发于T7T12、腰骶椎和最下面34根肋骨，止于肱骨结节间沟供血来源于胸背动脉和内乳动脉及肋间动脉的穿支神经支配为胸背神经功能：使肱骨内旋，上臂的内收和外展背阔肌肌皮瓣的应用历史历史：BaudetBaudet(1976)(1976)首先进行了游离移植首先进行了游离移植的报道。以后临床广泛应用，成为的报道。以后临床广泛应用，成为最常用的游离皮瓣之一最常用的游离皮瓣之一 皮瓣特点：血管分布恒定，蒂部管径在血管分布恒定，蒂部管径在1.52.0mm1.52.0mm。血管蒂长：血管蒂长：68cm68cm易于剥离和切取易于剥离和切取供区范围大：供区范围大：68cmX 1215cm68cmX 1215cm供区不遗留明显的功能障碍供区不遗留明显的功能障碍皮瓣血运丰富皮瓣血运丰富可形成单纯的肌瓣可形成单纯的肌瓣可用于进行肌肉功能的重建可用于进行肌肉功能的重建 应用范围：带蒂移植：胸部、上肢的组织缺损，带蒂移植：胸部、上肢的组织缺损，屈肘功能重建，乳房再造等屈肘功能重建，乳房再造等游离移植：头、面、颈、四肢、躯游离移植：头、面、颈、四肢、躯干等部位均可应用干等部位均可应用 转移背阔肌肌皮瓣修复术手术要点1术前先描画出手术切口全麻下，先仰卧位，行乳腺癌改良根治或根治术乳房切口彻底止血后用湿大纱布覆盖并用无菌手术膜隔离2再取侧卧位，在背阔肌表面按预先设计的梭形切口逐层切开沿背阔肌前缘切取背阔肌并向后方延续，注意保护前锯肌及大圆肌注意保护血管蒂把肌皮瓣经皮下隧道轻送到乳房创面3再改为仰卧位，将转移的肌皮瓣缝合固定于前胸壁切口并关闭皮肤切口切口轻度加压包扎引流管负压吸引手术技巧及注意事项1.体位1.先仰卧位；先仰卧位；2.侧卧位；侧卧位；3.最后仰卧位最后仰卧位2.保护胸背血管蒂胸背血管胸背血管胸外侧血管胸外侧血管3.防止肌皮瓣血管蒂扭转4.防止肌皮瓣坏死背阔肌肌皮瓣背阔肌肌皮瓣皮瓣在背阔肌肌性部分之上皮瓣在背阔肌肌性部分之上5.慎防误切大圆肌及前锯肌前锯肌前锯肌误切上述二肌肉会引起肩关节内收功能障碍误切上述二肌肉会引起肩关节内收功能障碍我院乳腺中心开展转移背阔肌肌皮瓣修复术病例资料姓名年龄分期 治疗陈XX53YbLDMF曾XX66YbLDMF李XX47YcLDMF张XX37YbLDMF临床体会临床体会体会1严格掌握适应症防止并发症发生Indicationsandcomplicationsoflatissimusdorsimyocutaneousflapsinoncologicbreastsurgery.METHODSTheuseofthelatissimusdorsimyocutaneousflap(LDMF)inreconstructivebreastsurgeryiswelldocumented.Fewreportsexistofitsuseinoncologicbreastsurgery.ThisseriesdescribesindicationsandcomplicationsoftheLDMFinlocallyadvancedcancer.Therecordsof83patientswereanalysedRESULTSTheindicationwastocoverdefectscausedbyresectionoflocallyadvancedbreastcancer(67cases),recurrentbreastcancer(13cases),radiationdamage(2cases),andsurgicalcomplications(1case).Themeanageofthepatientswas50.2years;52%werepostmenopausal.Theflapshadmeandiametersof32by14cm.Thedonorsitewasskingrafted.Clearmarginswereachievedin83%.AttheLDMFinsertionsite,woundinfectionrequireddrainagein1case;flapnecrosisrequiredreinterventionin7cases.In2casesasecondskingraftwasdonefortheLDMFdonorsite.CONCLUSIONSTheuseoftheLDMFmadewideresectionoflocallyadvancedlesionsandradionecrosispossible;majorcomplicationswererare.LDMFhasitsplaceinthearmamentariumofthesurgeonwhoregularlyseeslocallyadvancedbreastcancer.World J Surg.2002 Sep;26(9):1088-93.Epub 2002 Jun 21 体会2术后开始辅助放射治疗的时间选择Use of the extended V-Y latissimus dorsi myocutaneous flap for chest wall reconstruction in locally advanced breast cancerTheextendedV-YlatissimusdorsimyocutaneousflapdescribedbyMicaliandCarramaschiprovidesaninnovativemethodofclosinglargeanteriorchestdefectsafterresectionofbreastcancer.ThetechniqueprovidesrobustchestwallcoveragethatisabletowithstandimmediatepostoperativeradiotherapyTwelvepatientswhounderwentresectionoflocallyadvancedbreastcancerhadimmediatechestwallreconstructionwiththeextendedV-Ylatissimusdorsimusculocutaneousflap.TheVtoYdesignoftheflapscutaneousislandallowedprimaryclosureofchestwoundanddonordefect.Therewerenoinstancesofchestwounddehiscence.Thechestwoundshealed,allowingpatientstoundergoadjuvantradiotherapyinameantimeintervalof6weeksaftersurgery.Woo E et al.Ann Thorac Surg.2006 Aug;82(2):752-5.summary局部晚期乳腺癌的治疗是以手术为主的多学科综合治疗转移背阔肌肌皮瓣修复术是局部晚期乳腺癌切除术后修复皮肤缺损的一种安全合适的手术方式THANKYOU!