乳腺癌的保乳手术20090627.ppt

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,乳腺癌的保乳治疗,青岛大学医学院附属医院乳腺外科,曹明智,乳腺癌外科发展历程,原始治疗时期-缺乏科学理论(19世纪前),解剖学时代-Halsted理论(19世纪末)乳癌根治术 (,Halsted 1894),乳癌扩大根治术(,Margottini 1949,;,Urban 1951,)生物学时代-Fisher理论(20世纪70年代)乳癌改良根治术(,Patey 1949;,Auchincloss 19,51,),保乳手术 (,Veronesi 1973,),前哨淋巴结活检(DavidKrag 1992)两种乳腺癌生物学理论,Halsted,.早期阶段是局部区域性疾病。,.区域淋巴结是肿瘤细胞通过的屏障。,.肿瘤细胞通过直接，逐段浸润淋巴管。,Fisher,.早期阶段即属全身性疾病。,.区域淋巴结对肿瘤细胞播散无屏障作用。,.肿瘤细胞通过栓子间断进入淋巴管。,NSABP B-04临床试验,1971,n=1700,根治性乳房切除,单纯乳房切除+局部放疗,单纯乳房切除,10年存活(%),58,59,54,15年存活(%),45,46,41,25年存活(%),22,21,17,NIH Conference,1979,目的,解决基于二种肿瘤生物学假说的,乳癌外科治疗的争议,讨论,是否有乳癌根治术的替代术式以减少,手术创伤又不降低生存率的问题,否定,传统的Halsted理论,推荐,单纯乳房切除+腋窝切除,替代Halsted 的根治性乳房切除。,提出,积极对保乳手术做出评价,Fisher理论的确立保乳术的肯定,Milan,I,（1973-1980）NSABP B06（1976-1984）,Milan I study,19711980,LR,OS,BCT,n=352,8.8%,59.3%,RM,n=349,2.3%,59.8%,NSABP B06,1976,n=1843,无瘤生存率,年度,L,L+R,M,1985,72%,66%,1989,58%,54%,1995,49%,50%,50%,2002,35%,35%,36%,无远处转移生存率,年度,L,L+R,M,1985,76%,72%,1989,65%,62%,1995,Data not shown but no significant diff.,2002,46%,47%,49%,L：lumpectomy，L+R：lumpectomy+radiation,M：mastectomy,总生存率,年度,L,L+R,M,1985,85%,76%,1989,71%,71%,1995,63%,62%,2002,46%,47%,47%,NSABP B06 20年生存率,Comparisons for Conservative Surgery and Radiation(CS and RT)Versus Mastectomy in Prospective Randomized Trials,Overall survival(%,),Local recurrence(%),Trial Follow-up(yr)CS+RT Mastectomy CS+RT Mastectomy,I,GR,15 73 65,9 14,Milan I 20,58,59,9 2,NSABP B-06 20,4,7,47,14 10,NC,I 18,5,4,58,22,0,EORTC,1,3,65 66,20,12,D,BCCG,6,79 82,3,4,IGRInstitute Gustave-Roussy,;EORTC=European Organization for Research and Treatment of Cancer;DBCG=Danish Breast Cooperative Cancer Group,NIH Conference,1990,肯定,-保乳手术,确定,-部分乳腺切除、腋窝切除的概念及,操作规范,探讨,-缩小腋窝切除的可能性,If anybody may have doubts about the safety of breast conservation,this slide is the answer.,（The 26th Annual San Antonio Breast Cancer Symposium.Umberto Veronesi,MD）,Morrow教授,“It is time to declare the case against breast-conserving therapy CLOSED”,反对保乳手术一案该结案了,保乳手术现状,欧美,50%,新加坡,70-80%,日本,台湾,香港,30%,中国,10%,Breast-Conserving Therapy provides,Good Locoregional Control,Distant Survival=Mastectomy,Good Cosmetic Results,Better Quality of Life,保乳手术适应症,1、保证疗效,：（1）,能完整切除肿瘤：单发局限病灶，病理设备及技术。（2）能接受放射治疗：无放疗禁忌症，设备及技术支持。,2、保证美观：肿块乳房大小适宜，术后乳房外观患者接受。,保乳手术禁忌症,1.局部复发危险因素：广泛恶性钙化，多中心病灶单一切口无法切除，切缘阳性或/和再次切除仍阳性。,2.不能放疗：残疾不能平卧，怀孕，局部放疗史，结缔组织病。经济状况差。,3.肿瘤大于5cm，术前化疗未能缩小，乳房大小不适，乳房外形可能不满意。,4.病人要求切除乳房。,肿瘤部位，腋淋巴结情况，乳房假体不为保乳禁忌,操作要点,GUIDELINES OF SURGERY,Incision,Technique,Closure,Axillary Dissection,Recommended incision,Nonrecommended incision,Clips mark the six edges of the cavity for the radiotherapist.,Risk Factors for LR,Patient factors:,young age,inherited susceptibility,Tumor factors:,EIC,Tumor size and Axillary status,margins of resection,Treatment factors:,extent of resection,use of boost,use of adjuvant systemic therapy,including sequencing of systemic therapy and RT,年轻乳腺癌患者的保乳治疗,35岁或40岁以下年轻乳腺癌患者保乳治疗（BCT）后同侧乳房复发（IBR）较其他年龄段患者显著增加。,年龄越小或预后越好的患者，其IBR累积风险越大，越倾向于接受乳房切除手术。临床实践中应告知年轻患者BCT后IBR的风险。,Family historyBRCA Gene,It is not clear that the risk of ipsilateral breast tumor recurrence is increased.,At a substantially increased risk of new primary breast cancers in both the ipsilateral and contralateral breast,广泛的导管内癌成分(EIC),EIC阳性是保乳术后局部高复发的原因之一，可能有残留的肿瘤超过了原发肿瘤范围。,切缘阴性、close（切缘与肿瘤之间少于2mm）、阳性之间的局部复发有相当差别。,5年LRR：,EIC()15，EIC(-)1。,因此,EIC可能仅是肿瘤比较广泛的标志，并不是保乳的禁忌症，只要手术边缘阴性就,可达到较好局控率。,保乳手术与切缘距离,对浸润性乳腺癌，染料标记的切缘阴性即可，对导管内癌，切缘距离要求为2 mm，同时术后须钼靶摄片证实钙化灶已被完全切除。,100%的专家支持切缘有浸润性癌或导管内癌必须行再次扩大切除，而切缘存在小叶原位癌时则不需要。对于导管内癌切缘距离小于2 mm时是否须行扩大切除，专家意见不一致。,“Tumor-free Margins”?,SG-Panel 2009 Considerations,Shall re-excision be compulsary in case of tumor-cells in surgical margins:,Invasive breast cancer:,100%Yes,0 No,0?,DCIS?,80%Yes,18%No,2%?,LCIS?13%Yes,82%No,5%?,Shall re-excision be compulsary in patients with DCIS and tumor-free margins of 2mm?,Great discussion,no consensus!(43%,48%,10%),(Morrow M,Wu S.The Breast 2009(Suppl.1)18:12(abstract S28),新辅助化疗与保乳手术,新辅助化疗前标记肿瘤范围,空芯针活检时可于肿瘤中央留置金属标记物,有密集钙化点者标本应作钼靶片，证实钙化点完全切除,Satisfaction rate,20-30%of patient have unsatisfactory out come,Factors predisposing for poor cosmetic results,Badly sited surgical incisions.,Volume of excised tissue(Tumor size/Breast size).,Poor tissue handling(fat necrosis&infection).,Radiotherapy.,How to improve the cosmetic outcome?,Quadrantectomy,Milan(Veronesi),欧洲技术,Lumpectomy,NSABP(Fisher),美国技术,腋窝清扫,前哨淋巴结活检,时至今日，不为乳腺癌患者提供SLNB已经不符合伦理要求了。须作出腋清扫术或SLNB的选择时，应该总是首选SLNB。,Radiotherapy,保乳术后放疗-同侧乳腺复发率,NSABP B06,年度,保乳手术,保乳手术,+放疗,1989,39%,10%,1995,35%,10%,2002,39.2%,14.3%,其P值都小于0.001,加速部分乳腺照射(,APBI,),Reduce Overall Treatment Time,Interstitial brachytherapy,Limited external beam irradiation,(,3D-CRT&IMRT),Intracavitary brachytherapy,Intraoperative limited RT,Interstitial Brachytherapy,Limited External Beam Irradiation,Intracavitary Brachytherapy,Mammosite,Shall“accelerated whole breast RT”be an accepted therapeutic option?,83%Yes,10%No,7%?,Is the intraoperative RT(PBRT)still regarded as an experimental approach?,84%Yes,16%No,0?,SG SG-Panel 2009 Considerations,拯救乳房！,谢谢,!,