1、乳腺癌外科治疗乳腺癌外科治疗Edwin Smith Surgical Papyrus,另译印和阗)全乳切除术 Volkman.1863腋淋巴结切除 Moore.1866根治术 Meyer.1891 Halsted.1894扩大根治术 Margottini.1949 Urban.1951改良根治术 Patey.1949 Auchincloss.1951保乳手术 Veronesi.1973 Atkin&Hayward.1977前哨淋巴结活检 David Krag.1992Halsted（18521922）1，乳腺癌的转移是机械式的，先有淋巴转移，再有血道转移。2，淋巴结转移是肿瘤散播的标志，说明肿
2、瘤有远处转移的可能。3，区域淋巴结对肿瘤的转移有一定的防御作用。4，血道转移在肿瘤转移中并不重要。5，可手术的乳腺癌是局部疾病，手术治疗可影响预后。根治术时期根治术时期扩大根治术时期扩大根治术时期1，内乳淋巴结的发现，内乳和腋窝淋巴结均接受腋窝的淋巴回流。2，新的病理学观点的推动。形成了“治疗疾病就是消灭其病理状态，彻底清除病灶，对可能产生转移的途径和部位予以预防性扫除”的病理学观点。改良根治术时期改良根治术时期1，扩大手术范围的根治术并没有明显改善患者生存率。2，胸大肌及其筋膜无淋巴管，肿瘤很少经此转移。3，生理学观点，首先考虑如何保留正常组织。4，乳腺癌化疗放疗等综合治疗技术的发展。5，人
3、们对乳腺癌的重视和检查手段的进步，乳腺癌在较早期被发现。保乳手术时期保乳手术时期1，乳腺癌即使在早期也可以通过血道播散,因而一开始即为全身性疾病。2,手术切除病灶及转移淋巴结,可以减轻肿瘤的负荷,改善机体对肿瘤的反应,提高机体的防御能力,但无限扩大手术范围,除了并发症增加外,还影响患者的免疫功能。3，原发肿瘤的局部处理方式不影响生存率。4，区域淋巴结在肿瘤发展过程中无防御功能,癌细胞可绕过淋巴结,或直接进入血道,淋巴结转移是影响生存率的指标,但不是决定性因素。5，各种综合治疗逐渐进入到乳腺癌的第一线治疗。6，大量前瞻性试验证明了乳腺癌保乳手术的可行性。中国抗癌协会乳腺癌诊治指南与规范(2015
4、版)Catanuto G,Rocco N,Nava MB.Surgical decision making in conservative mastectomies.Gland Surg.2016 Feb;5(1):69-74.中国抗癌协会乳腺癌诊治指南与规范(2015版)Voineskos SH,Frank SG,Cordeiro PG.Breast reconstruction following conservative mastectomies:predictors of complications and outcomes.Gland Surg.2015 Dec;4(6):484-9
5、6.推荐联合使用蓝染料和核素示踪剂，荧光染料和纳米碳作为示踪剂的价值有待进一步证实，目前中国专家团不建议其作为临床常规应用-中国抗癌协会乳腺癌诊治指南与规范(2015版)屠俊浩,张浩,陆奕含,王水,凌立君.纳米碳悬浊液在乳腺癌前哨淋巴结活检中的应用.中华实验外科杂志.2015,32(12):3147-3150 “我们必须认识到，清除淋巴结不管是多枚、数枚还是一枚，不管淋巴结是否转移，都不会对预后有所改善”Life comes with many challenges.The ones that should not scare us are the ones we can take on an
6、d take control of Position Statement on Prophylactic Mastectomy.Guiliano AE,Boolbol S,Degnim A,et al.:Society of surgical oncology:Position statement on prophylactic mastectomy.Ann Surg Oncol 2007;14:24252427.Lostumbo L,Carbine N,Wallace J,et al.:Prophylactic mastectomy for the prevention of breast
7、cancer.Cochrane Database Syst Rev 2004;CD002748.Portschy PR,Marmor S,Nzara R,et al.:Trends in incidence and management of lobular carcinoma in situ:A population based analysis.Ann Surg Oncol 2013;20:32403246Alexander NE,et al.The effect of an educational intervention on the perceived risk of breast
8、cancer.J Gen Intern Med 1996;11:9297.McDonnell SK,Schaid DJ,Myers JL,et al.:Efficacy of contralateral prophylactic mastectomy in women with a personal and family history of breast cancer.J Clin Oncol 2001;19:39383943.Lostumbo L,Carbine NE,Wallace J:Prophylactic mastectomy for the prevention of breas
9、t cancer.Cochrane Database Syst Rev 2010;CD002748.Frost MH,Slezak JM,Tran NV,et al.:Satisfaction after contralateral prophylactic mastectomy:The significance of mastectomy type,reconstructive complications,and body appearance.J Clin Oncol 2005;23:78497856.Intraoperative RadiotherapyZhang L,Zhou Z,Me
10、i X,Yang Z,Ma J,Chen X,Wang J,Liu G,Yu X,Guo X.Intraoperative Radiotherapy Versus Whole-Breast External Beam Radiotherapy in Early-Stage Breast Cancer.Medicine(Baltimore).2015 Jul;94(27):e1143.2191篇文献纳入4篇进行Meta-Analysis“Ipsilateral breast tumor recurrence was significantly higher in patients with IORT”“Identifying appropriate patients with a low risk of local recurrence is very important.For carefully selected patients who have a low risk of local recurrence,IORT should be a feasible choice”稀释液4h内应用（2-8）单独用药：50mg/m2 联合用药：30mg/m2 5ml 注射用水溶解5%Glucose 250-500mliv.gtt 2h q3w10mg/支 50mg/支谢谢！
