1、乳腺癌的保乳治疗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 1951)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两种乳腺癌生物学理论 HalstedHalsted.早期阶段是局部区早期阶
2、段是局部区域性疾病。域性疾病。.区域淋巴结是肿瘤区域淋巴结是肿瘤细胞通过的屏障。细胞通过的屏障。.肿瘤细胞通过直接肿瘤细胞通过直接，逐段浸润淋巴管。，逐段浸润淋巴管。FisherFisher.早期阶段即属全身早期阶段即属全身性疾病。性疾病。.区域淋巴结对肿瘤区域淋巴结对肿瘤细胞播散无屏障作用细胞播散无屏障作用。.肿瘤细胞通过栓子肿瘤细胞通过栓子间断进入淋巴管。间断进入淋巴管。NSABP B-04NSABP B-04临床试验临床试验 ,1971,1971n=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年存活年存活(%)58595415年存活年存活(%)45464125年存活年存活
3、(%)222117NIH Conference,1979NIH Conference,1979目的目的 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否定 传统的Halsted理论推荐推荐 单纯乳房切除+腋窝切除 替代Halsted 的根治性乳房切除。提出提出 积极对保乳手术做出评价FisherFisher理论的确立理论的确立保乳术的肯定保乳术的肯定 Milan Milan I I（1973-19801973-1980）NSABP B06NSABP B06（1976-19841976-1984）Milan I stu
4、dyMilan I study 1971198019711980LROSBCTn=3528.8%59.3%RMn=3492.3%59.8%NSABP B06NSABP B06 1976,n=1843 无瘤生存率无瘤生存率年度LL+RM198572%66%198958%54%199549%50%50%200235%35%36%无远处转移生存率无远处转移生存率年度LL+RM198576%72%198965%62%1995Datanotshownbutnosignificantdiff.200246%47%49%L：lumpectomy，L+R：lumpectomy+radiationM：maste
5、ctomy总生存率总生存率年度LL+RM198585%76%198971%71%199563%62%200246%47%47%NSABP B06 20NSABP B06 20年生存率年生存率Comparisons for Conservative Surgery and Comparisons for Conservative Surgery and Radiation(CS and RT)Versus Mastectomy in Radiation(CS and RT)Versus Mastectomy in Prospective Randomized TrialsProspective
6、Randomized Trials Overall survival(%)Local recurrence(%)Trial Follow-up(yr)CS+RT Mastectomy CS+RT MastectomyIGR 15 73 65 9 14Milan I 20 58 59 9 2NSABP B-06 20 47 47 14 10NC I 18 54 58 22 0EORTC 13 65 66 20 12DBCCG 6 79 82 3 4IGR=Institute Gustave-Roussy;EORTC=European Organization for Research and T
7、reatment of Cancer;DBCG=Danish Breast Cooperative Cancer GroupNIH Conference,1990NIH Conference,1990肯定肯定-保乳手术确定确定-部分乳腺切除、腋窝切除的概念及 操作规范探讨探讨-缩小腋窝切除的可能性If anybody may have doubts about the safety of If anybody may have doubts about the safety of breast conservation,this slide is the answer.breast conse
8、rvation,this slide is the answer.（The 26th Annual San Antonio Breast Cancer Symposium.Umberto Veronesi,MD）MorrowMorrow教授教授“It is time to declare“It is time to declare the case against breast-the case against breast-conserving therapy conserving therapy CLOSED”CLOSED”反对保乳手术一案该结案了反对保乳手术一案该结案了保乳手术现状欧美欧
9、美50%新加坡新加坡70-80%日本日本,台湾台湾,香港香港30%中国中国 10%Breast-Conserving Therapy providesGood Locoregional ControlDistant Survival=MastectomyGood Cosmetic ResultsBetter Quality of Life保乳手术适应症保乳手术适应症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。保乳手术禁忌症保乳手术禁忌症1.局部复发危险因素：广泛恶性钙
10、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操作要点点GUIDELINES OF SURGERYGUIDELINES OF SURGERYIncisionIncisionTechniqueTechniqueClosure Closure Axillary DissectionAxillary DissectionRecommended incisionNonreco
11、mmended incisionClips mark the six edges of Clips mark the six edges of the cavity for the the cavity for the radiotherapist.radiotherapist.Risk Factors for LR Patient factors:young age,inherited susceptibility Tumor factors:EIC,Tumor size and Axillary status,margins of resection Treatment factors:e
12、xtent 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 ris
13、k 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 5年年LRRLRR：EIC(EIC()15)15，EIC(-)1EIC(-)
14、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”?“Tumor-free Margins”?SG-Panel 2009 Considerations Shall re-excision be compulsar
15、y 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(abs
16、tract S28)新辅助化疗与保乳手术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 rate20-30%of patient have unsatisfactory out comeFactors predisposing for poor cosmetic results Badly sited surgical incisions.Volume of excised tissue(Tumor size/Breast size).Poor tissue handling(fa
17、t necrosis&infection).Radiotherapy.How to improve the cosmetic How to improve the cosmetic outcome?outcome?QuadrantectomyQuadrantectomyMilan(Veronesi)Milan(Veronesi)欧洲技术欧洲技术 Lumpectomy Lumpectomy NSABP(Fisher)NSABP(Fisher)美国技术美国技术腋腋窝窝清清扫扫前哨淋巴结活检前哨淋巴结活检 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
18、该总是首选SLNB。Radiotherapy保乳保乳术术后后放疗放疗-同侧乳腺复发同侧乳腺复发率率NSABP B06NSABP B06年度保乳手术保乳手术+放疗198939%10%199535%10%200239.2%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&IMRT3D-CRT&IMRT)Intracavitary brachytherapy Intraoperative limi
19、ted RTInterstitial BrachytherapyLimited External Beam IrradiationIntracavitary BrachytherapyMammosite Shall“accelerated whole breast RT”be Shall“accelerated whole breast RT”be an accepted therapeutic option?an accepted therapeutic option?83%Yes,83%Yes,10%No,7%?10%No,7%?Is the intraoperativeIs the intraoperative RT(PBRT)still RT(PBRT)still regarded as an experimental approach?regarded as an experimental approach?84%Yes84%Yes,16%No,16%No,0?0?SG SG-Panel 2009 Considerations
