保留乳头乳晕乳房切除术联合即刻乳房重建手术中乳头乳晕安全性保留预测模型的建立

目的 探讨保留乳头乳晕复合体乳房切除术（NSM）联合即刻乳房重建手术（IBR）手术中乳头乳晕复合体（NAC）安全性保留的相关危险因素,并建立预测模型。方法 回顾性分析2017年1月至2019年8月在复旦大学附属肿瘤医院乳腺外科行NSM联合IBR的474例病人的临床资料。依据乳头后方组织术后石蜡病检结果进行病例分组即NAC（+）组与NAC（-）组。分析两组病人的临床、影像及病理学特征,进行多因素分析,对独立预测指标赋值,计算不同分值的NAC阳性率,建立相应预测模型并验证。结果 474例病例中,NAC阳性率为13.71%（65/474）,单因素分析显示肿瘤位置、乳头溢液、乳头凹陷、NAC皮肤湿疹样改变、临床肿瘤大小、肿瘤至乳头距离（TND）、临床淋巴结状态、MG-乳头后方钙化、恶性特征钙化灶、合并原位癌成分、组织学类型、组织学分级、脉管癌栓、分子分型与NAC肿瘤阳性相关。多因素分析显示乳头血性溢液、乳头凹陷、NAC皮肤湿疹样改变、临床肿瘤大小、TND、临床淋巴结状态、脉管癌栓是NAC肿瘤阳性独立预测指标。建立NAC预测指数（Predictive Index of NAC,PI-NAC）预测模型提示,0～1分为NAC肿瘤累及低风险,2～4分为中风险,5分及以上为高风险。该模型内部验证ROC曲线AUC值0.85（95%CI 0.80-0.89）,具有较好预测效能。结论 乳头血性溢液、乳头凹陷、NAC皮肤湿疹样改变、临床肿瘤大小、TND、临床淋巴结状态、脉管癌栓是NAC受累的重要独立指标。预测模型有助于术前更好地评估NSM的肿瘤安全性。     

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目的 研究乳腺癌乳头乳晕复合体(NAC)的浸润规律。方法 选择临床手术的女性原发乳腺癌病人86例。对可能影响NAC浸润的因素进行单、多因素分析。结果 NAC浸润率43％。NAC浸润率随肿瘤缘距乳晕边缘的距离(D)值的增加而下降，腋窝淋巴结有转移时NAC浸润率较无转移时高。肿瘤部位、临床分期、乳头异常、肿瘤大小也可影响NAC的浸润；年龄、病理类型并不影响NAC的浸润。结论 乳腺癌的NAC浸润并不少见。D值和腋窝淋巴结状态是影响NAC浸润的主要因素。     

乳腺癌患者术后远处转移及其不良结局的危险因素

目的探讨乳腺癌患者术后发生远处转移及其不良结局的危险因素。 方法回顾分析2012年1月至2015年10月期间行手术治疗后发生术后远处转移67例和未发生远处转移130例的女性乳腺癌患者病例资料,随访时间截止2020年10月。采用SPSS 22.0统计软件包分析数据,单因素生存分析采用K-M法,行Log-rank检验;Cox回归模型分析乳腺癌术后转移的多因素分析。 结果脉管状态、组织学分级、肿瘤大小、淋巴结阳性数及化疗方案和靶向治疗是影响乳腺癌术后远处转移的独立危险因素（P<0.05）。67例远处转移患者死亡48例,存活19例,中位生存时间为39个月。多因素分析显示,脉管状态、肿瘤大小、临床分期、组织学分级、转移数目、Her-2状态及化疗方案和靶向治疗是影响远处转移患者预后不良的独立危险因素（P<0.05）。 结论发生脉管癌栓、肿瘤直径越大、临床分期和组织学分级越高、多部位转移、Her-2阳性是影响远处转移患者预后的独立危险因素,术后蒽环类联合紫杉类化疗可以降低远处转移率,提高患者预后。     

70岁以上女性乳腺癌临床病理特征及预后分析

目的:分析70岁以上女性乳腺癌患者的临床病理特征、治疗方式及预后影响因素。方法:回顾2007年1月—2010年12月哈尔滨医科大学附属肿瘤医院乳腺外科接诊并接受手术治疗的203例70岁以上老年女性乳腺癌患者的临床资料,分析其临床病理特点及生存情况。结果:203例患者中,临床TNMⅠ期患者67例(33.0%),Ⅱ期患者117例(57.6%);无腋窝淋巴结转移患者92例(53.5%);浸润性导管癌166例(81.8%),为主要病理类型;177例行免疫组织化学检查,ER、PR阳性与HER-2过表达患者分别为123例(69.5%)、114例(64.4%)、23例(13.0%);乳腺癌改良根治术153例(75.4%),为主要手术方式;术后接受内分泌治疗患者111例(54.7%),化疗患者28例(13.8%)。单因素分析显示年龄、淋巴结状态、ER、PR、组织学分级与内分泌治疗与患者总生存时间(OS)有关,淋巴结状态、ER、PR、HER-2、内分泌治疗与化疗与患者无病生存时间(DFS)有关(均P0.05);COX多因素分析显示年龄、淋巴结状态和PR为OS的独立影响因素,淋巴结状态为DFS的独立影响因素(均P0.05)。结论:老年女性乳腺癌具有独特生物学特性,主要治疗方式为手术治疗。年龄、淋巴结状态和PR是老年女性乳腺癌的独立预后因素。     

保留乳头乳晕复合体改良根治术的选择和比较

目的 总结乳腺癌根治术中保留乳头乳晕复合体（NAC）的效果与体会。方法 选择2018年3月至2021年3月在我院因乳腺癌进行外科手术治疗的女性患者,纳入标准：①原发性肿瘤位于乳晕外;②肿瘤距离乳晕边缘>2 cm,共有99例患者入组,包括45例实施保留NAC的改良乳癌根治术（NSM）（NAC保留组）和未保留NAC的手术44例（NAC未保留组）。观察NSM后的临床效果,比较NAC保留和未保留患者术后病理特征、并发症,观察术后NAC感觉恢复情况。结果 术前检查：两组患者在年龄、NAC直径、乳头距离肿瘤、术前肿瘤分期、类型、肿瘤部位及多病灶例数间的差异没有统计学意义（P>0.05）。NAC保留组术后病理：35例（77.8%）浸润性癌,10例（22.2%）属于导管原位癌,中位肿瘤大小为2.4 cm（0.2~4.1 cm）,5例发现腋窝淋巴结转移;NAC未保留组中,浸润性癌37例（84.1%）,7例（15.9%）原位癌,中位肿瘤大小为2.6 cm（0.2~4.7）cm,7例腋窝淋巴结转移。两组各有12例发生脂肪液化和血清肿,各有2例切口轻度感染,经保守治疗愈合。NAC保留组有8例乳头或乳晕坏死,其中7例为小部分坏死,经保守治疗愈合,1例坏死面积大行NAC切除。另NAC保留组和未保留组分别有3例和5例皮瓣坏死,均通过保守处理愈合。NAC保留患者中有3例（7.3%）乳晕感觉完全恢复,18例（43.9%）部分恢复,20例无感觉,乳头感觉恢复最差,仅1例患者术后乳头感觉敏感。两组患者术后满意度接近。结论 保留NAC的改良乳癌根治术可行,美容效果良好,但只有较少部分NAC感觉恢复。     

P-糖蛋白(Pgp)在乳腺癌中的表达及与预后的关系

目的探讨P-糖蛋白(P-glycoprotein,Pgp)在乳腺癌中的表达,评估其在乳腺癌预后中的作用。方法对我院1993年1月～1994年12月用免疫组织化学方法检测62例手术切除的乳腺癌组织中Pgp的表达的资料进行回顾分析,研究其与临床病理特征的关系及对预后的影响。结果(1)Pgp在乳腺癌组织中的阳性表达率为32.2%(20/62)。(2)Pgp表达与月经状况、肿瘤大小、腋淋巴结转移个数、组织学分级之间均无相关性(P>0.05)。(3)Kaplan-Meier生存分析结果表明Pgp阴性表达组的无病生存期(DFS)及总生存期(OS)均明显优于阳性表达组(P<0.05)。(4)Cox回归单因素分析显示腋窝淋巴结转移个数、组织学分级、肿瘤大小、TNM分期及Pgp表达与DFS及OS明显相关;Cox回归多因素分析表明除了腋窝淋巴结转移个数、组织学分级及肿瘤大小与DFS及OS明显相关外,Pgp表达与OS缩短有关,但和DFS无关。结论Pgp在乳腺癌组织中有一定程度的表达,Pgp阳性表达与乳腺癌患者生存期的缩短有关,有可能成为判断乳腺癌患者预后的指标。     

前哨淋巴结阳性Luminal B型早期乳腺癌非前哨腋窝淋巴结状态对预后影响研究

目的研究前哨淋巴结(sentinel lymph node,SLN)阳性的Luminal B(HER2阴性)型早期乳腺癌非前哨腋窝淋巴结状态对预后的影响。方法回顾性分析2008—2014年北京大学第一医院乳腺疾病中心经治的142例临床腋窝淋巴结阴性、SLN阳性的Luminal B(HER2阴性)型早期乳腺癌病例,对其临床病理学特点及与非前哨腋窝淋巴结是否存在转移进行相关性分析,并对非前哨腋窝淋巴结转移病人和无转移病人无疾病存活率(DFS)和总存活率(OS)进行对比分析。结果 142例SLN阳性病人中,平均每例病人检出SLN(2.06±1.26)枚,Spearman双变量相关性分析显示SLN转移数目与非前哨腋窝淋巴结是否存在转移具有相关性(r=0.167,P=0.047),而二元Logistics回归分析显示年龄、体重指数、是否绝经、原发肿瘤T分期、肿瘤组织学分级、脉管癌栓与该组SLN阳性病人非前哨腋窝淋巴结是否转移无相关性。非前哨腋窝淋巴结无转移病人78例(54.9%),DFS为93%,OS为93.1%;非前哨腋窝淋巴结转移病人64例(45.1%),DFS为95.2%,OS为91.9%。经Log-rank(Mantel-Cox)检验,两组在DFS(χ~2=0.011,P=0.918)及OS(χ~2=0.348,P=0.555)上差异均无统计学意义。结论 SLN阳性的Luminal B(HER2阴性)型早期乳腺癌病人,其阳性SLN数目与非前哨腋窝淋巴结是否转移存在相关性,其他临床病理因素无相关性,而非前哨腋窝淋巴结转移组和无转移组DFS和OS差异无统计学意义。     

保留乳头的乳腺癌切除术在早期乳腺癌患者中临床效果研究

目的对比分析保留乳头的乳腺癌切除术(NSM)及传统乳腺癌根治术(CM)在早期乳腺癌患者中临床效果及近远期疗效。方法纳入2012年1月至2014年3月收治的76例早期乳腺癌患者资料进行回顾性分析,根据术式不同分为NSM组(n=42)和CM组(n=34)。采用统计软件SPSS 20.0进行分析,年龄、肿瘤大小等采用均数±标准差表示,独立t检验;术后并发症、美学评估等计数资料采用卡方检验。采用Kaplan-Meier进行生存分析,利用log-rank检验,评估5年预后生存情况。P<0.05差异有统计学意义。结果NSM组38例接受Ⅰ期乳房重建,4例接受Ⅱ期乳房重建;CM组仅3例接受Ⅱ期乳房重建。NSM组术后发生组织缺血坏死率大于CM组(P<0.05),但两组术后并发症总发生率差异无统计学意义(P>0.05)。术后3个月NSM组乳房重建美观度优良率90.5%高于CM组79.4%(P<0.05);术后5年两组局部复发率(7.1%vs.5.9%)、无病生存率(83.3%vs.82.4%),总生存率(90.5%vs.91.2%),差异无统计学意义(P>0.05)。结论较CM术相比,NSM在早期乳腺癌的治疗中同样具有安全性,且术中保留乳头乳晕复合体并不会增加其术后局部复发的风险,两组5年预后差异无统计学意义。     

血清HBeAg状态对肝细胞癌患者术后生存的影响

目的研究肝癌患者血清HBeAg状态对肝癌切除术后复发及生存的影响。方法收集1999~2005年在我科行根治性切除的223例肿瘤直径≤3cm的肝癌患者的资料。根据患者术前血清HBeAg状态,分为HBeAg阳性组(n=73)和HBeAg阴性组(n=150),比较2组患者无瘤生存率(DFS)和总体生存率(OS),并分析影响DFS和OS的危险因素。结果HBeAg阳性和HBeAg阴性患者的1、3、5年的OS分别为91.5%、76.8%、60.1%和95.2%、85.3%、73.2%(P=0.053);1、3、5年DFS分别为73.3%、53.7%、40.3%和86.6%、65.5%、54.5%(P=0.002)。与HBeAg阴性组比较,HBeAg阳性组患者年龄较轻(P=0.004),肝硬变较重(P=0.008),而在肿瘤因素及手术相关因素方面2组间的差异无统计学意义(P>0.05)。对DFS和OS的多因素分析显示,年龄>50岁、HBeAg阳性和大结节肝硬变是影响OS的独立危险因素,而HBeAg阳性和多发肿瘤是影响DFS的独立危险因素。结论小肝癌患者术后HBeAg阳性患者较HBeAg阴性者更易早期复发,而且总体生存较差。     

不同肝功能Child-Pugh分级对肝癌肝移植受者预后的影响

目的探讨不同Child-Pugh分级对肝细胞癌(肝癌)肝移植受者术后肝癌复发和生存的影响。方法回顾性分析125例接受肝移植的肝癌受者临床资料,用Kaplan-Meier方法计算肝癌肝移植受者术后3年的无瘤生存率(DFS)和总生存率(OS)。采用Cox比例风险回归模型分析可能影响肝癌肝移植受者术后复发及生存的独立危险因素。结果中位随访时间为25.6个月,3年总的DFS和OS分别为68.4%和65.7%。Child-Pugh A、B级肝癌患者(113例)的3年DFS和OS分别是68.6%和66.2%,Child-Pugh C级肝癌患者(12例)的3年DFS和OS分别是66.7%和65.6%,两者差异均无统计学意义(均为P0.05)。Cox回归分析结果表明,血管侵犯(P=0.001)和肿瘤数目3个(P=0.025)是影响肝癌肝移植受者复发的独立危险因素。甲胎蛋白(AFP)400μg/L(P=0.035)、血管侵犯(P=0.031)和肿瘤数目3个(P=0.008)是影响肝癌患者生存的独立危险因素。结论 Child-Pugh C级与A、B级肝癌患者肝移植术后预后无显著性差异,AFP、血管侵犯和肿瘤数目是影响肝癌患者肝移植术后预后的重要因素,肝移植可作为Child-Pugh C级肝癌患者的有效治疗手段。     

Defining a Place for Nipple Sparing Mastectomy in Modern Breast Care: An Evidence Based Review

Abstract: Breast cancer is a diverse disease that requires a fully integrated multidisciplinary approach. Breast surgery has undergone a revolutionary change leading us from the conventional radical mastectomy of the Halstedian era to the current motion of nipple sparing mastectomy (NSM). Despite the lack of randomized controlled trials, the technique of NSM continues to gain popularity as a prophylactic procedure in high risk patients. The current indications for NSM, if any, in the treatment of early invasive breast cancer remains uncertain and requires rigorous scientific scrutiny. This article aims to critically review the indications and limitations of NSM, discuss evidence based intra‐operative protocols and to discuss ways in which radiation therapy may be incorporated in treatment planning following NSM. A comprehensive search of the scientific literature was carried out using PubMed to access all publications related to nipple sparing mastectomy. The search focused specifically on technique, current management, safety, and complications of these procedures. Keywords searched included “Nipple sparing mastectomy,”“breast conserving surgery,”“Nipple areola complex preservation” and “skin sparing mastectomy.” NSM offers an opportunity to preserve native breast envelope without mutilation of nipple‐areola complex (NAC), and avoids multiple surgical procedures required for reconstruction. NSM may be a reasonable alternative for prophylactic and select breast cancer patients without NAC involvement; however, oncological safety of NSM has not yet been fully demonstrated. Best available evidence suggests that patients should be selected based on study of breast duct anatomy by breast Magnetic Resonance Imaging, mammographic distance between tumor and nipple and obligatory intra‐operative frozen section from retro‐areolar tissue. Additional factors such as tumor size, axillary lymph node status, lymphovascular invasion and degree of intraductal component are also being used to either include or exclude NSM candidates based on institutional protocols. Heterogeneity of patients selected for NSM is great and the lack of standardization of preoperative investigations, intra‐operative technique and pathologic sampling of retro‐areola tissues mandates a multi‐institutional prospective study to define and validate a role for NSM in invasive breast cancer and DCIS. Nipple necrosis or sloughing is an important problem after NSM which can be greatly reduced using alternative skin incisions. Even if the nipple survives, an insensate nipple and lack of sexual function is common and requires preoperative counseling and discussion. Finally the relation and timing of intra‐operative versus adjuvant breast radiation and tailoring of dosage and delivery methods has not been fully explored. Although NSM reduces the psychological trauma associated with nipple loss, the oncologic safety as well as functional and aesthetic outcomes needs additional investigation.     

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??Objective:o compare the effects of breast conservative therapy (BCT) with modified radical mastectomy (MRM) in women with early stage breast cancer. Methods: matched retrospective cohort study using data on patients derived from a prospectively collected breast cancer database was conducted.The database included patients who received MRM or BCT from 1995 to 2002 in Cancer Hospital of Fudan University.The match was conducted according with four variables:age at diagnosis,axillary lymph node status,sexual hormone receptor status and the dimension of tumor.The match ratio was 1??2.Controls were patients who received MRM (n=254).Cases were patients who received BCT (n=127).Median follow??up for the controls and cases were 58 months and 49 months respectively.The differences of incidence of loco??regional recurrence,disease free survival and overall survival at 5 years were compared.There were no significant differences in incidence of loco??regional recurrence,DFS and OS at 5 years between the two groups of patients. Results:he incidence of loco??regional recurrence was 1.4% in MRM group and 3??39% in BCT group (P=0.5).The OS in MRM and BCT patient were 97.7% and 96.73% (P=0.66).The DFS in MRM and BCT patients were 91.57% and 86??04% (P=0.37). Conclusion:For appropriate breast cancer patients,classic lumpectomy plus axillary lymph node dissection and post??operative radiotherapy lead to excellent local control and good survival rate.The BCT can result in the same effects as MRM in breast cancer patients with better cosmetic appearances.     

Sentinel Lymph Node Biopsy Alone Has No Adverse Impact on the Survival of Patients with Breast Cancer

Abstract:   We do not yet know the results from multicenter randomized trials comparing survival after sentinel lymph node biopsy (SLNB) alone and axillary lymph node dissection (ALND). Therefore, in this study, the prognostic significance of the type of axillary surgery is analyzed in combination with other known prognostic factors in patients with breast cancer. In a series of 1325 consecutive patients with unilateral breast cancer who underwent SLNB between January 1999 and June 2004 at a single institution, 884 underwent SLNB alone following an intraoperative negative histologic investigation and 441 underwent ALND. Disease-free survival (DFS) and overall survival (OS) were analyzed to correlate with clinicopathologic features and treatment methods using both univariate and multivariate analyses Cox proportional hazard regression models. With a median follow-up period of 31 months, 29 (3.3%) and 37 (8.4%) patients relapsed after SLNB alone and ALND, respectively. Tumor size (Tis, T1–2 versus T3–4), histologic nodal involvement (negative versus positive), nuclear grade (NG) (1, 2 versus 3), lymphatic vessel invasion (LVI) (absent, weak versus intense), estrogen receptor (ER) status (positive versus negative), type of axillary surgery (SLNB alone versus ALND), type of breast surgery (partial versus total mastectomy), and radiation therapy (yes versus no) significantly correlated with DFS by univariate analysis, demonstrating better DFS in the former category than the latter for each variable. The multivariate analysis revealed that NG, LVI, ER status, and radiation therapy significantly correlated with DFS, and ER and histologic nodal involvement correlated with OS. As the type of axillary surgery had no impact on the prognosis of patients with breast cancer, a SLNB alone is safe as determined by a negative histologic investigation.      

The relationship between lymph node metastases and DNA-ploidy status as prognostic factors in invasive breast cancer

We evaluated the relationship between the regional lymph node metastases and the DNA ploidy status in 207 patients with invasive breast cancer, as well as their prognostic values in estimating the prognosis of breast cancer. A significantly higher incidence of aneuploidy was found in patients with a large T3 or T4 tumor, a positive axillary lymph node status, more than 4 positive axillary lymph nodes or positive internal mammary lymph nodes. In a univariate study, the overall survival was significantly correlated with tumor size, axillary lymph node status, axillary and internal mammary lymph node metastases, and DNA ploidy status. In the multivariate analysis, however, only axillary and internal mammary lymph node metastases were recognized as important independent prognostic factors on survival. In this series, the DNA ploidy status did not appear to be an independent prognostic factor either in the entire series or in negative axillary node patients, since it was closely correlated with the axillary or internal mammary lymph node metastases, and the axillary node negative patients had an extremely favorable prognosis.     

Outcome of radiotherapy for clinically overt metastasis to the internal mammary lymph node in patients receiving neoadjuvant chemotherapy and breast cancer surgery

PurposeThis study was aimed to assess the outcome of radiotherapy and determine prognostic factors for survival in breast cancer patients with clinically overt metastasis to the internal mammary lymph node (IMN+).MethodsWe retrospectively reviewed the medical records of 193 patients with IMN + breast cancer who received neoadjuvant chemotherapy (NAC), breast surgery without internal mammary lymph node (IMN) dissection, and postoperative radiotherapy at 9 hospitals between 2009 and 2013. Breast-conserving surgery or mastectomy was performed after taxane-based NAC. Radiotherapy was administered to the whole breast/chest wall and regional nodes. IMN-covering radiotherapy was performed in 92.2% of patients with median dose of 58.4 Gy (range, 44.9–69.1 Gy). The overall survival (OS), disease-free survival (DFS), and IMN failure-free survival (IMNFFS) were analyzed.ResultsAfter median follow-up of 71 months, 9 patients (4.7%) developed IMN failure and simultaneous distant metastasis. The 5-year DFS, OS, and IMNFFS was 68.6%, 81.8%, and 95.3%, respectively. Non-triple-negative breast cancer, Ki-67 ≤ 10%, pathological complete response (CR) in tumor and axillary node, and radiologic CR of IMN after NAC were significant factors for predicting higher DFS; however, IMN radiation dose was not significant determinants for DFS. The 5-year DFS of patients with IMN-dose ≤ 50.0 Gy and those with >50.0 Gy was 86.7% and 76.7%, respectively (p = 0.41).ConclusionsA multimodality strategy including NAC, breast surgery, and IMN-covering radiotherapy was effective for patients with overt IMN + breast cancer. Even without an IMN dissection, most patients were IMN failure-free with an IMN-focusing radiotherapy.     

男性乳腺癌的治疗及预后因素分析:附37例报告

目的　探讨男性乳腺癌 (MBC )的治疗和预后因素。方法　回顾性分析 3 7例男性乳腺癌的临床资料。手术方式包括经典根治术 (10例 ) ,改良根治术 (19例 ) ,单纯乳房切除术 同侧腋窝淋巴结摘除术 (4例 ) ,单纯乳房切除术 (4例 )等。结果　上述手术方式的患者 5年生存率依次为 80 .0 %,78.9%,2 5 .0 %,2 5 .0 %;腋窝淋巴结有转移和无转移的患者 5年生存率分别为 5 0 .0 %和 93 .3 %;雌激素受体 (ER)阳性和阴性的患者 5年生存率分别是 80 .0 %和 42 .8%(P <0 .0 5 ) ;结论　改良根治术是MBC的首选术式 ,术后可根据情况辅以其他治疗 ;腋窝淋巴结转移、病理类型及肿瘤分期等因素影响预后 ,其中手术方式和腋窝淋巴结状况为影响预后的主要因素。