外科多专业合作胸壁切除与重建术在乳腺癌侵犯胸壁患者治疗中的地位

Significance of multidisplinary surgery in chest wall resection and reconstruction for selected patients with breast cancer

目的探讨由切除外科及重建外科医师合作完成的胸壁切除与重建术(CWRR)在乳腺癌侵犯胸壁患者治疗中的地位。方法由切除外科和重建外科合作完成CWRR 44例,切除后胸壁软组织缺损35～800cm^2；同时切除骨性胸壁15例,骨性胸壁缺损5～320cm^2。切除后立即重建43例,因伤口原因延迟重建1例。根治切除36例,姑息切除8例。进行以电话及门诊复查为主的随访,随访时间为5．0～285．0个月。结果全组无手术后30d死亡者。CWRR术后,根治性切除患者术后中位生存时间＞36．0个月,1、3、5年生存率分别为71．5%、65．7%和65．7%；姑息性切除患者术后中位生存时间为15．1个月,1、3、5年生存率分别为35．1%、23．4%和7．8%。根治性切除患者的生存率高于姑息性切除患者(P=0．018)。原发乳腺癌患者术后中位生存时间为44．7个月,1、3、5年生存率分别为78．4%、78．4%和39．2%。复发乳腺癌患者术后中位生存时间为36．0个月,1、3、5年生存率均为70．9%。有转移者术后中位生存时间为16．0个月,1、3、5年生存率分别为30．O%、15．0%和0。原发性乳腺癌患者与复发性乳腺癌患者术后生存率差异无统计学意义(P=0．752),而有转移者术后生存率明显低于原发乳腺癌患者(P=0．003)或复发乳腺癌患者(P=0．018)。结论只有切除外科和重建外科同时参与才能完成符合肿瘤治疗原则的复杂CWRR。在完成乳腺癌全盘治疗计划、全身和局部疾病得到良好控制的前提下,根治性CWRR能改善侵及胸壁乳腺癌患者的生存,适当的姑息性CWRR可改善患者的生活质量。

Objective To evaluate the clinical significance and survival benefits of chest wall resection and reconstruction （CWRR） by multidisciplinary surgery for selected patients with locally advanced or recurrent breast cancer in order to address the importance of collaboration between ablative （ breast surgery or/and thoracic surgery） and reconstructive teams during CWRR. Methods The data of 44 patients who underwent multidisciplinary CWRR at The University of Texas M. D. Anderson Cancer Center between March 2001 and June 2004 were retrospectively analyzed, which included the CWRR techniques used, patient characteristics and treatment outcomes. Survival of patients with primary, recurrent or metastatic disease, and that of those with curative or palliative resection were also compared. Results All patients were female aged 34-83 years with primary （n = 19 ）, recurrent （n= 15 ） or metastatic breast cancer （n = 10）. The surgery modes included curative resection（n =36） and palliative （n =8） with a mean defect size of skin： 218.4 cm^2 ; of bony chest wall： 113.9 cm^2 （ n = 15 ）. Immediate reconstruction （ n = 43 ） with prosthesis （n = 10） or without （n =34） for most of these patients. All of them required soft tissue coverage with pedicled flap （ n = 37 ） or free flap （ n = 13 ）. The average hospital and ICU stay was 6.6 days and 3.4 days （ n = 8 ）, respectively. The morbidity was acceptable and no 30-day mortality happened. Neither was there difference in median survival（44. 7 m vs. 36.0 m,P =0.752） nor in 1-, 2-, and 3-year survival rates between primary breast cancer （78.4%, 78.4% , 39.2% ） and recurrent one （70.9% , 70.9% , 70.9% , P〉0.05）. However, both median survival （16.0 m） and the 1-, 2-, and 3-year survival rates （30.0%, 15.0%, 0） in patients with metastasis were much poorer than that in those with primary breast cancer（ P= 0. 003 ） or recurrence （P = 0.018 ）. The survival of patients underwent curative resection （36.0 m, 71.5%,65.7% , 65.7% ） were much longer than those with palliative resection （15.1 m, 35.1% , 23.4% , 7.8% , P =0. 018 ）. Conclusion With full control of systemic and local disease by up-front multidisciplinary strategy, chest wall resection and reconstruction could improve long-term survival if curative resection achieved or the quality of life if palliative resection done for breast cancer patients with tumor invading the chest wall or local recurrence. Ablative and reconstructive surgeons should be included in surgery team in order to guarantee the possibility of extensive resection and effective reconstruction in a single stage with high safety, good survival and minimal morbidity.