早期乳腺癌的外科治疗策略

Surgical management of early breast cancer

目的分析早期乳腺癌的外科治疗方式，探讨早期乳腺癌的外科治疗策略。方法收集2173例早期乳腺癌患者的临床资料，分析不同手术方式的适应证和禁忌证，比较不同手术的治疗效果和美容效果。结果全部患者的中位年龄为51岁（18～91岁）。未绝经患者1155例（53．2％）。0～Ⅰ期患者547例，Ⅱ期患者1626例。行根治性全乳切除1817例（83．6％），保乳手术229例（10．5％），术后一期再造55例（2．5％）。年轻和未停经患者、0～Ⅰ期患者和非浸润性癌患可选择保乳或再造；病理类型对选择保乳还是再造有影响（P=0．004）。全组中位随访14个月（3～64个月），保乳和全乳切除的无复发生存率（P=0．2435）、无病生存率（P=0．1395）和总生存率（P=0．9406）的差异无统计学意义。一期再造也未带来负面影响，随访期内1例复发，1例转移。保乳手术美容效果优良度为90．0％；乳房再造美容效果可接受度94．5％。结论有保乳意愿者，排除绝对禁忌并解决相对禁忌后方可保乳，保乳手术能同时满足治疗和美容目的。不适合保乳者，全乳切除后可行一期再造，能重塑乳房外形且不影响预后。在选择秩序上，保乳应先行考虑。将改良根治术、保乳手术和乳房再造有机统一，合理选择，更利于早期乳腺癌患者生理和心理的双重治疗。

Objective To evaluate the available surgical treatment modalities so as to explore the optimal strategy of managing early breast cancer. Methods The clinical data of 2173 consecutive earlystage breast cancer patients treated by surgery treatments were retrospectively reviewed in order to clarify the indications and contraindications of different modalities. Therapeutic outcome of different surgical treatment modes were compared in terms of recurrence-free survival （ RFS ）, disease-free survival （ DFS ）, overall survival （ OS ） . The cosmetic results of breast conservation and reconstruction were also evaluated. Results The median age of these patients was 51 years ranging from 18 to 91. Of 2173 patients, 547 had stage 0- Ⅰ lesions and 1626 stage Ⅱ , and 1155 （53.2%） premenopausal. The proportion of patients who received radical surgery, breast conservation and reconstruction after mastectomy was 83.6% （1817/2173）, 10.5% （229/2173） and 2.5% （55/2173）, respectively. Younger and premenopausal patients prefer conservative and reconstructive surgeries, which are reasonable for stage 0-Ⅰ and non-invasive breast cancer patients. Conservative surgery was not suitable for Paget＇s disease of breast （P = 0. 004 ）, mastectomy followed by reconstruction in this type of cancer was up to 38.5%. The recurrence and metastasis rate of conservation or mastectomy were similar with a comparable 3-year RFS of 97.4% and 95.4% , respectively; there were also no significant differences in RFS （ P = 0.2435 ） , DFS （ P = 0.1395 ） and OS （ P = 0.9406 ） after having been followed for 3 to 64 months. Similarly, immediate reconstruction did not show any negative effects with only 1 recurrence and 1 metastasis. Aesthetic outcomes were assessed as excellent or good in 90.0% of breast conservation surgery, and the acceptability of reconstruction was 94.5%. Conclusion Breast conserving surgery not only has comparable survival as mastectomy, but also has better cosmetic outcomes. Immediate breast reconstruction can be a suitable option without compromising survival. It is very important in the management for early breast cancer by selecting the most suitable surgery mode for every individual patient not only to cure her disease but also to satisfy the patient psychologically. Conservation should be preferred prior to reconstruction whenever possible.