Kronowitz Steven J, Robb Geoffrey L
Department of Plastic and Reconstructive Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA.
Plast Reconstr Surg. 2004 Sep 15;114(4):950-60. doi: 10.1097/01.prs.0000133200.99826.7f.
Two recent trials have demonstrated superior locoregional control, disease-free survival, and overall survival in node-positive breast cancer patients with the addition of postmastectomy radiation therapy to mastectomy and chemotherapy. Based on these results, there has been an increased use of postmastectomy in patients with early-stage breast cancer. The inability to determine which patients will require postmastectomy radiation therapy has increased the complexity of planning for immediate breast reconstruction. There are two potential problems with performing an immediate breast reconstruction in a patient who will require postmastectomy radiation therapy. One problem is that postmastectomy radiation therapy can adversely affect the aesthetic outcome of an immediate breast reconstruction. Several studies have evaluated the outcomes of breast reconstructions that were performed before radiation therapy and have revealed a high incidence of complications and poor aesthetic outcomes. Furthermore, these studies have found that often an additional flap is required to restore breast shape and symmetry. The other potential problem is that an immediate breast reconstruction can interfere with the delivery of postmastectomy radiation therapy. During planning for immediate breast reconstruction, it is imperative to carefully review the stage of disease and the likelihood the patient will require postmastectomy radiation therapy. Unfortunately, the ability to detect and predict the presence or extent of axillary lymph node involvement is limited, and the need for postmastectomy radiation therapy is usually not known until after mastectomy. In all cases of decision making regarding possible postoperative radiation therapy and whether or not to perform immediate breast reconstruction, the situation should be discussed at a multidisciplinary conference or addressed among the various medical, surgical, and radiation teams, with active participation by the patient. Immediate breast reconstruction probably should be avoided in patients known to require postmastectomy radiation therapy and delayed until it is certain the therapy will be needed in patients who may require the therapy.
最近的两项试验表明，对于淋巴结阳性的乳腺癌患者，在乳房切除术和化疗基础上加用乳房切除术后放疗，可实现更好的局部区域控制、无病生存期和总生存期。基于这些结果，早期乳腺癌患者中乳房切除术后放疗的使用有所增加。无法确定哪些患者需要乳房切除术后放疗增加了即刻乳房重建计划的复杂性。对于需要乳房切除术后放疗的患者进行即刻乳房重建存在两个潜在问题。一个问题是乳房切除术后放疗可能会对即刻乳房重建的美学效果产生不利影响。多项研究评估了放疗前进行乳房重建的结果，发现并发症发生率高且美学效果不佳。此外，这些研究还发现，通常需要额外的皮瓣来恢复乳房形状和对称性。另一个潜在问题是即刻乳房重建可能会干扰乳房切除术后放疗的实施。在计划即刻乳房重建时，必须仔细评估疾病分期以及患者需要乳房切除术后放疗的可能性。不幸的是，检测和预测腋窝淋巴结受累的存在或程度的能力有限，通常直到乳房切除术后才知道是否需要乳房切除术后放疗。在所有关于可能的术后放疗以及是否进行即刻乳房重建的决策案例中，都应在多学科会议上进行讨论，或在各医疗、外科和放疗团队之间进行沟通，患者应积极参与。已知需要乳房切除术后放疗的患者可能应避免即刻乳房重建，对于可能需要该治疗的患者，应推迟到确定需要该治疗时再进行。
