Edlich Richard F, Winters Kathryne L, Faulkner Brent C, Lin Kant Y
University of Virginia Health System, Charlottesville, VA, USA.
J Long Term Eff Med Implants. 2006;16(4):301-14. doi: 10.1615/jlongtermeffmedimplants.v16.i4.40.
Breast cancer is a malignant proliferation of epithelial cells lining the ducts or lobules of the breast. Excluding skin cancer, breast cancer is the most common cancer in women. Only lung cancer accounts for more cancer deaths in women. Breast cancer may exist for a long period either as an invasive or noninvasive disease, but not as a nonmetastatic disease. Consequently, timely diagnosis and appropriate management are lifesaving. Approximately 10% of human breast cancers are linked to germline mutations, such BRCA1 and BRCA2. Correct staging of breast cancer patients is critical. It permits an accurate diagnosis, as well as in many cases, therapeutic decisions based largely on the TNM classification. Staging provides the most important prognostic variable. Second opinions of the staging of breast cancer by pathologic examination of the tissue is recommended. There are some variables in which the association with disease-free survival and overall survival seem clear and include estrogen and progesterone receptor cells, S-phase analysis using flow cytometry, histologic classification, molecular changes in the tumor as well as neovasculature semi-quantitative scoring systems. There are four objectives to risk-reducing mastectomy. First, risk-reducing mastectomy should reduce the incidence of breast cancer in high-risk women, for example, BRCA1 or BRCA2 carriers. It should reduce mortality from breast cancer in high-risk women. Moreover, it should have psychological benefits in relieving anxiety about developing breast cancer. Finally, there must be a balance in the reduction in risk against cosmetic outcome, with subsequent quality of life issues. Women should be offered risk reduction mastectomy only on the basis of a strict selection and management plan, like that used in Manchester protocol. This protocol involves a minimum of two sessions with a geneticist/oncologist, a session with a psychiatrist and two sessions with a plastic and reconstructive surgeon with the support of a breast care nurse. The surgical technique should aim at removing substantially all at-risk breast tissue. However, there is an obvious balance between reduction of cancer risk and cosmetic outcome. The surgical technique involves several operations to include the risk-reducing mastectomy as well as breast reconstructive procedures. Skin-sparing mastectomy represents a new surgical approach that allows a mastectomy, whereas preserving the natural skin envelope of the breast. Breast reconstruction will involve several operations, especially if the nipple areola complex is resected and is subsequently reconstructed. The contraindications to risk-reducing mastectomy include the following. The status of the family history or Munchausen's syndrome has not been confirmed. The risk-reducing mastectomy is not the women's own choice. The patient has a current psychiatric disorder including clinical depression, cancer phobia or body dysmorphic syndrome. If the co-morbidity outweighs the clinical benefits, surgery should not be undertaken. Finally, the patient must not have unrealistic expectations of the benefits of surgery. She must understand the subsequent risk-reducing mastectomy may significantly reduce, but not eliminate the risk of subsequent breast cancer.
乳腺癌是乳腺导管或小叶内衬上皮细胞的恶性增殖。除皮肤癌外，乳腺癌是女性中最常见的癌症。在女性癌症死亡病例中，只有肺癌的死亡人数超过乳腺癌。乳腺癌可能以浸润性或非浸润性疾病的形式长期存在，但不会以非转移性疾病的形式存在。因此，及时诊断和恰当治疗是挽救生命的关键。大约10%的人类乳腺癌与种系突变有关，如BRCA1和BRCA2。对乳腺癌患者进行准确分期至关重要。这有助于准确诊断，而且在许多情况下，很大程度上基于TNM分类来做出治疗决策。分期是最重要的预后变量。建议通过对组织进行病理检查来二次评估乳腺癌分期。有一些变量与无病生存期和总生存期的关联似乎很明确，包括雌激素和孕激素受体细胞、使用流式细胞术进行的S期分析、组织学分类、肿瘤的分子变化以及新生血管半定量评分系统。降低风险的乳房切除术有四个目标。首先，降低风险的乳房切除术应降低高危女性患乳腺癌的几率，例如BRCA1或BRCA2基因携带者。它应降低高危女性因乳腺癌导致的死亡率。此外，它应在缓解对患乳腺癌的焦虑方面具有心理益处。最后，在降低风险与美容效果及后续生活质量问题之间必须取得平衡。女性只有在严格的选择和管理计划基础上，如曼彻斯特方案中所采用的那样，才应接受降低风险的乳房切除术。该方案至少需要与遗传学家/肿瘤学家进行两次会诊、与精神科医生进行一次会诊以及在乳腺护理护士的支持下与整形和重建外科医生进行两次会诊。手术技术应旨在基本上切除所有有风险的乳腺组织。然而，在降低癌症风险和美容效果之间存在明显的平衡。手术技术包括多项操作，包括降低风险的乳房切除术以及乳房重建手术。保留皮肤的乳房切除术是一种新的手术方法，它在进行乳房切除术的同时保留乳房的天然皮肤包膜。乳房重建将涉及多项手术，特别是如果乳头乳晕复合体被切除并随后进行重建。降低风险的乳房切除术的禁忌证包括以下情况。家族病史或孟乔森综合征的状况尚未得到证实。降低风险的乳房切除术不是女性自己的选择。患者目前患有精神疾病，包括临床抑郁症、癌症恐惧症或躯体变形综合征。如果合并症超过临床益处，则不应进行手术。最后，患者对手术益处不能抱有不切实际的期望。她必须明白，后续的降低风险的乳房切除术可能会显著降低，但不能消除患后续乳腺癌的风险。
