Petit J Y, Veronesi U, Rey P, Rotmensz N, Botteri E, Rietjens M, Garusi C, De Lorenzi F, Martella S, Bosco R, Manconi A, Luini A, Galimberti V, Veronesi P, Ivaldi G B, Orecchia R
Department of Plastic Surgery, European Institute of Oncology, Via Ripamonti 435, Milan, 20 141, Italy.
Breast Cancer Res Treat. 2009 Mar;114(1):97-101. doi: 10.1007/s10549-008-9968-6. Epub 2008 Mar 22.
When the conservative treatment is not recommended, Nipple Sparing Mastectomy (NSM) is proposed more and more frequently for the surgical treatment of breast cancer. The risk of local recurrence behind the nipple areolar complex (NAC) is the main limiting factor of the NSM procedure. To minimize such risk, we proposed in 2002 a intraoperative radiotherapy of the preserved NAC.
From March 2002 to November 2006, 579 cases (in 570 patients) of NSM were performed for carcinoma. The median follow up time was 19 months (Range: 1-60). The subcutaneous mastectomy was performed through an incision removing a portion of the skin overlying the tumour. An extemporaneous histological examination was performed on the retroareolar glandular tissue. If the histology was positive the patient was not considered eligible. Then an intraoperative radiotherapy with electrons (ELIOT) of 16 Gy in one shot was delivered on the NAC area. An immediate breast reconstruction was done using implants in most cases and in several cases a musculocutaneous flaps, usually in large breast. The number of local recurrences was recorded and the correlation between their occurrence and the clinical and histological criteria were analysed using the Gray test statistical method in a competing framework.
In 516 cases the negative retroareolar frozen section biopsy was confirmed by the final histology, while in 63 cases, the final histology showed foci of carcinoma. Seven out of these 63 cases underwent a secondary NAC removal. In the 56 cases which preserved areolas we did not observe any local recurrence after 19 months follow up. The probability of retro areola positive histology increases with the tumour size. and was not related to the nodal status. The rate of local relapses was 0.9% per year. We didn't find any significant difference in the local relapse rate according to different patient's and tumour's features. Most relapses were located close to the tumour bed but never in the NAC area.
Our study confirms that the local recurrence rate in the NSM completed with local radiotherapy on the NAC is not higher than the usual rate observed in the literature and the preservation of the NAC does not increase the risk. The absence of local recurrence in the region where a portion of glandular tissue has been purposely preserved is a good argument in favour of ELIOT.
当不推荐保守治疗时，乳头保留乳房切除术（NSM）越来越频繁地被用于乳腺癌的外科治疗。乳头乳晕复合体（NAC）后方局部复发的风险是NSM手术的主要限制因素。为了将这种风险降至最低，我们在2002年提出了对保留的NAC进行术中放疗。
从2002年3月至2006年11月，对570例患者的579例NSM进行了癌症手术。中位随访时间为19个月（范围：1 - 60个月）。通过切除肿瘤上方部分皮肤的切口进行皮下乳房切除术。对乳晕后腺组织进行术中组织学检查。如果组织学检查呈阳性，则该患者被认为不符合条件。然后在NAC区域一次性给予16 Gy的电子术中放疗（ELIOT）。大多数情况下使用植入物进行即刻乳房重建，在一些病例中使用肌皮瓣，通常用于大乳房。记录局部复发的数量，并在竞争框架下使用格雷检验统计方法分析其发生与临床和组织学标准之间的相关性。
在516例病例中，乳晕后冰冻切片活检阴性经最终组织学证实，而在63例病例中，最终组织学显示癌灶。这63例中有7例接受了二次NAC切除。在保留乳晕的56例病例中，随访19个月后未观察到任何局部复发。乳晕后组织学阳性的概率随肿瘤大小增加，且与淋巴结状态无关。局部复发率为每年0.9%。根据不同的患者和肿瘤特征，我们未发现局部复发率有任何显著差异。大多数复发位于肿瘤床附近，但从未在NAC区域。
我们的研究证实，在NSM中对NAC进行局部放疗后的局部复发率不高于文献中观察到的通常发生率，并且保留NAC不会增加风险。在特意保留部分腺组织的区域未出现局部复发是支持ELIOT的有力论据。
