El-Marakby Hamdy H, Kotb Magdy H
Department of Surgery, National Cancer Institute, Cairo, Egypt.
J Egypt Natl Canc Inst. 2011 Dec;23(4):163-9. doi: 10.1016/j.jnci.2011.11.002. Epub 2011 Dec 13.
Oncoplastic breast conservative surgery has evolved as a safe alternative to the standard mastectomy in the treatment of early breast cancer. The procedure involves tumour resection with an adequate safety margin and either breast reshaping with volume displacement procedures (large or ptotic breasts) or volume replacement with latissimus dorsi myocutaneous flap (LDF) (small to medium sized non-ptotic breasts). A contra lateral mastopexy procedure is usually necessary with the volume displacement oncoplastic surgery, a procedure that is often rejected by a significant number of patients. This limits the choice of the reconstruction of breast defects in such patients to autologous tissues i.e. LDF.
Aim is to evaluate the feasibility of volume replacement oncoplastic breast conservative surgery with latissimus dorsi myocutaneous flaps for patients with large ptotic breasts. This involves testing the oncologic safety in terms of adequate safety margin, the complications rate and the final cosmetic outcome. The loco regional recurrence rate will be recorded and compared with oncoplastic volume displacement for similar sized breast defects.
A group of 50 female patients with early breast cancers (T2) who presented to the department of surgery at the National Cancer Institute, Cairo, Egypt in the period between January 2004 and November 2009 were included in the study. Bilateral soft tissue mammography was carried out in all patient groups and was used to annually follow up the patients. All patients were detected with T2 N0 breast cancer by both clinical and radiological examinations. All patients underwent partial mastectomy and reconstruction with LDFs.
The average age at presentation was 46.5±9years and the range was 26-65years. Most of the patients were subjected to partial mastectomy in 30 patients (60%), excision of a single quadrant from the four major quadrants was carried out in 15 patients (30%) where skin sparing wide local excision was carried out in only five patients (10%). The safety margin ranged from 1.1 to 3.2cm with an average of 1.8±0.5cm. There was no total flap loss in any patient where as we reported partial flap loss in two patients. Nipple and areola sloughing were reported in two patients, wound infection in five patients, haematoma in four patients, seroma in 16 patients, and donor site morbidity in six patients. The vast majority of patients were either satisfied (score >3 out of 5) (62%) or very satisfied (score 4 or more) (18%) with the results of reconstruction.
The results of the current study showed the feasibility and the versatility of volume replacement oncoplastic surgery in patients with large ptotic breasts with myocutaneous flaps. The adequacy of safety margin and the acceptable complications rate as well as the comparable local recurrence rate to volume displacement oncoplastic surgery, make it a suitable alternative in a subset of patients who object an immediate contra lateral mastopexy procedure.
肿瘤整形保乳手术已发展成为早期乳腺癌治疗中标准乳房切除术的一种安全替代方法。该手术包括切除具有足够安全切缘的肿瘤，对于大乳房或下垂乳房采用容积置换手术进行乳房重塑，对于中小尺寸不下垂乳房采用背阔肌肌皮瓣（LDF）进行容积替代。在容积置换肿瘤整形手术中，通常需要进行对侧乳房上提术，而这一手术往往被大量患者拒绝。这就将此类患者乳房缺损重建的选择限制为自体组织，即背阔肌肌皮瓣。
目的是评估采用背阔肌肌皮瓣进行容积替代肿瘤整形保乳手术治疗大而下垂乳房患者的可行性。这包括从足够安全切缘、并发症发生率和最终美容效果方面测试肿瘤学安全性。将记录局部区域复发率，并与类似尺寸乳房缺损的肿瘤整形容积置换手术进行比较。
纳入一组50例早期乳腺癌（T2）女性患者，这些患者于2004年1月至2009年11月期间就诊于埃及开罗国家癌症研究所外科。所有患者组均进行了双侧软组织乳房X线摄影，并用于对患者进行年度随访。通过临床和放射学检查，所有患者均被诊断为T2 N0期乳腺癌。所有患者均接受了部分乳房切除术并用背阔肌肌皮瓣进行重建。
就诊时的平均年龄为46.5±9岁，范围为26 - 65岁。大多数患者（30例，60%）接受了部分乳房切除术，15例患者（30%）从四个主要象限中切除了一个象限，仅5例患者（10%）进行了保乳的广泛局部切除。安全切缘范围为1.1至3.2厘米，平均为1.8±0.5厘米。没有患者出现背阔肌肌皮瓣完全丢失的情况，不过我们报告有2例患者出现了部分背阔肌肌皮瓣丢失。2例患者出现乳头和乳晕脱落，5例患者出现伤口感染，4例患者出现血肿，16例患者出现血清肿，6例患者出现供区并发症。绝大多数患者对重建结果感到满意（评分>3分，满分5分）（62%）或非常满意（评分4分及以上）（18%）。
本研究结果表明，对于大而下垂乳房患者，采用肌皮瓣进行容积替代肿瘤整形手术具有可行性和多功能性。安全切缘足够、并发症发生率可接受以及局部复发率与容积置换肿瘤整形手术相当，使其成为一部分反对立即进行对侧乳房上提术患者的合适替代方法。
