Kieback D G, Beller F K, Nitsch C D, Krieg V, Nienhaus H, Niedner W E
Dept. of Gynecology, M. D. Anderson Cancer Center, Houston, Texas.
Geburtshilfe Frauenheilkd. 1990 Oct;50(10):754-70. doi: 10.1055/s-2008-1026360.
A retrospective clinical study included 1283 patients with breast cancer. 307 of 762 tumours with known diameter (mm) were classified as stage pT1 (TNM, 70). Four groups were formed to compare the prognosis in subgroups of pT1 cancers: 0-5 mm (n = 22), 6-9 mm (n = 22), 10 mm (n = 53) and 11-20 mm (n = 210). A comparison of three types of surgery was made: Radical subcutaneous mastectomy (12), bilateral modified subcutaneous mastectomy (10, 11), and modified radical mastectomy (Auchincloss, 3). Both forms of subcutaneous mastectomy were combined with adjuvant postoperative radiotherapy to the side of the tumour. In this trial, patients were younger at diagnosis than usually stated in the literature. Small breast cancers had the same localisation and histology as large ones. Axillary lymph node metastases were identified from a tumour diameter of 6 mm upwards. Bilateral tumours were seen in 2 of 22 patients with tumours less than or equal to 5 mm. Multifocal growth was observed also in the same size range. Histologically different simultaneous invasive unilateral cancers were seen starting at a diameter of 8 mm of the larger tumour. Systemic metastases were observed in tumours of 10 mm in diameter. Local recurrences occurred in breast cancers with a diameter of 2 mm and more. There were no recurrences in the area of the nipple or areola in pT1 cancers. Small breast cancers did not appear to be biologically different from larger lesions. No prognostic subgroups of pT1 were evident beyond the established TNM staging. Disease-free survival was not significantly different between the three surgical approaches. Local recurrence was significantly less frequent after breast-conserving surgery. A negative influence of local recurrence on the prognosis was observed to a similar extent irrespective of the type of surgery. The concept of "minimal breast cancer" suggesting ablative surgery for a heterogeneous group of preinvasive and small invasive lesions is outdated. The different forms of subcutaneous mastectomy are a therapeutic alternative in the context of breast-conserving surgery of small infiltrating breast cancers. Especially the modified subcutaneous mastectomy (Beller) combines a good cosmetic result without prognostic impairment and with a potential reduction of the risc of contralateral breast cancer. Further potential applications include prophylactic treatment of high-risk patients with preinvasive lesions.
一项回顾性临床研究纳入了1283例乳腺癌患者。在762个已知直径（毫米）的肿瘤中，307个被分类为pT1期（TNM，70）。将pT1期癌症亚组分为四组以比较预后：0 - 5毫米（n = 22）、6 - 9毫米（n = 22）、10毫米（n = 53）和11 - 20毫米（n = 210）。对三种手术类型进行了比较：根治性皮下乳房切除术（12例）、双侧改良皮下乳房切除术（10例、11例）和改良根治性乳房切除术（Auchincloss法，3例）。两种皮下乳房切除术形式均联合术后对肿瘤侧进行辅助放疗。在本试验中，患者诊断时的年龄比文献中通常报道的要年轻。小乳腺癌与大乳腺癌具有相同的定位和组织学特征。肿瘤直径从6毫米起可发现腋窝淋巴结转移。在22例肿瘤直径小于或等于5毫米的患者中有2例出现双侧肿瘤。在相同大小范围内也观察到多灶性生长。组织学上不同的同时性浸润性单侧癌在较大肿瘤直径达到8毫米时出现。直径10毫米的肿瘤出现全身转移。直径2毫米及以上的乳腺癌发生局部复发。pT1期癌症在乳头或乳晕区域未出现复发。小乳腺癌在生物学上似乎与较大病变无差异。除已确立的TNM分期外，pT1期无明显的预后亚组。三种手术方式之间的无病生存率无显著差异。保乳手术后局部复发明显较少。无论手术类型如何，均观察到局部复发对预后有类似程度的负面影响。“微小乳腺癌”这一概念建议对一组异质性的癌前病变和小浸润性病变进行切除手术，这种概念已过时。在小浸润性乳腺癌的保乳手术背景下，不同形式的皮下乳房切除术是一种治疗选择。特别是改良皮下乳房切除术（Beller法）结合了良好的美容效果，且不影响预后，并有可能降低对侧乳腺癌的风险。进一步的潜在应用包括对癌前病变高危患者的预防性治疗。
