Wang Frederick, Peled Anne Warren, Chin Robin, Fowble Barbara, Alvarado Michael, Ewing Cheryl, Esserman Laura, Foster Robert, Sbitany Hani
San Francisco, Calif. From the Division of Plastic and Reconstructive Surgery, the Carol Franc Buck Breast Care Center, Department of Surgery, and the Department of Radiation Oncology, University of California, San Francisco.
Plast Reconstr Surg. 2016 Jan;137(1):1-9. doi: 10.1097/PRS.0000000000001866.
Total skin-sparing mastectomy, with preservation of the nipple-areola complex, must account for adjuvant medical and surgical treatments for cancer. The authors assessed risk factors for complications after second-stage tissue expander-implant exchange.
The authors reviewed all institutional total skin-sparing mastectomy cases that had completed tissue expander-implant exchange with at least 3 months of follow-up. They developed multivariate generalized estimating equation models to obtain adjusted relative risks of radiation therapy, type of lymph node dissection, and hormonal therapy in relation to postoperative complications.
The authors performed 776 cases in 489 patients, with a median follow-up of 26 months (interquartile range, 10 to 48 months). Radiation therapy was associated with increased wound breakdown risk [relative risk (RR), 3.3; 95 percent CI, 2.0 to 5.7]; infections requiring oral antibiotics (RR, 2.2; 95 percent CI, 1.31 to 3.6), intravenous antibiotics (RR, 6.4; 95 percent CI, 3.9 to 10.7), or procedures (RR, 8.9; 95 percent CI, 4.5 to 17.5); implant exposure (RR, 3.9; 95 percent CI, 1.86 to 8.3); and implant loss (RR, 4.2; 95 percent CI, 2.4 to 7.4). Axillary lymph node dissection was associated with an increased risk of implant loss (RR, 2.0; 95 percent CI, 1.11 to 3.7) relative to sentinel lymph node biopsy.
Axillary lymph node dissection increases the risk of implant loss compared with sentinel lymph node biopsy, independent of radiation therapy. Patients who require axillary lymph node dissection may be encouraged to undergo breast conservation or autologous reconstruction when possible.
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
保留乳头乳晕复合体的全乳皮肤切除乳房切除术，必须考虑癌症的辅助药物和手术治疗。作者评估了二期组织扩张器 - 植入物置换术后并发症的危险因素。
作者回顾了所有在机构内完成组织扩张器 - 植入物置换且随访至少3个月的全乳皮肤切除乳房切除术病例。他们建立了多变量广义估计方程模型，以获得放疗、淋巴结清扫类型和激素治疗与术后并发症相关的调整后相对风险。
作者对489例患者进行了776例手术，中位随访时间为26个月（四分位间距，10至48个月）。放疗与伤口裂开风险增加相关[相对风险（RR），3.3；95%置信区间，2.0至5.7]；需要口服抗生素治疗的感染（RR，2.2；95%置信区间，1.31至3.6）、静脉用抗生素治疗的感染（RR，6.4；95%置信区间，3.9至10.7）或手术治疗的感染（RR，8.9；95%置信区间，4.5至17.5）；植入物外露（RR，3.9；95%置信区间，1.86至8.3）；以及植入物丢失（RR，4.2；95%置信区间，2.4至7.4）。与前哨淋巴结活检相比，腋窝淋巴结清扫与植入物丢失风险增加相关（RR，2.0；95%置信区间，1.11至3.7）。
与前哨淋巴结活检相比，腋窝淋巴结清扫增加了植入物丢失的风险，且与放疗无关。对于需要进行腋窝淋巴结清扫的患者，可能应鼓励其尽可能接受保乳手术或自体乳房重建。
临床问题/证据水平：治疗性，III级
