Haffty B G, Wilson L D, Smith R, Fischer D, Beinfield M, Ward B, McKhann C
Department of Therapeutic Radiology, Yale University School of Medicine, New Haven CT 06510, USA.
Int J Radiat Oncol Biol Phys. 1995 Aug 30;33(1):53-7. doi: 10.1016/0360-3016(95)00165-U.
It has been suggested that patients presenting with breast cancers within 2 cm of the nipple areolar complex represent a relative contraindication to conservative management due to either a compromised cosmetic result associated with sacrifice of the nipple areolar complex, reluctance to include the entire nipple areolar complex in the conedown field, or increased risk of multicentricity. We have reviewed our experience of conservatively treated patients with specific reference to the subset of patients presenting with tumors within 2 cm of the nipple areolar complex.
Between January 1970 and December 1989, 1014 patients with early stage breast cancer were treated at Yale-New Haven Hospital by excisional biopsy with or without axillary lymph node dissection. Of the 1014 charts reviewed, a total of 98 patients fulfilled the criteria of having a central/ subareolar breast cancer. Reexcision was performed on only 16 patients. Following conservative surgery, patients were treated with radiation therapy to the intact breast to a total median dose of 48 Gy with conedown to a total of 64 Gy. adjuvant systemic therapy and regional nodal irradiation were administered as clinically indicated.
As of December 1993, the median follow-up for the 98 patients in this study was 9.03 years. The majority of patients had presented with either a palpable mass or a mammographically detected lesion. Three patients presented with Paget's disease, five with nipple discharge, and seven with nipple inversion. Ten of the 98 patients had the nipple areolar complex sacrificed at the time of surgery, while the remaining 88 patients had the entire nipple areolar complex included in the conedown field. Four of these 88 patients had the nipple partially blocked during the electron conedown. There were no significant complications associated with including the entire nipple areolar complex within the conedown field to a median dose of 64 Gy. Six of the 98 patients experienced a local recurrence, three experienced a regional recurrence, and nine experienced distant metastasis. The actuarial 10-year survival (0.79 +/- 0.06), distant disease-free survival (0.88 +/- 0.04) and breast recurrence-free survival (0.84 +/- 0.07) were not significantly different from those patients who presented with cancers in other parts of the breast.
Patients presenting with subareolar breast cancers within 2 cm of the nipple areolar complex are suitable candidates for conservative surgery and radiation therapy. In the majority of patients in this study, the nipple areolar complex did not need to be sacrificed and could be safely included in the electron conedown field with acceptable complications and cosmesis. A subareolar breast cancer does not represent a relative contraindication to conservative management in patients with early stage breast cancer.
有人提出，乳头乳晕复合体2厘米范围内出现乳腺癌的患者是保守治疗的相对禁忌证，原因在于牺牲乳头乳晕复合体可能会影响美容效果，不愿将整个乳头乳晕复合体纳入缩野范围，或者多中心性风险增加。我们回顾了保守治疗患者的经验，特别关注乳头乳晕复合体2厘米范围内出现肿瘤的患者亚组。
1970年1月至1989年12月期间，耶鲁-纽黑文医院对1014例早期乳腺癌患者进行了切除活检，部分患者还进行了腋窝淋巴结清扫。在审查的1014份病历中，共有98例符合中央/乳晕下乳腺癌的标准。仅对16例患者进行了再次切除。保守手术后，对完整乳房进行放射治疗，总中位剂量为48 Gy，缩野后总剂量为64 Gy。根据临床指征给予辅助全身治疗和区域淋巴结照射。
截至1993年12月，本研究中98例患者的中位随访时间为9.03年。大多数患者表现为可触及的肿块或乳腺X线检查发现的病变。3例患者出现佩吉特病，5例有乳头溢液，7例有乳头内陷。98例患者中有10例在手术时牺牲了乳头乳晕复合体，其余88例患者的整个乳头乳晕复合体被纳入缩野范围。这88例患者中有4例在电子缩野期间乳头部分受阻。将整个乳头乳晕复合体纳入缩野范围至中位剂量64 Gy，未出现明显并发症。98例患者中有6例出现局部复发，3例出现区域复发，9例出现远处转移。10年精算生存率（0.79±0.06）、无远处疾病生存率（0.88±0.04）和无乳腺复发生存率（0.84±0.07）与乳房其他部位出现癌症的患者相比无显著差异。
乳头乳晕复合体2厘米范围内出现乳晕下乳腺癌的患者适合进行保守手术和放射治疗。在本研究的大多数患者中，无需牺牲乳头乳晕复合体，可将其安全纳入电子缩野范围，并发症和美容效果均可接受。乳晕下乳腺癌并非早期乳腺癌患者保守治疗的相对禁忌证。
