Salas A P, Helvie M A, Wilkins E G, Oberman H A, Possert P W, Yahanda A M, Chang A E
Department of Surgery, University of Michigan Medical Center, Ann Arbor 48109-0932, USA.
Ann Surg Oncol. 1998 Jul-Aug;5(5):456-63. doi: 10.1007/BF02303866.
Skin-sparing mastectomy with immediate transverse rectus abdominis musculocutaneous (TRAM) flap reconstruction is being used more often for the treatment of breast cancer. Mammography is not used routinely to evaluate TRAM flaps in women who have undergone mastectomy. We have identified the potential value of its use in selected patients.
We report on four women who manifested local recurrences in TRAM flaps after initial treatment for ductal carcinoma in situ (DCIS) or DCIS with microinvasion undergoing skin-sparing mastectomy and immediate reconstruction. All four patients presented with extensive, high-grade, multifocal DCIS that precluded breast conservation. Three of four mastectomy specimens demonstrated tumor close to the surgical margin. Three of the four recurrences were detected by physical examination; the remaining local recurrence was documented by screening mammography. The recurrences had features suggestive of malignancy on mammography.
We conclude that all patients undergoing mastectomy and TRAM reconstruction for extensive, multifocal DCIS should undergo regular routine mammography of the reconstructed breast. Our experience with this subgroup of patients raises concern about the value of skin-sparing mastectomy with immediate reconstruction for therapy. Adjuvant radiation therapy should be recommended for those patients with negative but close surgical margins.
保留皮肤的乳房切除术联合即刻横行腹直肌肌皮瓣（TRAM瓣）重建术在乳腺癌治疗中的应用越来越广泛。乳房X线摄影术并不常规用于评估接受乳房切除术的女性的TRAM瓣。我们已经确定了其在特定患者中使用的潜在价值。
我们报告了4例女性患者，她们在接受保留皮肤的乳房切除术及即刻重建术，初始治疗为导管原位癌（DCIS）或伴有微浸润的DCIS后，TRAM瓣出现局部复发。所有4例患者均表现为广泛的、高级别、多灶性DCIS，无法进行保乳治疗。4例乳房切除标本中有3例显示肿瘤靠近手术切缘。4例复发中有3例通过体格检查发现；其余局部复发通过乳房X线筛查记录。这些复发在乳房X线摄影上具有提示恶性肿瘤的特征。
我们得出结论，所有因广泛多灶性DCIS接受乳房切除术和TRAM瓣重建术的患者均应定期对重建乳房进行常规乳房X线摄影。我们对这一亚组患者的经验引发了对保留皮肤的乳房切除术联合即刻重建术治疗价值的关注。对于手术切缘阴性但切缘接近的患者，应推荐辅助放疗。
