Gershenwald J E, Hunt K K, Kroll S S, Ross M I, Baldwin B J, Feig B W, Ames F C, Schusterman M A, Singletary S E
Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston 77030, USA.
Ann Surg Oncol. 1998 Sep;5(6):529-38. doi: 10.1007/BF02303646.
The role of elective contralateral mastectomy (ECM) in women with early-stage breast cancer who elect or require an ipsilateral mastectomy and desire immediate bilateral breast reconstruction (IBR) is an intellectual and emotional dilemma for both patient and physician. In an attempt to clarify the rationale for this approach, we reviewed our experience with ECM and IBR and evaluated operative morbidity, the incidence of occult contralateral breast cancer, and patterns of recurrence.
We retrospectively reviewed the records of 155 patients with primary unilateral breast cancer (stage 0, I, or II) and negative findings on physical and mammographic examinations of the contralateral breast who underwent ipsilateral mastectomy and simultaneous ECM with IBR between 1987 and 1995.
The median age of the patients was 46 years (range, 25 to 69 years). Clinical stage at diagnosis was stage 0, I, and II in 19.4%, 54.2%, and 26.4% of patients, respectively. Factors likely to influence the use of ECM were family history of breast cancer in first-degree relatives (30%), any family history of breast cancer (56%), difficulty anticipated in contralateral breast surveillance (48%), associated lobular carcinoma in situ (23%), multicentric primary tumor (28%), significant reconstructive issues (14%), and failure of mammographic identification of the primary tumor (16%). Skin-sparing mastectomies were performed in 81% of patients. Overall, 70% of patients underwent reconstruction using autogenous tissue transfer. Reoperations for suspected anastomotic thrombosis were performed in seven patients. Two patients experienced significant partial or complete flap loss. Histopathologic findings in the ECM specimen were as follows: benign, 80% of patients; atypical ductal hyperplasia, 12% of patients; lobular carcinoma in situ, 6.5% of patients; ductal carcinoma in situ, 2.7% of patients; and invasive carcinoma, 1.3% of patients. Eighteen patients (12%) had evidence of locoregional or distant recurrences, with a median follow-up of 3 years. In one patient (0.6%), invasive ductal carcinoma developed on the side of the elective mastectomy.
The use of ECM and IBR cannot be justified if the only oncologic criterion considered is the incidence of occult synchronous contralateral disease. However, in a highly selected population of young patients with a difficult clinical or mammographic examination and an increased lifetime risk of developing a second primary tumor, ECM and IBR is a safe approach.
对于选择或需要进行同侧乳房切除术并希望即刻进行双侧乳房重建（IBR）的早期乳腺癌女性患者，选择性对侧乳房切除术（ECM）的作用对于患者和医生而言都是一个理智和情感上的两难问题。为了阐明这种方法的基本原理，我们回顾了我们在ECM和IBR方面的经验，并评估了手术并发症、隐匿性对侧乳腺癌的发生率以及复发模式。
我们回顾性分析了1987年至1995年间155例原发性单侧乳腺癌（0期、I期或II期）患者的记录，这些患者对侧乳房的体格检查和乳腺X线检查结果均为阴性，均接受了同侧乳房切除术及同期ECM和IBR。
患者的中位年龄为46岁（范围25至69岁）。诊断时的临床分期为0期、I期和II期的患者分别占19.4%、54.2%和26.4%。可能影响ECM使用的因素包括一级亲属中有乳腺癌家族史（30%）、有任何乳腺癌家族史（56%）、预计对侧乳房监测困难（48%）、合并小叶原位癌（23%）、多中心原发性肿瘤（28%）、重大重建问题（14%）以及乳腺X线检查未能识别原发性肿瘤（16%）。81%的患者进行了保留皮肤的乳房切除术。总体而言，70%的患者采用自体组织移植进行重建。7例患者因疑似吻合口血栓形成而再次手术。2例患者出现明显的部分或完全皮瓣丢失。ECM标本的组织病理学结果如下：良性，80%的患者；非典型导管增生，12%的患者；小叶原位癌，6.5%的患者；导管原位癌，2.7%的患者；浸润性癌，1.3%的患者。18例患者（12%）有局部或远处复发的证据，中位随访时间为3年。1例患者（0.6%）在选择性乳房切除侧发生浸润性导管癌。
如果仅考虑隐匿性同步对侧疾病的发生率这一肿瘤学标准，ECM和IBR的应用是不合理的。然而，在经过严格筛选的年轻患者群体中，这些患者临床或乳腺X线检查困难且发生第二原发性肿瘤的终生风险增加，ECM和IBR是一种安全的方法。
