乳腺癌化疗后肿瘤整形对比传统保乳
对于肿瘤较小的早期乳腺癌患者，肿瘤切除（保乳）与乳房切除相比，可安全有效地保持乳房外形，长期生存结局相似。对于肿瘤较大的早期乳腺癌患者，可以通过术前新辅助化疗对肿瘤进行降期，将乳房切除候选者转为保乳候选者。2017年英国《柳叶刀》肿瘤学分册发表早期乳腺癌试验者协作组（EBCTCG）早期乳腺癌术前新辅助化疗与术后辅助化疗相关10项随机对照试验长期生存结局的4756例女性患者个体数据协作荟萃分析，术前新辅助化疗与术后辅助化疗分别占64.8%与49.0%，虽然局部复发率为21.4%比15.9%，但是远处复发率、乳腺癌死亡率、总死亡率相似。因此，术前新辅助化疗后的肿瘤切除范围和肿瘤切缘阳性率，仍然是外科医师关注的问题。2001年英国阿什福德医院、2003年英国诺丁汉市立医院的研究表明，一旦20%的乳房体积被切除，就有明显畸形风险。此外，保乳期间某些区域畸形风险较高，例如从乳房下缘切除肿瘤时通常可见“鸟嘴”畸形。为此，肿瘤整形技术已被用于保乳，可以通过切除更大体积扩大保乳适应证，尤其对于美观敏感区域。2014年美国埃默里大学的荟萃分析表明，3165例肿瘤整形患者与5494例传统保乳患者相比，切缘阳性率（12%比21%，P<0.0001）、再次切除率（4%比14.6%，P<0.0001）、局部复发率（4%比7%，平均随访64比37个月）都显著较低，美观结局满意率显著较高（89.5%比82.9%，P<0.001）。不过，对于乳腺癌术前新辅助化疗后患者，比较肿瘤整形与传统保乳的已发表回顾研究样本量都较小，例如2016年发表的巴西研究仅78例、2018年发表的埃及研究仅70例。
2021年8月12日，美国《整形外科学报》在线发表复旦大学附属肿瘤医院陈颖、郝爽、陈嘉健、黄晓燕、曹阿勇、胡震、柳光宇、邵志敏、吴炅等学者的研究报告，对498例乳腺癌术前新辅助化疗后患者的传统保乳与肿瘤整形进行了比较。
该单中心定群回顾研究对2008年1月1日～2019年12月31日在复旦大学附属肿瘤医院接受术前新辅助化疗后进行传统保乳手术或肿瘤整形手术的全部乳腺癌患者进行病案回顾分析。
结果，399例乳腺癌患者接受术前新辅助化疗＋传统保乳手术、99例患者接受术前新辅助化疗＋肿瘤整形手术。
肿瘤整形手术组患者与传统保乳手术组患者相比：
平均年龄较小：43比48岁（P=0.017）
基线超声测定肿瘤较大：31.3比28.1毫米（P=0.013）
新辅助化疗前临床肿瘤分期相似
新辅助化疗前临床总体分期相似
肿瘤位于腺体相对较少区域比例较高
内上：18.18%比12.53%
正上：20.20%比15.29%
内下：11.11%比6.77%
外下：5.05%比3.51%
术后切缘宽度相似
病理类型分布相似
分子亚型分布相似
病理完全缓解率相似
因此，单中心定群回顾研究结果表明，对于乳腺癌术前新辅助化疗后患者，与传统保乳相比，采用肿瘤整形技术使保乳成为可能，即使对于肿瘤较大、分期较差、肿瘤位置不利的患者，故有必要进一步开展多中心前瞻研究进行验证。
相关链接
Ann Plast Surg. 2021 Aug 12. Online ahead of print.
A Retrospective Cohort Study Comparing Traditional Breast Conservation With Oncoplastic Surgery in Breast Cancer Patients After Neoadjuvant Chemotherapy.
Chen Y, Hao S, Chen J, Huang X, Cao A, Hu Z, Liu G, Shao Z, Wu J.
Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fujian; Fudan University Shanghai Cancer Center, Shanghai Medical College, Fudan University, Shanghai, China.
BACKGROUND: To better understand the difference between traditional breast-conserving surgery (BCS) and oncoplastic surgery (OPS), we conducted a retrospective cohort study involving breast cancer patients who received neoadjuvant chemotherapy (NAC) and then underwent breast conservation at the Fudan University Shanghai Cancer Center.
METHODS: A retrospective chart review was conducted. All breast cancer patients who received NAC and then underwent traditional BCS or OPS at the Fudan University Shanghai Cancer Center from January 1, 2008, to December 31, 2019, were included.
RESULTS: Three hundred ninety-nine breast cancer patients received NAC and underwent traditional BCS, and 99 patients underwent OPS. The average age of the patients in the OPS group was younger than that in the BCS group (43 vs 48 years, P = 0.017). The size of the tumor assessed by ultrasonography at baseline in the OPS group was larger than that in the BCS group (31.3 vs 28.1 mm, P = 0.013). The same trend was observed in the clinical T stage and overall staging assessments before the administration of NAC in these 2 groups. Oncoplastic techniques were more frequently applied when tumors were located in areas with relatively few glands, such as the upper inner quadrant. There were no significant differences in the margins and distributions of pathological types and molecular subtypes between these 2 groups. The rates of pathological complete response were similar in the traditional BCS and OPS groups.
CONCLUSIONS: Unlike traditional BCS, in breast cancer patients after NAC, the adoption of oncoplastic techniques makes breast conservation feasible, even in patients with large tumors, late stages, and unfavorable tumor locations.
PMID: 34387578
DOI: 10.1097/SAP.0000000000002971