乳腺癌新辅助化疗后局部病灶的外科处理原则  

The Principles of Surgical Treatment Following the Neoadjuvant Chemotherapy in Locally Advanced Breast Cancer

作　　者：张斌[1] 汤小川[1] 林辉[1] 曹旭晨[1] 

机构地区：[1]乳腺癌防治教育部重点实验室天津市肿瘤防治重点实验室天津医科大学附属肿瘤医院乳腺一科

出　　处：《中国肿瘤临床》2009年第3期172-175,共4页Chinese Journal of Clinical Oncology

基　　金：天津市应用基础研究计划项目资助(编号:07JCYBJC091000)

摘　　要：新辅助化疗是局部晚期乳腺癌标准治疗方案中的重要组成部分之一，可提高肿瘤切除率与保乳率。对于早期乳腺癌，新辅助化疗可使原发肿瘤降期以提高局部切除的可行性，并可早期评价化疗敏感性从而指导个体化治疗。一些研究已经证实新辅助化疗的反应与患者生存率相关，许多患者将得益于其对远处器官内微小转移灶的控制。本文将就新辅助化疗后保乳的选择、乳房再造术的时机以及区域淋巴结治疗等局部病灶外科处理的研究进展作一综述。1）新辅助化疗后的保乳手术不应为追求保乳而以降低生存率或增加局部复发为代价，且选择标准应与直接手术相一致，存在局部晚期病变但对化疗反应好的患者也考虑保乳手术。2）新辅助化疗后的晚期乳腺癌患者行即刻乳房再造术，其并发症发生率并无增加；但放疗可导致假体再造乳房的包膜挛缩或反复感染，对自体乳房再造的影响尚无定论，因此局部晚期乳腺癌患者应考虑行延迟乳房再造术；Kronowitz等人提出的“延迟一即刻”乳房再造是一种具有实用价值的方法。3）对新辅助化疗敏感的患者可考虑通过前哨淋巴结活检进行腋窝淋巴结分期；在新辅助化疗前后行活检各有利弊，一些研究中将超声和前哨淋巴结活检相结合来判断腋窝淋巴结状态的方法值得借鉴，但尚需更多的研究加以证实。Neoadjuvant chemotherapy is one of the most important standard treatment strategies for patients with locally advanced breast cancer, which can improve resectability and the rate of breast conservation. For early-stage brest cancer, neoadjuvant therapy has down-staging effect and is helpful for chemosensitivity evaluation and individualized therapy. Several studies have shown that patient response is correlated with survival and many patients benefit from the control of occult micrometastases in distant organs by neoadjuvant chemotherapy. In this article, we review the progress in research about locally surgical treatment （breast-conserving surgery, immediate breast reconstruction and axillary lymph node dissection） after neoadjuvant chemotherapy. The breast-conserving surgery after neoadjuvant chemotherapy should not increase the risk of Ioco-regional recurrence or decrease the survival rate. The selection criteria applied in breast-conserving surgery decisions should be consistent with primary surgery or surgery after neoadjuvant chemotherapy. The breast-conserving surgery is safe for patients with a strong response to neoadjuvant chemotherapy, even if they present with locally advanced disease. Immediate breast reconstruction can be considered for LABC patients who recieved neoadjuvant chemotherapy, without increasing the rate of postoperative complications. Radiation can cause contractures or recurrent infection of breast prosthesis, but its effect on autologous breast has not been elucidated. So delayed breast reconstruction should be considered for LABC patients. The delayed - immediate breast reconstruction advanced by Kronowitz is a method of clinical vaule. For patients sensitive to neoadjuvant chemotherapy, axillary lymph node staging can be obtained through sentinel lymph node biopsy. The combination of ultrasound and SLNB to identify axillary lymph node status is recom-mended and warrants further study.

关 键 词：新辅助化疗 乳腺癌 保乳手术 即刻乳房再造术 前哨淋巴结 

分 类 号：R737.9[医药卫生—肿瘤] R657.3[医药卫生—临床医学]