Current surgical management of breast cancer
Current surgical management of breast cancer
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DOI：
10.1097/00001703-200202000-00008
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发表时间：
2002-02-01
影响因子：
2.1
通讯作者：
Cody, HS
中科院分区：
文献类型：
--
作者：
Cody, HS
乳腺癌手术继续变得更加保守。支持这一保守观点的是：（1）通过乳腺X线筛查进行早期诊断，（2）超声和磁共振成像在诊断中的作用越来越大，（3）图像引导的粗针活检的进一步发展，（4）前哨淋巴结活检作为传统腋窝淋巴结清扫术的替代方法。对于导管原位癌患者，在手术切除的基础上加用放疗和他莫昔芬可减少局部复发，但与单纯切除相比，生存率尚未提高。可能存在低风险的导管原位癌患者亚组，仅保守性手术就足以治疗。对于浸润性癌症患者，乳房保护仍然没有得到充分利用。乳腺切除术后辅助放疗的小生存获益被心血管死亡率的增加所抵消，这一现象尚未被证明用于乳房保护后的放疗。前哨淋巴结活检代表了绝大多数高危导管原位癌和1-11期浸润性癌乳腺癌患者腋窝淋巴结分期的新护理标准。该程序是可行的，准确的，并与蓝色染料和放射性同位素映射的组合最好的作品。经过适当的验证研究，前哨淋巴结阴性的患者不需要腋窝淋巴结清扫。前哨淋巴结微转移的预后意义，通过增强病理技术确定仍然是一个有争议的问题。预防性乳房切除术可降低具有高危家族史和BRCA 1 -2突变的患者的乳腺癌发病率和死亡率，但对一小部分不可预测的患者具有显著的不良心理社会后遗症，不应轻易进行。预防性卵巢切除术应提供给所有BRCA 1 -2突变的妇女，特别是那些超过生育年龄的妇女。
Breast cancer surgery continues to become more conservative. Supporting this conservatism are (1) earlier diagnosis through mammographic screening, (2) an increasing role for diagnostic ultrasound and magnetic resonance imaging, (3) the further development of image-guided core-needle biopsy, and (4) the advent of sentinel lymph node biopsy as an alternative to conventional axillary dissection. For patients with duct carcinoma in situ, the addition of radiotherapy and tamoxifen to surgical excision reduces local recurrence but has not yet improved survival over the rate observed with excision alone. There may be low-risk subgroups of duct carcinoma in situ patients for whom conservative surgery alone is adequate treatment. For patients with invasive cancer, breast conservation remains underutilized. A small survival benefit from post-mastectomy adjuvant radiotherapy is offset by an increased incidence of cardiovascular mortality, a phenomenon which has not yet been demonstrated for radiotherapy following breast conservation. Sentinel lymph node biopsy represents a new standard of care for axillary lymph node staging in the large majority of breast cancer patients with high-risk duct carcinoma in situ and stage 1-11 invasive cancers. The procedure is feasible, accurate, and works best with a combination of blue dye and radioisotope mapping. After proper validation studies, patients with negative sentinel lymph nodes do not require axillary dissection. The prognostic significance of sentinel lymph node micrometastases identified by enhanced pathologic techniques remains a matter of debate. Prophylactic mastectomy reduces breast cancer incidence and mortality among those with a high-risk family history, and mutations of BRCA1-2, but has significant adverse psychosocial sequelae for a small and unpredictable fraction of patients and should not be undertaken lightly. Prophylactic oophorectomy should be offered to all women with BRCA1-2 mutations, especially those beyond the years of childbearing.