乳腺癌(4)

Breast Cancer

乳腺癌

Treatment

治療

For most patients, primary treatment is surgery, often with radiation therapy. Chemotherapy, hormone therapy, or both may also be used, depending on tumor and patient characteristics. For inflammatory or advanced breast cancer, primary treatment is systemic therapy, which, for inflammatory breast cancer, is followed by surgery and radiation therapy; surgery is usually not helpful for advanced cancer. Paget's disease of the nipple is treated as for other forms of breast cancer, although a very few patients can be treated successfully with local excision only.

大多數(shù)病人主要用外科治療，通常伴隨放射療法。也可以采用化療、激素療法或兩者兼用，這要取決于腫瘤及病人性質(zhì)。炎性或晚期乳腺癌病人主要采用系統(tǒng)療法，炎性乳腺癌則還要進(jìn)行外科和放射治療。外科療法對晚期乳腺癌通常無效。乳頭偑吉特病治療與其他乳腺癌相同，但只用局部切除就能成功治療的病人極少。

Surgery: Most patients with DCIS are cured by simple mastectomy. However, more patients are being treated with wide excision alone, especially when the lesion is < 2.5 cm and histologic characteristics are favorable, or with wide excision plus radiation therapy when size and histologic characteristics are less favorable.

外科：多數(shù)DCIS病人可用單純?nèi)榉壳谐�術(shù)治愈。不過，更多的病人采用廣泛切除療法，尤其是當(dāng)病灶< 2.5 cm，組織學(xué)特征較為有利，或者，在腫瘤大小及組織學(xué)特征不太有利情況下，采用廣泛切除＋放射療法。

For patients with invasive cancer, survival rates do not differ significantly whether modified radical mastectomy (simple mastectomy plus lymph node dissection) or breast-conserving surgery (lumpectomy, wide excision, partial mastectomy, or quadrantectomy) plus radiation therapy is used. Thus, patient preference can guide choice of treatment within limits. The main advantage of breast-conserving surgery plus radiation therapy is cosmetic. In 15% of patients treated with breast-conserving surgery and radiation therapy, cosmetic results are excellent. However, need for total removal of the tumor with a tumor-free margin overrides cosmetic considerations. With both types of surgery, a lymph node dissection or node sampling should be done. Routine use of extensive procedures is not justified because the main value of lymph node removal is diagnostic, not therapeutic. However, results of frozen section analysis may change the extent of surgery needed. Some surgeons get prior agreement for more invasive surgery in case nodes are positive; others wake the patient and do a 2nd procedure if needed.

對浸潤性乳腺癌病人來說，不管是采用改良式根治性乳房切除（單純?nèi)榉壳谐�＋淋巴結(jié)清掃)還是乳房保守性存手術(shù)（局部病灶切除，廣泛切除，部分乳房切除，或四分切除法)＋放射療法，其存活率并無顯著差別。因此，病人喜好可以在一定范圍內(nèi)引導(dǎo)治療選擇。乳房保存手術(shù)＋放射療法的好處在美容方面。采用這種療法的病人，有15%取得了很好的美容結(jié)果。不過，乳房全切及無腫瘤邊緣的需要比美容更重要。兩類手術(shù)都應(yīng)作淋巴結(jié)切除或淋巴結(jié)標(biāo)本采樣。常規(guī)使用廣泛性手術(shù)并不恰當(dāng)，因?yàn)榱馨徒Y(jié)切除的主要價值在于診斷，而非治療。然而，冰凍切片分析結(jié)果可能改變手術(shù)的需要程度。一旦結(jié)節(jié)陽性，有些外科醫(yī)生通常會先得到入侵性手術(shù)協(xié)議，有些會叫醒病人，并在必要時二次手術(shù)。

Some physicians use preoperative chemotherapy to shrink the tumor before removing it and applying radiation therapy; thus some patients who might otherwise have required mastectomy can have breast-conserving surgery. Early data suggest that this approach does not affect survival. Radiation therapy after mastectomy significantly reduces incidence of local recurrence on the chest wall and in regional lymph nodes and may improve overall survival in patients with primary tumors > 5 cm or with involvement of ≥ 4 axillary nodes. Adverse effects of radiation therapy are usually transient and mild.

有些醫(yī)生會在切除和實(shí)施放射療法前做術(shù)前化療縮小腫瘤，這樣，有些可能需要乳房切除的病人就可以做乳房保守性手術(shù)。早期的資料表明，這種手術(shù)不會影響存活。乳房切除后進(jìn)行放射療法極大地減少了胸壁及局部淋巴結(jié)局部性癌灶復(fù)發(fā)率，可以改善原發(fā)性腫瘤> 5 cm或累及腋淋巴結(jié)≥ 4的病人的總存活率。放射療法的負(fù)作用通常是暫時的，輕微的。

Procedures for reconstruction include submuscular or subcutaneous (less common) placement of a silicone or saline implant, use of a tissue expander with delayed placement of the implant, muscle flap transfer using the latissimus dorsi or the lower rectus abdominis, and creation of a free flap by anastomosing the gluteus maximus to the internal mammary vessels. Free flap transfer is being increasingly used for DCIS.

重建手術(shù)包括肌下或皮下（較少用)硅酮安置鹽水植入、使用組織擴(kuò)張器和后期植入、背闊肌或下腹直肌肌瓣轉(zhuǎn)移及臀大肌乳房內(nèi)血管吻合型游離瓣建立。DCIS已越來越多地采用游離瓣轉(zhuǎn)移。

After axillary dissection or radiation therapy, lymphatic drainage of the ipsilateral arm can be impaired, sometimes resulting in significant swelling due to lymphedema; magnitude of the effect is roughly proportional to the number of nodes removed. Venipuncture, BP measurement, and IV infusions are avoided on the affected side. A specially trained therapist must treat lymphedema. Special massage techniques once or twice daily may help drain fluid from congested areas toward functioning lymph basins; low-stretch bandaging is applied immediately after manual drainage, and patients should exercise daily as prescribed. After the lymphedema resolves, typically in 1 to 4 wk, patients continue daily exercise and overnight bandaging of the affected limb indefinitely.

經(jīng)過腋淋巴切除或放射療法，同側(cè)胳膊的淋巴引流可能受損，有時會因淋巴水腫引起嚴(yán)重腫脹。淋巴引流受損程度與切除的淋巴結(jié)數(shù)量大致成比率�；紓�(cè)應(yīng)避免行靜脈穿刺、量血壓和靜脈輸液。淋巴水腫應(yīng)由經(jīng)過專門訓(xùn)練的治療師治療，每天一至兩次專門按摩可幫助擁塞部位液體流向功能正常的淋巴盆。手工引流后就立即進(jìn)行低伸張綁扎，病人應(yīng)按規(guī)定進(jìn)行鍛煉。淋巴水腫消除后，一般需要1－4周，病人繼續(xù)進(jìn)行每天鍛練，并不定期地對患肢進(jìn)行整夜綁扎。

Adjuvant systemic therapy: Patients with LCIS are treated with daily oral tamoxifen. If tamoxifen is unsuitable or refused, bilateral mastectomy may be considered.

輔助性全身療法：LCIS病人每天服用他莫昔芬治療。如不適合服用節(jié)莫昔芬或病人拒絕接受，可考慮雙側(cè)乳房切除術(shù)。

For patients with invasive cancer, chemotherapy or hormone therapy is usually begun soon after surgery and continued for months or years; these therapies delay or prevent recurrence in almost all patients and prolong survival in some. However, some experts believe that these therapies are not necessary for tumors < 1 cm (particularly in postmenopausal patients) if lymph nodes are not involved because the prognosis is already excellent. Some experts begin adjuvant systemic therapy before surgery if tumors are > 5 cm.

浸潤性乳腺癌病人應(yīng)在手術(shù)后不久就開始化療或激素療法，并持續(xù)數(shù)月或數(shù)年。這些療法可延遲或阻止幾乎所以病人的復(fù)發(fā)，延長某些病人的存活期。不過，有些專家認(rèn)為，如果未累及淋巴結(jié)，< 1 cm的腫瘤并不需要這些療法(尤其是絕經(jīng)后病人)，因?yàn)轭A(yù)后已經(jīng)很好。如果腫瘤> 5 cm，有些專家在手術(shù)前開始輔助性全身療法。

Relative reduction in risk of recurrence and death associated with chemotherapy or hormone therapy is the same regardless of the clinical-pathologic stage of the cancer. Thus, absolute benefit is greater for patients with a greater risk of recurrence or death (ie, a 20% reduction reduces a 10% recurrence rate to 8% but a 50% rate to 40%). Adjuvant chemotherapy reduces annual odds of death on average by 25 to 35% for premenopausal patients; for postmenopausal patients, the reduction is about 1⁄2 of that (9 to 19%), and the absolute benefit in 10-yr survival is much smaller. Postmenopausal patients with ER– tumors benefit the most from adjuvant chemotherapy (see Table 3: Breast Disorders: Preferred Breast Cancer Adjuvant Systemic Therapy).

不管癌癥處于何種臨床病理階段，與化療或激素療法相關(guān)的復(fù)發(fā)及死亡危險的相對減少都是一樣的。因此，對復(fù)發(fā)或死亡危險較大的病人來說，其絕對好處也更大（即，20%就可以將復(fù)發(fā)率由10%減到8%，而50%的復(fù)發(fā)率只能減到40%)。輔助性化療可以將絕經(jīng)前病人的年死亡機(jī)率平均減少25%至35%。絕經(jīng)后病人的減少率約1/2(9－19%)，10年存活期的絕對好處要小得多。絕經(jīng)后ER腫瘤病人從輔助性化療受益最多（見表3：乳房疾病：理想的乳腺癌輔助性全身療法)。

Combination chemotherapy regimens (eg, cyclophosphamide, methotrexate, plus 5-fluorouracil; doxorubicin plus cyclophosphamide) are more effective than a single drug. Regimens given for 4 to 6 mo are preferred; they are as effective as regimens given for 6 to 24 mo. Acute adverse effects depend on the regimen but usually include nausea, vomiting, mucositis, fatigue, alopecia, myelosuppression, and thrombocytopenia. Long-term adverse effects are infrequent with most regimens; death due to infection or bleeding is rare (< 0.2%). Whether increasing dose density (giving treatments more frequently) or adding a taxane (eg, docetaxel, paclitaxel) improves response or survival is uncertain.

聯(lián)合化療方案（如環(huán)磷酰胺、甲氨蝶呤、＋5－氟尿嘧啶；多柔比星＋環(huán)磷酰胺)比單種藥物更有效。最好是服用4－6個月，效果與服用6－24個月相同。急性不良作用要看治療方案，但通常包括惡心、嘔吐、粘膜炎、疲勞、脫發(fā)、骨髓抑制及血小板減少等。多數(shù)方案很少有長期的不良作用，因感染或出血引起的死亡罕見（< 0.2%)。增加劑量密度（增加治療頻度)或添加紫杉烷（如多西紫杉醇、紫杉醇)是否改善效果或存活率尚不確定。

High-dose chemotherapy plus bone marrow or stem cell transplantation offers no therapeutic advantage over standard therapy and should not be used.

與標(biāo)準(zhǔn)療法相比，大劑量化療＋骨髓或干細(xì)胞移植并無治療優(yōu)勢，不應(yīng)使用。