转移背阔肌肌皮瓣在局部晚期乳腺癌手术

转移背阔肌肌皮瓣修复术在局部晚期乳腺癌手术中的应用,汕头大学医学院附属肿瘤医院乳腺中心黄文河主任医师,Contents,局部晚期乳腺癌定义,局部晚期乳腺癌治疗现状,背阔肌解剖学,背阔肌肌皮瓣修复术手术要点,注意事项及临床体会,什么是局部晚期乳腺癌,局部晚期乳腺癌定义,IIIA（T3N1M0除外）、IIIB或IIIC期的非炎性乳腺癌,Locally advanced breast cancer (LABC) is characterized by varying clinical presentations such as presence of a large primary tumour (5 cm), associated with or without skin or chest-wall involvement or with fixed (matted) axillary lymph nodes or with disease spread to the ipsilateral internal mammary or supraclavicular nodes in the absence of any evidence of distant metastases.,J Cancer Res Ther. 2005 Jan-Mar;1(1):21- 30,局部晚期乳腺癌治疗现状？,发展中国家局部晚期乳腺癌治疗现状,Locally advanced breast cancer (LABC) accounts for a sizeable number (30-60%) of breast cancer cases and is a common clinical scenario in developing countries. Treatment of LABC has evolved from single modality treatment, consisting of radical mutilating surgery or higher doses of radiotherapy in inoperable disease to multimodality management consisting of surgery, radiation therapy (RT), chemotherapy with or without hormonal therapy. The 5 year overall survival for mastectomy group was 67% and 80% for the BCT group. Multidisciplinary therapy has now become the standard for women with LABC.,2005 | Volume : 1 | Issue : 1 | Page : 21-30Management of locally advanced breast cancer: Evolution and current practice Ashish Rustogi, Ashwini Budrukkar, Ketayun Dinshaw, Rakesh JalaliDepartment of Radiation Oncology, Tata Memorial Hospital, Parel, Mumbai, India,Impact of progression during neoadjuvant chemotherapy on surgical management of breast cancer.,METHODS: We reviewed clinicopathological data on patients who received NCT for stage I-III breast cancer from 1994 to 2007. Chemotherapy regimens were anthracycline-and/or taxane-based as determined by the treating medical oncologist. RESULTS: Of 1,928 patients who received NCT, 1,762 (91%) had a partial or complete response, 107 (6%) had stable disease (SD), and 59 (3%) progressed (PD) while receiving at least one regimen. Of the patients with progressive disease, 40 (68%) patients underwent mastectomy, 12 (20%) underwent BCT, and 7 (12%) did not undergo surgery. In patients who underwent mastectomy, only three (8%) were BCT candidates before progression. Overall, disease progression changed the operative plan in 11 (0.5%) patients: 3 developed distant metastasis, 2 developed clinical lymphadenopathy, 3 required mastectomy instead of BCT, 2 became inoperable, and 1 required flap closure.CONCLUSIONS: Disease progression while receiving NCT is infrequent (3%), but early identification may allow for change to other, potentially beneficial, therapeutic interventions. Patients with breast cancer who receive NCT should be evaluated frequently for response to therapy. Overall, progression during NCT changes the surgical management in a small proportion of patients.,Caudle AS et al. Ann Surg Oncol. 2011 Apr;18(4):932-8.,转移背阔肌肌皮瓣修复术适应症及禁忌症,适应症：乳房切除术后皮肤缺损乳腺癌根治术后自体组织乳房重建保乳术后局部畸形放疗后胸壁溃疡,禁忌症开胸术后背阔肌被切断胸背血管受损者上胸壁大面积皮肤缺损者,背阔肌的解剖学基础,背阔肌解剖学,位于肩胛骨下方，三角形发于T7T12、腰骶椎和最下面34根肋骨，止于肱骨结节间沟供血来源于胸背动脉和内乳动脉及肋间动脉的穿支神经支配为胸背神经功能：使肱骨内旋，上臂的内收和外展,背阔肌肌皮瓣的应用,历史：Baudet (1976) 首先进行了游离移植的报道。以后临床广泛应用，成为最常用的游离皮瓣之一 皮瓣特点：血管分布恒定，蒂部管径在1.52.0mm。血管蒂长：68cm易于剥离和切取供区范围大：68cmX 1215cm供区不遗留明显的功能障碍皮瓣血运丰富可形成单纯的肌瓣可用于进行肌肉功能的重建 应用范围：带蒂移植：胸部、上肢的组织缺损，屈肘功能重建，乳房再造等游离移植：头、面、颈、四肢、躯干等部位均可应用,转移背阔肌肌皮瓣修复术手术要点,1,术前先描画出手术切口全麻下，先仰卧位，行乳腺癌改良根治或根治术乳房切口彻底止血后用湿大纱布覆盖并用无菌手术膜隔离,2,再取侧卧位，在背阔肌表面按预先设计的梭形切口逐层切开沿背阔肌前缘切取背阔肌并向后方延续，注意保护前锯肌及大圆肌注意保护血管蒂把肌皮瓣经皮下隧道轻送到乳房创面,3,再改为仰卧位，将转移的肌皮瓣缝合固定于前胸壁切口并关闭皮肤切口切口轻度加压包扎引流管负压吸引,手术技巧及注意事项,1.体位,1.先仰卧位；2.侧卧位；3.最后仰卧位,2.保护胸背血管蒂,胸背血管,胸外侧血管,3.防止肌皮瓣血管蒂扭转,4.防止肌皮瓣坏死,背阔肌肌皮瓣,皮瓣在背阔肌肌性部分之上,5.慎防误切大圆肌及前锯肌,前锯肌,误切上述二肌肉会引起肩关节内收功能障碍,我院乳腺中心开展转移背阔肌肌皮瓣修复术病例资料,临床体会,体会1,严格掌握适应症防止并发症发生,Indications and complications of latissimus dorsi myocutaneous flaps in oncologic breast surgery.,METHODS The use of the latissimus dorsi myocutaneous flap (LDMF) in reconstructive breast surgery is well documented. Few reports exist of its use in oncologic breast surgery. This series describes indications and complications of the LDMF in locally advanced cancer. The records of 83 patients were analysedRESULTS The indication was to cover defects caused by resection of locally advanced breast cancer (67 cases), recurrent breast cancer (13 cases), radiation damage (2 cases), and surgical complications (1 case). The mean age of the patients was 50.2 years; 52% were postmenopausal. The flaps had mean diameters of 32 by 14 cm. The donor site was skin grafted. Clear margins were achieved in 83%. At the LDMF insertion site, wound infection required drainage in 1 case; flap necrosis required reintervention in 7 cases. In 2 cases a second skin graft was done for the LDMF donor site. CONCLUSIONS The use of the LDMF made wide resection of locally advanced lesions and radionecrosis possible; major complications were rare. LDMF has its place in the armamentarium of the surgeon who regularly sees locally advanced breast cancer.,World J Surg. 2002 Sep;26(9):1088-93. Epub 2002 Jun 21,体会2,术后开始辅助放射治疗的时间选择,Use of the extended V-Y latissimus dorsi myocutaneous flap for chest wall reconstruction in locally advanced breast cancer,The extended V-Y latissimus dorsi myocutaneous flap described by Micali and Carramaschi provides an innovative method of closing large anterior chest defects after resection of breast cancer. The technique provides robust chest wall coverage that is able to withstand immediate postoperative ra