转移背阔肌肌皮瓣在局部晚期乳腺癌手术课件

1、转移背阔肌肌皮瓣在局部晚期乳腺癌手术 乳腺中心 黄文河主任医师 转移背阔肌肌皮瓣在局部晚期乳腺癌手术 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 转移背阔肌肌皮瓣在局部晚期乳腺癌手术 转移背阔肌肌皮瓣在局部晚期乳腺癌手术 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

2、 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 J

3、an-Mar;1(1):21- 30 转移背阔肌肌皮瓣在局部晚期乳腺癌手术 局部晚期乳腺癌局部晚期乳腺癌 治疗现状治疗现状？ 转移背阔肌肌皮瓣在局部晚期乳腺癌手术 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

4、 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 8

5、0% for the BCT group. Multidisciplinary therapy has now become the standard for women with LABC. 2005 | Volume : 1 | Issue : 1 | Page : 21-30 Management of locally advanced breast cancer: Evolution and current practice Ashish Rustogi, Ashwini Budrukkar, Ketayun Dinshaw, Rakesh Jalali Department of R

6、adiation Oncology, Tata Memorial Hospital, Parel, Mumbai, India 转移背阔肌肌皮瓣在局部晚期乳腺癌手术 Impact of progression during neoadjuvant Impact of progression during neoadjuvant chemotherapy on surgical management of breast chemotherapy on surgical management of breast cancer.cancer. METHODS:METHODS: We reviewed

7、 clinicopathological data on patients who received NCT for stage I- III breast cancerbreast cancer from 1994 to 2007. Chemotherapy regimens were anthracycline-and/or taxane-based as determined by the treating medical oncologist. RESULTS:RESULTS: Of 1,928 patients who received NCT, 1,762 (91%) had a

8、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 m

9、astectomy, only three (8%) were BCT candidates before progression. Overall, disease progression changed the operativeoperative 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 f

10、lap closure. CONCLUSIONSCONCLUSIONS: : Disease progression while receiving NCT is infrequent (3%), but early identification may allow for change to other, potentially beneficial, therapeutic interventions. Patients with breast cancerbreast cancer who receive NCT should be evaluated frequently for re

11、sponse to therapytherapy. Overall, progression during NCT changes the surgicalsurgical management in a small proportion of patients. Caudle AS et al. Ann Surg Oncol. 2011 Apr;18(4):932-8. 转移背阔肌肌皮瓣在局部晚期乳腺癌手术 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

12、上胸壁大面积皮肤缺损 者 转移背阔肌肌皮瓣在局部晚期乳腺癌手术 背阔肌的解剖学基础 转移背阔肌肌皮瓣在局部晚期乳腺癌手术 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 转移背阔肌肌皮瓣在局部晚期乳腺癌手术 背阔肌肌皮瓣的应用 历史历史： Baudet (1976) Baudet (1976) 首先进行了游离移植首先进行了游离移植 的报道。以后临床广泛应用，成为的报道。以后临床广泛应用，成为 最常用的游离皮瓣之一最常用的游离皮瓣之一 皮

13、瓣特点： 血管分布恒定，蒂部管径在血管分布恒定，蒂部管径在 1.52.0mm1.52.0mm。 血管蒂长：血管蒂长：68cm68cm 易于剥离和切取易于剥离和切取 供区范围大：供区范围大：68cmX 1215cm68cmX 1215cm 供区不遗留明显的功能障碍供区不遗留明显的功能障碍 皮瓣血运丰富皮瓣血运丰富 可形成单纯的肌瓣可形成单纯的肌瓣 可用于进行肌肉功能的重建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，带蒂移植：胸部、上肢的组织缺损， 屈肘功能重建，乳房再造等屈肘功能重建，乳房再造等 游离移植：头、面、颈、四肢、躯游离移植：头、面、颈、四肢、躯 干等部位均可

14、应用干等部位均可应用 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 手术要点 转移背阔肌肌皮瓣在局部晚期乳腺癌手术 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 转移背阔肌肌皮瓣在局部晚期乳腺癌手术 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 转移背阔肌肌皮瓣在局部晚期乳腺癌手术 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

15、压包扎 引流管负压吸引 转移背阔肌肌皮瓣在局部晚期乳腺癌手术 手术技巧及注意事项 转移背阔肌肌皮瓣在局部晚期乳腺癌手术 1.体位 1.先仰卧位；2.侧卧位；3.最后仰卧位 转移背阔肌肌皮瓣在局部晚期乳腺癌手术 2.保护胸背血管蒂 胸背血管 胸外侧血管 转移背阔肌肌皮瓣在局部晚期乳腺癌手术 3.防止肌皮瓣血管蒂扭转 转移背阔肌肌皮瓣在局部晚期乳腺癌手术 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 转移背阔肌肌皮瓣在局部晚期乳腺癌手术 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 转移背阔肌肌皮瓣在局部晚期乳腺癌手术 我院乳腺中心开展转移背阔肌肌皮瓣修

16、复术病例资料 姓名年龄分期 治疗 陈XX53YbLDMF 曾XX66YbLDMF 李XX47YcLDMF 张XX37YbLDMF 转移背阔肌肌皮瓣在局部晚期乳腺癌手术 临床体会 转移背阔肌肌皮瓣在局部晚期乳腺癌手术 体会1 严格掌握适应症 防止并发症发生 转移背阔肌肌皮瓣在局部晚期乳腺癌手术 Indications and complications of latissimus dorsi myocutaneous flaps in oncologic breast surgery. METHODSMETHODS The use of the latissimus dorsi myocutan

17、eous 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 analysed RESULTSRESULTS The indication was to co

18、ver 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 do

19、nor 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. CONCLUSIONSCONCLUSIONS The use of the LDMF made w

20、ide 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 转移背阔肌肌皮瓣在局部晚期乳腺癌手术 体会2 术后开始辅助放射治疗的时间选择

21、 转移背阔肌肌皮瓣在局部晚期乳腺癌手术 Use of the extended V-Y latissimus dorsi myocutaneous flap for chest wall Use of the extended V-Y latissimus dorsi myocutaneous flap for chest wall reconstruction in locally advanced breast cancerreconstruction 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 robus