乳腺癌(4)

Breast Cancer

乳腺癌

Treatment

治疗

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.

大多数病人主要用外科治疗，通常伴随放射疗法。也可以采用化疗、激素疗法或两者兼用，这要取决于肿瘤及病人性质。炎性或晚期乳腺癌病人主要采用系统疗法，炎性乳腺癌则还要进行外科和放射治疗。外科疗法对晚期乳腺癌通常无效。乳头偑吉特病治疗与其他乳腺癌相同，但只用局部切除就能成功治疗的病人极少。

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：多数DCIS病人可用单纯乳房切除术治愈。不过，更多的病人采用广泛切除疗法，尤其是当病灶< 2.5 cm，组织学特征较为有利，或者，在肿瘤大小及组织学特征不太有利情况下，采用广泛切除＋放射疗法。

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.

对浸润性乳腺癌病人来说，不管是采用改良式根治性乳房切除（单纯乳房切除＋淋巴结清扫)还是乳房保守性存手术（局部病灶切除，广泛切除，部分乳房切除，或四分切除法)＋放射疗法，其存活率并无显著差别。因此，病人喜好可以在一定范围内引导治疗选择。乳房保存手术＋放射疗法的好处在美容方面。采用这种疗法的病人，有15%取得了很好的美容结果。不过，乳房全切及无肿瘤边缘的需要比美容更重要。两类手术都应作淋巴结切除或淋巴结标本采样。常规使用广泛性手术并不恰当，因为淋巴结切除的主要价值在于诊断，而非治疗。然而，冰冻切片分析结果可能改变手术的需要程度。一旦结节阳性，有些外科医生通常会先得到入侵性手术协议，有些会叫醒病人，并在必要时二次手术。

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.

有些医生会在切除和实施放射疗法前做术前化疗缩小肿瘤，这样，有些可能需要乳房切除的病人就可以做乳房保守性手术。早期的资料表明，这种手术不会影响存活。乳房切除后进行放射疗法极大地减少了胸壁及局部淋巴结局部性癌灶复发率，可以改善原发性肿瘤> 5 cm或累及腋淋巴结≥ 4的病人的总存活率。放射疗法的负作用通常是暂时的，轻微的。

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.

重建手术包括肌下或皮下（较少用)硅酮安置盐水植入、使用组织扩张器和后期植入、背阔肌或下腹直肌肌瓣转移及臀大肌乳房内血管吻合型游离瓣建立。DCIS已越来越多地采用游离瓣转移。

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.

经过腋淋巴切除或放射疗法，同侧胳膊的淋巴引流可能受损，有时会因淋巴水肿引起严重肿胀。淋巴引流受损程度与切除的淋巴结数量大致成比率。患侧应避免行静脉穿刺、量血压和静脉输液。淋巴水肿应由经过专门训练的治疗师治疗，每天一至两次专门按摩可帮助拥塞部位液体流向功能正常的淋巴盆。手工引流后就立即进行低伸张绑扎，病人应按规定进行锻炼。淋巴水肿消除后，一般需要1－4周，病人继续进行每天锻练，并不定期地对患肢进行整夜绑扎。

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

辅助性全身疗法：LCIS病人每天服用他莫昔芬治疗。如不适合服用节莫昔芬或病人拒绝接受，可考虑双侧乳房切除术。

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.

浸润性乳腺癌病人应在手术后不久就开始化疗或激素疗法，并持续数月或数年。这些疗法可延迟或阻止几乎所以病人的复发，延长某些病人的存活期。不过，有些专家认为，如果未累及淋巴结，< 1 cm的肿瘤并不需要这些疗法(尤其是绝经后病人)，因为预后已经很好。如果肿瘤> 5 cm，有些专家在手术前开始辅助性全身疗法。

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).

不管癌症处于何种临床病理阶段，与化疗或激素疗法相关的复发及死亡危险的相对减少都是一样的。因此，对复发或死亡危险较大的病人来说，其绝对好处也更大（即，20%就可以将复发率由10%减到8%，而50%的复发率只能减到40%)。辅助性化疗可以将绝经前病人的年死亡机率平均减少25%至35%。绝经后病人的减少率约1/2(9－19%)，10年存活期的绝对好处要小得多。绝经后ER肿瘤病人从辅助性化疗受益最多（见表3：乳房疾病：理想的乳腺癌辅助性全身疗法)。

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.

联合化疗方案（如环磷酰胺、甲氨蝶呤、＋5－氟尿嘧啶；多柔比星＋环磷酰胺)比单种药物更有效。最好是服用4－6个月，效果与服用6－24个月相同。急性不良作用要看治疗方案，但通常包括恶心、呕吐、粘膜炎、疲劳、脱发、骨髓抑制及血小板减少等。多数方案很少有长期的不良作用，因感染或出血引起的死亡罕见（< 0.2%)。增加剂量密度（增加治疗频度)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确定。

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

与标准疗法相比，大剂量化疗＋骨髓或干细胞移植并无治疗优势，不应使用。