目的:乳腺手术是乳腺癌治疗的基石。它的适应症和程序在不断发展。要更新最佳实践,四个问题已提交给法国国家妇科和妇产科学院(CNGOF)的Senology委员会(SC),涵盖肿瘤手术的适应症和模式1)最初,2)新辅助系统治疗后,3)在局部复发的情况下,和4)适用于该手术的护理质量和安全性指标。
方法:CNGOFSC基本上基于法国癌症研究所关于乳腺浸润性癌的临床实践建议和指南。排除标准为原位癌,肉瘤和腋窝手术。
结果:要定义乳房手术的类型,四个参数的知识是必不可少的:患者的风险水平,转移的存在,乳腺肿瘤的大小及其病灶(通过临床/乳房X线照相术/超声三脚架评估)。1)在初始管理的情况下,乳房切除术的6个适应症是患者的选择(特别是在高风险的情况下),放疗的禁忌症,炎症性癌症(T4d),切缘阳性的手术(经过几次手术干预),在具有多个病灶的肿瘤的情况下,不能作为整体进行的手术,和不良的预期美学结果。所有其他情况都应保守对待。2)新辅助系统治疗后适用相同的标准,无论初始肿瘤的大小(不包括癌性乳腺炎)和病灶,保守治疗仍然可能。3)在局部复发的情况下,全乳房切除术是参考治疗,为没有第二次复发危险因素的患者保留第二次保守治疗,没有不良预后因素,经过多学科会议的验证。4)四个质量和安全指标适用于乳房手术:必须在获得组织学诊断后进行,在不到6周的乳房X线照相术,在超过80%的病例中进行一次手术,并在保守治疗的情况下进行局部放疗。
结论:乳房手术的适应症和方式正在迅速发展。为了提高美学效果,致癌技术,立即乳房重建,皮肤或乳头-乳晕复合体的保存需要进一步开发和长期评估。在法国,这些发展必须伴随着针对乳腺外科医生的培训政策。
OBJECTIVE: Breast surgery is the cornerstone of breast cancer treatment. Its indications and procedures are constantly evolving. To update best practices, four questions were submitted to the Senology Commission (SC) of the Collège national des gynécologues et obstétriciens français (CNGOF), covering the indications and modalities of tumor surgery: (1) initially, (2) following neoadjuvant systemic treatment, (3) in case of local recurrence, and (4) the quality and safety of care indicators applicable to this surgery.
METHODS: The CNGOF SC essentially based its responses on the clinical practice recommendations and guidelines of the French Cancer Institute concerning invasive carcinomas of the breast. Exclusion criteria were carcinoma in situ, sarcoma and axillary surgery.
RESULTS: To define the type of breast surgery, knowledge of four parameters is essential: the patient\'s level of risk, the presence of metastases, the size of the breast tumor and its focality (assessed by the clinical/mammography/ultrasound tripod). (1) In the case of initial management, the 6 indications for mastectomy are patient choice (particularly in case of high risk), contraindication to radiotherapy, inflammatory cancer (T4d), surgery with positive margins (after several surgical intervention), surgery that cannot be performed as a monobloc in the case of tumors with multiple foci, and poor expected aesthetic results. All other situations should be treated conservatively. (2) The same criteria apply after neoadjuvant systemic treatment, with conservative treatment still possible whatever the size (excluding carcinomatous mastitis) and focality of the initial tumor. (3) In case of local recurrence, total mastectomy is the reference treatment, with a second conservative treatment reserved for patients with no risk factors for a second recurrence, and no poor prognostic factors, after validation in a multidisciplinary meeting. (4) Four quality and safety indicators apply to breast surgery: it must be performed after obtaining a histological diagnosis, within less than 6 weeks of mammography, in a single surgery in over 80% of cases, and followed by local radiotherapy in the case of conservative treatment.
CONCLUSIONS: The indications and modalities of breast surgery are evolving rapidly. To improve aesthetic results, oncoplastic techniques, immediate breast reconstruction, and preservation of the skin or nipple-areolar complex need to be further developed and evaluated in the long-term. These developments must necessarily be accompanied in France by a training policy for breast surgeons.