RU2523649C1 - Method of organ-preserving treatment of breast cancer - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: planned partial mastectomy and a rounded scar location are marked. A ringed tool is used to make a rounded incision with a patient's skin left intact. A lower glandular crus is formed to a submammary fold. The formed crus is de-epithelised. A mammary sector containing the tumour is incised together with a nipple-areola complex. The patient's mammary skin area on the lower glandular crus is placed within the removed areola. Skin-glandular flaps are sutured together above the de-epithelised area of the crus. A subcuticular continuous suture is applied.

EFFECT: method enables removing up to a half of a mammary tissue with the acceptable aesthetic effect.

1 ex, 4 dwg

Description

The invention relates to medicine, namely to surgery, and can be used in radical organ-preserving treatment of breast cancer (hereinafter referred to as MF), with tumor localization in central quadrants.

The generally accepted criteria for selecting patients for organ-preserving treatment are: the size of the tumor node up to 3 cm, slow or moderate monocentric tumor growth, the absence of tumor invasion in the nipple-areolar complex and pectoral muscles, and the absence of cancerous infiltration in the cellulose of regional zones, as well as the patient’s desire to preserve the breast. As well as the absence of severe decompensated concomitant diseases (cardiovascular, pulmonary pathology, diabetes mellitus, etc.).

The organ-preserving treatment of primary breast cancer today includes radical resections from one or 2 skin accesses (axillary and paraareolar), radical resections with a plastic fragment of the latissimus dorsi muscle, radical resections with simultaneous reconstruction with a silicone endoprosthesis or tissue expander, subtotal radical resections with movement fragment of the proximal rectus abdominis muscle. All of the above methods involve the removal of a tumor in a single block, 4-5 cm from its palpable edges, a fragment of the fascia of the pectoralis major muscle, axillary, subscapular and subclavian tissue with lymph nodes, followed by replacement of the mammary gland tissue with some other material ( adipose tissue, muscle or silicone endoprosthesis), minimizing the manipulation of the remaining glandular tissue (Chissov V.I., Trakhtenberg A.Kh., Paches A.I. Atlas of oncological operations. - M. - 2008).

Known methods have several disadvantages that significantly reduce the aesthetic effect of the operation:

- operated MF becomes significantly higher compared to healthy;

- there is frequent deformation of the remaining part of the MF, in particular, the correct conical shape of the operated MF is violated;

- there is a lateral displacement of the nipple-areolar complex;

- a long hard-to-hide postoperative scar of the skin of the breast with a transition to the chest wall.

There is also known a method of extended radical resection of the breast, in which they perform isolated resection of the breast, axillary lymphadenectomy and parasternal lymphadenectomy (Sigal E.I., Ismailov A.Kh., Khamidulin R.A. “Surgical treatment of breast cancer of central and medial localization using video thoracoscopy "Minimally invasive surgery and anatomy in the clinic and experiment, pp. 122-123, Perm, 1998). This method also has a number of significant disadvantages:

- the operation is quite traumatic, since it involves the intersection of the cartilaginous segments of the II-IV ribs;

- an extended postoperative scar reduces the cosmetic effect of the operation.

Closest to the claimed method according to the set of methods used is breast plastic surgery, including resection of a part of the gland, cutting out the flaps with subsequent adhering of the lower flap, in which the upper flap is cut from the skin to the fascia of the pectoralis major muscle, it is divided into two parts - flat cutaneous-subcutaneous and rounded glandular fat on one nutrient leg, after which a resection is made and a lower flap is inserted between the parts of the upper one (RU 2116756). This method is adopted as a prototype. However, the known method cannot be used in the surgical treatment of malignant breast formations due to the fact that when it is carried out, only a fragmentary resection of the part of the tissue lying between the rounded glandular-fatty substrate and the lower flap is performed. The radicalism of the intervention requires excision of the gland tissue fragment with the tumor to the fascia of the pectoralis major muscle, departing at least 4 cm from the palpable boundaries of the formation.

The invention is aimed at solving the problem of improving aesthetic results after performing a radical organ-preserving surgical manual for breast cancer with tumor localization in the central quadrant.

Using in clinical practice the proposed method allows to achieve several technical (therapeutic) results:

- reducing the likelihood of complications due to the rejection of the use of allografts (flap of the latissimus dorsi muscle on the vascular pedicle, TRAM flap), silicone endoprostheses, as well as the maximum use of the patient’s own tissues;

- the ability to remove up to ½ of the breast tissue with an acceptable cosmetic result, due to the fact that the lost breast volume is made up by moving the previously cut lower glandular leg;

- restoration of the lower contour of the breast (submammary fold) identical in height to the contralateral breast;

- the possibility of forming an analogue of the removed nipple-areolar complex from the epidermis;

- scar formation at the lower, less noticeable, pole of the breast;

- preservation of sensitive nerves and branches of the internal thoracic artery.

These technical (therapeutic) results in the implementation of the invention are achieved due to the fact that, as in the known method, the treatment of breast cancer is carried out by resection of a part of the gland and cutting out the flaps with their subsequent dermization. Reconstruction of the breast is carried out by manipulation of the parenchyma of the gland.

A feature of the proposed method lies in the fact that they mark up the forthcoming resection of the breast, including the planned location of the analogue of the nipple-areolar complex. The lower glandular pedicle is formed, deepithelization of the formed pedicle is carried out, leaving a portion of the epidermis for the subsequent formation of an analog of the nipple-areolar complex. The breast sector containing the tumor is isolated and excised with the nipple-areolar complex. The lower glandular leg is moved to the area of the removed nipple-areolar complex, and it is fixed in the upper corner of the incision formed. An analogue of the nipple-areolar complex is formed, which is a portion of the breast’s own skin, moved to the area of the removed nipple-areolar complex on the lower glandular leg. Sutured skin-glandular flaps formed on the right and left of the lower legs above the de-epithelialized section of the legs. In this case, first, the subcutaneous fat layer is compared, and then an intracutaneous continuous suture is applied to the skin wound.

The lower cutaneous glandular pedicle is formed by a round incision made using a ring-shaped device that borders the nipple-areolar complex.

SUMMARY OF THE INVENTION

The inventive method develops a new direction in oncology - oncoplastic surgery.

Tumor localization in the central quadrant of the breast was previously an absolute indication for radical mastectomy. The main distinguishing feature of the proposed method is the ability to replenish the lost volume of the breast by moving the previously cut lower glandular leg - glandular fat flap from the lower quadrant of the breast when the tumor is localized in the central quadrants.

The method is as follows.

The first step is to determine the volume of tissue removed and calculate the approximate volume of the flap. At the preoperative stage, the MF is marked up in a patient standing position. The levels of the submammar fold, the present and planned line of location of the analogue of the nipple-areolar complex, are noted. Also mark the boundaries of skin incisions and the boundaries within which de-epithelization of the skin flap will be made.

The second stage is the formation of the lower cutaneous glandular pedicle. A rounded incision is performed using a metal ring that borders the nipple-areolar complex. From the lateral and medial edges of the nipple-areolar complex, the cuts extend vertically downward and parallel to each other. Upon reaching the submammary fold, the sections continue 3-4 cm medially and laterally on each side along the submammary fold.

Then, the formed pedicle is de-epithelialized, leaving also with the help of a metal ring in the upper pole a section of the epidermis comparable in size to the nipple-areolar complex.

In the third stage, the breast sector containing the tumor is isolated and excised along with the nipple-areolar complex, departing at least 4 cm from the palpable edges of the formation. The glandular tissue is dissected to the entire depth to the external fascia of the pectoralis major muscle. When dissecting a layer of subcutaneous fat and glandular tissue, the incision is made strictly vertically in order to maximize the complete comparison of the flaps in the future. Starting from the sucker region, moving outwards, the fascia of the anterior surface of the underlying sections of the pectoralis major muscle is excised to its lateral edge. The breast sector is removed along with the area of the skin containing the puncture channel after a preliminary biopsy.

The plastic stage of the operation consists in moving the lower glandular pedicle with the epidermis to the area of the removed nipple-areolar complex, its fixation, and the formation of the final appearance of the breast. Skin-glandular flaps formed on the right and left of the lower leg are sutured over the de-epithelialized section of the leg. First, a comparison of the subcutaneous fat layer is carried out, and then an intracutaneous continuous suture is applied to the skin wound. The formed analogue of the nipple-areolar complex, which is a portion of the breast’s own skin, moved to the area of the removed nipple-areolar complex on the lower glandular leg, is fixed with a continuous intradermal suture in the upper corner of the incision.

Lymphodissection is carried out according to the classical methodology (Chissov V.I., Trakhtenberg A.Kh., Paches A.I. Atlas of oncological operations. - M. - 2008).

As a result of the application of the proposed technique, a T-shaped suture remains on the reconstructed breast, the horizontal part of which is hidden in a submammary fold, and the vertical part smoothly passes into a rounded scar, imitating the nipple-areolar complex. If the patient wishes, simultaneous mastopexy or reduction mammoplasty of the contralateral breast can be performed.

In total, according to the claimed method, in the Department of General Oncology, P.A. Herzen 5 operations were performed. In all cases, a good and excellent cosmetic effect was obtained. Postoperative observation showed no early postoperative complications.

Radical resection with plastic surgery of the lower glandular pedicle with removal of the nipple-areolar complex is performed according to general indications in terms of surgical or combined treatment of breast cancer. When using the proposed method, it is possible to fully replenish the volume of removed breast tissue during localization in the central departments. The cosmetic result of the operation increases due to the replenishment of the breast tissue with a displaced fragment of its own parenchyma and the improvement of its shape.

Execution example.

Patient Z., 37 years old, was treated in the Department of General Oncology, Moscow P.A. Herzen from 03/27/10 to 04/17/10 with a diagnosis of cancer of the right breast IIA Art. pT2N0M0. Tumor localization is the central quadrant.

On preoperative ethane, the MF was marked in the position of the patient standing. MF volume - No. 3 for bra cups (340 cc), there is ptosis of the III degree. A radical resection of the right breast with plastic surgery using our own tissues on the lower glandular leg was performed according to the method described above. MF tissue of 152 cubic meters was dissected. cm to the fascia of the pectoralis major muscle, the lower glandular peduncle was cut, its dermisation was made, including a section of the epidermis, similar in size to the RNS. This site was moved and fixed in the area of the remote nipple-areolar complex at the border of the upper quadrants. Skin-glandular flaps formed on the right and left of the lower leg are stitched over the de-epithelialized section of the leg. Fabrics are sutured in layers. 1 drain left.

In the postoperative period, no early postoperative complications were noted. The wound healed by first intention. Lymphorrhea is insignificant. Drainage removed on the 6th day. Sutures were removed on the 21st day. The volume of the right breast was 190 cubic meters. cm, the formed analogue of the nipple-areolar complex is located along the midclavicular line, there is no ptosis of the operated breast, submammary folds on the right and left are at the same level. During the dynamic observation of loco-regional recurrence was not detected.

Morphologically, the 2.5 × 1.52 × 1.4 cm node is represented by infiltrative streaming cancer of the III degree of malignancy (8 points). At the edges of the resection - without tumor growth. In all examined lymph nodes (11) of regional fiber, there is hyperplasia of lymphoid tissue, without metastases.

The stages of treatment are illustrated by the following graphic material.

Figure 1 shows:

1 - cut lines;

2 - removable breast tissue from the nipple-areolar complex.

Figure 2 shows the cut lower glandular leg, where

3 - adermized cut bottom leg;

4 - a bed of a tumor.

Figure 3 shows the plastic tissue of the breast, where

5 - adermized lower leg, which will be immersed under the lateral and medial flaps;

6 - lateral and medial flaps.

Figure 4 shows the formed MF, where

7 - lines of the skin suture.

Claims (1)

A method for organ-preserving treatment of breast cancer with localization of a tumor in the central quadrant, including resection of a part of the gland, cutting out flaps with their subsequent adhermization and reconstruction of the mammary gland by manipulating the gland parenchyma, characterized in that the forthcoming breast resection is marked out, including the planned location the location of the analogue of the nipple-areolar complex, form the lower glandular leg, by means of a round incision made using a device in the form of rings , bordering the nipple-areola complex, from the lateral and medial edges of the nipple-areola complex, the incisions continue vertically down and parallel to each other, when the submammary fold is reached, the incisions continue 3-4 cm medially and laterally on each side along the submammary fold, de-epithelization formed legs with leaving a portion of the epidermis for the subsequent formation of an analog of the nipple-areolar complex, a sector of the mammary gland containing the tumor is isolated and excised with with the cove-areola complex, move the lower glandular pedicle to the area of the removed nipple-areolar complex, fix it in the upper corner of the formed incision, form an analog of the nipple-areola complex, which is a section of the breast’s own skin, moved to the area of the removed nipple-areola complex on the lower glandular the leg, sutured skin-glandular flaps formed on the right and left of the lower leg above the de-epithelialized portion of the leg, while first matching the subcutaneous ovogo layer, and then placing a continuous seam intradermal skin wound.

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