RU2731523C2 - Method of breast resection with cancer in lower quadrants i or ii stage - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to operative surgery and oncology. Skin is incised and the required volume of the mammary gland with tumor node is removed. Note here that skin is incised laterally and medially at acute angle to submammary fold at 2 cm from tumor node and connected by third incision in the form of isosceles triangle so that submammary fold is triangle base. Gland tissue with a tumor node in the center is removed and a major pectoral muscle underlying fascia. Isosceles triangle is closed; a provisional suture is applied, deviating from the lateral cuts-legs of the triangle at distance of 0.5 cm, above the base, and the suture is tied, a T-shaped suture is formed. Then, the base of the triangle is closed in layers with transition to the side walls and the second semi-oval skin incision is made in the axillary region, subcutaneous fat is dissected and a sentinel lymph node is separated and an axillary-subscapular lymphadenectomy is performed, a wound in the axillary region is closed in layers. Additionally, the silicone drainage is installed into the axillary area through a counter-aperture.

EFFECT: method enables improving the aesthetic effect after the organ-preserving operation, achieving a stable and symmetrical shape of the mammary glands – operated and healthy, reducing duration of anesthesia, blood loss and traumatism due to absence of necessity of corrective operations on the second mammary gland.

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Description

The invention relates to medicine, namely to breast surgery (MF) for cancer in the lower quadrants when performing organ-preserving surgical interventions.

A known method of removing a tumor node at the border of the outer squares and somewhat lower, radical resection is carried out by performing two semi-oval incisions bordering the sector of the mammary gland to be removed and converging in the nipple region and at the edge of the latissimus dorsi muscle. The gland tissue is dissected to the full depth, excised with the underlying fascia covering the pectoralis major muscle, after separation of the gland tissue and withdrawal of this muscle inwardly, the breast sector with subclavian, axillary and subscapularis tissue and lymph nodes is removed in one block (A.D. Kaprin, A. D. Zikiryakhodzhaev. Oncoplastic surgery of the breast // M., 2017, 293 p.).

The disadvantages of this method are that often there is a deformation and change in the shape of the mammary gland, especially with its small size, and the closer to the border of the lower quadrants the tumor node, the more pronounced deformation of the mammary gland, namely, "pecking" of the nipple-areola nipple. To preserve the shape of the mammary gland, options for oncoplastic resections (T-inverse, Hall-Findley) have been proposed; when performing these operations, a good aesthetic effect is achieved, but the negative aspect of this operation is only pronounced asymmetry with the contralateral mammary gland and the need for symmetrizing surgery on the contralateral mammary gland, which lengthens the operation time and increases the rehabilitation period. With the localization of the tumor node in the lower inner quadrant, various options for the rotation of glandular flaps are used after performing a known incision of the T-inverse type (A.D. Kaprin, A.D. Zikiryakhodzhaev. Oncoplastic breast surgery // M., 2017, 293 p.) ... A possible complication of these operations is partial necrosis of the skin of the mammary gland and the nipple-areola complex in the case of intersection of the feeding vessels during rotation of the breast flaps.

A variant of the operation is possible using the movement of breast tissue from the nearest parts of the breast, the so-called "no name" flap ("by name Par"). A flap is cut out in the shape of a triangle in the upper-inner or lower-inner part of the mammary gland, from the areola (acute angle) to the upper border of the mammary gland or submammary fold (base of the triangle). The defect is closed by rotating the upper-outer or lower-outer part of the breast.

All of the above methods have certain disadvantages, since the shape of the mammary gland and the location of the nipple-areola complex change significantly due to pronounced downward rotation in the case of localization of the tumor node on the border of the lower quadrants. There is an asymmetry of the mammary glands, which can only be prevented by additional symmetrizing surgery on the opposite mammary gland.

There is a known method of resection of the mammary gland with a T-shaped scar, while the skin incision has the form of an anchor or an inverted letter T (Zikiryakhodzhaev A.D., Rasskazova E.A., Tyischenko E.V. Oncoplastic resection of the mammary gland with simultaneous reconstruction of local tissues ( use of the lower glandular pedicle according to D. Hammond's SPAIR type and the T-inverse method) // Research and practice in medicine. No. 1, 2016-С.39-45).

However, this method involves the removal of the lower quadrants of the mammary gland, and the lost volume of the mammary gland is replenished by mobilizing the glandular pedicle, including a de-epithelialized glandular-fatty flap with the nipple-areola complex, its movement to the resection area and the formation of the final form of the breast. The exact place of the future nipple is the intersection point of the projection of the submammary fold and the middle meridian of the mammary gland. The new position of the areola is determined using a Wize keyhole stencil. The center of the rounded part of the stencil should coincide with the center of the future nipple. In the known method, the lower quadrants are removed and the breast tissue is displaced by an incision of the skin in the form of a triangle. In our invention, the breast tissue is moved and the nipple-areola complex is not moved.

The technical result of the proposed invention is the development of an optimal and stable aesthetic effect of resection in breast cancer with the localization of the tumor node in the lower quadrant in compliance with the principles of oncological radicalism.

Achievement of radical and aesthetic results in the implementation of the invention is achieved due to the fact that, as in the known method, a skin incision is made and the tumor node is removed.

образно на расстоянии 0,5 см от основания боковых разрезов накладывают провизорный шов, далее ушивают подкожную клетчатку основания треугольника с переходом на боковые и выполняют второй полуовальный кожный разрез в подмышечной области, рассекают подкожную клетчатку и выделяют сторожевой лимфатический узел и выполняют подмышечно-подлопаточную лимфаденэктомию, рану в подмышечной области послойно ушивают, дополнительно в подмышечную область устанавливают силиконовый дренаж через контрапертуру.The peculiarity of the proposed method lies in the fact that, departing from the tumor node 2 cm, a skin incision is performed laterally and medially at an acute angle to the submammary fold and connected by a third incision in the form of an isosceles triangle, so that the submammary fold is the base of the triangle, the tissue of the gland with the tumor node in center and underlying fascia of the pectoralis major muscle, the wound is sutured

figuratively at a distance of 0.5 cm from the base of the lateral incisions, a provisional suture is applied, then the subcutaneous tissue of the base of the triangle is sutured with the transition to the lateral ones and a second semi-oval skin incision is made in the axillary region, the subcutaneous tissue is dissected and the sentinel lymph node is isolated and axillary-subscapularis lymphadenectomy is performed, the wound in the axillary region is sutured in layers, additionally a silicone drainage is installed in the axillary region through a counter-opening.

There are no analogues of the method for closing a triangular skin incision in the mammary gland in domestic and foreign literature. Since a triangular skin incision can be sutured only by performing an additional skin incision with the formation of a triangle opposite to the first one and displacement of tissues with the formation of a Z-shaped incision.

The invention is illustrated by a detailed description, a clinical example and illustrations, which depict:

FIG. 1 - photo of a skin incision.

FIG. 2 - the photo shows the volume of the removed sector of the breast.

FIG. 3 - the final view of the postoperative scar.

FIG. 4 - photo of patient X., before the operation: a) in frontal and b) lateral projection.

FIG. 5 - photo of patient X., 2 weeks after the operation: a) in frontal projection;

образный шов.b) in the side; in)

shaped seam.

The indications for this invention are for patients diagnosed with breast cancer stages I-II, both at stage I of treatment, and after neoadjuvant drug therapy with localization of the tumor node in the lower quadrants.

The method is carried out as follows.

образно на расстоянии 0,5 см от основания боковых разрезов накладывают провизорный шов (Фиг. 3). Ушивают подкожную клетчатку основания треугольника с переходом на боковые и выполняют второй полуовальный кожный разрез в подмышечной области, рассекают подкожную клетчатку и выделяют сторожевой лимфатический узел и выполняют подмышечно-подлопаточную лимфаденэктомию. Рану в подмышечной области послойно ушивают, дополнительно в подмышечную область устанавливают силиконовый дренаж через контрапертуру.On the border of the lower quadrants of the breast, departing 2 cm from the tumor node, a skin incision is made laterally and medially at an acute angle to the submammary fold and connected by a third incision in the form of an isosceles triangle, so that the submammary fold is the base of the triangle (Fig. 1). Remove the tissue of the gland with the tumor node in the center and the underlying fascia of the pectoralis major muscle (Fig. 2). The wound is sutured

figuratively at a distance of 0.5 cm from the base of the lateral incisions, a provisional seam is applied (Fig. 3). The subcutaneous tissue of the base of the triangle is sutured with the transition to the lateral ones and a second semi-oval skin incision is made in the axillary region, the subcutaneous tissue is dissected and the sentinel lymph node is isolated, and axillary-subscapularis lymphadenectomy is performed. The wound in the axillary region is sutured in layers, in addition, a silicone drainage is installed in the axillary region through a counter-opening.

In order to close a triangular skin incision in our method, we do not use separation of breast tissue or performing an additional skin incision to the axillary region with complete separation of the lower outer and outer quadrants of the mammary gland from the fascia of the pectoralis major muscle and displacement of these quadrants towards the breast defect.

Clinical example.

Patient X., 59 years old, was admitted to the Department of Oncology and Reconstructive Plastic Surgery of the Breast and Skin of the Moscow Oncological Institute. P.A. Herzen with a diagnosis of Cancer of the left breast at the stage of treatment, cT2N0M0G3, ycT2N0M0PR. Luminal type B, Her2-negative. Condition after NAPHT (Fig. 4).

From the anamnesis: from 28.02.2019 to 22.08.2019, NAPHT was performed at stage 1 according to the 4AC + 12T scheme with a positive effect in the form of a decrease in the tumor node in the mammary gland.

Clinically, in the left mammary gland at the border of the lower quadrants in the area of the transitional fold, a nodular formation with retraction of the skin above it is determined. In the right mammary gland, clear nodules are not palpable.

MRI of the mammary glands from 02.28.2019: Left mammary gland: in the lower quadrants at a distance of 1 mm from the areola, 16 mm from the pectoralis major muscle, 19 mm from the lateral edge and 5 mm from the lower edge of the parenchyma of the gland, a formation with fuzzy irregular contours with dimensions 46x37x34 is determined mm, rapidly and heterogeneously accumulating contrast agent with signs of washout in the delayed phase of contrasting, diffusion limitation.

MRI of the mammary glands from 08/11/2019: On the border of the lower quadrants of the left mammary gland, a formation of 25 × 17 × 16 mm, a decrease in the size of the tumor node was noted. The right mammary gland was without nodules.

According to CT of the chest, scintigraphy of the bones of the skeleton, ultrasound of the abdominal organs without distant metastases.

09/26/2019 - resection of the left breast with the definition of a "sentinel" lymph node.

Under intravenous anesthesia, a skin incision was made according to the markings, in the form of an isosceles triangle, where the lateral legs are 8 cm, and the base is 4 cm. The gland sector with the tumor node and the fascia of the pectoralis major muscle was removed. 3 radiopaque clips are installed in the area of the removed sector. Through a separate semi-oval skin incision in the axillary region, 3 sentinel lymph nodes were isolated using a gamma detector intraoperatively and the lymph nodes were removed. An urgent cytological examination of scraping from 3 lymph nodes and four edges of the wound revealed no cancer cells. The isosceles triangle was closed, a provisional suture was applied, stepping back from the lateral incisions (legs of the triangle) at a distance of 0.5 cm above the base, and a thread was tied and a ┴-shaped suture was formed. Next, the base of the triangle was sutured in layers with the transition to the side walls (legs).

A silicone drainage tube was placed in the axillary region through a counter-opening. An intradermal suture was performed with an absorbable suture.

An excellent aesthetic effect of the shape of the mammary gland was obtained, there was no deformation of the gland, and there was no need for additional symmetrizing surgery on the contralateral breast. The operation time is 40 minutes. There are no intraoperative complications.

Routine histological examination: AE 40146-73 / 0.

Macroscopic description No. 1: "Sentinel" lymph nodes - two fragments of adipose tissue measuring 2.5 × 2 × 1.5 cm and 4 × 1.5 × 1 cm, with 3 "sentry" soft-elastic lymph nodes up to 2 cm in diameter. Fragment breast tissue measuring 7 × 3.5 × 6 cm, with a skin flap measuring 8 × 4 cm, without the nipple and areola. On the incision, in the gland tissue, 2.5 cm from the upper, 1.3 cm from the lower, 0.5 cm from the cutaneous, 2 cm from the fascial, 1 cm from the lateral and 1 cm from the medial edges of the resection - a dense tumor node without clear boundaries, gray, measuring 3.5 × 2 × 3.5 cm. The rest of the gland tissue is represented by lobular adipose tissue with wide, whitish layers.

Microscopic description No. 2: Infiltrative breast cancer without signs of specificity, solid-trabecular structure with hyalinosis and stromal sclerosis is determined in the breast tissue, corresponding to the macroscopically described tumor node. The tissue of an invasive tumor with signs of therapeutic mild pathomorphosis in the form of dystrophy of a part of tumor cells, pronounced fibrosis of the stroma, focal lymphocytic inflammatory infiltration. Perineural and perivascular growth is noted, without reliable signs of lymphovascular invasion. In the surrounding tissue of the mammary gland, among the invasive tumor and along its periphery, there is carcinization of lobules, complexes of intraductal carncinoma in situ of a solid and cribrous structure, focal fibrosis of the stroma. In the breast tissue far from the tumor - apocrine metaplasia of the epithelium of a part of the ducts. There is no tumor growth at the edges of the resection.

Conclusion: Infiltrative breast cancer without signs of specificity with signs of therapeutic pathomorphosis of mild severity (1 degree).

There are no tumor metastases in 3 sentinel lymph nodes of regional tissue.

The patient was discussed at a consultation on 10/16/2019 with the participation of a chemotherapist, radiologist, surgeon, radiation therapy was recommended at stage 3, then hormone therapy (aromatase inhibitors).

As a result of this operation, the postoperative scar is hardly noticeable due to localization in the lower quadrants of the mammary gland and in the axillary region (Fig. 5a, b, c). There were no postoperative complications.

The use of the proposed method in clinical practice allows achieving several results:

- improve the aesthetic effect after breast-conserving surgery;

- achieving symmetry of the mammary glands - operated and healthy;

- to reduce the duration of anesthesia, blood loss and trauma due to the absence of the need for corrective surgery on the contralateral mammary gland.

Claims (1)

A method of breast resection for cancer in the lower quadrants of stage I or II, including a skin incision and removal of the required volume of the mammary gland with a tumor node, characterized in that, departing 2 cm from the tumor node, a skin incision is performed laterally and medially at an acute angle to the submammary fold and connect with a third incision in the form of an isosceles triangle, so that the submammary fold is the base of the triangle, remove the tissue of the gland with the tumor node in the center and the underlying fascia of the pectoralis major muscle, close the isosceles triangle, apply a provisional suture, departing from the lateral incisions-legs of the triangle at a distance of 0, 5 cm, above the base and tie a thread, form

a shaped suture, then the base of the triangle is sutured in layers with the transition to the side walls and a second semi-oval skin incision is made in the axillary region, the subcutaneous tissue is dissected and the sentinel lymph node is isolated and the axillary-subscapular lymphadenectomy is performed, the wound in the axillary region is sutured in layers, additionally in the axillary region. silicone drainage through counter-opening.

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