乳头保留乳房切除术前新辅助化疗

　　随着乳头保留乳房切除术的需求增加，外科医师不断扩大患者入选标准，一部分术前新辅助化疗患者可能成为候选人。不过，由于目前文献报告结果不一，故术前新辅助化疗对术后并发症的影响尚不明确。

　　2019年5月23日，美国乳腺外科医师学会和肿瘤外科学会《肿瘤外科学报》在线发表华盛顿乔治城大学医院、纽约大学医疗中心的研究报告，探讨了术前新辅助化疗与乳头保留乳房切除的时间安排和术后并发症。

　　该单中心回顾研究对1989～2017年华盛顿乔治城大学医院进行乳头保留乳房切除术的患者进行病案复习，收集患者的人口统计学、手术干预、全身治疗、并发症发生率数据。主要结局为术后30天并发症，包括乳头乳晕坏死、皮瓣坏死、感染、伤口裂开、血肿、血清肿。次要结局包括化疗与手术干预之间的时间安排特征，以及对并发症发生率的影响。对每个乳房进行独立分析，并且对术前化疗或首先手术的乳房进行比较。

　　结果，该研究对832个乳房进行分析，其中术前化疗88个（10.6%）、首先手术744个（89.4%）。

　　术前化疗组与首先手术组相比，术后并发症发生率：

• 乳头乳晕坏死：0%比2.7%（P=0.256）

• 血肿或血清肿：0%比2.3%（P=0.242）

• 皮瓣坏死：2.3%比3.9%（P=0.764）

• 伤口裂开：2.3%比1.9%（P=0.639）

• 感染：4.6%比3.5%（P=0.234）

• 所有并发症：5.7%比10.6%（P=0.119）

　　对年龄、体重指数、吸烟、既往放疗等影响因素进行校正后，术前化疗并非并发症的预测因素。

　　术前化疗完成至手术的时间为中位40.5天（四分位范围31.3～55.3，范围20～165天），并且间隔缩短与并发症发生率增加无显著相关性。

　　因此，该研究结果表明，术前化疗患者与首先手术患者相比，乳头保留乳房切除术后并发症发生率相似，术前化疗患者的乳头乳晕或皮瓣坏死、血肿或血清肿、意外再次手术风险并未显著增加，术前化疗不应被视为乳头保留乳房切除术的禁忌证。

Ann Surg Oncol. 2019 May 23. [Epub ahead of print]

Neoadjuvant Chemotherapy and Nipple-Sparing Mastectomy: Timing and Postoperative Complications.

Alex J. Bartholomew, Ornela A. Dervishaj, Michael Sosin, Lauren T. Kerivan, Shawndeep S. Tung, Diana L. Caragacianu, Shawna C. Willey, Eleni A. Tousimis.

MedStar Georgetown University Hospital, Washington, USA; NYU Langone Health, New York, USA.

BACKGROUND: As the demand for nipple-sparing mastectomy (NSM) increases and surgeons expand the eligibility criteria, a subset of patients may become candidates following neoadjuvant chemotherapy (NACT). However, the impact of NACT on postoperative complications remains unclear as the current literature is discordant.

METHODS: A single-institution, retrospective chart review was performed on patients undergoing NSM from 1989 to 2017. Patient demographics, surgical intervention, systemic treatment, and complication rates were collected. Primary outcomes were 30-day postoperative complications, including nipple-areolar necrosis, skin flap necrosis, infection, wound dehiscence, hematoma, and seroma. Secondary outcomes included characterization of the timing between chemotherapy and surgical intervention, and the impact on complication rates. Each breast was considered independently for analysis, and breasts undergoing either NACT or primary surgery (PS) were compared.

RESULTS: Of the 832 breasts included, 88 (10.6%) received NACT and 744 (89.4%) underwent PS. Baseline complication rates were not significantly different between the NACT group and the PS group (5.7% vs. 10.6%; p = 0.119). When controlling for age, body mass index (BMI), smoking, and prior radiation, NACT was not a predictor of complications. Time from completion of NACT to PS occurred at a median of 40.5 days (interquartile range 31.3-55.3), and decreased intervals were not associated with increased complication rates.

CONCLUSIONS: Postoperative complications following NSM in patients completing NACT are comparable with those receiving PS. Patients undergoing NACT do not have a significantly increased risk of necrosis, unintended reoperations, or nipple loss. NACT should not be considered a contraindication for NSM.

DOI: 10.1245/s10434-019-07418-4