Download 腔镜下皮下腺体切除、腋窝淋巴结清扫加假体植入术与传统保乳手术

A prospective comparison of endoscopic subcutaneous mastectomy plus
immediate reconstruction with implants versus breast conserving surgery
for breastcancer
FAN Lin-jun, JIANG Jun, YANG Xin-hua, ZHANG Yi, LI Xing-gang, CHEN Xian-chun and
ZHONG Ling
Key words: breast neoplasms; endoscopes; subcutaneous mastectomy; segmental mastectomy;
breast implants
Background Breast conserving surgery (BCS) has been a normative process for the
treatment of clinical earlier breast cancer, while endoscopic subcutaneous mastectomy (ESM)
plus immediate reconstruction with implants is a new choice in recent years. The objective of
this prospective study was to evaluate the clinical outcomes of these two operations.
Methods From March 2004 to October 2007, 43 patients with breast cancer underwent
ESM plus axillary lymph node dissection and immediate reconstruction with implants and 54
patients underwent BCS in our center. The clinical pathological characteristics, operation
safety and therapeutic effects were compared between the two groups.
Results There were no differences in the age, clinical stage, histopathological type of tumor,
operative bleeding volume, postoperative drainage time and postoperative complications
between the two groups (P＞0.05). The postoperative complications were necrosis of partial
nipple and superficial skin flap in ESM patients, whereas hydrops in axilla and residuary
cavity in BCS patients. And there was no remarkable difference in satisfactory rate of
postoperatively cosmetic result between ESM (88.4%, 38/43) and BCS (92.6%, 50/54)
patients (P＞0.05). During the follow-up for 6 months to 4 years, all cases treated with ESM
were disease-free, but 3 cases underwent BCS were found metastasis or recurrence, one of
which died of multiple organ metastasis.
Conclusions Considering the wide indications, high safety and favorable cosmetic result,
ESM plus axillary lymph node dissection and immediate reconstruction with implants is a
new choice of the surgery in breast cancer.
Breast conserving surgery, the normative process for the treatment of clinical earlier breast
cancer, is not markedly different to modified radical mastectomy in long-term survival but in
local recurrence rate even though postoperative radiotherapy is completed regularly.1-3
Besides, the postoperative cosmetic result of smaller breast will still be affected after a wide
Breast Disease Center, Southwest Hospital, Third Military Medical University, Chongqing 400038, China
Corresponding to: Prof. JIANG Jun, Breast Disease Center, Southwest Hospital, Third Military Medical
University, Chongqing 400038, China (Tel: 86-23-68754160. Fax: 86-23-65310689. Email:
[email protected])
This study was supported by Clinical Study Foundation of Southwest Hospital, Third Military Medical
University (No. SWH2006B012).
local excision.4, 5 To explore a new appropriate procedure, we compared the clinical outcomes
of endoscopic subcutaneous mastectomy (ESM) plus axillary lymph nodes dissection and
immediate reconstruction with implants and breast conserving surgery (BCS) from March
2004 to October 2007.
METHODS
Patients enrollment and grouping
This prospective study enrolled 97 patients with breast cancer. All patients were told and
allowed to select procedures preoperatively, then assigned to ESM group (n=43, treated with
ESM plus axillary lymph nodes dissection and immediate reconstruction with implants) and
BCS group (n=54, treated with BCS) according to their preference and disease condition.
The inclusion criteria of patients were: female; age <55 years; invasive breast cancer
confirmed histopathologically by preoperative core needle biopsy or excision biopsy; the
largest tumor diameter smaller than 3 cm primarily or after neoadjuvant chemotherapy; no
deviation or retraction of nipple; no obviously enlarged or fused axillary lymph nodes; no
distant metastasis found by auxiliary examination; consent of neoadjuvant chemotherapy with
TE regimen (taxol 175 mg/m2, epirubicin 80 mg/m2, IV day 1; cycled every 21 days for 1-4
cycles).
In addition, patients in ESM group should meet: each breast <350 ml without obvious
mastoptosis; no dimple sign or Peau deorange on the surface of tumor; the distance between
tumor surface and skin was more than 0.5 cm by preoperative ultrasound examination;
intraoperative frozen section analysis (FSA) of the glands inferior to nipple and superior to
tumor showed no cancer infiltration; and the prosthesis could be accepted psychologically. At
the same time, patients in BCS group should meet: the preoperative ultrasound and
molybdenum target X-ray indicated no multicentric lesions; the distance between tumor
margin and areola margin was more than 1 cm and intraoperative FSA displayed no cancer
infiltration to the incisal margin; no previous radiotherapy on the diseased breast and
ipsilateral chest wall; no collagenosis such as systemic lupus erythematosus and scleroderma
or other contraindications to radiotherapy; patients were willing to accept BCS and
postoperative radiotherapy.
Operation procedures
ESM group
ESM Under general anesthesia with tracheal intubation, the patient was placed in supine
position with diseased side raised to 15° to 30°, ipsilateral arm abducted to 90° and fixed on
headframe. Three 0.5-cm incisions were made at the axillary transverse striation beyond the
superior lateral margin of breast (superior incision), the midaxillary line at nipple level (lateral
incision) and anterior axillary line at the inferior lateral margin of breast (inferior incision),
respectively. Lipolysis solution (250 ml of sterile purified water, 250 ml of physiological
saline injection, 20 ml of 2% lidocaine, and 1 ml of 0.1% adrenaline mixed as 521 ml solution)
was injected into the subcutaneous and retromammary spaces through the three incisions. The
amount of solution injected (about 500-800 ml each side) should be adjusted according to the
size of the breast. At about 10 minutes after injection of lipolysis solution, sufficient
liposuction was performed in subcutaneous and retromammary spaces of breast using a metal
aspiration tube with side apertures (a suction tip used for uterine curettage) via the lateral and
inferior incision, especially the fat inferior to nipple and superior to tumor. Then three 5-mm
trocars were placed via those three incisions and CO2 was insufflated to establish an operating
space, and the inflation pressure was maintained at 8 mmHg (Fig 1). After sufficient
liposuction, there remained only the Cooper ligaments between gland and skin, the major
ducts between gland and nipple, and the marginal glands connecting with surrounding fascia
around the retromammary space, which were transected using an electric hook to excise the
whole glands under endoscopic monitoring (Fig 2). Then the superior incision was prolonged
to 5 cm along axillary transverse striation to remove the glands. Furthermore, assisted by the
mark of tumor location, tissue inferior to nipple and superior to tumor were taken for
intraoperative FSA (Fig 3). After operation region flushing and thorough hemostasis,
endoscope and trocars were taken out.
Axillary lymph node dissection
Through the prolonged superior incision, axillary flaps
were dissociated; minor pectoral muscle was disclosed along the outer edge of major pectoral
muscle; and coracoclavicular fascia was opened at the outer edge of minor pectoral muscle to
expose the axillary vein. Then the axillary lymph nodes above level II were dissected.
Prosthesis implantation From the lateral border to the medial and inferior margin of major
pectoral muscle, the retropectoral space was fully separated via superior incision, and partial
attachment of the major pectoral muscle was cut off when necessary. In the light of the
excised gland volume and contralateral breast size, a suitable prosthesis (180-260 ml) was
selected and placed into retropectoral space (Fig 4), and adjusted to bisymmetry as far as
possible. One latex drainage tube was placed in residual cavity near the submammary fold,
educed from the inferior incision and fixed firmly; the other was placed at axilla and educed
from the lateral incision and fixed. After operation was completed, a mild compressive
dressing was applied for at least 2 weeks to avoid the prosthesis displacement upward.
BCS group
Lumpectomy Under general anesthesia with tracheal intubation, a transverse fusiform
incision was made for the tumor in upper inner and upper outer quadrants, and a radiate
fusiform incision for the tumor in lower quadrants, which was at least 1 cm away from tumor
border. Then the skin flaps with thin subcutaneous fat were dissociated to more than 2 cm
away from tumor margin, and the tumor with its surrounding normal tissue about 1 cm thick
were resected radially, whose incisal margins were marked for FSA. If FSA showed cancer
infiltration, the positive incisal margin should be further resected extendedly by 1 cm; if the
margin was examined to be positive again, modified radical mastectomy was performed.
Axillary lymph node dissection A 6-cm incision between the outer edge of major pectoral
muscle and the anterior edge of latissimus dorsi muscle was made along the axillary
transverse striation, through which the axillary lymph node dissection was performed in the
same way of ESM group. After the operation a drainage tube was placed at the axilla, and
followed by low negative pressure suction.
Postoperative management
As preventive medication, antibiotics were administered for 3-5 days after operation. The
drainage tube was removed when drain amount was less than 10 ml per day. Postoperative
chemotherapy regimen the same as neoadjuvant chemotherapy was applied for 4-6 cycles in
all patients. However, radiotherapy of breast was not performed routinely in ESM group but
in BCS group, while radiotherapy of internal mammary, axillary and infraclavicular regions
was performed in patients whose involved axillary lymph nodes were more than 4. After
radiotherapy, patients with positive estrogen receptor or progestogen receptor were managed
with endocrine therapy for 5 years.
Follow-up
After treatment, all patients were followed up by out-patient reexamination every 3-6 months,
and the patients defaulted were reviewed with questionnaire or telephone.
Evaluation criterion for postoperative cosmetic effect6
The cosmetic outcome was scored in 3 months after operation. The items to be scored were:
The appearance of the surgical scar, breast size, breast shape, nipple position, and areola
shape. In scoring these items the treated breast was compared with the contralateral breast,
using a 4-point scale: Excellent (0) if there was no difference between both breasts; good (1)
if there was only a slight difference; fair (2) when a more marked difference was present but
could be masked by dressing; and poor (3) in case of a disturbing difference.
Statistical analysis
Statistical analyses were performed with SPSS13.0 (SPSS 13.0 for Windows, Apache
Software Foundation, SPSS Inc., USA). Continuous variables and constituent ratio were
expressed as mean ± standard deviation ( x ± SD). Comparisons between two groups were
made by a two tailed Student’s t test for measurement data and chi-square test for numeration
data. Difference was considered statistically significant when P value was less than 0.05.
RESULTS
Clinical pathological characteristics of the two groups
There were no differences in patient age, tumor size, tumor staging (according to the AJCC
Cancer Staging Atlas, the 6th edition7), pathological type of tumor, status of hormone receptor
and Her-2, and preoperative chemotherapy cycles between the two groups (P＞0.05).
However, The average distance between tumor and areola was significantly shorter in ESM
group (2.2±1.1) than in BCS group (3.4±1.3) (P＜0.01), and there was 8 cases with
subareolar lesions in ESM group. (Table 1)
Operation results
Intraoperative FSA showed no cancer infiltration of subcutaneous tissue superior to tumor in
ESM group, and no residual cancer in incisal margin tissue in BCS group. There were no
significant differences in bleeding volume and postoperative drainage duration between the
two groups (P＞0.05), but the operation duration was markedly longer in ESM group than in
BCS group (P＜0.01). In ESM group, the total time of lipolysis and liposuction was about 30
minutes. (Table 1)
Postoperative complications
The major complications in ESM group, with a total incidence of 11.6% (5 of 43), were
partial necrosis of nipple in 2 cases, and superficial island necrosis and blister of breast skin in
3 cases, which would recover with little change of breast appearance after incrustation and
decrustation. No complete nipple necrosis or subcutaneous hydrops were observed. In BCS
group the complications were hydrops in axilla and residual cavity with total incidence of
11.1% (6 of 54), which was cured by puncture and re-drainage within 1 month. There was no
significant difference in the total incidence of complications between the two groups (P＞
0.05).
Follow up results
All of the 43 cases (100.0%, 43/43) in ESM group and 51 cases (94.4%, 51/54) in BCS group
were followed up for 6 months to 4 years. Patients in ESM group all had a
disease-free-survival, while 3 patients in BCS group had distant metastasis or local recurrence.
Of the 3 patients, one had multiple bone metastases and liver metastasis in 37 months after
operation, and died of multiple organ failure in 41 months as a result of abandoning treatment;
one developed massive ascites and intra-abdominal multiple metastases in 15 months
postoperatively, and was stable after chemotherapy and symptomatic treatment; the other had
local recurrence in 28 months after operation, and was survival after modified radical
mastectomy, postoperative chemotherapy and radiotherapy. However, there were no
significant differences in total survival, local recurrence and distant metastasis between the
two groups (P＞0.05).
Postoperative cosmetic evaluation showed (Figs 5 and 6) that in ESM group, excellent
outcome was achieved in 9 cases (20.9%), good in 16 cases (37.2%), fair in 13 (30.2%) and
poor in 5 (11.6%), with a total satisfactory rate (excellent + good + fair) of 88.4% (38/43). Of
the 5 cases with poor cosmetic outcome, 2 cases had serious asymmetry on account of the
upper reconstructed breast and the ptotic untreated one; 3 on account of the smaller
reconstructed breast and the bigger untreated one. The reconstructed breast could be slightly
upper than the contralateral at the initial stage after operation in ESM group, which would
result in a discontent to operative cosmetic outcome. But 3 months later, the cosmetic effect
became much better due to the reconstructed breast shifting down and moulding, and
subcutaneous fat thickening. In BCS group, the total satisfactory rate was 92.6% (50/54), in
which the 4 cases with poor cosmetic result had marked asymmetry because the removed
gland and skin was too much. There was no significant difference in satisfactory rate of
cosmetics outcome between the two groups (χ2＝0.507，P＝0.504).
DISCUSSION
The ESM can avoid breast radiotherapy for breast cancer
The history of breast cancer treatment from radical mastectomy to modified radical
mastectomy to breast conserving surgery has displayed the improvement and progress of
conception and techniques in breast surgery, as well as the pursuit of “cure of disease
concomitant with maximal conservation of breast” in both doctors and patients. BCS includes
lumpectomy plus axillary lymph node dissection, and postoperative breast radiotherapy for all
staging in order to avoiding recurrence, and the local recurrence rate will reach 26.4% without
breast radiotherapy.8 In our study patients in BCS group underwent outpatient radiotherapy
once a day for more than one month, which would prolong the total therapy time, cause
complications such as skin damage, breast edema, radiation pneumonitis, etc9 and increase
more pain and financial burden for patients10, while patients treated with ESM could avoid
postoperative breast radiotherapy because of the removal of total gland, thus preventing
irradiation complications, as well as postoperatively local recurrence and breast stump
carcinoma. In this study there were no significant differences in prognostic factors such as
tumor staging, hormone receptor status and Her-2 status between the two groups, but 3
patients in BCS group developed recurrence and metastasis postoperatively in spite of the
regular radiotherapy, while all patients in ESM group survived healthily. However, the
differences between the two groups did not reach statistical significance, which might be due
to the smaller number in this study.
The wider indications of ESM plus axillary lymph node dissection and immediate breast
reconstruction comparing with BCS
Patients with tumor of more than 3 cm in diameter, or less than 2 cm away from areola, or
multicentric lesions should be excluded from BCS.4 However, ESM principally has no severe
limitation for tumor size and position as long as the skin and main duct are not involved by
cancer. In addition, ESM is also suitable for the multicentric lesions, which is just one of the
key factors causing postoperative recurrence after BCS 11, 12.
Similarly, central breast cancer is regarded to a contraindication for BCS and modified
mastectomy with conservation of nipple/areola complex as well.13 In fact, the chances of
malignant nipple/areola involvement may be overestimated.14 In ESM group that included 8
cases of central cancer, the distance between tumor and areola was much shorter than that in
BCS group, but no cancer infiltration of the subcutaneous tissue over tumor were found by
intraoperative FSA, and no cancer recurrence or metastasis were observed during the
follow-up period. Therefore, central cancer without involvement of nipple/areola and skin by
preoperative examination can be managed with ESM. The indication of ESM plus axillary
lymph node dissection and immediate breast reconstruction is wider than BCS.
The feasibility and safety of ESM plus axillary lymph node dissection and immediate
breast reconstruction
The use of endoscopic technique in subcutaneous excision of breast tumor has been mature
and reported.15-17 Unlike conventional BCS under direct vision, ESM is performed through
small incisions in hidden sites following sufficient lipolysis and liposuction. Axillary lymph
node dissection, and finally prosthesis implanting through the axillary incision. But the time
of ESM group is longer than that of BCS group whose incision is made directly on tumor
surface and excision is performed under direct vision. In ESM group, the average operation
time (168 min) was markedly longer than that of BCS group. Besides that lipolysis and
liposuction are time-consuming, the longer operation duration might partly be due to
unskilled technique of the operator in ESM group. In addition, for the purpose of avoiding
residual cancer in endoscopic operation, the inclusion criteria should be controlled strictly
before operation and FSA of the tissue inferior to nipple and superior to tumor should be
observed intraoperatively. In ESM group of this study, no recurrence or metastasis were found
during follow-up period, indicating the safety of endoscopic technique as long as operation
indications are selected appropriately.
The postoperative complications in ESM group were partial necrosis of nipple and superficial
necrosis of breast skin, which were caused by insufficient blood supply to the nipple. Nipple
blood supply comprises of two parts: the vascular net from surrounding skin and subcutis and
the perforating vessels from mammary gland. After subcutaneous mastectomy the nipple
blood supply only depends on the vascular net from surrounding skin and subcutis.18 In the
ESM group, 2 cases suffered from partial nipple necrosis and 3 from superficial skin necrosis,
but all recovered with little change of appearance one month later. These complications
occurred at the early stage of developing technology and could be avoided with accumulating
of the experiences and skills. In ESM group, no nipple necrosis was found in other 38 patients,
which is mainly because the vascular net from surrounding skin and subcutis was well
protected. We suggest that the hole of suction tip do not face skin during subcutaneous
liposuction so as to avoid injuring subcutaneous vascular net, and small amount of gland
behind nipple and areola be reserved to prevent nipple ischemia and aversion. Differently
with ESM, the postoperative complication in BCS group was subcutaneous hydrops, which
was caused by the impaired lymphatic drainage of breast resulted from axillary lymph node
dissection and the leakage of lymph fluid.19 Compared with BCS, endoscopic operation can
reduce subcutaneous hydrops since whole breast tissues, the source of breast lymph fluid, are
resected totally; as a result, lymph drainage-associated lymph fluid leakage can be avoided.
Postoperative cosmetic effect of ESM plus axillary lymph node dissection and immediate
breast reconstruction for breast cancer
One of the aims of both BCS and ESM is to maximally retain a favorable breast contour after
operation.20-22 After a wide local excision, for a large breast the postoperatively cosmetic
effect is satisfactory, but for a small one the effect is not good since it is difficult to keep
bisymmetry in BCS.4 Of the 54 cases in BCS group of this study, 4 with small breasts had
poor cosmetic effect because of asymmetry. While in ESM group, subcutaneous mastectomy
can be performed through 3 incisions in the hidden site beyond breast margin to conserve
whole skin to provide a good condition for breast reconstruction, and the prosthesis can also
be implanted through the axillary incision to reconstruct breast contour, thus obtaining an
ideal cosmetic result. Especially for breast in middle or small size, only prosthesis can attain
bisymmetry and achieve the ideal cosmetic effect. On the contrary, for large or drooping
breast, endoscopic operation is difficult and time-consuming to perform. Moreover, the
reconstructed breast is usually lack of natural ptosis and smaller than untreated breast because
the prosthesis can only be implanted into the retropectoral space whose interstitial volume is
quite limited. Therefore, breast reconstruction with prosthesis isn’t suitable for patients with
large or drooping breasts, whose better cosmetic results can be gained by autologous tissue
flap transferring.23
In our study, although the difference in satisfactory rate of cosmetics outcome between ESM
and BCS was not significant, the cosmetic effect was worse in ESM group (88.4%) than in
BCS group (92.6%). The possible reason includes: the prosthesis deviation due to technical
factors, the disturbing asymmetry due to the ptotic or bigger contralateral healthy breast, and
too high expected value of cosmetic result in some patients underwent ESM. Accordingly, in
order to acquire an optimal aesthetic result, BCS should be applied to patients with large
breasts, while ESM plus axillary lymph node dissection and breast reconstruction with
implants to patients with smaller and non-droopy breasts. These two operations will be
complementary in indications.
Considering the wide indication, the high safety and favorable cosmetic result, ESM plus
axillary lymph node dissection and immediate reconstruction with implants is a new choice of
the surgery in breast cancer.
References
1. Veronesi U, Cascinelli N, Mariani L, Greco M, Saccozzi R, Luini A, et al. Twenty-year follow-up of a
randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer.
N Engl J Med 2002; 347: 1227-1232. PMID: 12393819
2. Arriagada R, Lê MG, Guinebretière JM, Dunant A, Rochard F, Tursz T. Late local recurrences in a
randomized trial comparing conservative treatment with total mastectomy in early breast cancer
patients. Ann Oncol 2003; 14: 1617-1622. PMID: 15151962
3. Blichert-Toft M, Nielsen M, Düring M, Møller S, Rank F, Overgaard M, et al. Long-term results of
breast conserving surgery vs. mastectomy for early stage invasive breast cancer: 20-year follow-up of
the Danish randomized DBCG-82TM protocol. Acta Oncol 2008; 47: 672-681. PMID: 18465335
4. Young AE. The surgical management of early breast cancer. Int J Clin Pract 2001; 55: 603-608. PMID:
11770357
5. Chinese Anti-Cancer Association-Committee of Breast Cancer Society. Clinical Practice Guidelines in
Breast Cancer (Version 2007). China Oncology (Chin)* 2007 ; 17 : 410-428.
6. Vrieling C, Collette L, Fourquet A, Hoogenraad WJ, Horiot JH, Jager JJ, et al. The influence of patient,
tumor and treatment factors on the cosmetic results after breast-conserving therapy in the EORTC
‘boost vs. no boost’ trial. EORTC Radiotherapy and Breast Cancer Cooperative Groups. Radiother
Oncol 2000; 55: 219-232. PMID: 10869738
7. Singletary SE, Allred C, Ashley P, Bassett LW, Berry D, Bland KI, et al. Revision of the American
Joint Committee on Cancer staging system for breast cancer. J Clin Oncol 2002; 20: 3628-3636. PMID:
12202663
8. Kantorowitz DA, Poulter CA, Rubin P, Patterson E, Sobel SH, Sischy B, et al. Treatment of breast
cancer with segmental mastectomy alone or segmental mastectomy plus radiation. Radiother Oncol
1989; 15: 141-150. PMID: 2503859
9. Van Limbergen E, Weltens C. New trends in radiotherapy for breast cancer. Curr Opin Oncol 2006; 18:
555-562. PMID: 16988575
10. Wang SM. Concerns on diagnosis and treatment of breast cancer in China. Chin Med J (Engl) 2007;
120: 1741-1742. PMID: 18028763
11. Paterson DA, Anderson TJ, Jack WJ, Kerr GR, Rodger A, Chetty U. Pathological features predictive of
local recurrence after management by conservation of invasive breast cancer: importance of
non-invasive carcinoma. Radiother Oncol 1992; 25:176-180. PMID: 1470694
12. Gentilini O, Botteri E, Rotmensz N, Da Lima L, Caliskan M, Garcia-Etienne CA, et al. Conservative
surgery in patients with multifocal/multicentric breast cancer. Breast Cancer Res Treat 2008 Mar 11
[Epub ahead of print]. PMID: 18330695
13. Cunnick GH, Mokbel K. Skin-sparing mastectomy. Am J Surg 2004; 188: 78-84. PMID: 15219490
14. Simmons RM, Brennan M, Christos P, King V, Osborne M. Analysis of nipple/areolar involvement
with mastectomy: can the areola be preserved? Ann Surg Oncol 2002; 9: 165-168. PMID: 11888874
15. Jiang J, Yang XH, Fan LJ, Zhang Y, Zhang F, Zhou Y. Application of endoscopy-assistant operation in
surgical treatment of breast diseases. Zhonghua Yi Xue Za Zhi (Chin)* 2005; 85:181-183. PMID:
15854464
16. Zhu J, Huang J. Surgical management of gynecomastia under endoscope. J Laparoendosc Adv Surg
Tech A 2008; 18: 433-437. PMID: 18503380
17. Kitamura K, Ishida M, Inoue H, Kinoshita J, Hashizume M, Sugimachi K. Early results of an
endoscope-assisted subcutaneous mastectomy and reconstruction for breast cancer. Surgery 2002; 131:
S324-S329. PMID: 11821832
18. Weitzel D, Bässler R. Contributions of the angioarchitecture of the female breast. Represented by
methods of injections and x-ray-angiographic studies. Z Anat Entwicklungsgesch 1971; 133: 73-88.
PMID: 5573138
19. Jeffrey SS, Goodson WH 3rd, Ikeda DM, Birdwell RL, Bogetz MS. Axillary lymphadenectomy for
breast cancer without axillary drainage. Arch Surg 1995; 130: 909-912. PMID: 7632155
20. Yu L, Wang J, Zhang B, Zhu C. Endoscopic transaxillary capsular contracture treatment. Aesthetic
Plast Surg 2008; 32: 329-332. PMID: 18157566
21. Serra-Renom JM, Guisantes E, Yoon T, Benito-Ruiz J. Endoscopic breast reconstruction with
intraoperative complete tissue expansion and partial detachment of the pectoralis muscle. Ann Plast
Surg 2007; 58:126-130. PMID: 17245136
22. Luo CY, Zhou YQ, Lin H, Ji XX , Guan C, Li J, et al. A standardized surgical technique for
mastoscopic axillary lymph node dissection. Surg Laparosc Endosc Percutan Tech 2005; 15: 153-159.
PMID: 15956900
23. Cocquyt VF, Blondeel PN, Depypere HT, Van De Sijpe KA, Daems KK, Monstrey SJ, et al. Better
cosmetic results and comparable quality of life after skin-sparing mastectomy and immediate
autologous breast reconstruction compared to breast conservative treatment. Br J Plast Surg 2003; 56:
462-470. PMID: 12890459
Table 1 The analysis of clinical pathological characteristics of breast cancer in the two groups
Items
t or χ2 value
P value
42.4±7.9
1.624
0.108
2.7±0.9
2.6±0.9
0.429
0.669
2.2±1.1
3.4±1.3
5.001
＜0.01
0.687
0.709
0.492
0.569
ESM group
BCS group
43
54
Age (years)
39.7±8.2
Tumor size (cm)
Distance from the areola (cm)
Number
Tumor staging
I
15
22
II
22
27
6
5
IIIA
Pathological types
Infiltrating ductal cancer
38
45
Other infiltrating cancer
5
9
Hormone receptor positive rate
23/43
29/54
0.000
1.000
Her-2 positive rate
16/43
24/54
0.517
0.536
Preoperative chemotherapy cycles
2.1±1.1
1.9±1.1
1.181
0.241
Operation duration (min)
168±32
139±37
4.094
＜0.01
Intraoperative blood loss (ml)
115±44
102±48
1.409
0.162
Postoperative drainage volume (ml)
150±63
160±69
0.726
0.470
Postoperative drainage duration (d)
6.7±2.1
6.3±2.1
1.070
0.284
5/43
6/54
0.006
1.000
38/43
50/54
0.507
0.504
16.9±11.2
20.1±11.9
1.332
0.186
0/43
3/51
2.613
0.247
43/43
50/51
0.852
1.000
Postoperative complication
Postoperative
satisfactory
cosmetics
outcome
Follow-up time (mon)
Recurrence and metastasis
Total survival
Fig 1
Setting up an operating space after lipolysis
and liposuction for ESM.
Fig 2
Transecting Cooper ligaments between skin
and gland with an electric hook under endoscopic
monitoring.
Fig 3
Excising the gland superior to tumor marked
by methylene blue for intraoperative FSA.
Fig 4
Implanting a prosthesis to retropectoral space
through the superior incision after axillary lymph node
dissection.
Fig 5
Fair cosmetic outcome in ESM group at 3
months after operation.
Fig 6
Poor cosmetic outcome and deformity of the
treated breast in BCS group, on account of small breast
and large tumor (3 cm in diameter).