探讨保留乳头、乳晕的乳房切除术(NSM)加一期假体乳房重建的安全性和术后美容效果。

本回顾性研究收集了2011年3月至2018年12月在广东省妇幼保健院接受NSM或全乳切除术联合一期假体乳房重建的81例乳腺癌患者的临床资料。其中，45例接受NSM＋假体重建术，36例接受全乳切除＋假体重建术。对全部患者进行随访，随访时间4～97个月，中位随访36个月。采用Harris乳房评价标准评价术后美容效果，采用乳腺癌患者生活质量测定量表(FACT-B)评价患者术后生活质量。采用χ²检验比较2组患者临床病理特征、美容效果优良率及术后并发症发生率；采用两独立样本非参数检验(Mann-Whitney U检验)比较2组患者术后美容效果；采用t检验比较2组患者生活质量评分；生存分析采用Kaplan-Meier法及log-rank检验。

NSM＋假体重建组与全乳切除＋假体重建组术后近期并发症和远期并发症发生率比较，差异均无统计学意义[24.4%(11/45)比22.2%(8/36)，χ²＝0.055，P＝0.815；2.2%(1/45)比2.8%(1/36)，P＝1.000]。全乳切除＋假体重建组术后美容效果评价等级为优、良、中、差的例数分别为14、7、9、6例，NSM＋假体重建组分别为20、18、5、2例，2组比较，差异无统计学意义(Z＝－1.626，P＝0.104)。NSM＋假体重建组的术后美容效果优良率为84.4% (38/45)，全乳切除＋假体重建组为58.3% (21/36)，2组比较，差异有统计学意义(χ²＝6.892，P＝0.009)。乳腺癌术后生活质量评分中，NSM＋假体重建组的生理状况、社会/家庭状况及附加关注3个部分评分均明显优于全乳切除＋假体重建组(t＝2.720、2.585、3.160，P＝0.009、0.013、0.004)；2组的感情状况及功能状态比较，差异均无统计学意义(t＝0.396、1.258，P＝0.694、0.212)。共3例患者出现复发转移，其中，NSM＋假体重建组有2例(1例乳头、乳晕部位复发，1例为患侧腋窝淋巴结复发)，全乳切除＋假体重建组1例出现局部复发和纵隔淋巴结转移。2组患者DFS曲线比较，差异无统计学意义(χ²＝0.398, P＝0.528)。2组5年OS率均为100%。

与全乳切除＋假体重建术比较，NSM＋假体重建术不增加术后并发症风险，具有较高的美容效果优良率及生活质量评分，在严格选择适应证的前提下，NSM＋假体即刻乳房重建术也是一种可选择的手术方式。

To investigate the safety and postoperative cosmetic effect of nipple-areola complex sparing mastectomy (NSM) combined with immediate breast reconstruction using implant.

We retrospectively analyzed the clinical data of 81 patients with breast cancer who underwent NSM or mastectomy combined with immediate breast reconstruction using implant from March 2011 to December 2018 in the Women and Children’s Hospital of Guangdong Province, including 45 patients with NSM plus implant breast reconstruction and 36 patients with mastectomy plus implant breast reconstruction. All patients were followed up for 4 to 97 months, median 36 months. The Harris standard was used to evaluate postoperative cosmetic effect, and the functional assessment of cancer therapy-breast (FACT-B) was used to evaluate postoperative quality of life of the patients. The χ² test was used to compare clinicopathological characteristics, rate of excellent and good cosmetic effect and incidence of postoperative complications between two groups; the nonparametric test of two independent samples (Mann-Whitney U test) were used to compare the postoperative cosmetic effects between two groups; the t test was used to compare the quality of life scores between two groups. The Kaplan-Meier method and log-rank test was used for survival analysis.

There was no significant difference in the incidences of postoperative short-term and long-term complications between the NSM plus implant breast reconstruction group and the mastectomy plus implant breast reconstruction group [24.4%(11/45) vs 22.2%(8/36), χ²=0.055, P=0.815; 2.2%(1/45) vs 2.8%(1/36), P=1.000]. As for postoperative appearance, the number of patients with excellent, good, moderate and poor cosmetic effect was 14, 7, 9 and 6 in the mastectomy plus implant breast reconstruction group, 20, 18, 5 and 2 in the NSM plus implant breast reconstruction group, indicating no significant difference(Z=-1.626, P=0.104). The patients with excellent and good cosmetic effect accounted for 84.4% (38/45) in the NSM plus implant breast reconstruction group, 58.3% (21/36) in the mastectomy plus implant breast reconstruction group, indicating a significant difference (χ²=6.892, P=0.009). As for quality of life, the NSM plus implant breast reconstruction group presented significantly higher scores in three sections including physical well-being, social/family status, and additional condition, compared with the mastectomy plus implant breast reconstruction group (t=2.720, 2.585, 3.160, P=0.009, 0.013, 0.004), while the scores of emotional status and functional status showed no significant difference(t=0.396, 1.258, P=0.694, 0.212). Three cases had recurrence and metastasis, including 2 cases in the NSM plus implant breast reconstruction group (one case of recurrence in nipple-areola complex, one in axillary lymph node), and one case of local recurrence and mediastinal lymph node metastasis in the mastectomy plus implant breast reconstruction group. The DFS showed no significant difference between two groups (χ²=0.398, P=0.528). The 5-year OS in both groups was 100%.

Compared with mastectomy plus implant breast reconstruction, NSM plus implant breast reconstruction increases little risk of postoperative complications, and shows a higher rate of excellent and good cosmetic effect and higher scores in quality of life. It is a surgical option in clinic under the premise of carefully restricting its indications.