부산대병원학술지통권제 32 호, 2012 유방외상부혹은외중앙부에위치한유방암의부분유방절제술후상부축회전진피유선조직피판을이용한유방종양성형술 부산대학교병원외과 이석원, 배영태 Oncoplastic breast surgery for the upper quadrant breast cancers: Superior based dermoglandular rotational flap Seok Won Lee, Young Tae Bae Department of Surgery, Pusan National University College of Medicine Abstract * Purpose: An anticipated poor cosmetic result has been deemed a relative contraindication for breast conservation therapy. Upper quadrant tumors are the most difficult to treat because this area has the least glandular tissue. The authors applied superior based rotational dermoglandular flap as oncoplastic surgery for patient with the upper lateral or upper central quadrant breast cancers to assess the usefulness of this procedure. Patients and methods: A total of forty-eight patients with upper out or upper central portion of breast cancer underwent a partial mastectomy with immediate * 본연구는 2012 년도부산대학교병원임상연구비지원으로이루어졌음. - 145 -
이석원, 배영태 superior based rotational dermoglandular flap. The clinicopathologic factors were analyzed retrospectively and the cosmetic outcomes were evaluated based on 4-point scoring system. Results: The mean age was 42.2 years and mean tumor size was 1.3cm. All tumors had upper outer or upper central location. The mean excised breast volume was 52.9 mm3. Histopathological analysis had revealed 75.0% infiltrating ductal carcinoma of no otherwise specified type. Ductal carcinoma in situ was found in 7(21.9%). The cosmetic result showed excellent in 12 (37.5%) and good in 16 (50.0%). Conclusion: Immediate superior based rotational flaps with adjacent skin and breast tissue after partial mastectomy are an acceptable method of achieving satisfactory cosmesis in selected patients who desire breast conservation surgery. Key words: breast cancer, oncoplastic surgery. local flap, immediate reconstruction 서론 부분절제술후결손부위에대한종양성형술에는두가지방법이있는데하나는국소유선조직피판 (local glandular flap) 혹은진피유선조직피판 (dermoglandular flap) 등으로하는조직이동술 (volume displacement) 법과다른하나는다른부위에서조직을갖고오는조직대체술 (volume replacement) 법이다. 저자들은유방암이유방외상부혹은중앙상부에위치한유방암의경우보다쉽게시술할수있는종양성형술로서의국소피판술중상부축회전진피유선조직피판을소개하여유방외과의가직접유방종양성형술을보다쉽게시행할수있도록돕고자한다. 1 대상및방법 1. 연구대상 2006년 1월부터 2008년 12월까지부산대 학교병원외과에서유방암으로수술받은환자들중외상부또는상중심부에있는종양을유방부분절제술및즉각적국소피판을시술한 32예를후향적으로고찰하였다. 전자차트의기록을참고하여임상병리학적인자들즉나이, 신체질량지수 (body mass index), 종양의크기, 위치및개수, 절제된유방부피, 수술시간, 재원기간등을조사하였고, 조직학적인자들은조직병리결과지를바탕으로종양의종류, 에스트로겐혹은프로게스테론수용체존재여부, c-erbb2 유전자발현정도, 종양의림프혈관계침윤여부등을후향적으로조사하였다. 종양의특성에따라수술이후항암치료또는방사선치료를병행하였으며, 모든예에서방사선치료종결이후 3개월이되는시점에서 Danoff 등이 2 제안한 4단계유방의미용학적평가법을기준으로환자와의사에의해미용적평가가이루어졌다. - 146 -
유방외상부혹은외중앙부에위치한유방암의부분유방절제술후상부축회전진피유선조직피판을이용한유방종양성형술 2. 수술방법환자를앙와위로하여전신마취하에예상되는절제선을결정하고국소피판을위해부분유방절제술후생길결손부위상연에서액와부까지피부절개를연장한다. 이때필요하면감시림프절을생검한다. 감시림프절검사결과에따라액와부림프절곽청을결정하며안전한변연부를확보하기위해주위정상조직 2cm를포함하여종양을절제한후그경계부에대한동결절편을시행하여추가절제의여부를확인한다. 피판을결손이있는영역으로회전하여결손부위를피판으로채우고결손부위의남은유방조직에고정시킨후피부를다시배치한다. 이때액와부에견이 (dog ear) 변형을교정하고적절하게지혈한후폐쇄흡인관을유치하고 4-0 monofilament 흡수성봉합사로피부를연속봉합하고피부는자동봉합기를이용하여봉합한다 (Fig.1) 결과 환자들의평균연령은 42.2세, 평균신체질량지수는 23.1 kg/m 2 이었다. 수술전유방초음파에서측정된종양의평균크기는 1.3 cm이었으며, 종양의위치는유방의외상부외중앙부각각 18예 (56.3%), 14예 (43.7) 이었다. 이들중 3예 (9.4%) 는다발성이었다. 절제된유방의평균부피는 52.9 mm 3 이었다. 평균수술시간은 112분이었으며, 평균재원일수는 7일이었다 (Table 1). 종양의종류는침윤성유관암이 24예 (75.0%) 로가장많았으며, 상피내암이 7예 (21.9%), 침윤성소엽암이 1예 (3.1%) 이었다. 에스트 로겐수용체와프로게스테론수용체는각각 28예 (86.8%), 24예 (71.1%) 에서양성을보였으며, c-erbb2 유전자는 13예 (44.7%) 에서양성을보였고, 6예 (10.5%) 에서종양세포의림프혈관계침윤이있었다. 종양의병기는 0기가 7예 (21.9%)), I기가 14 예 (43.7%), IIA, IIB, IIIA기는각각 8 예 (25.0%), 2 예 (6.3%), 1 예 (3.1%) 이었다 (Table 2). 미용적결과는매우만족이 12 예, 만족이 16예로 87.5% 가미용적으로만족하였다.(Table 3) 고찰 유방절제술받은군과부분유방절제술및액와곽청술과술후방사선치료를받은군에대한대규모무작위연구들 3,4 에서양군의무병생존율과전체생존율이유사하다고보고된이후유방보존술이유방암수술의표준치료로되고있다. 유방보존술의미용적효과는종양의크기와위치, 유방의크기, 수술절제범위등에의해결정된다. 5,6 Audretsch 등 7 에의하면외과의는안전한변연부를위해서가능한많은유방실질을제거해야하며반면미용적만족을얻기위해가능한많은양의유방실질을보존해야하는갈등에놓이게되고이갈등을해결하기위해종양특이성즉각적재건술 (tumor -specific immediate reconstruction) 이필요하다고하였다. 만족할만한미용적효과의확보와안전한절제연의종양학적안정성이보장받기위해종양제거술후즉각적성형술을시술하는이음새없는종양성형술이필요하다고하였다. 8-147 -
이석원, 배영태 부분절제술후결손부위에대한종양성형술에는두가지방법중조직대체술은형태크기대칭성을복원할수있으며대칭성을회복시키기위해반대편유방의수술이필요없을수있으나추가적인수술시간이필요하고공여부위의이환과피판상실등의합병증과회복기간의연장등의단점이있으나국소피판술인진피유선조직피판과같은조직이동술은공여부위가없기때문에덜침습적이다. 1 종양이상부유방에위치한경우함께유방상부조직과피하지방그리고상부유방을싸고있는피부를부분유방절제술후결손부위로상부를토대 (superiorly based) 로회전시켜넣을수있다. 9 저자들의경우결손부위가전유방의 25% 이하를차지하는상방에위치한경우에상부축 (inferiorly based) 을중심으로회전시켜국소피판을이용하여결손부위를재건하였다. 먼거리피판술없이국소피판술로써유방종양성형술이가능하였다. 안전한절제연확보을위해술중동결절편생검을시행하였으며절제연이양성으로나오면추가절제를시행하였다. 만약추가절제하여결손부위가 25% 이상이추정되면 LDMCF 이나유방전절제술을시술하였다. 종양이유방의외측에위치한경우에는겨드랑이밑 (subaxillary) 피부를포함하여피하지방조직을유방결손부위를메우는수술방법을선택할수있다. 10 또한종양이유방의상부에위치한경우유방의상부조직과함께피하지방과피부를포함하여부분유방절제술을시행한후결손부위로상부축을중심으로회전시켜넣거나, 9 하부축으로넣을수있다. 11 저자들의경우상부축중심으로한회전국소피판술을 시술한경우미용적결과가 excellent와 good이 87.5% 의높은만족도를보였다. References 1. Hoffmann J and Wallwiener D. Classifying breast cancer surgery: a novel, complexity- based system for oncological, oncoplastic and reconstructive procedures, and proof of principle by analysis of 1225 operations in 1166 patients BMC Cancer 2009; 9: 108-116 2. Danoff BF, Goodman RL, Glick JH, Haller DG, Pajak TF. The effect of adjuvant chemotherapy on cosmesis and complications in patients with breast cancer treated by definitive irradiation. Int J Radiat Oncol Biol Phys 1983;9:1625-1630. 3. Veronesi U, Cascinelli N, Mariani L, Greco M, Saccozzi R, Luini A, Aguilar M. Marubini E. 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; 16: 1233-1241 4. Fisher B, Anderson S, Bryant J, Margolese RG, Deutsch M, Fisher ER, Jeong JH, and Wolmark N. Twenty- Year Follow-up of a Randomized Trial Comparing Total Mastectomy, Lumpectomy, and Lumpectomy plus - 148 -
유방외상부혹은외중앙부에위치한유방암의부분유방절제술후상부축회전진피유선조직피판을이용한유방종양성형술 Irradiation for the Treatment of Invasive Breast Cancer N Engl J Med Volume 2002; 347; 16: 1233-1241 5. Clough KB, Cuminet J, Fitoussi A, Nos C, Mosseri V. Cosmetic sequelae after conservative treatment for breast cancer: classification and results of surgical correction. Ann Plast Surg 1998;41:471 81. 6. Clough KB, Nos C, Salmon RJ, Soussaline M, Durand JC. Conservative treatment of breast cancers by mammaplasty and irradiation: a new approach to lower quadrant tumors. Plast Reconstr Surg 1995;96:363 70. 7. Audretsch W, Rezai M, Kolotas C Zambolglou N, Schnabel T, and Bojar H. Tumor specific immediate reconstruction in breast cancer patients. Perspect plast surg. 11; 71-103,1998 8. Clough KB, Lewis JS, Couturaud B, Fitoussi A, Nos C, Falcou MC. Oncoplastictechniques allow extensive resections for breast-conserving therapy of breast carcinomas. Ann Surg 2003; 237: 26-34. 9. Kroll SS, Singletary SE: Repair of partial mastectomy defects. Clin Plastic Surg. 1998; 25:303~310 10. Clough KB, Kroll SS, Audretsch W. An approach to the repair of partial mastectomy defects. Plast Reconstr Surg 1999; 104: 409-420. 11. Audretsch W. Reconstruction of the partial mastectomy defect: classification and method. In: Spear SL, ed. Surgery of the Breast: Principles and Art. 1th ed. Philadelphia: Lippincott-Raven, 1998; 155-196. - 149 -
이석원, 배영태 Table 1. Clinicopathologic characteristics of 32 patients who underwent superior based dermograndular rotational flap Mean age (yrs, range) 42.2 (32-74) Mean BMI* (kg/m2, range) 23.1 (18.0-29.3) Mean clinical tumor size (cm, range) 1.3 (1.2-2.6) Mean pathologic tumor size (cm, range) 1.6 (0.2-3.7) Location of tumor(n, %) Upper outer 18 (56.3) Upper central 14 (43.7) Cases of multifocality(n, %) 3 (9.4) Mean excised breast volume (mm3, range) 52.9 (10.6-170.9) Mean operative time (min, range) 112 (80-219) Mean hospital stay (day, range) 7 (5-114) Mean follow-up period (mo, range) 28.2 (15-42) *Body Mass Index, complication was allergic dermatitis which was resolved with conservative treatment. Table 2. Histopathologic characteristics of the 32 patients who underwent superior based dermograndular rotational flap Variables n (%) Histology Ductal carcinoma in situ 7 (21.9%) Invasive ductal carcinoma 24 (75.0%) Invasive lobular carcinoma 1 (3.1%) Estrogen receptor Positive 28 (86.8) Negative 4 (13.2) Progesterone receptor Positive 24 (71.1) Negative 8 (28.9) c-erbb2 gene Positive 13 (44.7) Negative 19 (55.3) Lymphovascular invasion Positive 6 (10.5) Negative 26 (81,2) Tumor stage Stage 0 7 (21.9) Stage I 14 (43.7) Stage IIA 8 (25.0) Stage IIB 2 (6.3) Stage IIIA 1 (3.1) - 150 -
유방외상부혹은외중앙부에위치한유방암의부분유방절제술후상부축회전진피유선조직피판을이용한유방종양성형술 Table 3. Cosmetic outcome of 32 patients who underwent superior based dermograndular rotation flap Cosmetic outcome N (%) Excellent 12(37.5) Good 16(50.0) Fair 4(12.5) Poor 0 FIG. 1. A view of a patient with invasive ductal carcinoma of the left lateral quadrant and designation of a partial mastectomy was made(a). Normal adjacent breast tissue was then rotated to fill the defect by extension of the segmental mastectomy incision into a region of adjacent breast parenchyma with insurance of negative frozen section pathologic examination (B) And then, adjacent dermograndular tissue was rotated into the defect in the direction of the arrow and the dog ear deformy was corrected in the axillary fossa (C). The skin of incision was closed with subcuticular suture and then the flap reconstruction was completed. Drains were placed into the site of rotational flap closure of the defect(d). Postoperative frontal and oblique views after 9 months show nearly normal breast shapes(e,f). - 151 -