乳腺癌根治术后胸部放射性溃疡的修复策略及其临床效果

杜伟力; 沈余明; 程琳; 代强; 车可心

doi:10.3760/cma.j.cn501225-20240315-00099

乳腺癌根治术后胸部放射性溃疡的修复策略及其临床效果

doi: 10.3760/cma.j.cn501225-20240315-00099

首都医科大学附属北京积水潭医院烧伤科，北京　　100035

基金项目:

国家重点研发计划 2018YFA0703104

北京市属医院科研培育计划 PX2024016

北京积水潭医院学科骨干 XKGG202209

详细信息

通讯作者:
沈余明，Email：shenyuming1963@163.com

计量
- 文章访问数: 250
- HTML全文浏览量: 14
- PDF下载量: 42
- 被引次数: 0
出版历程
- 收稿日期: 2024-03-15

Repair strategy of chest radiation ulcer after radical mastectomy for breast cancer and its clinical effect

Department of Burns, Beijing Jishuitan Hospital, Capital Medical University, Beijing 100035, China

Funds:

National Key Research and Development Program of China 2018YFA0703104

Research and Cultivation Program of Beijing Capital Hospital PX2024016

Subject Backbone of Beijing Jishuitan Hospital XKGG202209

More Information

Corresponding author: Shen Yuming, Email: shenyuming1963@163.com

摘要

摘要: 目的探讨乳腺癌根治术后胸部放射性溃疡的修复策略及其临床效果。方法该研究为回顾性观察性研究。2020年9月—2023年9月，首都医科大学附属北京积水潭医院收治符合入选标准的罹患乳腺癌根治术后胸部放射性溃疡的女性患者27例，其年龄为37~83岁，其中7例患者出现胸部区域明显疼痛。完善各项检查，准确评估有无肿瘤以及放射性溃疡累及深度。排除肿瘤复发后，对溃疡创面行彻底清创（清创后创面大小为8 cm×7 cm~18 cm×18 cm），同时行创面组织病理学检查与创面组织/分泌物标本细菌培养，清创后同期或行负压封闭引流（VSD）治疗1周后行创面修复手术。根据创面位置与大小、患者年龄与全身情况，以及供区损伤最小化原则，选择最适合的组织瓣修复创面，对供区创面行断层皮片移植或拉拢缝合。记录放射性损伤累及层次与组织结构、移植组织瓣类型及大小，统计术后创面组织病理学检查及创面组织/分泌物标本细菌培养结果、疼痛缓解情况、组织瓣成活情况及创面愈合情况。随访时，观察组织瓣外形、溃疡是否复发、供区创面愈合情况及腹直肌肌皮瓣供区是否发生腹壁疝。结果放射性损伤累及肋骨与肋软骨者21例，累及肋骨、胸骨与锁骨者4例，累及锁骨及锁骨下动脉者2例。12例患者移植了腹直肌肌皮瓣，8例患者移植了背阔肌肌皮瓣，3例患者移植了胸廓内动脉穿支皮瓣，3例患者移植了腹壁上动脉穿支皮瓣，1例患者移植了游离腹壁下动脉穿支皮瓣，组织瓣大小为14 cm×8 cm~20 cm×20 cm。术后，创面组织病理学检查未见肿瘤成分；创面组织/分泌物标本细菌培养结果：25例患者为阳性，2例患者为阴性；7例患者疼痛完全缓解。25例患者术后组织瓣完全成活，创面愈合；2例患者术后腹直肌肌皮瓣尖端部分坏死，经行清创与组织瓣修整术后愈合。随访6个月~2年，组织瓣外形均良好，溃疡均未复发，供区创面遗留线性瘢痕，腹直肌肌皮瓣供区均未发生腹壁疝。结论准确评估损伤程度后彻底清创并行VSD治疗，以及根据患者全身情况与创面特点和供区损伤最小化原则选择合适的组织瓣修复创面，是乳腺癌根治术后胸部放射性溃疡的较佳修复策略，采用该策略可尽快封闭创面，防止溃疡复发，预后良好。
- 胸部 /
- 辐射损伤 /
- 慢性病 /
- 清创术 /
- 外科皮瓣 /
- 创面修复
Abstract: Objective To explore the repair strategy of chest radiation ulcer after radical mastectomy for breast cancer and its clinical effect. Methods The study was a retrospective observational study. From September 2020 to September 2023, 27 female patients (aged 37-83 years) with chest radiation ulcers after radical mastectomy for breast cancer who met the inclusion criteria were admitted to Beijing Jishuitan Hospital Affiliated to Capital Medical University, of which 7 patients developed significant pain in the chest region. Various examinations were completed to accurately assess the presence of tumors and depth of radiation ulcers. After tumor recurrence was ruled out, the ulcer wounds were thoroughly debrided (the wound size after debridement was 8 cm×7 cm to 18 cm×18 cm). At the same time, pathological examination of the wound tissue and bacterial culture of the wound tissue/exudate samples were performed. The wound repair surgery was performed at the same time after debridement or one week after vacuum sealing drainage (VSD) treatment. Based on the location and size of the wound, the age and overall condition of the patient, as well as the principle of minimizing damage to the donor site, the most suitable tissue flap was selected to repair the wound. The donor site wound was transplanted with a split-thickness skin graft or sutured together. The level and tissue structure of radiation injury, and the type and size of transplanted tissue flap were recorded. The results of postoperative pathological examination of wound tissue and bacterial culture of wound tissue/exudate samples, pain relief, survival of tissue flap, and wound healing were recorded. During the follow-up, the shape of the tissue flap, whether the ulcer recurred, the wound healing of the donor site, and whether the abdominal wall hernia occurred in the donor site of the rectus abdominis myocutaneous flap were observed. Results Radiation injury involved ribs and costal cartilage in 21 cases, ribs, sternum, and clavicle in 4 cases, and clavicle and subclavian artery in 2 cases. Twelve patients were transplanted with rectus abdominis myocutaneous flap, eight patients with latissimus dorsi myocutaneous flap, three patients with internal thoracic artery perforator flap, three patients with superior epigastric artery perforator flap, and one patient with free deep inferior epigastric perforator flap. The size of tissue flap was 14 cm×8 cm to 20 cm×20 cm. After surgery, no tumor component was found in the pathological examination of wound tissue; 25 patients were positive and 2 patients were negative in bacterial culture results of wound tissue/exudate samples; the pain of 7 patients was completely relieved. The tissue flaps of 25 patients survived completely after surgery, and the wounds healed. Two patients had partial necrosis at the tip of the rectus abdominis myocutaneous flap, which healed after debridement and tissue flap repair. The patients were followed up for 6 months to 2 years. The appearance of the tissue flaps was good, and no ulcer recurred. The linear scar was left on the donor site, and no abdominal wall hernia occurred in the donor site of the rectus abdominis myocutaneous flap. Conclusions Thorough debridement and VSD treatment after accurate assessment of the extent of damage, and the selection of appropriate tissue flap to repair the wound based on the patient's general condition, the wound characteristics, and the principle of minimizing damage to the donor site are good repair strategies for the chest radiation ulcers after radical mastectomy for breast cancer. By using the strategies, the wounds could be closed as soon as possible, preventing ulcer recurrence and having a good prognosis.
- Thorax /
- Radiation injuries /
- Chronic disease /
- Debridement /
- Surgical flaps /
- Wound repair
杜伟力：患者管理、手术实施、文章撰写；沈余明：指导手术的设计与实施过程、指导文章撰写；程琳、代强：患者管理、手术实施、数据收集；车可心：病例图片编辑修改

所有作者均声明不存在利益冲突

HTML全文

参考文献(30)

[1]	程琳,杜伟力,张颖,等.骶尾部慢性放射性溃疡的分期修复策略[J].中华烧伤杂志,2021,37(3):225-231.DOI: 10.3760/cma.j.cn501120-20210104-00003.
[2]	李罡,张志,李叶扬,等.颈横动脉颈段皮支皮瓣修复颈部放射性溃疡的临床效果[J].中华烧伤杂志,2021,37(12):1116-1121.DOI: 10.3760/cma.j.cn501120-20200807-00371.
[3]	杨飞,谢卫国,张伟,等.放射性溃疡严重程度分型及临床治疗分析[J].组织工程与重建外科杂志,2022,18(1):62-66.DOI: 10.3969/j.issn.1673-0364.2022.01.015.
[4]	SpałekM.Chronic radiation-induced dermatitis: challenges and solutions[J].Clin Cosmet Investig Dermatol,2016,9:473-482.DOI: 10.2147/CCID.S94320.
[5]	BorrelliMR,ShenAH,LeeGK,et al.Radiation-induced skin fibrosis: pathogenesis, current treatment options, and emerging therapeutics[J].Ann Plast Surg,2019,83(4S Suppl 1):S59-64.DOI: 10.1097/SAP.0000000000002098.
[6]	覃凤均,宁方刚,陈欣,等.26例慢性放射性溃疡的治疗分析[J].中国全科医学,2018,21(z1):232-234.DOI: 10.3969/j.issn.1007-9572.2018.z1.099.
[7]	MaX,JinZ,LiG,et al.Classification of chronic radiation-induced ulcers in the chest wall after surgery in breast cancers[J].Radiat Oncol,2017,12(1):135.DOI: 10.1186/s13014-017-0876-y.
[8]	WaghmareCM.Radiation burn--from mechanism to management[J].Burns,2013,39(2):212-219.DOI: 10.1016/j.burns.2012.09.012.
[9]	李翌,刘会攀,王姊,等.68Ga-枸橼酸PET/CT在炎症及感染疾病中的应用进展[J].国际医学放射学杂志,2020,43(2):219-223.DOI: 10.19300/j.2020.Z17466.
[10]	郁步惠,苏洪星,孙娜,等.放射性核素显像在肌肉骨骼感染中的研究进展[J].中华核医学与分子影像杂志,2021,41(9):566-573.DOI: 10.3760/cma.j.cn32182-20210713-00233.
[11]	LiuS,ZhangJ,YinH,et al.The value of ¹⁸F-FDG PET/CT in diagnosing and localising deep sternal wound infection to guide surgical debridement[J].Int Wound J,2020,17(4):1019-1027.DOI: 10.1111/iwj.13368.
[12]	HamadaM,NakaharaT,YazawaM,et al.Radiation-induced osteomyelitis/osteonecrosis of the rib: SPECT/CT imaging for successful surgical management[J].Plast Reconstr Surg Glob Open,2019,7(12):e2536.DOI: 10.1097/GOX.0000000000002536.
[13]	ZhouB,LongY,LiS,et al.Reconstruction of chronic radiation-induced ulcers in the chest wall using free and pedicle flaps[J].Front Surg,2022,9:1010990.DOI: 10.3389/fsurg.2022.1010990.
[14]	WangC,ZhangJ,LiuZ.Vacuum-assisted closure therapy combined with bi-pectoral muscle flap for the treatment of deep sternal wound infections[J].Int Wound J,2020,17(2):332-338.DOI: 10.1111/iwj.13277.
[15]	张龙城,林文彪,韦干观,等.创面准备原则在采用胸大肌皮瓣修复颈部放射性溃疡中的应用[J].中华耳鼻咽喉头颈外科杂志,2014,49(6):509-510.DOI: 10.3760/cma.j.issn.1673-0860.2014.06.015.
[16]	ChenL,ZhangS,DaJ,et al.A systematic review and meta-analysis of efficacy and safety of negative pressure wound therapy in the treatment of diabetic foot ulcer[J].Ann Palliat Med,2021,10(10):10830-10839.DOI: 10.21037/apm-21-2476.
[17]	LiX,ZhangF,LiuX,et al.Staged treatment of chest wall radiation-induced ulcer with negative pressure wound therapy and latissimus dorsi myocutaneous flap transplantation[J].J Craniofac Surg,2019,30(5):e450-e453.DOI: 10.1097/SCS.0000000000005514.
[18]	SteenvoordeP,van EngelandA,OskamJ.Vacuum-assisted closure therapy and oral anticoagulation therapy[J].Plast Reconstr Surg,2004,113(7):2220-2221.DOI: 10.1097/01.prs.0000123603.32963.11.
[19]	ZhouY,ZhangY.Single- versus 2-stage reconstruction for chronic post-radiation chest wall ulcer: a 10-year retrospective study of chronic radiation-induced ulcers[J].Medicine (Baltimore),2019,98(8):e14567.DOI: 10.1097/MD.0000000000014567.
[20]	Fernández CanedoI,Padilla EspañaL,Francisco Millán CayetanoJ,et al.Hyperbaric oxygen therapy: an alternative treatment for radiation-induced cutaneous ulcers[J].Australas J Dermatol,2018,59(3):e203-e207.DOI: 10.1111/ajd.12763.
[21]	RyanJL.Ionizing radiation: the good, the bad, and the ugly[J].J Invest Dermatol,2012,132(3 Pt 2):985-993.DOI: 10.1038/jid.2011.411.
[22]	张鲜英,刘毅,肖斌,等.慢性放射性溃疡创面的综合治疗[J].中国美容医学,2017,26(12):13-16.
[23]	宋达疆,李赞,周晓,等.不同形式横行腹直肌肌皮瓣在乳房再造和胸壁溃疡修复中的应用经验教训及对策[J].中国医师杂志,2018,20(4):511-516.DOI: 10.3760/cma.j.issn.1008-1372.2018.04.009.
[24]	王欣.带蒂腹直肌肌皮瓣修复胸壁深度放射性溃疡[J].组织工程与重建外科杂志,2020,16(4):295-297.DOI: 10.3969/j.issn.1673-0364.2020.04.008.
[25]	赵奎背阔肌、腹直肌肌皮瓣修复乳腺癌术后胸壁放射性溃疡的临床疗效对比分析南宁广西医科大学2019 赵奎.背阔肌、腹直肌肌皮瓣修复乳腺癌术后胸壁放射性溃疡的临床疗效对比分析[D].南宁:广西医科大学,2019.
[26]	陈保国,宋慧锋,许明火,等.应用对侧胸廓内动脉穿支皮瓣修复乳腺癌术后高位放射性溃疡[J].中国美容整形外科杂志,2016,27(8):452-454.DOI: 10.3969/j.issn.1673-7040.2016.08.002.
[27]	LeppardW,PomposelliT,ChangEI,et al.Internal mammary usability as recipient vessels in DIEP breast reconstruction in the setting of previous radiation[J].J Plast Reconstr Aesthet Surg,2018,71(8):1123-1128.DOI: 10.1016/j.bjps.2018.05.041.
[28]	YamamotoT,KageyamaT,SakaiH,et al.Thoracoacromial artery and vein as main recipient vessels in deep inferior epigastric artery perforator (DIEP) flap transfer for breast reconstruction[J].J Surg Oncol,2021,123(5):1232-1237.DOI: 10.1002/jso.26421.
[29]	NaraparajuV,MoslehW,AlmnajamM,et al.The utility of radiographic assessment of the internal mammary arteries in chest wall irradiated patients[J].Front Biosci (Landmark Ed),2022,27(1):30.DOI: 10.31083/j.fbl2701030.
[30]	武雷,丁英状,郝敏如,等.两种下腹部组织瓣修复四肢大面积皮肤软组织缺损后患者的腹部功能与外形[J].中华烧伤与创面修复杂志,2023,39(10):959-967.DOI: 10.3760/cma.j.cn501225-20230428-00145.

下载: 全尺寸图片幻灯片

1 采用腹壁上动脉穿支皮瓣修复例1患者右胸部乳腺癌根治术后放射性溃疡创面的效果。1A.入院时右胸部溃疡创面；1B.彻底清除坏死的第4、5肋软骨及肋骨，并将周围色素沉着及质地硬的皮肤切除；1C.彻底清创后用负压封闭引流（VSD）材料覆盖创面；1D.VSD治疗1周后，基底组织血运良好；1E.设计切取右侧腹壁上动脉穿支皮瓣；1F.掀起皮瓣，见血运良好；1G.转移皮瓣覆盖创面并将供区创面直接缝合后即刻；1H.术后半年复查，皮瓣存活良好，溃疡未复发

下载: 全尺寸图片幻灯片

2 采用腹直肌肌皮瓣修复例2患者右胸部乳腺癌根治术后放射性溃疡创面的效果。2A.入院时右胸部溃疡创面；2B.入院时胸部CT可见右侧肋骨炎症侵蚀改变；2C.清创后1周，设计左侧腹直肌肌皮瓣；2D.Ⅱ期术中采用聚丙烯补片无张力修补腹壁，将肌皮瓣通过皮下隧道转移至胸部创面；2E.用肌皮瓣封闭胸部创面，将供区创面直接缝合； 2F.术后11个月复查，肌皮瓣存活良好，溃疡未复发，供区创面愈合良好，无腹壁膨隆或腹壁疝发生

下载: 全尺寸图片幻灯片

3 采用游离腹壁下动脉穿支皮瓣修复例3患者左胸部乳腺癌根治术后放射性溃疡创面的效果。3A.入院时胸部溃疡创面；3B.入院时胸部CT显示，左胸部肋骨受侵蚀；3C.彻底清创，切除溃疡及周围瘢痕组织，去除坏死的第2~4肋骨及肋软骨；3D.清创术后1周，见基底创面新鲜，渗血良好，设计游离腹壁下动脉穿支皮瓣；3E.断蒂之前采用吲哚菁绿血管造影，判断皮瓣血运，见皮瓣Ⅳ区灌注较差；3F.切取腹壁下动脉穿支皮瓣，标记拟切除的Ⅳ区皮瓣；3G.腹部供区放置聚丙烯补片增强腹壁强度；3H.将皮瓣游离移植至左胸部，腹壁下动脉及静脉与胸背动脉及静脉分别端端吻合；3I.皮瓣封闭创面后血运良好，将供区创面直接缝合后即刻；3J.术后3个月复查，重建乳房外形良好，未见溃疡复发，供区遗留横行线性瘢痕

下载: 全尺寸图片幻灯片