目的 探讨免补片经单切口分层充气法腔镜下乳房切除术后一期假体植入联合胸肌筋膜乳房重建的手术方法和临床应用价值.方法 回顾性分析2 例早期乳腺癌患者的临床资料,分别经侧胸壁切口、腋窝切口入路在腔镜下完成乳房皮下腺体切除术后,完成全腔镜下胸肌筋膜联合假体植入的乳房重建术.观察其手术并发症发生情况,并运用BREAST-Q量表调查患者术前术后满意度.结果 2 例患者均顺利完成手术,无术后感染、乳头乳晕或皮瓣缺血坏死、假体外露或取出、术后运动畸形、术后胸壁疼痛、包膜挛缩、"波纹"征等并发症.BREAST-Q量表调查结果显示患者均对术后乳房感到满意,除了偶有牵拉感,未报告其他胸壁不适,社会心理状态和性健康状态较术前无明显下降.结论 分层充气法腔镜下乳房切除术后胸肌筋膜联合假体植入一期乳房重建可为无条件使用补片的患者提供一种新的技术选择,该方法实现腔镜下分离解剖胸肌筋膜的技术要点,对于部分合适的人群值得进一步探索研究.

目的 探讨精益医疗管理在提高中医乳腺科住院医师专科诊疗方案知晓率中的作用.方法 以广州中医药大学第二附属医院乳腺科住院医师为主要研究对象,运用精益医疗管理的理念和方法,通过临床培训及考核,比较精益医疗管理前后的中医乳腺科住院医师专科诊疗方案知晓率的变化情况,以期寻找更优化的中医乳腺科住院医师规范化培训(简称住培)模式和方法.结果 通过精益医疗管理后,广州中医药大学第二附属医院乳腺科住院医师的专科诊疗方案知晓率由55.5％提高到83.33％.结论 精益医疗管理有助于提高中医乳腺科住院医师专科诊疗方案知晓率,优化住培模式,提高带教质量,效果显著.

Objective:To explore the application effect of evidence-based case study in the standardized training of clinical residents in a department of mammary gland.Methods:A total of 24 regular trainees in Department of Mammary Gland, Second Affiliated Hospital of Guangzhou University of Chinese Medicine from April to December 2021 were divided into a control group and an experimental group according to when they started to worked at this department. The control group had 11 ones, including 4 males and 7 females, and took the traditional teaching method. The experimental group had 13 ones, including 6 males and 7 females, and did the teaching of evidence-based case study. The teaching effects of the two groups were evaluated through the questionnaire survey and graduation examination results. The measurement data of normal distribution were compared between these two groups by independent-sample t test, and the count data by χ2 test. Results:There were no statistical differences in the scores of graduation examination, subjective questions, and objective questions (all P>0.05). The experimental group had higher praise on the teaching of evidence-based case study than the control group on the traditional teaching; the scores of study interest, clinical thought, achieving information, self-evidence in receiving patients, and questioning in the experimental group were higher than those in the control group [(6.08±2.02) vs. (4.00±1.55), (6.62±1.66) vs. (4.00±1.34), (7.00±1.35) vs. (5.00±1.48), (6.23±1.92) vs. (3.45±1.37), and (6.23±1.92) vs. (4.00±1.90)], with statistical differences (all P<0.05). Conclusion:The teaching of evidence-based case study for regular trainees in a department of mammary gland can improve their self-teaching and problem-solving abilities.

目的 探讨桃红四物汤辅助治疗胫骨平台骨折术后的疗效及对骨代谢指标的影响.方法 选取2017年12月—2019年12月期间在广州中医药大学附属深圳市宝安中医院骨伤科行胫骨平台骨折手术的92例患者作为研究对象,随机分为对照组和治疗组,各46例.两组患者均进行锁定钢板内固定治疗,对照组在术后给予常规治疗.治疗组在对照组基础上,加用桃红四物汤治疗.治疗后观察两组疗效.分别于治疗前后,采用美国特种外科医院(HSS)膝关节评分评价两组患者膝关节功能恢复情况,采用视觉模拟评分法(VAS)评价两组患者疼痛状况,并计算两组患者双侧下肢周径差.检测患者的总I型前胶原氨基端延长肽(T-PINP)、β胶原特殊序列(β-Crosslaps)和N-中端骨钙素(N-MID)水平.结果 治疗后治疗组优良率95.65％(44/46)明显高于对照组82.61％(38/46),差异有统计学意义(P<0.05).两组患者治疗后HSS膝关节评分均高于治疗前(P<0.05),且治疗组HSS膝关节评分高于对照组,两组比较差异有统计学意义(P<0.05).两组患者治疗后VAS评分和双侧下肢周径差均明显低于治疗前(P<0.05),且治疗组VAS评分和双侧下肢周径差明显低于对照组,两组比较差异有统计学意义(P<0.05).两组患者治疗后T-PINP、β-Crosslaps、N-MID水平均高于治疗前(P<0.05),且治疗组T-PINP、β-Crosslaps、N-MID水平均高于对照组,两组比较差异有统计学意义(P<0.05).结论 使用桃红四物汤辅助胫骨平台术后治疗,能够明显改善疗效和膝关节功能恢复,且能够有效减轻患者疼痛和肿胀症状,提高骨代谢水平.

腔镜技术已经被广泛应用于外科领域,在乳腺外科中的应用也不断深入,尤其是近年来腔镜微创的理念被更多人所重视,腔镜技术的变革也越来越多.对既往建腔方法、手术方式存在问题的思考催生了一些新观点、新术式和新技巧.笔者针对近10年来腔镜技术在乳腺外科应用的发展和变革进行综述,一方面总结了乳腺外科建腔方法的思路变革,从经典的3孔充气法到隐蔽的单切口设计,更体现"无痕化"的人文关怀理念;另一方面阐述了腔镜技术在乳腺癌保留乳房手术、保留乳头、乳晕的皮下全乳切除术、乳房重建修复整形术、腋窝淋巴结处理以及乳腺良性疾病等手术中的应用进展,探索优化手术操作流程、规范学习曲线对腔镜技术推广的意义.随着微创理念的推广,乳腺腔镜技术将会成为一部分合适患者的优选方案.

目的:探讨吲哚菁绿(ICG)分子荧光影像技术在单孔法腔镜前哨淋巴结活检术中的应用价值.方法:选取2019年3月至2019年12月收治的行腔镜前哨淋巴结活检术的20例早期乳腺癌患者,均以ICG联合纳米碳混悬注射液作为示踪剂.手术切除的前哨淋巴结送术中冰冻病理检查及常规石蜡病理检查.比较前哨淋巴结检出率、前哨淋巴结转移数量及ICG单独显影、纳米碳单独显影、ICG+纳米碳同时显影的前哨淋巴结数量.结果:ICG、纳米碳、ICG+纳米碳前哨淋巴结检出率分别为100.0％、95.0％、100％;前哨淋巴结检出数量分别为89枚、77枚、97枚,前哨淋巴结检出数量平均为(4.45±1.86)枚、(3.85±1.98)枚、(4.85±2.22)枚,ICG组与纳米碳组差异有统计学意义(P<0.05),ICG+纳米碳组与纳米碳组之间差异亦有统计学意义(P<0.001).20例患者中3例检出前哨淋巴结转移,转移前哨淋巴结7枚;7枚转移前哨淋巴结均被ICG检出,纳米碳仅检出其中2例患者共5枚转移前哨淋巴结.结论:ICG与单孔法腔镜前哨淋巴结活检术结合应用,具有较高的前哨淋巴结检出率及淋巴结检出数量,且前哨淋巴结假阴性率可能较低.

目的 探讨对伴有乳房下垂的乳腺癌病人使用改良延长内上蒂缩乳上提手术.方法 回顾性分析2018年4 月至2018年10 月首都医科大学附属北京友谊医院乳腺甲状腺外科收治的3例外上象限或外侧肿瘤直径较大且伴乳房下垂的乳腺癌病人行改良延长内上蒂缩乳上提手术的相关并发症和术后BREAST-Q评分.结果 3例病人病人术后均未出现脂肪液化、乳头乳晕复合体缺血坏死并发症.术后6个月BREAST-Q评分平均值与术前对比,生理状况评分为96.7分vs.66.7分,对乳房满意度评分为100.0分vs 64.7分,社会心理状态评分为100.0分vs.84.3分,性心理健康状态评分为97.7分vs.88.0分,术后乳头满意度均为满分20分.随访时间分别为13.7个月、16.6个月、19.3个月,均未见复发事件.结论 改良延长内上蒂乳房缩小术适用于外上、外侧象限病灶直径较大的病人,可以相对简便地修复术后局部缺损,同时改善乳房下垂,提高病人对乳房外观的满意度.

肉芽肿性小叶性乳腺炎(Granulomatous lobular mastitis,GLM)是指乳腺的非干酪样坏死局限于乳腺小叶的乳腺肉芽肿性改变[1].本病在中医学中无明确记载,根据其临床特点,认为其属于乳痈范畴,但应注意本病有别于常见的急性哺乳期化脓性乳腺炎,两者在病因病机、诊断、治疗、预后等方面存在明显差异.目前,西医往往采用激素、抗结核药物、手术等方法治疗GLM,但由于治疗药物存在不良反应及手术会一定程度上导致乳房毁形,仍存在较大争议.首届全国名中医林毅教授本着“祛邪不伤正,祛腐可生新”的治疗原则,提出“平衡脏腑,提脓祛腐”的中医综合疗法治疗乳腺炎,取得了较好的临床疗效[2].在长期临床实践过程中,应用“燮理阴阳、立法衡通”理论治疗GLM,可有效缩短疗程,减少对乳房外形的破坏,且乳房功能保留较好[3].本文介绍林毅教授运用中医外治法治疗GLM的经验,以飨读者.

目的:了解肉芽肿性小叶性乳腺炎在国内的诊治现状,引起临床医师对本病的关注.方法:依托网络媒体对国内乳腺科及从事乳腺病领域的临床医师进行问卷调查,内容包括肉芽肿性小叶性乳腺炎的诊断、病因、治疗及疗效评价等.结果:共回收有效问卷261份.83.1％的医师常规对本病行病理活检,但病理诊断存在一定困难;可结合临床诊断要点(如成脓后易形成窦道、乳房肿块伴疼痛、病灶始发于外周、发病年龄、哺乳史等)协助诊断;根据临床表现、疾病痛程、病变范围进行临床分期、分型具有一定的意义.77.39％的医师常规对本病行细菌培养,但阴性结果近半,检出的菌种以棒状杆菌属多见(占19.54％).手术是本病的主要治疗方法,时机多为迁延期/发病间期,方式以病灶大范围切除+整形为主;中医药治疗、激素治疗也是常用的治法.疗效评价应以临床表现、B超所见为主要依据;超声提示无病灶、红肿热痛等症状消失、窦道消失等可作为治愈标准的评判条件;疗效评价应综合考虑疗效、复发率、外形满意度、疗程长短、并发症发生率及患者生活质量等因素.结论:肉芽肿性小叶性乳腺炎发病明显增加,但临床医师对该病的病因、诊断等认识不足,尚未形成规范的治疗方案,疗效评价标准也不统一,应提高临床医师对本病的关注,提升对病因病机、诊疗方案的研究.

目的观察加味三骨汤防治芳香化酶抑制剂治疗相关骨丢失的临床疗效,探讨中医药方剂在防治AIs治疗相关骨丢失及改善生活质量的临床依据及治疗方法。方法连续选取西医院与中医院的绝经后激素受体(HR)阳性乳腺癌患者各65例,分别为对照组(N)及中药治疗组(CM),对照组为AIs+碳酸钙D3片0.6 qd po,中药治疗组在对照组的基础上加服中药加味三骨汤加减,每日一剂,共12个月。对比治疗前后的骨痛症状积分、骨密度T值、骨质疏松发生率等观察指标的变化。结果1.两组治疗前后骨痛积分均升高,对照组治疗后2～3级骨痛比例持续升高,治疗12个月比6个月升高8.7%(P=0.032);中药治疗组骨痛积分2～3级未见持续升高(P=0.259);组间比较对照组的2～3级骨痛积分占比较中药治疗组明显升高(P=0.023)。2.与基线相比,12个月后中药治疗组的T值平均值无明显变化(P=0.151),对照组T值平均值对比基线下降[(-1.646±0.760)比(-1.435±0.529),P=0.008]。3.两组均无骨折事件发生,但中药治疗组的骨质疏松发生率较对照组明显下降(28.3%比40.4%,P=0.032)。结论加味三骨汤对AIs治疗相关骨丢失引起的骨痛症状及骨质疏松发生率有改善作用。

目的：分析肉芽肿性小叶性乳腺炎病原菌分布情况，探讨细菌感染在该疾病中的作用。方法收集肉芽肿性小叶性乳腺炎患者组织块、脓液、分泌物等标本，经培养分离后再鉴定，并用 K －B 法进行相应的药敏试验。结果190例患者中，66例患者标本提示细菌阳性，阳性率为34．8％。其中49例分离出棒状杆菌，占74．2％（49／66），以水生棒状杆菌、微小棒状杆菌为主。通过延长培养时间、改善培养条件、留取脓肿周围组织等方式，棒状杆菌阳性率逐年升高。此外培养阳性率较多的细菌还有表皮葡萄球菌11例（16．7％），金黄色葡萄球菌2例（3．0％），铜绿假单胞菌2例（3．0％）。结论棒状杆菌与肉芽肿性小叶性乳腺炎的发病可能有着密切的联系，进一步研究棒状杆菌的致病机制，对该病的诊治具有重大意义。

目的:探讨曲安奈德为主的药物局部封闭治疗肉芽肿性小叶性乳腺炎(GLM)的临床效果.方法:回顾性分析2012 年12 月至 2015 年2 月期间收治的 52 例 GLM 患者,其中肿块期 16 例,脓肿期 22 例,迁延期14例. 在病灶周围多点局部注射曲安奈德混悬液(曲安奈德注射液20 ~ 40 mg + 2%盐酸利多卡因溶液5 mL + 0.9% NS 5 ~ 10 mL),局部炎症明显者,加入注射用头孢呋辛钠或硫酸阿米卡星. 间隔1 ~ 2 周重复治疗. 结果:52 例患者行曲安奈德为主的药物局部封闭治疗,次数最少者 1 次,最多者 6 次,平均 4.1次. 临床治愈8例,好转36 例. 治愈率为15%,有效率为85%. 结论:曲安奈德为主的药物局部封闭治疗GLM ,可控制病情发展,起效快、毒副反应小,明显提高临床疗效,是一种可供临床选择的新的治疗方法.

目的:观察扶正益气法对乳腺癌术后辅助化疗患者Th 1/Th2细胞漂移的影响,为进一步探讨扶正益气法通过改善肿瘤生存的内环境而对化疗起“减毒增效”的作用机制提供理论基础.方法:采用随机对照研究,将68例患者分为观察组和对照组各34例.2组均行6周期TEC方案化疗(21天/周期),观察组加用参芪扶正液静脉滴注.观察比较2组第1周期化疗前、第6周期化疗后第7天血清Th1细胞因子(IL-2、TNF-α、IFN-γ)及Th2细胞因子(IL-4、IL-6、IL-10)的水平.结果:乳腺癌患者化疗后Th1细胞因子IL-2、TNF-α、IFN-γ均较化疗前降低,差异有显著性或非常显著性意义(P＜ 0.05,P＜0.01);Th2细胞因子IL-4、IL-6、IL-10仍呈高表达强势,与化疗前比较,差异均无显著性意义(P＞0.05).对照组化疗后Th1细胞因子IL-2、TNF-α、IFN-y均较化疗前降低,差异均有非常显著性意义(P＜0.01).观察组化疗后Th1细胞因子IL-2、TNF-α、IFN-γ与化疗前比较,差异均无显著性意义(P＞0.05).2组在化疗后Th1细胞因子IL-2、TNF-α、IFN-γ比较,差异有显著性或非常显著性意义(P＜ 0.05,P＜0.01).对照组化疗后Th2细胞因子IL-4、IL-6、IL-10变化不明显,与化疗前比较,差异均无显著性意义(P＞0.05).观察组化疗后Th2细胞因子IL-6、IL-10变化不明显,与化疗前比较,差异均无显著性意义(P＞0.05);而IL-4与化疗前比较,差异有非常显著性意义(P＜ 0.01).化疗后观察组Th2细胞因子IL-4、IL-6、IL-10降低较对照组明显,但差异均无显著性意义(P＞0.05).结论:化疗可降低Th1细胞因子的水平,而Th2呈高表达强势,提示Th1向Th2漂移,表明辅助化疗可导致进一步的免疫抑制.参芪扶正液可改善辅助化疗患者的Th1细胞因子水平,抑制使其在化疗后进一步降低,提示扶正益气法可以抑制Th1向Th2漂移,有效改善机体免疫抑制和纠正免疫紊乱.

Objective To investigate the effect of Xiaopi oral solution on angiogenesis in breast precancerous lesion rats,and to explore its possible reversing mechanism for breast precancerous lesion. Methods The rat model of breast precancerous lesion was established by 1, 7, 12- dimethyl- benzanthracene(DMBA) combined with estrogen and progesterone sequential method. After modeling and treatment, we compared microvessel density(MVD) and the expression of vascular endothelial growth factor(VEGF) in the mammary gland of Xiaopi oral liquid group,tamoxifen group and the model group. Results Xiaopi oral liquid could reduce the incidence of breast cancer in breast precancerous lesion rats,significantly lower MVD,but had no inhibitory effect on the expression level of VEGF in the mammary gland of breast precancerous lesion rats. Conclusion Xiaopi oral liquid can inhibit the angiogenesis in precancerous lesion rats, thus to block the development of breast cancer, but its mechanism is not through the inhibition of the VEGF pathway.

Objective:To investigate the role of Xiaopi Granule in preventing breast precancerosis and its mechanism,we observed the effect of Xiaopi Granule on DMBA-induced pre-cancerosis in SD rat models,and the influence on the expressions of EGFR and STAT3.Methods:24 SD rats were randomly divided into three groups,including conctrol group(N group),Xiaopi Granule group(X group)and TAM group(T group).At the 26th week after being treated with DMBA and DES,the specimens of rats' breast were collected and assayed with the incidence of cancer and the expressions of EGFR and STAT3.And statistical analysis was performed among the three groups.Results:Compared with N group,the incidence of cancer in X group,T group significantly decreased,which were 25%,37.5% and 87.5% respectively(P<0.05).Among three groups,no difference was found on the expressions of both EGFR and STAT3(P>0.05).Conclusion:Xiaopi Granule may prevent breast caner.The mechanism of its action may be not associated with the expressions of EGFR and STAT3,and further studies should be performed to explore whether its action is associated with the other related factors in the pathway of EGFR-STAT3.

目的:对艾灸防治乳癌化疗所致恶心呕吐进行疗效评价,并探讨其作用机理。方法:将58例符合纳入标准的患者按照1∶1的比例随机分为治疗组和对照组。两组均采用盐酸格拉司琼针(化疗前后各静脉推注1次,总用量(6 mg)止呕治疗;治疗组配合隔姜艾灸疗法,从化疗前1天开始,1次/d,每次30 m in,共3 d。观察化疗第1~7天的消化道反应情况,按WHO抗癌药物毒性反应分级,同时记录不良反应,评价患者一般状况Karnofsky得分。结果:恶心的完全控制率,治疗组均高于对照组(化疗第1天P>0.05;第2~7天P值均<0.05)。t检验比较两组恶心的持续时间,结果显示P<0.05。结论:该研究结果表明,艾灸联合盐酸格拉司琼注射液较单用可更有效改善乳腺癌联合化疗方案所致恶心,提高患者生活质量。

<正>浆细胞性乳腺炎(Plasma Cell Mastitis,PCM)亦称化学性乳腺炎、乳腺导管扩张症,属于中医外科学粉刺性乳痈范畴[1]。临床上可分为溢液期、肿块期、化脓期、窦道期等[2],但由于

OBJECTIVE:To observe the effect of Fukangling capsule on the short-term curative effect of neoadjuvant Chemotherapy for breast cancer and drug-resistant gene p170,GST-π,and to explore the mechanism of traditional Chinese medicine in decreasing the toxicity but increasing the curative effect of neoadjuvant chemotherapy.METHODS:53 patients with breast cancer receiving neoadjuvant chemotherapy were divided into trial group and control group.The trial group received Fukangling capsule and chemotherapy concomitantly while the control group received chemotherapy alone.After receiving three cycles of chemotherapy,the improvement of breast tumor,the expression of p170 and GST-π in breast tumor tissue were compared between the two groups.RESULTS:In the trial group,the complete remission rate(CR) was 12.1% and partial remission rate(PR) was 60.6%,versus 0 CR and 45% PR in the control group,and there were statistical differences between the two groups(P<0.05).The positive rate of p170 was 12.1% in the trial group versus 40% in the control gr-oup,and statistical difference had been found in two groups(P<0.05).The positive rate of GST-π was 36.4% in the trial gr-oup versus 55% in the control group,and no statistical difference had been found in two groups(P>0.05).CONCLUSION:Tr-aditional Chinese medicine with the function of strengthening the body resistance and detoxicating can increase the curative effect of chemotherapy,and one of the mechanisms is associated with its regulatory effect on the expression of drug-resistant gene.

目的探讨乳腺浸润性导管癌肺耐药相关蛋白(LRP)、多药耐药相关蛋白(MRP)的表达及其与临床因子的相关性。方法采用SP免疫组化方法对332例乳腺癌组织进行MRP、LRP、C-erbB2、P53和ER、PR表达的联合检测,并与年龄、临床分期及淋巴结转移情况进行比较研究。结果332例乳腺浸润性导管癌组织中,MRP高表达率为8.13%,在≤45岁与>45岁阳性表达率分别为3.28%和10.95%(P<0.05)。在ER(-)与ER(+)患者中MRP高表达率分别为14.19%和4.55%,两者间具有显著的负相关性(P<0.05);C-erbB2(+)与C-erbB2(-)患者中MRP高表达率分别为10.70%和4.83%,两者间具有显著的正相关性(P<0.05);PR(+)LRP高表达率66.67%,PR(-)为54.31%,两者间具有显著的负相关性(P<0.05);MRP、LRP与临床分期、淋巴结转移情况均无显著相关性(P>0.05)。结论MRP高表达可能与老年乳腺癌对化疗不敏感的特点及内分泌治疗不敏感,尤其是与三苯氧胺的治疗不敏感有关。MRP、LRP与乳腺浸润性导管癌的预后关系不大。