专家共识与争议:保留乳头乳晕复合体乳房切除术(2015年版)

2016-07-06 SIBCS整理 中国癌症杂志

共识专家讨论组 整理执笔:胡震 复旦大学附属肿瘤医院乳腺外科 胡震:复旦大学附属肿瘤医院乳腺外科医师,主任医师,硕士研究生导师。1991年就读于上海医科大学,1998年获临床医学七年制硕士学位,2000~2003年就读于复旦大学附属肿瘤医院乳腺外科,获肿瘤学博士学位。2002年赴美国加利福尼亚大学洛杉矶分校肿瘤外科学习。2009年赴美国德克萨斯大学MD安德森癌症中心整形外科和哈佛

共识专家讨论组
整理执笔:胡震
复旦大学附属肿瘤医院乳腺外科

胡震:复旦大学附属肿瘤医院乳腺外科医师,主任医师,硕士研究生导师。1991年就读于上海医科大学,1998年获临床医学七年制硕士学位,2000~2003年就读于复旦大学附属肿瘤医院乳腺外科,获肿瘤学博士学位。2002年赴美国加利福尼亚大学洛杉矶分校肿瘤外科学习。2009年赴美国德克萨斯大学MD安德森癌症中心整形外科和哈佛大学达纳法伯癌症研究所学习。目前就职于复旦大学附属肿瘤医院乳腺外科,擅长乳腺恶性肿瘤的手术治疗和乳房重建手术。长期从事遗传性乳腺癌的基础研究工作,并致力于遗传性肿瘤相关预防、诊断和治疗的转化性研究。

随着乳房重建技术的发展,越来越多的乳腺癌患者可以在术后保持形体的完整。传统乳房切除术要求切除乳头乳晕复合体(NAC),因此在乳房重建手术时需要对NAC进行重建。但是根据文献报道,有36%的乳房重建患者对乳头重建的效果并不满意【1】,同时乳头的缺失也会引起患者的心理问题【2】。1962年,Freeman【3】首先提出了保留NAC乳房切除术(NSM)的理念,但是该术式用于乳腺癌治疗后也引起了肿瘤安全性的争议。

在我国,目前尚缺少NSM的大规模临床报道,为了调查该术式在中国医师中的认知和应用情况,我们于2015年9月19日在上海举行了“NSM专家讨论会”。大会主席为复旦大学附属肿瘤医院的吴炅教授,邀请了胡震、董佳生、陈前军、陈益定、范照青、方仪、聂建云、水若鸿、宋向阳、杨子昂、俞晓立、朱丽教授等为嘉宾。参会的医师共50名,大部分为从事乳腺肿瘤诊治工作的外科医师,同时还邀请了整形外科、放疗科和病理科医师参会。会议就NSM的适应证、禁忌证、手术方法、病理学评估和放疗等问题进行了讨论和表决,现整理如下,供各位同道参考。

1 NSM的适应证与禁忌证

1.1 临床评估

术前对乳腺癌患者进行仔细的体格检查是挑选适合接受NSM者的关键。有文献报道,在乳腺体格检查有NAC异常表现的患者(如乳头凹陷、乳头部位可以扪及肿块、乳头溢液或乳头溢血等)中,有61%存在NAC的癌累及【4】,这类患者在绝大多数的文献和教材中都列为NSM的禁忌。因此参会的所有医师都不赞成炎性乳腺癌和乳头Paget病的患者接受NSM手术。

1.2 肿瘤到乳头的距离(TND)

TND指肿瘤边缘到乳头乳晕复合体的最近距离,是一个非常重要的评估指标。很多研究显示TND越小,NAC存在癌累及的概率越高。对于TND最佳临界值的设定尚存在争议,一般认为是2cm,但也有研究认为1cm也是安全的【4】。可能是由于这些争议的存在,高达64.9%的参会者认为,即使是TND小于2cm,只要乳头后方切缘病理检查未发现恶性证据,患者仍然可以接受NSM。

1.3 病灶大小

肿瘤的大小也是影响NAC有无癌累及的重要因素,但这一点仍存在争议。大部分研究显示,随着肿瘤病灶大小的增长,NAC癌累及率明显增加。Mallon等【5】发现,在肿瘤大于等于5cm时,NAC累及率高达31.8%;但也有研究认为不论肿瘤大小如何,都能安全地进行NSM【6】。针对这个问题进行投票时,60%的医师认为可以在病灶大于5cm的导管原位癌(DCIS)患者中施行NSM,但是当大于5cm的病灶变成浸润性癌时,就只有36%的医师愿意施行NSM。造成这个结果的原因:首先是出于安全性的考虑,其次是后续辅助治疗的考虑。当病灶为大于5cm的DCIS时,患者在接受了NSM后并不需要接受放疗,而大于5cm的浸润性癌则肯定需要放疗。NSM手术后往往会进行乳房重建,而放疗对于乳房重建特别是假体重建的患者会造成一定影响(切口愈合、重建效果等)。对于这些肯定会接受术后放疗的患者,目前更多的医师愿意选择二期重建,同时由于放疗后的皮肤纤维化而失去弹性,手术时需要将纤维化部位切除,因此更愿意选择自体组织乳房重建从而可以获得足量的健康皮肤。在这种情况下,乳房切除术时乳头的保留就失去了意义,从而不需要进行NSM。

1.4 多灶性及多中心性肿瘤

多发性病灶的乳腺癌往往是保乳手术的禁忌证,在这些患者中是否能够施行NSM也是关注的焦点。多发性病灶的乳腺癌根据多发性病灶的间距及病灶是否位于同一象限分为多灶性肿瘤和多中心性肿瘤,根据文献报道,与单病灶相比,多灶性乳腺癌的NAC癌累及率没有明显的差别,而多中心性乳腺癌则高达29.6%【5】。在针对这一问题的投票中,83.3%的医师支持在多灶性乳腺癌患者中施行NSM,而即使是NAC癌累及率更多的中心性乳腺癌,也有65.9%的医师认为适合做NSM。

1.5 淋巴结状态

Mallon等【5】发现,在腋淋巴结阳性的患者中,乳头侵犯的比例是24.4%,而腋淋巴结阴性的患者中则只有10%(P<0.05),但仍然有72.7%的医师支持在腋淋巴结阳性的患者中进行NSM。当这个议题再细分为不同的腋淋巴结转移个数时,有89.2%的医师支持腋淋巴结转移个数为1~3个的患者可以接受NSM,而只有28.6%的医师认为,腋淋巴结转移个数大于4个的患者也能接受NSM。这个结果也可能是两个因素所造成的:首先处于安全性的考虑,虽然淋巴结阳性个数的多少是否与NAC的累及率相关目前尚有争议,但有研究显示,NAC的累及率很可能随着阳性淋巴结数量的增多而升高【5】;其次是后续辅助治疗的考虑,当腋淋巴结转移个数大于4个时,患者肯定需要接受放疗。

1.6 肿瘤组织学分级与免疫组织化学染色类型

组织学级别高低与NAC的累及率同样具有相关性。组织学级别越高,越易出现NAC的累及。根据文献报道,肿瘤组织学分级为3级者NAC的癌累及率为17.2%,而1级者仅为8.7%【5】。有60.4%的参会专家认为,即使是肿瘤分级为3级的乳腺癌患者,也能接受NSM。乳腺癌常用的免疫组织化学染色指标包括雌激素受体(ER)、孕激素受体(PR)和HER2的表达情况与NAC的癌累及率也有一定的关系。很多研究显示,HER2阳性的乳腺癌NAC累及率高于HER2阴性的乳腺癌【7】。但是ER和PR的表达情况与NAC的累及率是否相关尚存争议【8】。与会专家在对不同免疫组织化学染色类型的乳腺癌进行NSM可行性投票时结果差别不大,其中肿瘤激素受体阳性、HER2阴性的乳腺癌的患者接受NSM得到最多医师的支持(93%),其余类型的支持率为80.5%~83.7%。

1.7 伴有乳头溢液的乳腺癌

伴有乳头溢液的乳腺癌患者(溢液涂片发现恶性细胞)是否能接受NSM的问题,目前存在争议。既往的NSM临床研究往往排除了具有血性溢液的患者【9】,因此缺少相应的安全性数据,即便如此,仍然有34.9%的医师选择这部分患者可以接受NSM。支持的理由是虽然乳头溢液中有癌细胞,但病灶并没有侵犯乳头,只是通过乳管排出乳头而已;同时在进行NSM手术时,严格地切除乳头内部的大导管,只保留乳头的表皮和真皮,应该可以获得很好的安全性【10】。反对的意见认为肿瘤病灶通过乳管排出带有癌细胞的溢液,不能排除在乳管中种植的可能;另外,对于乳头后方的病理取材具有一定的局限性,在这种情况下很难对单个导管上皮进行连续精确地取材,从而容易产生误判,因此不建议在这类患者中进行NSM。

1.8 NSM与保乳手术的选择

NSM手术最大的目的在于能够保留乳房外部轮廓的完整性,从而为之后的乳房重建手术创造条件。另一种同样以保留乳房完整外形为目标的手术方式——保乳手术,与NSM相比,到底有什么不同?适应证和禁忌证存在怎样的差别?会议就可以接受保乳手术或保乳手术联合整形手术的患者是否建议接受NSM进行了投票,结果大部分的医师认为适合保乳手术的患者不应该做NSM。在讨论中发现,反对意见包含了两方面的信息:一方面,保乳手术较NSM简单,对患者的创伤更小,所以能做保乳手术者不建议NSM;另一方面,NSM更应该适合那些不能接受保乳手术的患者,因此NSM的适应证应该更宽泛。会场中,这种占绝对优势的意见左右了前面针对NSM适应证的投票结果。

但是,在NSM已经广泛开展的西方国家中,这一问题还是存在着分歧。具有代表性的观点有,很多医师认为NSM并不是无法进行保乳手术患者的替代手术方式,很多不能施行保乳手术的患者同样也不具有NSM的适应证。相反地,NSM适合于想要保留乳房完整外形而又不愿意接受放疗的患者,而这些患者往往也是保乳手术的适合人群。以美国乔治城大学的NSM适应证为例,乔治城大学要求患者的肿瘤病灶小于3cm,TND大于2cm,临床腋淋巴结阴性,没有肿瘤皮肤侵犯、炎性乳癌及Paget病等【11】。在这样严格适应证的限定下,很多患者同样适合进行保乳手术。另外的观点认为,保乳手术使乳腺癌患者保持形体的完整成为可能,但是通过长期的随访,保乳手术仍然有8.8%~20%的复发率【10】。NSM是无法接受保乳手术患者的另一个选择,但并不意味着完全替代。NSM往往被推荐在保乳手术预期效果不佳的患者中施行,如乳房较小、预期保乳手术无法获得安全切缘等【12】。另外,在一些具有高危因素的年轻患者中,NSM与保乳手术相比,可能会在保证乳房外形完整的前提下,获得更好的安全性。

2 NSM的手术操作

在对NSM的手术操作的具体细节进行讨论时,72.7%的参会专家支持必须切除穿刺活检的针道。支持这一观点的理由是,有文献报道,穿刺活检时皮肤癌细胞污染比例为25%【13】。虽然针道被癌细胞污染并不意味着癌细胞能够存活并种植,同时穿刺切口发生肿瘤复发的概率也非常低,但是由于切除针道操作简单,也不会给乳房外形带来显著的影响,所以还是建议在术中切除针道。

另一个手术操作的细节问题是,是否应该在NSM时完全剔除乳头后方的大导管,只有17.4%的参会医师支持这一观点。造成这一结果的原因可能是,NSM手术后,乳头完全失去了来自于下方乳腺腺体的血供,而完全依靠真皮层的血管网来提供血液供应,很多医师担心在手术操作中如果对乳头内的大导管剥离得过于彻底时,不可避免地会对真皮层的血管网造成伤害,从而造成乳头的坏死。虽然美国纪念斯隆·凯特琳癌症中心规定NSM时应该严格地切除乳头内部的大导管,只保留乳头的表皮和真皮,并且也能获得较低的NAC坏死率【10】,但在我们的实际操作中,由于担心对NAC真皮层的伤害,乳头内或多或少都会有大导管组织的残留。经在会场调查,这一手术细节在各位医师中存在显著差异,因此提示需要规范化的培训来推广正确的手术操作标准。

3 NSM的病理学评估

乳头乳晕区后方组织的病理检查是NSM能否成功的关键步骤,因此高达88.9%的参会专家同意应该施行这项检查。但是,在选择术中是否一定需要进行冰冻切片时却产生了分歧。支持进行冰冻切片的学者认为,术时冰冻切片发现阳性的患者可以直接进行乳头或NAC的切除术,而不用等到术后常规病理检查发现阳性后再行二次手术,这样可以避免70%~80%的二次手术【14,15】;反对者认为乳头后方组织过少,冰冻制片比较困难,容易导致送检组织制片不全,从而造成假阴性,文献报道假阴性率为4%~8%【16,17】。

4 NSM与放疗

NSM联合放疗这一理念来源于保乳治疗,因为同样都是保留下来的腺体组织,放疗应该会降低肿瘤复发率。意大利的研究【18】和瑞典的研究【19】是目前为数不多的NSM与放疗联合治疗的前瞻性临床试验,结果都提示了不论是术后放疗(瑞典研究)还是术中放疗(意大利研究)联合NSM都能降低局部复发率;然而,对比联合放疗的研究和未放疗的研究,显示NSM后局部复发率相似,因此从整个NSM的治疗原则出发,患者的选择和手术质控是整个治疗的关键,对于不同复发风险的患者需要采取不同的联合放疗的方案。因此在投票时,只有4.4%的医师支持NSM术后进行放疗。

由于目前我国尚缺少NSM的大规模临床研究,所以讨论会所应用的临床证据基本上是通过对国外文献进行综述而获得的。我们希望通过这样的方式来推广NSM,催生我们自己的临床试验,最终能够造福乳腺癌患者。

原文参见:中国癌症杂志. 2016;26(6):476-480.

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  1. [GetPortalCommentsPageByObjectIdResponse(id=1876812, encodeId=ae6918e68125d, content=<a href='/topic/show?id=67c5319121e' target=_blank style='color:#2F92EE;'>#切除术#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=31912, encryptionId=67c5319121e, topicName=切除术)], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/aLGWoFXAyMbIu3qymFOyheQLjPSX3OUs5GmkyBlcCOwTPIeq3why9NGibxxUqYo6hcx8qZLHZFgNPnBK1yzWeOFpyg2OnWOt0/0, createdBy=fa4716, createdName=仁心济世, createdTime=Tue May 09 14:50:00 CST 2017, time=2017-05-09, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1844486, encodeId=f95e1844486b2, content=<a href='/topic/show?id=5d2f206482e' target=_blank style='color:#2F92EE;'>#专家共识#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=31, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=20648, encryptionId=5d2f206482e, topicName=专家共识)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=568152, createdName=snowpeakxu, createdTime=Wed Apr 12 15:50:00 CST 2017, time=2017-04-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1937724, encodeId=c662193e7245f, content=<a href='/topic/show?id=ca28426010b' target=_blank style='color:#2F92EE;'>#复合体#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=34, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=42601, encryptionId=ca28426010b, topicName=复合体)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=395f25, createdName=bioon1, createdTime=Sun Apr 16 02:50:00 CST 2017, time=2017-04-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=119550, encodeId=93b511955002, content=好文章,百姓也能从中学到好多医学知识, beContent=null, objectType=article, channel=null, level=null, likeNumber=72, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/jW482SpianMayicTRbRZ5RzdAIB7UwTkHt6fQkBP8ictliaXtc5gCUmYdAW1sAETC2nhO3q6YjRHkUibyOCtP8ibmXNObTyd63A076/0, createdBy=d4111948983, createdName=1e10c84am36(暂无匿称), createdTime=Sat Sep 10 17:05:00 CST 2016, time=2016-09-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=115118, encodeId=09411151183b, content=非常全面, beContent=null, objectType=article, channel=null, level=null, likeNumber=86, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160815/IMG57B100B1A28768639.jpg, createdBy=dfbd1935601, createdName=外科好医生, createdTime=Fri Sep 09 12:56:00 CST 2016, time=2016-09-09, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=103092, encodeId=29021030928f, content=关键个问题,规范, beContent=null, objectType=article, channel=null, level=null, likeNumber=53, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160417/IMG5713A450556263030.jpg, createdBy=b2e11713968, createdName=永恒光辉, createdTime=Wed Aug 24 15:27:00 CST 2016, time=2016-08-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1620027, encodeId=36d9162002e1b, content=<a href='/topic/show?id=367c23645b8' target=_blank style='color:#2F92EE;'>#乳晕#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=28, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=23645, encryptionId=367c23645b8, topicName=乳晕)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ed2420064871, createdName=12499e01m53暂无昵称, createdTime=Fri Jul 08 02:50:00 CST 2016, time=2016-07-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=92222, encodeId=e612922221b, content=学习了,讲的很全面, beContent=null, objectType=article, channel=null, level=null, likeNumber=84, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=/v1.0.0/img/user_icon.png, createdBy=a37a1710612, createdName=oo902, createdTime=Thu Jul 07 12:49:00 CST 2016, time=2016-07-07, status=1, ipAttribution=)]
  2. [GetPortalCommentsPageByObjectIdResponse(id=1876812, encodeId=ae6918e68125d, content=<a href='/topic/show?id=67c5319121e' target=_blank style='color:#2F92EE;'>#切除术#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=31912, encryptionId=67c5319121e, topicName=切除术)], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/aLGWoFXAyMbIu3qymFOyheQLjPSX3OUs5GmkyBlcCOwTPIeq3why9NGibxxUqYo6hcx8qZLHZFgNPnBK1yzWeOFpyg2OnWOt0/0, createdBy=fa4716, createdName=仁心济世, createdTime=Tue May 09 14:50:00 CST 2017, time=2017-05-09, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1844486, encodeId=f95e1844486b2, content=<a href='/topic/show?id=5d2f206482e' target=_blank style='color:#2F92EE;'>#专家共识#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=31, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=20648, encryptionId=5d2f206482e, topicName=专家共识)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=568152, createdName=snowpeakxu, createdTime=Wed Apr 12 15:50:00 CST 2017, time=2017-04-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1937724, encodeId=c662193e7245f, content=<a href='/topic/show?id=ca28426010b' target=_blank style='color:#2F92EE;'>#复合体#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=34, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=42601, encryptionId=ca28426010b, topicName=复合体)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=395f25, createdName=bioon1, createdTime=Sun Apr 16 02:50:00 CST 2017, time=2017-04-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=119550, encodeId=93b511955002, content=好文章,百姓也能从中学到好多医学知识, beContent=null, objectType=article, channel=null, level=null, likeNumber=72, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/jW482SpianMayicTRbRZ5RzdAIB7UwTkHt6fQkBP8ictliaXtc5gCUmYdAW1sAETC2nhO3q6YjRHkUibyOCtP8ibmXNObTyd63A076/0, createdBy=d4111948983, createdName=1e10c84am36(暂无匿称), createdTime=Sat Sep 10 17:05:00 CST 2016, time=2016-09-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=115118, encodeId=09411151183b, content=非常全面, beContent=null, objectType=article, channel=null, level=null, likeNumber=86, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160815/IMG57B100B1A28768639.jpg, createdBy=dfbd1935601, createdName=外科好医生, createdTime=Fri Sep 09 12:56:00 CST 2016, time=2016-09-09, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=103092, encodeId=29021030928f, content=关键个问题,规范, beContent=null, objectType=article, channel=null, level=null, likeNumber=53, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160417/IMG5713A450556263030.jpg, createdBy=b2e11713968, createdName=永恒光辉, createdTime=Wed Aug 24 15:27:00 CST 2016, time=2016-08-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1620027, encodeId=36d9162002e1b, content=<a href='/topic/show?id=367c23645b8' target=_blank style='color:#2F92EE;'>#乳晕#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=28, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=23645, encryptionId=367c23645b8, topicName=乳晕)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ed2420064871, createdName=12499e01m53暂无昵称, createdTime=Fri Jul 08 02:50:00 CST 2016, time=2016-07-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=92222, encodeId=e612922221b, content=学习了,讲的很全面, beContent=null, objectType=article, channel=null, level=null, likeNumber=84, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=/v1.0.0/img/user_icon.png, createdBy=a37a1710612, createdName=oo902, createdTime=Thu Jul 07 12:49:00 CST 2016, time=2016-07-07, status=1, ipAttribution=)]
  3. [GetPortalCommentsPageByObjectIdResponse(id=1876812, encodeId=ae6918e68125d, content=<a href='/topic/show?id=67c5319121e' target=_blank style='color:#2F92EE;'>#切除术#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=31912, encryptionId=67c5319121e, topicName=切除术)], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/aLGWoFXAyMbIu3qymFOyheQLjPSX3OUs5GmkyBlcCOwTPIeq3why9NGibxxUqYo6hcx8qZLHZFgNPnBK1yzWeOFpyg2OnWOt0/0, createdBy=fa4716, createdName=仁心济世, createdTime=Tue May 09 14:50:00 CST 2017, time=2017-05-09, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1844486, encodeId=f95e1844486b2, content=<a href='/topic/show?id=5d2f206482e' target=_blank style='color:#2F92EE;'>#专家共识#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=31, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=20648, encryptionId=5d2f206482e, topicName=专家共识)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=568152, createdName=snowpeakxu, createdTime=Wed Apr 12 15:50:00 CST 2017, time=2017-04-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1937724, encodeId=c662193e7245f, content=<a href='/topic/show?id=ca28426010b' target=_blank style='color:#2F92EE;'>#复合体#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=34, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=42601, encryptionId=ca28426010b, topicName=复合体)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=395f25, createdName=bioon1, createdTime=Sun Apr 16 02:50:00 CST 2017, time=2017-04-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=119550, encodeId=93b511955002, content=好文章,百姓也能从中学到好多医学知识, beContent=null, objectType=article, channel=null, level=null, likeNumber=72, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/jW482SpianMayicTRbRZ5RzdAIB7UwTkHt6fQkBP8ictliaXtc5gCUmYdAW1sAETC2nhO3q6YjRHkUibyOCtP8ibmXNObTyd63A076/0, createdBy=d4111948983, createdName=1e10c84am36(暂无匿称), createdTime=Sat Sep 10 17:05:00 CST 2016, time=2016-09-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=115118, encodeId=09411151183b, content=非常全面, beContent=null, objectType=article, channel=null, level=null, likeNumber=86, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160815/IMG57B100B1A28768639.jpg, createdBy=dfbd1935601, createdName=外科好医生, createdTime=Fri Sep 09 12:56:00 CST 2016, time=2016-09-09, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=103092, encodeId=29021030928f, content=关键个问题,规范, beContent=null, objectType=article, channel=null, level=null, likeNumber=53, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160417/IMG5713A450556263030.jpg, createdBy=b2e11713968, createdName=永恒光辉, createdTime=Wed Aug 24 15:27:00 CST 2016, time=2016-08-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1620027, encodeId=36d9162002e1b, content=<a href='/topic/show?id=367c23645b8' target=_blank style='color:#2F92EE;'>#乳晕#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=28, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=23645, encryptionId=367c23645b8, topicName=乳晕)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ed2420064871, createdName=12499e01m53暂无昵称, createdTime=Fri Jul 08 02:50:00 CST 2016, time=2016-07-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=92222, encodeId=e612922221b, content=学习了,讲的很全面, beContent=null, objectType=article, channel=null, level=null, likeNumber=84, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=/v1.0.0/img/user_icon.png, createdBy=a37a1710612, createdName=oo902, createdTime=Thu Jul 07 12:49:00 CST 2016, time=2016-07-07, status=1, ipAttribution=)]
    2017-04-16 bioon1
  4. [GetPortalCommentsPageByObjectIdResponse(id=1876812, encodeId=ae6918e68125d, content=<a href='/topic/show?id=67c5319121e' target=_blank style='color:#2F92EE;'>#切除术#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=31912, encryptionId=67c5319121e, topicName=切除术)], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/aLGWoFXAyMbIu3qymFOyheQLjPSX3OUs5GmkyBlcCOwTPIeq3why9NGibxxUqYo6hcx8qZLHZFgNPnBK1yzWeOFpyg2OnWOt0/0, createdBy=fa4716, createdName=仁心济世, createdTime=Tue May 09 14:50:00 CST 2017, time=2017-05-09, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1844486, encodeId=f95e1844486b2, content=<a href='/topic/show?id=5d2f206482e' target=_blank style='color:#2F92EE;'>#专家共识#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=31, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=20648, encryptionId=5d2f206482e, topicName=专家共识)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=568152, createdName=snowpeakxu, createdTime=Wed Apr 12 15:50:00 CST 2017, time=2017-04-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1937724, encodeId=c662193e7245f, content=<a href='/topic/show?id=ca28426010b' target=_blank style='color:#2F92EE;'>#复合体#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=34, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=42601, encryptionId=ca28426010b, topicName=复合体)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=395f25, createdName=bioon1, createdTime=Sun Apr 16 02:50:00 CST 2017, time=2017-04-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=119550, encodeId=93b511955002, content=好文章,百姓也能从中学到好多医学知识, beContent=null, objectType=article, channel=null, level=null, likeNumber=72, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/jW482SpianMayicTRbRZ5RzdAIB7UwTkHt6fQkBP8ictliaXtc5gCUmYdAW1sAETC2nhO3q6YjRHkUibyOCtP8ibmXNObTyd63A076/0, createdBy=d4111948983, createdName=1e10c84am36(暂无匿称), createdTime=Sat Sep 10 17:05:00 CST 2016, time=2016-09-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=115118, encodeId=09411151183b, content=非常全面, beContent=null, objectType=article, channel=null, level=null, likeNumber=86, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160815/IMG57B100B1A28768639.jpg, createdBy=dfbd1935601, createdName=外科好医生, createdTime=Fri Sep 09 12:56:00 CST 2016, time=2016-09-09, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=103092, encodeId=29021030928f, content=关键个问题,规范, beContent=null, objectType=article, channel=null, level=null, likeNumber=53, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160417/IMG5713A450556263030.jpg, createdBy=b2e11713968, createdName=永恒光辉, createdTime=Wed Aug 24 15:27:00 CST 2016, time=2016-08-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1620027, encodeId=36d9162002e1b, content=<a href='/topic/show?id=367c23645b8' target=_blank style='color:#2F92EE;'>#乳晕#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=28, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=23645, encryptionId=367c23645b8, topicName=乳晕)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ed2420064871, createdName=12499e01m53暂无昵称, createdTime=Fri Jul 08 02:50:00 CST 2016, time=2016-07-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=92222, encodeId=e612922221b, content=学习了,讲的很全面, beContent=null, objectType=article, channel=null, level=null, likeNumber=84, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=/v1.0.0/img/user_icon.png, createdBy=a37a1710612, createdName=oo902, createdTime=Thu Jul 07 12:49:00 CST 2016, time=2016-07-07, status=1, ipAttribution=)]
    2016-09-10 1e10c84am36(暂无匿称)

    好文章,百姓也能从中学到好多医学知识

    0

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    2016-09-09 外科好医生

    非常全面

    0

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    2016-08-24 永恒光辉

    关键个问题,规范

    0

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  8. [GetPortalCommentsPageByObjectIdResponse(id=1876812, encodeId=ae6918e68125d, content=<a href='/topic/show?id=67c5319121e' target=_blank style='color:#2F92EE;'>#切除术#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=31912, encryptionId=67c5319121e, topicName=切除术)], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/aLGWoFXAyMbIu3qymFOyheQLjPSX3OUs5GmkyBlcCOwTPIeq3why9NGibxxUqYo6hcx8qZLHZFgNPnBK1yzWeOFpyg2OnWOt0/0, createdBy=fa4716, createdName=仁心济世, createdTime=Tue May 09 14:50:00 CST 2017, time=2017-05-09, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1844486, encodeId=f95e1844486b2, content=<a href='/topic/show?id=5d2f206482e' target=_blank style='color:#2F92EE;'>#专家共识#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=31, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=20648, encryptionId=5d2f206482e, topicName=专家共识)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=568152, createdName=snowpeakxu, createdTime=Wed Apr 12 15:50:00 CST 2017, time=2017-04-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1937724, encodeId=c662193e7245f, content=<a href='/topic/show?id=ca28426010b' target=_blank style='color:#2F92EE;'>#复合体#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=34, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=42601, encryptionId=ca28426010b, topicName=复合体)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=395f25, createdName=bioon1, createdTime=Sun Apr 16 02:50:00 CST 2017, time=2017-04-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=119550, encodeId=93b511955002, content=好文章,百姓也能从中学到好多医学知识, beContent=null, objectType=article, channel=null, level=null, likeNumber=72, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/jW482SpianMayicTRbRZ5RzdAIB7UwTkHt6fQkBP8ictliaXtc5gCUmYdAW1sAETC2nhO3q6YjRHkUibyOCtP8ibmXNObTyd63A076/0, createdBy=d4111948983, createdName=1e10c84am36(暂无匿称), createdTime=Sat Sep 10 17:05:00 CST 2016, time=2016-09-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=115118, encodeId=09411151183b, content=非常全面, beContent=null, objectType=article, channel=null, level=null, likeNumber=86, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160815/IMG57B100B1A28768639.jpg, createdBy=dfbd1935601, createdName=外科好医生, createdTime=Fri Sep 09 12:56:00 CST 2016, time=2016-09-09, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=103092, encodeId=29021030928f, content=关键个问题,规范, beContent=null, objectType=article, channel=null, level=null, likeNumber=53, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160417/IMG5713A450556263030.jpg, createdBy=b2e11713968, createdName=永恒光辉, createdTime=Wed Aug 24 15:27:00 CST 2016, time=2016-08-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1620027, encodeId=36d9162002e1b, content=<a href='/topic/show?id=367c23645b8' target=_blank style='color:#2F92EE;'>#乳晕#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=28, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=23645, encryptionId=367c23645b8, topicName=乳晕)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ed2420064871, createdName=12499e01m53暂无昵称, createdTime=Fri Jul 08 02:50:00 CST 2016, time=2016-07-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=92222, encodeId=e612922221b, content=学习了,讲的很全面, beContent=null, objectType=article, channel=null, level=null, likeNumber=84, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=/v1.0.0/img/user_icon.png, createdBy=a37a1710612, createdName=oo902, createdTime=Thu Jul 07 12:49:00 CST 2016, time=2016-07-07, status=1, ipAttribution=)]
    2016-07-07 oo902

    学习了,讲的很全面

    0

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