百例挑一:20cm巨大乳腺肿瘤新辅助化疗联合手术治疗1例

2019-01-09 SHY 中国医学论坛报今日肿瘤

48岁,已婚。主诉:因“发现左乳肿物1年余,局部皮肤破溃4个月”于2018年1月21日于我科住院治疗。

病例详情

一般情况+入院检查+初步诊断
一般情况

48岁,已婚。主诉:因“发现左乳肿物1年余,局部皮肤破溃4个月”于2018年1月21日于我科住院治疗。

现病史:住院前1年发现左乳肿物,8个月前肿物逐渐增大,4个月前局部破溃伴渗出,入院前9天外院就诊,后转至我院。既往体健。

个人史:月经4~5/30 d,自2017年9月12日至13日后,近4个月无月经,24岁结婚,育有1子,右乳积乳史。无乳腺癌家族史。

入院检查

体格检查:左乳可见巨大菜花样肿物,范围约20 cm×20 cm,呈向外性生长,残存乳腺区域质硬、固定。左侧腋窝可触及多枚肿大质硬淋巴结,最大直径约1.5 cm,活动可,未融合成团。右乳、右侧腋窝(-)及双侧锁骨上(-)。

乳腺ETC检查:左侧乳腺区域可见类圆形局限性核素分布增强。

外院超声检查(2018年1月12日):左乳腺腺体后方可见巨大实性包块,前后径4.1 cm,散在少许液性暗区。坐乳浅表部探及一巨大外生性包块,呈菜花状,内回声与腺体内包块回声类似。左腋窝探及多个淋巴结回声,大者约1.0 cm×0.5 cm,边界清,皮髓质分界不清。左侧锁骨上探及多个淋巴结回声,大者约1.0 cm×0.5 cm,边界清,皮髓质分界不清。

病理检查:(左乳)浸润性导管癌。免疫组化:ADFP(弱+);AR(约60%的肿瘤细胞呈弱-中等阳性表达);c-erbB-2(++);E-Cad(胞膜+);P63(-);PR(-);EMA(+);CK 5/6(-)。









CT检查:颅脑CT平扫未见明显异常;左乳肿块,考虑乳腺癌,左侧腋窝淋巴结肿大,考虑转移;上腹部CT平扫未见明显异常。







初步诊断

乳腺癌。临床分期:T4N3M0 Ⅲc期。分子分型:Luminal B HER2(-)型乳腺癌。 

治疗方案+疗效评估 

辅助化疗 



第一期化疗后7天,查血常规示:WBC 1.31×109/L ,Neu 0.26×109/L,伴发热38.5 ℃;G-CSF 150 μg bid+抗生素,床旁隔离;2日后体温正常,复查血常规示:WBC 12.00×109/L;Neu 10.54×109/L;后续化疗后第2天给予PEG-rhG-CSF,白细胞维持平稳;轻度食欲减退,无明显恶性、呕吐;无手足麻木等不适。

新辅助化疗前:





1周化疗后:





2周化疗后:




2周期后CT:







3周化疗后:





4周化疗后:



4周后超声:



5周化疗后:



6周化疗后至术前:







6周期后CT:





6周后超声:



手术治疗 

2018年6月13日行左乳癌改良根治术(切除肿瘤基底部胸大肌)+左锁骨上淋巴结清扫术+左侧假体植入联合背阔肌肌皮瓣I期乳房重建术。

术后12天恢复情况:





术后病理:(左乳房)浸润性导管癌,切面面积约8 mm×6 mm,间质纤维结缔组织增生伴玻璃样变性,局部见较多泡沫细胞浸润及异物反应。乳头、皮肤及基底切缘均未查见癌。腋窝淋巴结18枚(0/18)及左锁骨上淋巴结16枚(0/16)均未查见癌。另送胸肌间淋巴结为脂肪血管纤维结缔组织,未见淋巴结及癌。免疫组化:c-erbB-2(++);CK5/6(-);E-Cad(+);ER(约90%肿瘤细胞中至强阳性);Ki67(阳性肿瘤细胞约占40%);P120(胞膜+);P63(-);PR(-)。

专家点评

2018年《CSCO 乳腺癌诊疗指南》中指出,凡是满足以下的条件之一的可以选择术前新辅助化疗:①肿块较大,超过5 cm ;②腋窝淋巴结可触及。该患者处于乳腺癌T4N3M0 ⅢC期,左乳肿块远远超过5 cm,左侧腋窝可触及多枚肿大淋巴结,属于新辅助治疗适用人群。因此,对患者进行全面评估后,在初步治疗时选择新辅助化疗而未直接进行手术治疗是正确的,因为其通过新辅助化疗,后续还有可能获得手术机会。

该患者选择了指南推荐的AT方案。T包括紫杉醇、多西他赛和白蛋白紫杉醇;A为蒽环类药物,包括多柔比星、表柔比星和吡柔比星。本患者采用的为表柔比星联合白蛋白紫杉醇的治疗方案。经新辅助化疗1周期后可见局部肿块明显退缩,2、3周期后肿块持续退缩,一共经过6个周期的新辅助化疗,肿块得到明显控制,由20 cm消退为无明显病灶。6个周期新辅助化疗结束后对该患者行左乳癌改良根治术(切除肿瘤基底部胸大肌)+左锁骨上淋巴结清扫术+左侧假体植入联合背阔肌肌皮瓣I期乳房重建术。腋窝淋巴结18枚(0/18)及左锁骨上淋巴结16枚(0/16)均未查见癌。

对于此类局部晚期的Luminal B HER2(-)型乳腺癌患者,通过高效白蛋白紫杉醇联合蒽环类药物的新辅助化疗方案实现局部病灶的快速控制,同时成功接受手术治疗,并且获得了病理缓解,是新辅助治疗最成功的案例之一,值得我们临床医生的借鉴和学习。

病例提供者:李亮 
病例点评专家:殷咏梅 

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    2019-01-09 flysky120

    治疗效果好,但是患者为什么检查晚呢?

    0