根據衛生福利部統計，乳癌為我國婦女發生率第1位之癌症，每年有逾萬位婦女罹患乳癌，發生高峰約在45-64歲之間，佔國人女性癌症死因第四位，2016年資料顯示該年國人有2,176人因乳癌而死亡，亦即每10萬個女性人口中即有18.41人因乳癌而喪失寶貴生命，此項事實不僅造成個人健康的損失，甚至使家庭社會付出莫高的代價，因此如何提高警覺，早期診斷早期治?，將是一個重要的課題。
乳癌及原位癌的治療皆以手術切除為主，從傳統的乳房全切除，以及後來發展的乳房保留手術，為現今主要的兩種手術方法。乳房是女性的重要性特徵，過去的乳癌手術會將整個乳房及乳頭乳暈摘除，對外觀影響較大(圖一)，常對患者造成莫大的心理創傷。另外乳房保留手術也需於乳房皮膚劃上傷口，對腫瘤做局部廣範性切除，縱使乳房保留下來，術後也會對乳房外觀有一定程度的改變。而乳房手術也因此發展出可以隱藏傷口的方法，如內視鏡乳房切除、達文西機器手臂乳房切除。
圖一、傳統乳房全切除傷口
何謂微創3D內視鏡乳癌手術？
內視鏡手術在外科領域已經發展許久，在乳房手術方面也有相關的應用。微創3D內視鏡乳癌手術只需要一個約4-6公分的傷口執行單孔內視鏡操作，並在術中送冷凍切片，檢查確定乳頭沒有被癌細胞侵犯後，可進行乳頭乳暈保留的乳房全切手術，傷口位置藏在腋下或側胸(圖二)，讓乳房外觀看起來沒有傷口，再將乳腺組織從切口完整取出，並結合整形美容外科進行立即乳房重建。與傳統的兩階段重建(搭配組織擴張器)比較，讓病人免去第二次手術的需求。
至於手術中搭配3D的內視鏡影像設備，可讓醫師在術中對於乳房的立體結構(包括：景深方向、血管、乳腺組織、皮膚)有更清晰的成像(圖三)，大大提高手術的安全性及腫瘤切除的準確度。
3D內視鏡手術跟達文西手術的差別只在於人手與機械手臂的運作與否，兩者都是搭配3D影像設備，故手術成果都是差不多，但費用相對比較便宜。
圖二、內視鏡乳癌手術傷口位置
圖三、內視鏡下乳房結構示意圖
乳癌手術各種治療方案優缺點
|
方案 |
好處 |
風險/缺點 |
|
乳房部分切除
(乳房保留手術) |
² 傷口小、恢復快
² 保留大部分乳房知覺
² 不需要乳房重建 |
² 需接受術後放射性治療及其副作用
² 若手術檢體邊緣有癌細胞，需接受第二次手術
² 只能用於早期乳癌病人及腫瘤位置不能離乳頭太靠近 |
|
傳統乳房全切除 |
² 減少剩餘乳房組織復發風險
² 大部分不用接受放射性治療 |
² 傷口大，整體外觀改變大
² 術後皮膚麻木或無知覺
² 需切除乳頭乳暈組織 |
|
內視鏡乳房全切除
(乳頭乳暈保留) |
² 傷口小，且傷口設計在腋下中線，乳房上沒有傷口痕跡，美觀滿意
² 內視鏡具放大效果，具通常搭配3D內視鏡，能使細微構造更清楚
² 減少剩餘乳房組織復發風險
² 大部分不用接受放射性治療 |
² 乳房重建風險及費用
² 比傳統手術時間長
² 有衍生性的費用(較傳統手術高)
² 只能用於早期乳癌病人及腫癌位置不能離乳頭太靠近 |
內視鏡乳癌手術適應症
* 原位癌
* 第一期及第二期早期乳癌
* 多發性乳癌
* 預防性乳房切除
內視鏡乳癌手術禁制症
* 乳房大小不要太大(如Size E以上)
* 腫瘤位置離乳頭太近
* 發炎性乳癌
* 皮膚及胸壁肌肉被腫瘤侵犯
內視鏡乳癌手術的特點在於傷口可以隱藏在不明顯的地方，跟醫美的隆乳手術差不多。配合整形美容外科醫師的重建，可讓乳房術後外觀改變不大。許多民眾對於內視鏡手術都會有些疑問，例如：傷口較小，會不會切的較不乾淨或是比較容易復發？乳癌內視鏡手術發展將近20年，也有超過十年以上的追蹤，傳統手術與內視鏡手術的復發機率相同，兩者的差別只在於傷口大小、傷口位置及美觀。
結語
當得到乳癌後也不要因為害怕而延誤就醫，現在乳癌的治療包括：手術、化學治療、標靶治療、放射治療、免疫治療等的效果都非常好，只要跟醫師討論後，選擇對於自己最適合的治療方法，都可以讓病人不管在外觀以及癌症治療上都得到非常良好的效果。
乳癌的治療，回歸基本還是早期發現，早期治療，民眾可透過國民健康署現行推展的乳房攝影篩檢，無家族病史的婦女，年滿45歲到69歲每二年免費檢查一次；二等親內曾罹患乳癌的女性，可提早到40歲就開始接受乳房攝影檢查，定期接受檢查，及早治療以免延誤病情。
一般外科/乳房外科 雷秋文醫師介紹及門診連結
專長：乳癌及良性乳房疾病手術、內視鏡乳癌手術、腹腔鏡膽囊及膽道手術、傳統及內視鏡疝氣修補手術、傳統及腹腔鏡胃腸道手術、甲狀腺手術、皮膚腫瘤手術
https://www.femh.org.tw/section/sectionDetail2?CID=0281&&DoctorID=88542
3D Endoscopic Nipple Sparing Total Mastectomy
According to the data of the Ministry of Health and Welfare, breast cancer is the most common cancer among women in our country. More than 10,000 women suffer from breast cancer every year, and the incidence is between 45 and 64 years old. Breast cancer is the 4th cause of cancer death of Taiwan female. Therefore, early diagnosis and early treatmentwill be an important topic for breast cancer.
The treatment of breast cancer and carcinoma in situ is mainly based on surgical resection. Today, total mastectomy and breast-conserving surgery are the two main surgical methods of breast cancer operation. Breasts are an important feature of women. In the past, breast cancer surgery would remove the entire breast and nipple areolar complex, which greatly affected the body appearance (Figure 1), and often caused great psychological trauma to the patient. In addition, breast-conserving surgery also requires making a wound on the breast skin and performing a wide excision of the tumor. Even if the breast is preserved, the shape of the breast will be changed after the operation. Therefore, surgeon developed new operation method that can hide the wound, such as endoscopic mastectomy and Da Vinci robotic arm mastectomy.
Figure 1. The wound of traditional total mastectomy
What is 3D Endoscopic Nipple Sparing Total Mastectomy?
Endoscopic surgery has been developed in the field of surgery for a long time, especially of breast surgery. 3D endoscopic breast cancer surgery only requires a 4-6 cm wound to perform a single-port endoscopic operation.During the operation, we will sent the specimen of nipple margin for Frozen section examination. If the pathology report showed that the nipple was not invaded by cancer cells, we can performednipple and skin sparing total mastectomy.The wound is hidden under the lateral side of the chest wall(Figure 2), so there is no wound was found on the breast.Then the breast tissue is completely removed from the lateral wound, and immediate breast reconstruction is performed by plastic surgeon.
Figure 2. The wound of endoscopic total mastectomy
The 3D endoscopic imaging can allows doctors to have a clear image of the three-dimensional structure of the breast (including the depth of field, blood vessels, breast tissue, and skin) during the operation (Figure 3), which greatly improves the safety of the operation and the accuracy of tumor resection.
Figure 3. The Anatomy of breast during endoscopic operation.
The difference between breast cancer operation:
|
Method |
Advantages |
Disadvantages |
|
1.Breast conserving surgery |
l Small wound
l Preserve the sensation of breast
l No need for breast reconstruction |
l Received radiotherapy
l If the margin of the specimen showed cancer cell, it must be received second time of operation
l Only can used in early breast cancer |
|
2.Simple mastectomy |
l No need for radiotherapy |
l Big wound, big change of body appearance
l Numbness sensation of breast after operation
l Remove the nipple areolar complex |
|
3.Endoscopic nipple sparing total mastectomy |
l Small wound, can hide under lateral chest wall
l No need for radiotherapy |
l Cost of breast reconstruction
l Longer operation time
l Only can used in early breast cancer |
Indication of 3D Endoscopic Nipple Sparing Total Mastectomy
1. Ductal carcinoma is situ
2. Stage I and II breast cancer
3. Multicentric breast cancer
4. Prophylactic mastectomy
Contraindication of 3D Endoscopic Nipple Sparing Total Mastectomy
1. Big size of breast (Above E cup)
2. The tumor location near the nipple
3. Inflammatory breast cancer
4. Tumor invaded the skin or muscle layer
Conclusion
The advantages of endoscopic breast cancer surgery is that the wound can be hidden, which is similar to the breast augmentation surgery. In cancer surgery, endoscopic surgery of breast may be easier of tumor recurrence? The answer is not. Breast cancer endoscopic surgery has been developed for about 20 years and the oncological result has been followed more than ten years. The recurrence rate of traditional surgery and endoscopic surgery is the same. The difference is only the size of the wound, the location of the wound and the body appearance.
When you get breast cancer, don’t be afraid to find doctor. Breast cancer therapy includes surgery, chemotherapy, targeted therapy, radiation therapy, immunotherapy, have very good result. Just discuss with your doctor and choose the most suitable one for you.