Method for organ-preserving surgical treatment of breast cancer

Abstract

FIELD: surgery; oncology.SUBSTANCE: used in organ-preserving surgical treatment of breast cancer in patients with grade 2–3 mastoptosis with non-central tumor localization. At the preoperative stage, markings are performed using the original technique. The next step is to mark the boundaries of de-epithelialization. The skin inside the MUZ and ORW figures is designated as subject to excision. After treating the surgical field, 0.5 ml of a 1% aqueous solution of methylene blue is injected percutaneously into the subcutaneous fat tissue of the mammary gland along line h at intervals of 2.0 cm. De-epithelialization of the skin of the periareolar region is performed within the marking boundaries. Two skin-fat flaps are excised within the previously made markings. From the obtained accesses, the skin with subcutaneous fat tissue is separated step by step with an electric knife from the underlying parenchyma of the mammary gland, achieving their complete separation from the entire parenchyma of the mammary gland, at the same time forming the upper and lower dermal pedicles that feed the nipple-areolar complex. According to the projection of line h, taking into account the methylene blue marks, half of the parenchyma of the mammary gland is removed with a tumor of any localization, except the central one, with the underlying area of the superficial plate of the pectoral fascia. The remaining part of the mammary gland parenchyma after resection is moved to the vacated space so that the resected edge of the parenchyma lies with its entire surface on the pectoralis major muscle. The free edge of the parenchymal flap is fixed with interrupted sutures to the resected edge of the superficial plate of the pectoral fascia.EFFECT: method is effective in the treatment of patients with non-central tumor localization who have grade 2–3 mastoptosis; in particular, the method allows for organ-preserving surgical treatment with a sufficient degree of radicalism and the elimination of mastoptosis.1 cl, 8 dwg, 2 ex

Description

[0001] The invention relates to medicine, namely to surgery, and can be used for one-stage reconstruction of the mammary gland (MG) in organ-preserving surgical treatment of cancer with non-central tumor localization in patients with grade 2-3 mammary gland ptosis.

[0002] Breast cancer (BC) ranks first in the structure of oncological morbidity in the Russian Federation (RF) among the female population, and the upward trend persists (see Merabishvili V.M. The state of oncological care in Russia: breast cancer among the female population. Incidence, mortality, reliability of accounting, detailed localization and histological structure (population study at the federal district level) / / Voprosy onkologii. - 2022. - Vol. 68. - No. 3. - P. 286-293). Moreover, more than 60% of cases are detected with early cancer (stages I-II). In this regard, organ-preserving surgeries are becoming increasingly popular.

[0003] Organ-preserving surgeries involving resection of large volumes of glandular tissue and subsequent remodeling of the breast parenchyma to achieve uniform distribution are considered oncoplastic surgeries. In fact, oncoplastic resections involve the displacement, rotation, or transposition of large sections of breast tissue to fill a defect.

[0004] The risk of local recurrence remains relevant in discussions of organ-preserving surgery outcomes. Many researchers believe that decreased radicalism results in early relapses and locoregional metastases. The risk of local recurrence significantly correlates with tumor size and resection margin width. Thus, V.F. Semiglazov et al. note that the cumulative risk of local recurrence within 10 years after organ-preserving surgery is 10% for tumors ≤1 cm and 30-35% for tumors 2 to 5 cm (see V.F. Semiglazov, V.V. Semiglazov, A.E. Kletsel. Non-invasive and invasive breast tumors. St. Petersburg, 2006, 349 p.).

[0005] According to statistics, up to 90% of middle-aged and older women have mastoptosis. Given that women in this age group predominate in the age structure of breast cancer incidence, mastoptosis is a pressing issue in oncoplastic breast surgery. The most common option for organ-preserving surgery for ptosis, especially when tumors are located in the lower quadrants, is inverted-T mastectomy. However, experience shows that this type of reconstruction is most often associated with necrosis and suture failure at the T-junction.

[0006] Currently, silicone implants are used to replace complete or significant breast tissue removal. Depending on the clinical situation, reconstruction with an endoprosthesis can occur immediately or be delayed after the placement of a tissue expander. However, some women, despite their strong desire to preserve their breast tissue, still dislike the prospect of silicone implants and therefore choose not to undergo endoprosthetics.

[0007] Thus, the development of new effective methods of one-stage breast reconstruction in organ-preserving surgical treatment of breast cancer is an urgent task of modern medicine.

[0008] A search of scientific, medical and patent literature revealed methods for one-stage breast reconstruction in organ-preserving surgical treatment of breast cancer.

[0009] For example, Russian Patent No. 2444301 C1 (published March 10, 2012, Bulletin No. 7) protects a "Method for Organ-Preserving Treatment of Breast Cancer," which involves making a partial periareolar incision through which a quadrant of the breast containing the tumor is removed. The remaining breast tissue is separated from the pectoralis major muscle upward to the projection of the subclavian vein and outward to the latissimus dorsi muscle. The tissue between the pectoralis major and minor muscles is removed. The deep pectoral fascia is incised, and the subclavian-axillary tissue is removed. The shape of the breast tissue is restored by sharply displacing and suturing the remaining breast parenchyma and surrounding soft tissue.

[0010] A disadvantage of this method is the questionable radicalism of the operation for tumors larger than 2 cm in diameter (this method does not specify a maximum allowable tumor size). Radical surgery for breast cancer requires excision of the breast tissue fragment containing the tumor down to the fascia of the pectoralis major muscle, leaving at least 4 cm from the palpable borders of the tumor (see Chissov V.I., Trakhtenberg A.Kh., Paches A.I. Atlas of Oncological Operations. - Moscow. - 2008).

[0011] In the work of MJ Silverstein (2003) a method of oncoplastic surgery is described, which provides for horizontal reduction mammoplasty (see Silverstein MJ An argument against routine use of radiotherapy for ductal carcinoma in situ / / Oncology (Williston Park). - 2003. - No. 17. - P. 1511-1533). The method can be used when tumors are located on the border of the internal quadrants (see Ismagilov A. Kh., Vanesyan A. S, Khamitov A. R. et al. Oncoplastic surgery of the mammary gland: basics, classification, algorithm of execution / / Tumors of the female reproductive system. - 2014. - No. 4. - P. 37-45). During the preoperative stage, markings are made, in which the breast fragment to be removed along with the tumor is marked as an equilateral triangle with its base at the areola. On the opposite side, a similar equilateral triangle is symmetrically marked, also with its base at the areola. The border areas of skin between the areola and the bases of the triangles are de-epithelialized.Both triangular fragments are removed.

[0012] A disadvantage of the Silverstein method is the limited volume of tissue removed. Removing tissue larger than a quadrant on each side of the areola leads to tubular deformation of the breast, especially in cases of mastoptosis.

[0013] In a known method of oncoplastic resection of the mammary gland in the early stages of cancer, a skin incision is made in a circle - at the border of the areola with the skin in such a way that a periareolar circular incision is made along the border of the areola and the skin, then the skin edge is lifted with hooks on the outer side of the incision and the skin is gradually separated from the underlying mammary parenchyma along the perimeter with an electric knife and, gradually expanding the separation perimeter, complete separation of the skin from the underlying mammary tissue is achieved, a sector with a tumor of any localization, except for the central one, is removed, then the adjacent areas of the parenchyma are separated from the underlying fascia of the pectoralis major muscle to give the necessary mobility to the flaps and, bringing them to each other, they are connected with interrupted sutures (see Russian Federation Patent for Invention No. 2743613 C2, published 02 / 20 / 2021, Bulletin No. 5).

[0014] With this method, replenishment of the removed part of the mammary gland parenchyma is achieved through the mobilization of the patient's own parenchyma by its total separation from the skin, excluding the areola, and partial separation from the pectoralis major muscle.

[0015] A disadvantage of this method is the significantly limited volume of tissue removed. The area of ​​separation of the mammary gland parenchyma from the underlying pectoralis major fascia is directly related to the volume of tissue removed, and increasing this area, given the complete separation of the parenchyma from the skin, is associated with the risk of ischemic necrosis of the parenchymal flaps.

[0016] The objective of the method we propose is to improve the quality of medical care for women who require surgical treatment for non-central breast cancer, who have mastoptosis and who have refused endoprosthetics with an implant.

[0017] The technical result that emerges from the implementation of this method is the development of a method that allows for performing an organ-preserving operation with a sufficient degree of radicalism and correction of mastoptosis.

[0018] The technical result is achieved by performing preoperative marking, during which, in a standing position, the following lines are marked: the median sternal line - line a; the line designating the medial border of the mammary gland - line b; the horizontal line at the level of the submammary fold - line c; the line designating the level of the "spot" of the mammary gland - line d; the horizontal line at the level of the upper border of the mammary gland - line e; the line designating the lateral border of the mammary gland - line ƒ; then, in the skin marking, a conditional rectangle is formed by the intersections of lines e, c, ƒ and b, the vertices G, H, K, I are designated in it; the midpoints of the lines are marked on each side of the rectangle: point L is the middle of side GH, point M is the middle of side NK, point N is the middle of side IK, point O is the middle of side IG;then the center of the mammary gland mound is determined on the skin, for this purpose a line is drawn through the mammary gland mound perpendicular to lines e and c, connecting points L and N, forming segment LN; then a line is drawn through the mammary gland mound perpendicular to lines ƒ and b, connecting points O and M, forming segment OM, the intersection of these two lines is noted - point P, designating the center of the mammary gland mound; next, the projection of the tumor is marked on the skin of the mammary gland; a line is drawn from the center of the mammary gland mound to the center of the cutaneous projection of the tumor - line g; the next step is to draw a line through the center of the mammary gland mound perpendicular to line g across the entire mammary gland mound - line h, which is a cutaneous landmark of the resection line of the parenchyma of the mammary gland, the end points of line h are line d;then the future height of the mammary gland mound is determined by measuring the thickness of the mammary gland between the midpoints of segments PL and PN with a caliper, placing the jaws of the caliper above and below the mammary gland, as well as between the midpoints of segments RO and RM, placing the jaws of the caliper on the lateral surfaces of the mammary gland, while the average value is calculated from the two obtained dimensions; the height of the future mound is taken as; 1 / 2the average thickness of the mammary gland, denoting it as t; then the height of the "spot" of the mammary gland is measured, which corresponds to the length of the side GI of the rectangle GHKI; the next step is to determine the size of the zones of skin reduction of the mammary gland, for this purpose an approach is used in which the sagittal section of the mammary gland through the center of the mammary gland hill is taken as a conditional triangle with the apex in the center of the hill, that is, according to the markings, at point P, while the other two apexes are located in the middle of GH and IK, that is, at points L and N, and the base of the triangle is the height of the "spot" of the mammary gland; in accordance with the future change in the height of the mammary gland hill, the length of the sides of the triangle is reduced to their equal values, while the length of the base of the triangle does not change; the length of the future sides of the triangle is calculated using the formula where x is the size of the future equal sides of the triangle, namely, the distance from points L and N to the top of the future mammary gland mound; s is the base of the triangle, namely, the height of the "spot" of the mammary gland; t is the height of the future mammary gland mound; then the obtained size x is put off on segments LP and PN, starting from points L and N, respectively, in the form of segments LX and NY; then the circumference of the nipple-areolar complex is marked and its diameter is determined; then centrifugally from points X and Y on segments LX and NY, segments equal to the radius of the nipple-areolar complex are measured, respectively, XO and YE; segment RU is drawn perpendicular to segment LX, equal to the diameter of the nipple-areolar complex, the center of the segment is located at point X; then, perpendicular to the NY segment, draw the WZ segment, also equal to the diameter of the nipple-areolar complex, the center of the segment is located at point Y;Next, the ends of the segments RU and WZ are connected by a smooth arcuate curve through points O and E, respectively, forming the upper and lower semicircles of the future location of the nipple-areolar complex; the next step is to mark the boundaries of de-epithelialization; for this, two vertical paraareolar lines are drawn to the right and left of the nipple-areolar complex, connecting the future upper and lower semicircles of the nipple-areolar complex at points R and W, as well as U and Z; subsequently, they begin to mark the skin zones to be excised; for this, point M is connected by two segments with point U and point Z, similarly, point O is connected by two segments with point R and point W; the skin inside the geometric figure RUZW, formed by the boundaries of the future upper and lower semicircles of the nipple-areolar complex, as well as the right and left vertical paraareolar lines, is marked as subject to de-epithelialization, the skin inside the figures MUZ and ORW is designated as subject to excision;After preparing the surgical field, 0.5 ml of a 1% aqueous solution of methylene blue is injected percutaneously into the subcutaneous fat of the mammary gland along line h at intervals of 2.0 cm, de-epithelialization of the skin of the periareolar region is performed within the marking boundaries and two skin-fat flaps are excised within the boundaries of the previously made marking; in the next step, from the obtained approaches, an electric knife is used to separate the skin with subcutaneous fat from the underlying parenchyma of the mammary gland, achieving their complete separation from the entire parenchyma of the mammary gland, at the same time forming the upper and lower dermal legs that feed the nipple-areolar complex; then, according to the projection of line h, taking into account the methylene blue marks, half of the parenchyma of the mammary gland is removed with a tumor of any localization, except for the central one, with the underlying area of ​​the superficial plate of the pectoral fascia;the remaining part of the mammary gland parenchyma after resection is moved to the vacated space so that the resected edge of the parenchyma lies with its entire surface on the pectoralis major muscle; the free edge of the parenchymal flap is fixed with interrupted sutures to the resected edge of the superficial plate of the pectoral fascia.

[0019] For a better understanding of the method, we provide figures.

[0020] Figure 1 shows the preoperative marking lines: the midsternal line (line a); a line denoting the medial border of the mammary gland (line b); a horizontal line at the level of the submammary fold (line c); a line denoting the level of the "spot" of the mammary gland (line d); a horizontal line at the level of the upper border of the mammary gland (line e); a line denoting the lateral border of the mammary gland (line ƒ); at the intersection of lines e, c, ƒ and b, the vertices of the conditional rectangle GHKI are designated; on each side of the rectangle, the midpoints of the lines are marked: point L is the midpoint of side GH, point M is the midpoint of side NK, point N is the midpoint of side IK, point O is the midpoint of side IG; a line connecting points L and N (segment LN) is drawn through the mound of the mammary gland perpendicular to lines e and c; a line is drawn through the mound of the mammary gland perpendicular to lines ƒ and b, connecting points O and M (segment OM);the intersection of these two lines is marked (point P), indicating the center of the mammary gland mound; the cutaneous projection of the tumor is marked; line g is drawn from the center of the mammary gland mound to the center of the cutaneous projection of the tumor; line h is drawn through the center of the mammary gland mound perpendicular to line g across the entire mammary gland mound, which is a cutaneous landmark for the line of resection of the parenchyma of the mammary gland.

[0021] Figure 2 shows a sagittal section of the mammary gland through the center of the mound, the vertices of the conditional triangle are indicated: P (the center of the mammary gland mound), L (the middle of the GH side), N (the middle of the IK side); the base of the triangle is indicated (LN).

[0022] Figure 3 shows the cutaneous marking of the triangle side sizes calculated using the formula in the form of segments LX and NY; the circumference of the nipple-areolar complex is designated; segments XO and YE, corresponding to the radius of the nipple-areolar complex, are designated; segments RU and WZ, corresponding to the diameter of the nipple-areolar complex, are designated; the upper and lower semicircles of the future location of the nipple-areolar complex are designated in the form of smooth arcuate curves connecting the ends of segments RU and WZ, respectively; line h, which is a cutaneous landmark of the resection line of the mammary gland parenchyma, is designated; the cutaneous projection of the tumor is designated.

[0023] Figure 4 shows the marking of the boundaries of de-epithelialization, which correspond to two vertical paraareolar lines located to the right and left of the nipple-areolar complex, and connecting the future upper and lower semicircles of the nipple-areolar complex at points R and W, as well as U and Z; the marking of the boundaries of skin excision is shown, which correspond to the lines drawn from points M and O to the future semicircles of the nipple-areolar complex.

[0024] Figure 5 shows the de-epithelialization zone within the boundaries of the cross-hatching and the excision zone within the boundaries of the rectilinear hatching.

[0025] Figure 6 shows a block of removed tissue, including half of the parenchyma of the mammary gland with a tumor, separated from the pectoralis major muscle, as well as from the skin with subcutaneous fat; the remaining parenchyma of the mammary gland is separated only from the skin with subcutaneous fat.

[0026] Figure 7 shows the remaining portion of the mammary gland parenchyma, moved to the vacated space so that the resected edge of the parenchyma lies with its entire surface on the pectoralis major muscle; the free edge of the parenchymal flap is fixed with interrupted sutures to the resected edge of the superficial plate of the pectoral fascia.

[0027] Figure 8 shows photographs of patient G., who underwent surgical treatment for cancer of the right breast using the described method, on the 14th day of the postoperative period: a) side view on the right; b) frontal view; c) side view on the left.

[0028] The method is carried out as follows. At the preoperative stage, markings are performed (see Fig. 1). In a standing position, the following lines are marked: 1) the midsternal line (line a), marked from the jugular notch to the xiphoid process of the sternum; 2) a line marking the medial border of the mammary gland (line b), drawn along the inner edge of the mammary gland, parallel to line a, for this the mammary gland is pressed to the chest and shifted medially, a line is marked at the fracture and continued up and down; 3) a horizontal line at the level of the submammary fold (line c), located perpendicular to line b; 4) a line indicating the level of the "spot" of the mammary gland, which is marked by grasping and pulling the mammary gland to the sides; a mark is made at the border of the "fracture" (line d)\ 5) a horizontal line at the level of the upper border of the mammary gland (line e), located perpendicular to line b; 6) a line indicating the lateral border of the mammary gland, coincides with the anterior axillary line (line ƒ).In this case, intersecting lines e, c, ƒ and b form a conditional rectangle with vertices G, H, K, I. On each side of the rectangle, the midpoints of the lines are marked: point L is the midpoint of side GH, point M is the midpoint of side НК, point N is the midpoint of side IK, point O is the midpoint of side IG.

[0029] Locate the center of the mammary hill on the skin. To do this, draw a line through the mammary hill perpendicular to lines e and c, connecting points L and N (segment LN). Then, draw a line through the mammary hill perpendicular to lines f and b, connecting points O and M (segment OM). Mark the intersection of these two lines (point P), marking the center of the mammary hill.

[0030] The tumor projection is marked on the skin of the mammary gland. A line (line g) is drawn from the center of the mammary gland mound to the center of the tumor's cutaneous projection. A line (line h) is drawn through the center of the mammary gland mound perpendicular to line g across the entire mammary gland mound, with its endpoints at line d. Line h serves as a cutaneous landmark for the mammary gland parenchyma resection line.

[0031] Determine the future height of the mound by measuring the thickness of the mound between the midpoints of segments PL and PN with a caliper, placing the jaws of the caliper above and below the mound, as well as between the midpoints of segments RO and RM, placing the jaws of the caliper on the side surfaces of the mound. The average value is calculated from the two obtained measurements. The height of the future mound is taken as 1 / 2 average thickness of the mammary gland, designated as t.

[0032] The height of the “spot” of the MF is measured, which corresponds to the length of the side GI of the rectangle GHKI.

[0033] The size of the mammary gland skin reduction zones is determined. For this, an approach is used in which a sagittal section of the mammary gland through the center of the mammary gland mound is taken as a conventional triangle with its apex at the center of the mammary gland mound, that is, according to the markings, at point P, while the other two apexes are located at the midpoints of GH and IK, that is, at points L and N (see Fig. 2); the base of the triangle is the height of the mammary gland "spot." In accordance with the future change in the mammary gland mound height, the length of the triangle's sides is reduced to their equal values, while the length of the triangle's base remains unchanged. The length of the future triangle sides is calculated using the formula: where x is the size of the future equal sides of the triangle, namely, the distance from points L and N to the apex of the future mammary mound; s is the base of the triangle, namely, the height of the mammary "spot"; t is the height of the future mammary mound. The obtained size (x) is set off on segments LP and PN, starting from points L and N, respectively, in the form of segments LX and NY (see Fig. 3). The circumference of the nipple-areolar complex (NAC) is marked and its diameter is determined. Centrifugally from points X and Y on segments LX and NY, segments equal to the radius of the NAC, XO and YE, respectively, are measured. Perpendicular to segment LX, draw segment RU, equal to the diameter of the SAC, with the center of the segment located at point X. Then, perpendicular to segment NY, draw segment WZ, also equal to the diameter of the SAC, with the center of the segment located at point Y. The ends of segments RU and WZ are connected by a smooth arcuate curve through points O and E, respectively, forming the upper and lower semicircles of the future location of the SAC.

[0034] The next step is to mark the boundaries of de-epithelialization (see Fig. 4). For this, two vertical paraareolar lines are drawn to the right and left of the SAC, connecting the future upper and lower semicircles of the SAC at points R and W, as well as U and Z. The skin zones to be excised are then marked. For this, point M is connected by two segments to point U and point Z. Similarly, point O is connected by two segments to point R and point W. The skin inside the geometric figure RUZW, formed by the boundaries of the future upper and lower semicircles of the SAC, as well as the right and left vertical paraareolar lines, is marked as subject to de-epithelialization (see Fig. 5). The skin inside figures MUZ and ORW is marked as subject to excision.

[0035] After preparing the surgical field, 0.5 ml of a 1% aqueous solution of methylene blue is injected percutaneously into the subcutaneous fat of the mammary gland along line h at intervals of 1.5-2.0 cm. Skin de-epithelialization of the periareolar area is performed within the markings. Two skin-fat flaps are excised within the previously made markings. From the obtained approaches, the skin and subcutaneous fat are gradually separated from the underlying mammary gland parenchyma using an electric knife, achieving their complete separation from the entire mammary gland parenchyma, at the same time forming the upper and lower dermal pedicles that feed the SAC. According to the projection of line h, taking into account the methylene blue marks, half of the mammary gland parenchyma is removed with a tumor of any location, except for the central one, with the underlying portion of the superficial plate of the pectoral fascia (see Fig. 6). The remaining part of the mammary gland parenchyma after resection is moved to the vacated space so that the resected edge of the parenchyma lies with its entire surface on the pectoralis major muscle.The free edge of the parenchymal flap is secured with interrupted sutures to the resected edge of the superficial plate of the pectoral fascia (see Fig. 7). The axillary region is entered through the lateral aspect of the surgical field, and axillary lymph node dissection is performed in stages. A skin puncture is made along the anterior axillary line at the level of the submammary fold. Tubular vacuum drains are inserted through this puncture into the mammary gland and axillary fossa, and secured to the skin with ligatures. The mammary gland parenchyma in the projection of the dermal pedicle placement is partially excised to prevent mechanical compression. An intradermal suture is placed on the mammary gland skin, immersing the dermal pedicles under the suture line.

[0036] The practical feasibility of the claimed method is illustrated by examples from clinical practice.

[0037] Example 1. Patient G., 52 years old, was admitted to the Department of Breast and Skin Tumors of the State Budgetary Institution of the Rostov Region "Oncology Dispensary" on June 23, 2025 with a diagnosis of "Right breast cancer T2N1M0, Stage 2b, type Luminal B, Her2neu positive. Condition after 8 courses of neoadjuvant polychemotherapy."

[0038] At the stage of primary diagnosis, an ultrasound examination revealed a tumor with no clear contours up to 34 × 27 mm in the lower inner quadrant of the right mammary gland, at four o'clock on a conventional clock face, 4 cm from the areola at a distance of 21 mm from the skin. Two lymph nodes of 1.8 × 1.6 cm and 1.5 × 1.3 cm were detected in the right axillary region. Objectively, a mobile tumor with no clear contours up to 4 cm in diameter was determined in the lower inner quadrant of the right mammary gland. A mobile lymph node up to 2.0 cm in diameter was palpated in the right axillary region.

[0039] A core biopsy of the mammary gland tumor and a fine-needle aspiration biopsy of the affected axillary lymph node were performed. Histological analysis: invasive carcinoma G3. Immunohistochemical analysis: estrogen receptors - 100%, progesterone receptors - 100%, Ki67 - 45%, Her-2 / neu - 3+.

[0040] Cytological analysis of the right axillary lymph node biopsy results: a cluster of atypical cells characteristic of cancer metastasis. Eight courses of polychemotherapy were administered in the neoadjuvant setting, according to clinical guidelines, including trastuzumab in the last four courses. After completion of neoadjuvant polychemotherapy, a control ultrasound scan revealed no tumor in the breast, and the visualized axillary lymph nodes had a maximum size of 1.0 × 0.8 cm. Upon admission for surgery, grade 3 mastoptosis was observed. The tumor in the right breast was not palpable, and the regional lymph nodes were normal. Patient G. refrained from endoprosthetics with a silicone implant, therefore, after receiving consent, she underwent a radical hemi-resection of the right mammary gland with simultaneous reconstruction with local tissues according to the claimed method.

[0041] At the preoperative stage, the markings were performed. In a standing position, the following lines were drawn: 1) the midsternal line (line a), marked from the jugular notch to the xiphoid process of the sternum; 2) a line marking the medial border of the mammary gland (line b), drawn along the inner edge of the mammary gland, parallel to line a, for this, the mammary gland was pressed to the chest and simultaneously shifted medially, a line was marked at the break and continued upward and downward; 3) a horizontal line at the level of the submammary fold (line c); 4) a line marking the level of the mammary gland "spot", which was marked by grasping and pulling the mammary gland to the sides, marks were made at the border of the "fracture" (line d); 5) a horizontal line at the level of the upper border of the mammary gland (line e); 6) The line denoting the lateral border of the mammary gland coincided with the anterior axillary line (line J). At the same time, the intersecting lines e, c, f, and Ъ formed a conditional rectangle with vertices G, H, K, and I.On each side of the rectangle, the midpoints of the lines were marked: point L is the midpoint of side GH, point M is the midpoint of side NK, point N is the midpoint of side IK, and point O is the midpoint of side IG. The next step was to determine the center of the mammary hillock on the skin. To do this, a line was drawn through the mammary hillock perpendicular to lines e and c, connecting points L and N (segment LN). Then, a line was drawn through the mammary hillock perpendicular to lines f and b, connecting points O and M (segment OM). The intersection of these two lines (point P) was marked, which designated the center of the mammary hillock. Next, the tumor projection was marked on the mammary skin. Then, a line (line g) was drawn from the center of the mammary hillock to the center of the cutaneous projection of the tumor. A line (line h) was drawn through the center of the mammary hillock perpendicular to line g across the entire mammary hillock, the endpoints of which became line d. Line h served as a cutaneous landmark for the resection line of the mammary gland parenchyma.

[0042] The next step was to determine the future height of the mound. To do this, placing the jaws of a caliper above and below the mound, we measured the thickness of the mound between the midpoints of segments PL and PN, which was 6.7 cm. Next, placing the jaws of the caliper on the side surfaces of the mound, we measured the thickness between the midpoints of segments RO and RM, which was 7.6 cm. From these two measurements, we calculated the average value, which was 7.1 cm. Thus, the height of the future mound of the mound was approximately 7 cm.

[0043] The next step was to measure the height of the mammary gland "spot", which actually corresponded to the length of the side GI of the GHKI rectangle. The height of the mammary gland "spot" was 14 cm. Next, the size of the zones of mammary gland skin reduction was determined. For this, an approach was used in which the sagittal section of the mammary gland through the center of the mammary gland hillock was taken as an imaginary triangle with the apex in the center of the mammary gland hillock, that is, according to the markings, at point P, while the other two apexes are located at the midpoints of GH and IK, that is, at points L and N; the base of the triangle is the height of the mammary gland "spot". In accordance with the future change in the height of the mammary gland hillock, the length of the sides of the triangle is reduced to their equal values, while the length of the base of the triangle does not change. The length of the future sides of the triangle was calculated using the formula Where x is the size of the future equal sides of the triangle, namely, the distance from points L and N to the summit of the future hill MZh; s is the base of the triangle, namely, the height of the "spot" MZh; t is the height of the future hill MZh. For ease of calculation, we used the "My Office" spreadsheet. This yielded the length of the triangle's edges and, accordingly, the distances from the future summit of the hill MZh to points L and N: The resulting dimension of 9.8 cm was set off on segments LP and PN, starting from points L and N, respectively, as segments LX and NY. Next, the SAC circumference was marked and its diameter was determined to be 7 cm. Centrifugally from points X and Y on segments LX and NY, segments of 3.5 cm in length were measured, equal to the SAC radius, XO and YE, respectively. Segment RU, equal to the SAC diameter, i.e., 7 cm, was drawn perpendicular to segment LX, with the center of the segment located at point X. Then, segment WZ, also equal to the SAC diameter, i.e., 7 cm, was drawn perpendicular to segment NY, with the center of the segment located at point Y. The ends of segments RU and WZ were connected by a smooth arcuate curve through points O and E, respectively, forming the upper and lower semicircles of the future SAC location. The next step was to define the boundaries of de-epithelialization. To do this, two vertical paraareolar lines were drawn to the right and left of the SAH, connecting the future upper and lower semicircles of the SAH at points R and W, as well as U and Z.The skin areas to be excised were then marked. Point M was connected with two segments to point U and point Z. Similarly, point O was connected with segments to point R and point W. The skin within the geometric figure RUZW, formed by the boundaries of the future upper and lower semicircles of the SAC, as well as the right and left vertical paraareolar lines, was marked as subject to deepithelialization. The skin within the figures MUZ and ORW was marked as subject to excision.

[0044] After preparing the surgical field, 0.5 ml of a 1% aqueous methylene blue solution was percutaneously injected into the subcutaneous fat of the mammary gland along line h at intervals of 1.5-2.0 cm. The periareolar skin was de-epithelialized within the markings. Two skin-fat flaps were excised within the previously made markings. Using the obtained approaches, the skin and subcutaneous fat were gradually separated from the underlying mammary gland parenchyma using an electric knife, achieving complete separation from the entire mammary gland parenchyma and simultaneously forming the upper and lower dermal pedicles that supply the sacroiliac sinus. According to the projection of line h, taking into account the methylene blue marks, half of the mammary gland parenchyma was removed along with the tumor and the underlying portion of the superficial plate of the pectoral fascia. Thus, the block of removed breast parenchyma tissues comprised the entire lower-inner quadrant and the adjacent halves of the upper-inner and lower-outer quadrants.The remaining portion of the mammary parenchyma after resection was moved to the vacated space so that the entire resected parenchymal edge rested on the pectoralis major muscle. The free edge of the parenchymal flap was secured with interrupted sutures to the resected edge of the superficial plate of the pectoralis fascia.

[0045] The axillary region was entered through the lateral aspect of the surgical site, and axillary lymph node dissection was performed in stages. A skin puncture was made along the anterior axillary line, through which tubular vacuum drains were inserted into the mammary gland and axillary fossa areas and secured to the skin with ligatures. The mammary gland parenchyma in the projection of the dermal pedicles was partially excised to prevent mechanical compression. An intradermal suture was placed on the mammary gland skin, immersing the dermal pedicles under the suture line. The postoperative period was uneventful. The drainage tubes were removed 8 days after surgery. The patient was discharged on the 12th postoperative day, satisfied with the aesthetic result (see Figs. 8a, 8b, 8c). After completion of specialized antitumor treatment, the patient is scheduled to undergo symmetrization surgery.

[0046] Thus, in patient G., the use of the claimed method of surgical treatment of breast cancer made it possible to perform an organ-preserving operation with a sufficient degree of radicalism and eliminate mastoptosis.

[0047] Example 2. Patient M., 67 years old, was admitted to the Department of Breast and Skin Tumors of the State Budgetary Institution of the Rostov Region “Oncology Dispensary” on May 12, 2025 with a diagnosis of “Right breast cancer T1cN0M0, Stage 1a, type Luminal B, Her2neu negative.”

[0048] Histological analysis: invasive carcinoma G2. Immunohistochemical analysis: estrogen receptors - 93%, progesterone receptors - 15%, Ki67 - 42%, Her-2 / neu - 0.

[0049] Ultrasound revealed a tumor with no clear margins, up to 17 x 14 mm, at the border of the upper quadrants of the right breast, 6-7 cm from the areola and 18 mm from the skin. Regional lymph nodes are normal. Objectively: grade 2 mastoptosis is detected. A mobile tumor with no clear margins, up to 2.0-2.5 cm in diameter, is located in the right breast at the border of the upper quadrants. Regional lymph nodes are normal. Patient M. refused silicone implant replacement, so after obtaining consent, she underwent a radical hemi-resection of the right breast with simultaneous reconstruction using local tissues according to the proposed method.

[0050] At the preoperative stage, markings were performed. In a standing position, the following lines were drawn: 1) the midsternal line (line a); 2) a line indicating the medial border of the mammary gland (line b); 3) a horizontal line at the level of the submammary fold (line c); 4) a line indicating the level of the mammary gland "spot" (line d); 5) a horizontal line at the level of the upper border of the mammary gland (line e); 6) a line indicating the lateral border of the mammary gland (line ƒ). In this case, by intersecting, lines e, c, ƒ and b formed a conditional rectangle with vertices G, H, K, I. The midpoints of the lines were marked on each side of the rectangle: point L is the midpoint of side GH, point M is the midpoint of side NK, point N is the midpoint of side IK, point O is the midpoint of side IG. The next step was to determine the center of the mammary gland mound on the skin. To do this, a line connecting points L and N (segment LN) was drawn through hill MZh perpendicular to lines e and c. Then, a line connecting points O and M (segment OM) was drawn through hill MZh perpendicular to lines ƒ and b.The intersection of these two lines (point P) was marked, indicating the center of the mammary gland. Next, the tumor projection was marked on the skin of the mammary gland. A line (line g) was then drawn from the center of the mammary gland to the center of the cutaneous tumor projection. A line (line h) was drawn through the center of the mammary gland perpendicular to line g across the entire mammary gland, with its endpoints at line d. Line h served as a cutaneous landmark for the mammary gland parenchyma resection line.

[0051] The next step was to determine the future height of the mound. To do this, placing the jaws of a caliper above and below the mound, we measured the thickness of the mound between the midpoints of segments PL and PN, which was 5.8 cm. Next, placing the jaws of the caliper on the side surfaces of the mound, we measured the thickness of the mound between the midpoints of segments RO and RM, which was 6.4 cm. From these two measurements, we calculated the average value, which was 6.1 cm. Thus, the height of the future mound of the mound was approximately 6 cm.

[0052] The next step was to measure the height of the mammary gland "spot", which actually corresponded to the length of the side GI of the GHKI rectangle. The height of the mammary gland "spot" was 13 cm. Next, the size of the zones of mammary gland skin reduction was determined. For this, an approach was used in which the sagittal section of the mammary gland through the center of the mammary gland hillock was taken as an imaginary triangle with the apex in the center of the mammary gland hillock, that is, according to the markings, at point P, while the other two apexes are located at the midpoints of GH and IK, that is, at points L and N; the base of the triangle is the height of the mammary gland "spot". In accordance with the future change in the height of the mammary gland hillock, the length of the sides of the triangle is reduced to their equal values, while the length of the base of the triangle does not change. The length of the future sides of the triangle was calculated using the formula Where x is the size of the future equal sides of the triangle, namely, the distance from points L and N to the summit of the future hill MZh; s is the base of the triangle, namely, the height of the "spot" MZh; t is the height of the future hill MZh. For ease of calculation, we used the "My Office" spreadsheet. This yielded the length of the triangle's edges and, accordingly, the distances from the future summit of the hill MZh to points L and N: The resulting dimension of 8.8 cm was set off on segments LP and PN, starting from points L and N, respectively, as segments LX and NY. Next, the SAC circumference was marked and its diameter was determined to be 4 cm. Centrifugally from points X and Y on segments LX and NY, segments 2 cm long were measured, equal to the SAC radius, XO and YE, respectively. Segment RU, equal to the SAC diameter, i.e., 4 cm, was drawn perpendicular to segment LX, with the center of the segment located at point X. Then, segment WZ, also equal to the SAC diameter, i.e., 4 cm, was drawn perpendicular to segment NY, with the center of the segment located at point Y. The ends of segments RU and WZ were connected by a smooth arcuate curve through points O and E, respectively, forming the upper and lower semicircles of the future SAC location. The next step was to define the boundaries of de-epithelialization. To do this, two vertical paraareolar lines were drawn to the right and left of the SAH, connecting the future upper and lower semicircles of the SAH at points R and W, as well as U and Z.The skin areas to be excised were then marked. Point M was connected with two segments to point U and point Z. Similarly, point O was connected with segments to point R and point W. The skin within the geometric figure RUZW, formed by the boundaries of the future upper and lower semicircles of the SAC, as well as the right and left vertical paraareolar lines, was marked as subject to deepithelialization. The skin within the figures MUZ and ORW was marked as subject to excision.

[0053] After preparing the surgical field, 0.5 ml of a 1% aqueous methylene blue solution was percutaneously injected into the subcutaneous fat of the mammary gland along line h at intervals of 1.5-2.0 cm. The periareolar skin was de-epithelialized within the markings. Two skin-fat flaps were excised within the previously made markings. Using the obtained approaches, the skin and subcutaneous fat were gradually separated from the underlying mammary gland parenchyma using an electric knife, achieving complete separation from the entire mammary gland parenchyma and simultaneously forming the upper and lower dermal pedicles that supply the sacroiliac sinus. According to the projection of line h, taking into account the methylene blue marks, half of the mammary gland parenchyma was removed along with the tumor and the underlying portion of the superficial plate of the pectoral fascia.

[0054] Thus, the block of removed breast parenchyma tissue comprised the upper-inner and upper-outer quadrants. The remaining breast parenchyma was relocated to the vacated space so that the entire resected parenchymal edge rested on the pectoralis major muscle. The free edge of the parenchymal flap was secured with interrupted sutures to the resected edge of the superficial plate of the pectoral fascia. The axillary region was entered through the lateral aspect of the surgical field, and axillary lymph node dissection was performed in stages. A skin puncture was made along the anterior axillary line at the level of the submammary fold, through which tubular vacuum drains were inserted into the breast area and the axillary fossa, secured to the skin with ligatures. The mammary gland parenchyma in the area where the dermal pedicles were positioned was partially excised to prevent mechanical compression. An intradermal suture was placed on the mammary gland skin, submerging the dermal pedicles under the suture line. The postoperative period was uneventful.The drainage tubes were removed 7 days after surgery.

[0055] The patient was discharged on the 10th day of the postoperative period, satisfied with the aesthetic result.

[0056] Thus, in patient M., the claimed method of surgical treatment of breast cancer made it possible to perform an organ-preserving operation with a sufficient degree of radicalism and elimination of mastoptosis.

[0057] Twelve patients aged 46 to 67 years with non-central breast cancer, using the claimed method of organ-preserving surgery, were operated on at the Department of Breast and Skin Tumors of the State Budgetary Institution of the Rostov Region "Oncology Dispensary." Five patients had grade 2 mastoptosis, and eight had grade 3 mastoptosis. In all cases, the desired technical result was achieved: organ-preserving surgery with sufficient radicality and removal of the mastoptosis.

[0058] Thus, the claimed method of organ-preserving surgical treatment of breast cancer is effective in the treatment of patients with non-central tumor localization who have grade 2-3 mastoptosis; in particular, the method allows for organ-preserving surgical treatment to be performed with a sufficient degree of radicalism and to eliminate mastoptosis.

Claims

A method of organ-preserving surgical treatment of breast cancer, including preoperative marking, in which the following lines are marked in a standing position: midsternal line - line a; line designating the medial border of the mammary gland - line b; horizontal line at the level of the submammary fold - line c; line designating the level of the "spot" of the mammary gland - line d; horizontal line at the level of the upper border of the mammary gland - line e; line designating the lateral border of the mammary gland - line ƒ; as well as the isolation of the nipple-areolar complex on the upper and lower dermal legs, skin reduction and complete separation of the skin with subcutaneous fat from the underlying parenchyma of the mammary gland, resection of the parenchyma of the mammary gland and subclavian-axillary lymphadenectomy, characterized in that in the skin marking a conditional rectangle is isolated, formed by the intersections of lines e, c, ƒ and b, and the vertices G, H, K, I are designated in it;On each side of the rectangle, mark the midpoints of the lines: point L is the midpoint of side GH, point M is the midpoint of side НК, point N is the midpoint of side IK, point O is the midpoint of side IG; then determine the center of the mammary gland mound on the skin by drawing a line through the mammary gland mound perpendicular to lines e and c, connecting points L and N, forming segment LN; then draw a line through the mammary gland mound perpendicular to lines ƒ and b, connecting points O and M, forming segment OM; mark the intersection of these two lines - point P, indicating the center of the mammary gland mound; next, mark the projection of the tumor on the skin of the mammary gland; draw a line from the center of the mammary gland mound to the center of the cutaneous projection of the tumor - line g; the next step is to draw a line through the center of the mammary gland mound perpendicular to line g across the entire mammary gland mound - line h, which is a cutaneous landmark of the mammary gland parenchyma resection line, the end points of line h are line d;then the future height of the mammary gland mound is determined by measuring the thickness of the mammary gland between the midpoints of segments PL and PN with a caliper, placing the jaws of the caliper above and below the mammary gland, as well as between the midpoints of segments RO and RM, placing the jaws of the caliper on the lateral surfaces of the mammary gland, while the average value is calculated from the two obtained dimensions; the height of the future mound is taken as; 1 / 2the average thickness of the mammary gland, denoting it as t; then the height of the "spot" of the mammary gland is measured, which corresponds to the length of the side GI of the rectangle GHKI; the next step is to determine the size of the zones of skin reduction of the mammary gland, for this purpose an approach is used in which the sagittal section of the mammary gland through the center of the mammary gland hill is taken as a conditional triangle with the apex in the center of the hill, that is, according to the markings at point P, while the other two apexes are located in the middle of GH and IK, that is, at points L and N, and the base of the triangle is the height of the "spot" of the mammary gland; in accordance with the future change in the height of the mammary gland hill, the length of the sides of the triangle is reduced to their equal values, while the length of the base of the triangle does not change; the length of the future sides of the triangle is calculated using the formula where x is the size of the future equal sides of the triangle, namely the distance from points L and N to the top of the future mammary gland mound; s is the base of the triangle, namely the height of the "spot" of the mammary gland; t is the height of the future mammary gland mound; then the obtained size x is put off on segments LP and PN, starting from points L and N, respectively, in the form of segments LX and NY; then the circumference of the nipple-areolar complex is marked and its diameter is determined; then centrifugally from points X and Y on segments LX and NY, segments equal to the radius of the nipple-areolar complex are measured, respectively, XO and YE; segment RU is drawn perpendicular to segment LX, equal to the diameter of the nipple-areolar complex, the center of the segment is located at point X; then, perpendicular to the NY segment, draw the WZ segment, also equal to the diameter of the nipple-areolar complex, the center of the segment is located at point Y;then the ends of the segments RU and WZ are connected by a smooth arcuate curve through points O and E, respectively, forming the upper and lower semicircles of the future location of the nipple-areolar complex; the next step is to mark the boundaries of de-epithelialization; for this, two vertical paraareolar lines are drawn to the right and left of the nipple-areolar complex, connecting the future upper and lower semicircles of the nipple-areolar complex at points R and W, as well as U and Z; subsequently, they begin to mark the skin zones to be excised; for this, point M is connected by two segments with point U and point Z, similarly, point O is connected by two segments with point R and point W; the skin inside the geometric figure RUZW, formed by the boundaries of the future upper and lower semicircles of the nipple-areolar complex, as well as the right and left vertical paraareolar lines, is marked as subject to de-epithelialization, the skin inside the figures MUZ and ORW is designated as subject to excision;After preparing the surgical field, 0.5 ml of a 1% aqueous solution of methylene blue is injected percutaneously into the subcutaneous fat of the mammary gland along line h at intervals of 2.0 cm, de-epithelialization of the skin of the periareolar region is performed within the marking boundaries and two skin-fat flaps are excised within the boundaries of the previously made marking; in the next step, from the obtained approaches, an electric knife is used to separate the skin with subcutaneous fat from the underlying parenchyma of the mammary gland, achieving their complete separation from the entire parenchyma of the mammary gland, at the same time forming the upper and lower dermal legs that feed the nipple-areolar complex; then, according to the projection of line h, taking into account the methylene blue marks, half of the parenchyma of the mammary gland is removed with a tumor of any localization, except for the central one, with the underlying area of ​​the superficial plate of the pectoral fascia;the remaining part of the mammary gland parenchyma after resection is moved to the vacated space so that the resected edge of the parenchyma lies with its entire surface on the pectoralis major muscle; the free edge of the parenchymal flap is fixed with interrupted sutures to the resected edge of the superficial plate of the pectoral fascia.

Images