乳腺癌课件70985

1、Breast Cancer 乳腺癌,No.2 Affiliated Hospital Southern Medical University General Surgery 厉周 Richard Lee ,1. Introduction 概论,Western countries 100/100,000 stable incidence declined mortality China 7-10% of all malignancies 2nd most common Ca in 3% yearly increase rate (highest worldwide,2. Etiology 病因,

2、Exposure to estrogen Age at menarche 54y/o Age at first pregnancy 30y/o Family history and genetic disorder 2-3 folds higher (first degree relatives) 5-10% (BRCA1, BRCA2 genetic aberration,Previous benign breast disease: atypical hyperplasia Western life style Lipid diet Obesity Sexual concept 主要与雌激

3、素(estrogen)有明显关系 雌性激素与雌性激素受体结合-进入细胞核(nucleolus)-作用于DNA的合成-产生生物效应,3. Pathological typing 病理类型,Noninvasive breast carcinoma ductal carcinoma in situ, lobular carcinoma in situ, Pagets disease Early invasive breast carcinoma Special types of invasive breast cancer papillary, medullary, tubular, mucinou

4、s Ordinary types of invasive breast cancer invasive ductal, invasive lobular Others,1).非浸润性癌:导管内癌,小叶原位癌-属早期. (2).早期浸润性癌: (3).浸润性特殊癌 (4).浸润性非特殊癌 (5).其他罕见癌,4. 转移途径,1). Infiltrate, local invation 直接浸润 (2). lymphatic metastasis 淋巴转移 经胸肌外缘-同侧腋窝-锁骨上-胸导管 经胸骨旁-锁骨上-胸导管 (3). hematogenous metastasis 血行转移,along

5、 inter-fascial space,along ductules,Local invasion,invading Coopers ligaments Invading skin Invading muscles,Lymphatic metastasis,Hematogenous metastasis,late stage and early stage via lymphatic drainage or directly,5. Clinical Findings 临床表现,5.1. 好发部位:多见乳房外上象限, 次见乳晕乳头区(areola papillaris,5.2. 局部临床体征:

6、 (1)乳房肿块 (mass, lump, neoplasm) (2)皮肤凹陷 (retraction) (3)乳头牵扯偏向或内陷 (4)皮肤桔皮样变 (5)盔甲状癌 (6)乳癌破潰(ulcer,Presentation in breast,Palpable painless lump Local protrusion Changes in skin and nipple Delle and dimple sign Orange-peel sign，peau dorange Nipple retraction and inverted nipple Eczematoid change over

7、 areola or nipple Huge mass and ulceration Inflammatory breast cancer,Palpable painless lump,hard, irregular shape, rough surface, low mobility 80% in the upper half of the breast,Local protrusion,assymetricity of Bil. Breasts change in shape,assymetric breast,change in shape,Change in skin- Delle a

8、nd dimple sign,Delle: visible skin retraction,dimple sign: pinched skin retraction,invasion of Coopers ligaments and adjacent adipose incomplete fixation of skin,Change in skin- orange-peel sign,thickening of skin dermal edema induced by invasion of lymphatic vessels,Change in nipple- nipple retract

9、ion and inversion,differentiated from congenital nipple retraction invasion of mammary ducts,Change in nipple 预防的目的是早期诊断,防止癌扩散; 早期诊断应重视易感因素(susceptible)和进行普查(general investigation,Susceptible 易感因素,1.乳癌家族史(family history); 2.大于35岁未育(Nulliparous 35); 3.行经超过45岁(late menarche 45); 4.大于35岁头胎足月女性(first fu

10、ll-term pregnancy 35); 5.初次月经小于12岁( first menarche 12); 6.乳头有血性溢液(bloody discharge of nipple); 7.乳腺有局限性增生(logical hyperplasia); 8.乳癌术后病人另一侧乳房,8. Treatment principle 治疗原则,以手术治疗为主,化疗,放疗,激素,免疫等综合(colligate, synthesize) 措施的治疗为辅; Surgery: radical mastectomy (Halsted) modified radical mastectomy Extensive

11、 radical mastectomy Breast conservative surgery Sentinel axillary LN biopsy,8.1. Operation 手术治疗,1) radical mastectomy乳腺根治切除术 （切除内容及范围,2) Extended radical mastectomy 乳癌扩大根治切除术 扩大切除的内容,3) Segmental mastectomy + axillary dissection 改良根治术,保留乳头的乳腺癌根治术,保留乳头的乳腺癌根治术,Sentinel axillary LN biopsy,Percentage of

12、 LN metastasis is less than 10 % for tumor size 1cm For tumor size 1-2 cm, false negative SLNB is estimated to be less than 10% Isotope (Tc99 sulfur colloid), Blue dye injection Intratumor, subareolar, intraparenchymal injection Negative SLNB no radical axillary LN dissection Positive SLND-radical a

13、xillary LN dissection,8.2. 化学药物治疗 常用方案：5-氟脲嘧啶，氨甲蝶呤，环磷酰胺（CMF） 8.3. 放射治疗 时间:术后2-3周开始 目的：防止局部复发，常用于术后辅助治疗 照射区域：锁骨上，胸骨旁，腋窝 8.4. 激素治疗 闭经(menopause)前与闭经后的分界线:指月经终止后5年为绝经界线(boundary,demarcation line,激素(hormone)治疗方法: (1)卵巢切除(ovariotomy) (2)卵巢X线照射破坏 (3)肾上腺切除(adrenalectomy) (4)脑垂体切除 (5)三苯氧胺(tamoxifen)-雌激素吉抗剂 (6)雄激素(androgenic hormone)应用 (7)激素+化学药联合治疗 激素治疗的选择: （1）绝经前:卵巢切除,雄激素, 卵巢X线照射 或三苯氧胺(雌激素受体阳性) （2）绝经后:三苯氧胺,脑垂体切除,肾上腺切除,9. Progonosis,乳腺癌治疗预后: 取决于细胞生物学特性及其雌激素受体是否阳性 分化程度高则预后好,分化程度底则预后差 雌激素受体阳性则预后好,Reconstraction 隆乳术,Brief summary 总 结,1. anatomy 乳腺解剖 2. examination乳房检查