术前系统治疗指南图文

1、Relative:Relative: Prior radiation therapy to the chest wall or breast Active connective tissue disease involving the skin (especially scleroderma and lupus （注：因不能耐受放疗，可能导致严重的 纤维化和软组织或骨的坏死) Tumors 5 cm (category 2B) Focally positive margin（注：显微镜下不伴有广泛导管内癌成分的 局灶性阳性切缘可选择性保乳，更高剂量的瘤床推照） Women with a kno

2、wn or suspected genetic predisposition to breast cancer: 1: 1）May have an increased risk of ipsilateral breast recurrence（患侧复发） or contralateral（对侧） breast cancer with breast-conserving therapy 2 2）Prophylactic bilateral mastectomy for risk reduction may be considered（预防性双乳切除）. Stage IIA Stage IIA T

3、2, N0, M0 Stage IIB Stage IIB T2, N1, M0；T3, N0, M0 Stage lllA Stage lllA T3, N1, M0 Fulfills criteria for breast-conserving surgery except for tumor size History and physical exam CBC, platelets Liver function tests and alkaline phosphatase Bilateral mammogram（双乳X线）; Ultrasound Pathology review Tum

4、or ER/PR status and HER2 status Genetic counseling if patient is high risk for hereditary(遗传) breast cancer Breast MRI (optional), with special consideration for mammographically occult（钼靶隐匿） tumors Fertility counseling if premenopausal（绝经前） Consider systemic staging (particularly if signs and sympt

5、oms are present):Consider systemic staging (particularly if signs and symptoms are present): Chest diagnostic CT Abdominal（腹） pelvic（盆） diagnostic CT or MRI Bone scan or sodium fluoride（氟化钠：主评骨） PET/CT (category 2B) FDG PET/CT (optional, category 2B) Desires breast preservationDesires breast preserv

6、ation： Core biopsy with placement of image-detectable marker(s), if not previously performed, must be done to demarcate the tumor bed for post-chemotherapy surgical management. 即：术前需行瘤床定位即：术前需行瘤床定位 Does not desire breast preservationDoes not desire breast preservation：See Locoregional(局部) Treatment

7、of Clinical Stage I, IlA, or IlB Disease or T3, N1, M0. Clinically negative : Clinically negative : should have axillary ultrasound ; suspicious nodes should be sampled by FNA or core biopsy and clipped with image- detectable marker; positive clipped lymph nodes must be removed if FNA or core biopsy

8、 was positive prior to neoadjuvant therapy. Clinically positive:Clinically positive:should be sampled by FNA or core biopsy and clipped with image-detectable marker; positive clipped lymph nodes must be removed if FNA or core biopsy was positive prior to neoadjuvant therapy. 简言之，淋巴结怀疑阳性的需活检取样，若证实，在新

9、简言之，淋巴结怀疑阳性的需活检取样，若证实，在新 辅助治疗前切除。辅助治疗前切除。 Endocrine therapy alone may be considered for receptor- positive disease in postmenopausal patients ; An aromatase inhibitor(芳香化酶抑制剂) is preferred . Those chemotherapy regimens recommended（化疗方案推荐） in the adjuvant setting may be considered in the preoperative

10、 setting. A pertuzumab-containing regimen(含帕妥治疗) may be administered preoperatively to patients with T2 or N1, HER2-positive, early-stage breast cancer. Patients with HER2-positive tumors should be treated with preoperative system therapy incorporating trastuzumab(联合 曲妥) for at least 9 weeks of preo

11、perative therapy. CRCR(Complete response)：S=0 PRPR(Partial response)：S 50%S SDSD(Stable disease): 50%S S 125%S PDPD(progressive disease):S125%S D D d d S = D S = D d d Confirmed progressive Confirmed progressive disease at any timedisease at any time Partial response,Partial response, lumpectomy not

12、 lumpectomy not possiblepossible MastectomyMastectomy Partial response,Partial response, Lumpectomy Lumpectomy possible orpossible or Complete responseComplete response LumpectomyLumpectomy Mastectomy and surgical axillary staging reconstruction. If sentinel lymph node biopsy performed prechemothera

13、py and negative findings, may omit axillary lymph node staging 注意：化疗前 Lumpectomy with surgical axillary staging If sentinel lymph node biopsy performed prechemotherapy and negative findings, may omit axillary lymph node staging 注意：化疗前 CLINICAL STAGECLINICAL STAGE Stage IIIA Stage IIIA T0, N2, M0；T1,

14、 N2, M0；T2, N2, M0；T3, N2, M0 Stage IIIB Stage IIIB T4, N0, M0；T4, N1, M0；T4, N2, M0 Stage lllC Stage lllC Any T, N3, M0 History and physical exam CBC, platelets Liver function tests and alkaline phosphatase Bilateral mammogram; Ultrasound Pathology review Tumor ER/PR status and HER2 status Genetic

15、counseling if patient is at high risk for hereditary breast cancer Breast MRI (optional),with special consideration for mammographically occult tumors Fertility counseling if premenopausal Consider systemic staging (particularly if signs and symptoms are present):Consider systemic staging (particula

16、rly if signs and symptoms are present): Chest diagnostic CT Abdominal pelvic diagnostic CT or MRI Bone scan or fluoride PET/CT (category 2B) FDG PET/CT (optional, category 2B) Response:Response: 1)1)Total mastectomy Total mastectomy + level l/ll axillary dissection + radiation therapy to chest wall

17、and infraclavicular(锁骨下) and supraclavicular nodes (plus internal mammary nodes if involved(内乳淋巴结受累), strongly consider internal mammary nodes if not clinically involved category 2B) delayed breast reconstruction(延迟性乳房重建). 2)2) Consider lumpectomy Consider lumpectomy + level l/ll axillary dissection

18、 + radiation therapy to breast and infraclavicular and supraclavicular(锁骨上) nodes (plus internal mammary nodes if involved) For patients with skin and/or chest wall involvement (T4 non-inflammatory) prior to neoadjuvant therapy, breast conservation may be performed in carefully selected patients bas

19、ed upon a multidisciplinary assessment of local recurrence risk. Exclusion criteria for breast conservation include: inflammatory (T4d) disease before neoadjuvant therapy and incomplete resolution of skin involvement after neoadjuvant therapy. 18自动发卡平台 http:/ 嫓廰掆 Relative:Relative: Prior radiation t

20、herapy to the chest wall or breast Active connective tissue disease involving the skin (especially scleroderma and lupus （注：因不能耐受放疗，可能导致严重的 纤维化和软组织或骨的坏死) Tumors 5 cm (category 2B) Focally positive margin（注：显微镜下不伴有广泛导管内癌成分的 局灶性阳性切缘可选择性保乳，更高剂量的瘤床推照） Women with a known or suspected genetic predisposition to breast cancer: 1: 1）May have an increased risk of ipsilateral breast recurrence（患侧复发） or contralateral（对侧） breast cancer with breast-conserving therapy 2 2）Prophylactic bilateral mastectomy for risk reduction may be considered（预防性双乳切除）. CRC