乳腺疾病英文教学课件

1、Diseases of the BreastNormal adult breastIn the vertical axisbetween the 2nd and 6th ribsIn the horizontal axisbetween the sternal edge and the midaxillaryThe average breast measures 10 to 12 cm in diameter, and its average thickness centrally is 5 to 7 cmBreast tissue also projects into the axilla

2、as the axillary tailCoopers ligamentChest wallSkinMajor pectoral muscleFatLactiferous sinuse(输乳管窦) Breast AnatomyCoopers ligamentBlood SupplyInternal thoracic a.60% of the breast, mainly the medial, central partsLateral thoracic a.30% of the breast, mainly the upper, outer quadrantLymphatic Drainage

3、the apical or subclavicular nodesthe interpectoral (Rotter) nodesthe central nodesthe axillary vein lymph nodesthe scapular nodesAxillary Lymph NodesLevel III: medial to the pectoralis minor muscleLevel II: behind the pectoralis minor muscleLevel I: lateral to the pectoralis minor muscleCan be deter

4、mined accurately only at the time of surgeryAxillary Lymph NodesExamination of the BreastInspectionPalpationSelf examinationDiagnostic examinationInspectionSymmetry of bilateral breastSizeLocationAppearanceNippleLocalized enlargement:Big massLocalized retraction:Coopers ligaments invasion“Dimple Sig

5、n”(酒窝征)SkinOrange peel skinDermal involvement with tumorInflammatory breast cancerNippleNipple inversionUnilateralBilateralPagets diseaseNipple DischargeSingle or multiple ducts?Colour? From white to yellow to green to brown to blue-blackCause?Physiologic secretion?Intraductal papilloma?Malignancy?P

6、alpationSelf-examination90% breast cancer were self-discoveredRegular self-examination is an effective way for early detection of breast cancer Self-examinationWhen you batheWhen you sleepDiagnostic ExaminationMammographyUltrasoundMRIBiopsyroutine useDiagnostic value of mammographyHigh sensitivity i

7、n detecting calcificationDifferential diagnosis Benign or malignant?Mammography-guided calcification location/dissectionObjectiveDense breastX-ray radiationLimitation of breast mammgraphyMammography: Risk Signs Irregular mass Pleomorphic/fine linear calcification Architectural distortion Asymmetric

8、density Skin thickening and retraction Enlargement of lymph nodesBreast Imaging Reporting and Data System (BI-RADS)BI-RADS 0: need additional imaging evaluation BI-RADS 1: negativeBI-RADS 2: benign findingBI-RADS 3: probably benign finding(risk 0.1 cm, 0.5 cmT1b 0.5 cm, 1 cmT1c 1 cm, 2 cmT2 2 cm, 5

9、cmT3 5 cmT4 Tumor of any size with direct extension to (a) chest wall or (b) skin, only as described belowT4a Extension to chest wall, not including pectoralis muscleT4b Edema or ulceration of the skin of the breast, or satellite skin nodules confined to the same breastT4c Both T4a and T4bT4d Inflam

10、matory carcinomaLpmph Node(N) and Metastasis(M)NX Regional lymph nodes cannot be assessedN0 No regional lymph node metastasisN1 Metastasis to movable ipsilateral axillary lymph node(s)N2 Metastases in ipsilateral axillary lymph nodes fixed or matted, or in ipsilateral internal mammary nodes in the a

11、bsence of clinically evident axillary lymph node metastasisN3 Metastasis in ipsilateral supraclavicular/infraclavicular lymph node(s), or in both ipsilateral internal mammary lymph node(s) and axillary lymph node(s)MX Distant metastasis cannot be assessedM0 No distant metastasisM1 Distant metastasis

12、StageStageTNMStage IIIAT0N2M0T1N2M0T2N2M0T3N1M0T3N2M0Stage IIIBT4N0M0T4N1M0T4N2M0Stage IIICAny TN3M0Stage IVAny TAny NM1StageTNMStage 0TisN0M0Stage IT1N0M0Stage IIAT0N1M0T1N1M0T2N0M0Stage IIBT2N1M0T3N0M0PreventionComprehensive Treatment for Breast CancerTreatment depends on stage of cancerMore than

13、one treatment may be usedSurgeryChemotherapyRadiation therapyHormone therapyTargeted therapyGoal: Treatment Individualization!Moving away from one size fits all!Patey DH, Dyson WHBritish Journal of Cancer 1948;2:7-13The Prognosis of Carcinoma of the Breast in Relation to the Type of Operation Perfor

14、medPatientsHalsted mastectomy (45pts)Modified mastectomy (46pts)Result:3 years survival rateLacour J, Bucalossi PCancer , 1976;37:206-214Radical Mastectomy Versus Radical Mastectomy Plus Internal Mammary1580 patients(1963-1968)Halsted mastectomyExtended mastectomyResult: NS in 5 years survival rateM

15、odified Radical MastectomyPatey MaddenNo difference survival between modified and radical mastectomy.The most commonly performed operative treatment.Turner L Ann R Coll Surg Engl, 1981, 63: 239. Maddox W. Ann Surg, 1983, 198: 207.William Halsted 18521922Father of Breast SurgeryNoble guys in the hist

16、ory of breast surgery Umberto VeronesiHead of the National Cancer Institute in MilanThe director of the European Institute of OncologyLymphatic Mapping and Sentinel Node BiopsyThe “sentinel” node is the firstnode to receive lymphaticdrainage from a primary tumor.Thus, it is the first node to whicha

17、tumor will metastasize. If the sentinel node is negativefor metastatic disease, theremaining nodes in thelymphatic basin are also likely tobe negative.Radical mastecomy, HalstedMastectomy, VolkmanAxillary dissection, MooreExtensive radical mastecomy, Margottini19491866189418631951Lumpectomy plus axi

18、llary dissection, VeronesiModified radical mastecomy, Auchincloss1992Sentinel lymph node biopsy, Krag1973History of Breast Cancer Surgery1949Modified radical mastecomy, PateyFrom “Maximum tolerable treatment”To “Minimum effective treatment”Halsted vs. Systemic Theory of Breast Cancer SpreadHalstedSy

19、stemicCancer Treatment: Adjuvant TherapyTreatment given in addition to surgery to reduce the risk of recurrenceMay include radiation therapy, chemotherapy, hormone therapy and target therapyPost-mastectomy Radiation Therapy IndicationsEBCTCG, Lancet, 2005, 2087-2106EBCTCGMastectomy RadiotherapyEBCTC

20、G, Lancet, 2005, 2087-2106Post-BCS Radiation Therapy All patients should recieve radiation therapyCMFNo CT19704.2% improvementANTHRACYCLINES19804.3% improvementTAXANES20005.1% improvementAdjuvant Chemotherapy and Survival Improvement Over Past 40 YearsCT + TT (trastuzumab)6% improvement2006Chemother

21、apy continues to improve outcomes in ESBC and plays a leading role in treatmentCMFNo CT19704.2% improvementANTHRACYCLINES19804.3% improvementTAXANES20005.1% improvementCT + TT (Trastuzumab)6% improvement2006Chemotherapy continues to improve outcomes in ESBC and plays a leading role in treatmentNot s

22、tandard treament nowFor nearly all ptsFor LN(+) or high risk LN(-) ptsFor HER2(+) ptsAdjuvant Chemotherapy and Survival Improvement Over Past 40 YearsAdjuvant Chemothearpy: IndicationsGoldhirsch A, et al. Ann Oncol. 2009;20:1319-1329. Breast Cancer RiskAdjuvant Endocrine TherapyPremenopausal womenTa

23、moxifen is viewed as a standard adjuvantOvarian function suppression (OFS) is accepted as an alternative when tamoxifen is contraindicatedCombination of tamoxifen plus OFS is acceptablePostmenopausal womenan aromatase inhibitor should form part of therapythere were certain patients for whom tamoxife

24、n alone can be considered adequatearomatase inhibitors as up-front endocrine treatment particularly in patients at higher risk of early relapseGoldhirsch A, et al. Ann Oncol. 2009;20:1319-1329. 5-yr TAM vs Not in ER+ Breast CancerEBCTCG, Lancet, 2005: 1687-717Target therapy: Role of HER2A proto-onco

25、gene involved in the dysregulation of cell proliferationAssociated with poor prognosis and worse disease-free / overall survivalPossibly predict response to particular therapyAnti-HER2 Therapy: Trastuzumab for HER2(+) breast cancerHERAIHC orFISH1 v 2 年 赫赛汀观察IHC: ImmunohistochemistryFISH: Fluorescenc

26、e In Situ HybridizationNCCTG N9831BCIRG 006FISHNSABP B-31IHC orFISHIHC orFISHAnti-HER2 Therapy: TrastuzumabTrastuzumab: Clinical TrialsTrialsF/UNRecurrence Risk ReductionDeath Risk ReductionReferenceHERA4y34012415%NEJM 2009B31/N98312.9y39695137%ASCO 2007BCIRG 00665m322236%25%37%23%SABCS 2009PACS 044

27、7m52814HR = 1.27JCO 2009Gynecomastia(男性乳房发育症)Gynecomastia needs to be differentiated from, cancer, and less common lesionsS. Dali: Space Venus (Dali Universe, London)Welcome to the world of breast!Endocrine Responsiveness of Breast Cancer(2007 St. Gallen)Highly endocrine responsiveBoth ER and PR hig

28、h expressionIncompletely endocrine responsiveBoth ER and PR high expressionER(+) and PR (-)ER(-) and PR (+)None endocrine responsiveNone ER and PR expressionCandidates for endocrine therapyModified Radical MatectomyFor phase I, II and part of phase III breast cancerIs the major surgical approach of

29、breast cancerBreast Conserving Surgery: IndcationsCould receive postoperative radiation therapy Could ensure negative marginsCould ensure postoperative cosmetic effectBreast Conserving Surgery: Clinical TrialsTrialsYearNSize(cm)F/U(y)OS %MastectomyBCSNSABP B-061976-198418514204746*/47Milan Cancer In

30、stitute1973-198070122058.858.3NCI1979-1987237518.45854EORTC1980-1986868513.46665DBCCG1983-1989905568279Lisa A. Newman. J Clin Oncol, 2005*Without radiation therapyWe are going to see.Breast anatomyBreast examinationBenign breast diseasesBreast cancerDifferential diagnosis of breast mass BenignMalignantGrowth mannerexpansionInvasionGrowth speedslowfastMarginsmoothirregularRecurrence and metastasisuncommoncommonNuclear divisionuncommoncommonDifferentiation Gradehigh differentiation,