乳腺疾病英文教学课件

DiseasesoftheBreastNormaladultbreastIntheverticalaxisbetweenthe2ndand6thribsInthehorizontalaxisbetweenthesternaledgeandthemidaxillaryTheaveragebreastmeasures10to12cmindiameter,anditsaveragethicknesscentrallyis5to7cmBreasttissuealsoprojectsintotheaxillaastheaxillarytailCooper’s

ligamentChestwallSkinMajorpectoralmuscleFatLactiferous

sinuse(输乳管窦)BreastAnatomyCooper’sligamentBloodSupplyInternalthoracica.~60%ofthebreast,mainlythemedial,centralpartsLateralthoracica.~30%ofthebreast,mainlytheupper,outerquadrantLymphaticDrainagetheapicalorsubclavicularnodestheinterpectoral(Rotter)nodesthecentralnodestheaxillaryveinlymphnodesthescapularnodesAxillaryLymphNodesLevelIII:medialtothepectoralisminormuscleLevelII:behindthepectoralisminormuscleLevelI:lateraltothepectoralisminormuscleCanbedeterminedaccuratelyonlyatthetimeofsurgeryAxillaryLymphNodesExaminationoftheBreastInspectionPalpationSelfexaminationDiagnosticexaminationInspectionSymmetryofbilateralbreastSizeLocationAppearanceNippleLocalizedenlargement:BigmassLocalizedretraction:Cooper`sligamentsinvasion“DimpleSign”(酒窝征)SkinOrangepeelskinDermalinvolvementwithtumorInflammatorybreastcancerNippleNippleinversionUnilateralBilateralPaget’sdiseaseNippleDischargeSingleormultipleducts?Colour?Fromwhitetoyellowtogreentobrowntoblue-blackCause?Physiologicsecretion?Intraductalpapilloma?Malignancy?PalpationSelf-examination90%breastcancerwereself-discoveredRegularself-examinationisaneffectivewayforearlydetectionofbreastcancer

Self-examinationWhenyoubatheWhenyousleepDiagnosticExaminationMammographyUltrasoundMRIBiopsyroutineuseDiagnosticvalueofmammographyHighsensitivityindetectingcalcificationDifferentialdiagnosisBenignormalignant?Mammography-guidedcalcificationlocation/dissectionObjectiveDensebreastX-rayradiationLimitationofbreastmammgraphy

Mammography:RiskSigns

Irregularmass

Pleomorphic/finelinearcalcificationArchitecturaldistortionAsymmetricdensitySkinthickeningandretractionEnlargementoflymphnodesBreastImagingReportingandDataSystem(BI-RADS)BI-RADS0:needadditionalimagingevaluationBI-RADS1:negativeBI-RADS2:benignfindingBI-RADS3:probablybenignfinding(risk<2%,aninitialshort-termfollow-up(6months)examination)BI-RADS4:suspiciousabnormality(breastinterventionalproceduresshouldbeused)BI-RADS5:highlysuggestiveofmalignancy(risk≥95%)BI-RADS6:biopsyprovenmalignancy28DiagnosticvalueofultrasoundDifferentialdiagnosisofbreastmass

Cysticorsolid?Benignormalignant?Ultrasound-guidedmassbiopsy/dissectionRepeatableOperatordependentSubjectiveOccultbreastleisonsLimitationofbreastultrasoundUltrasoundShapeOrientationMarginLesionboundaryEchopatternPosterioracousticfeaturesMalignantLesionsinMRIMRIVeryhighsensitivityEnablethedetectionofbreastcancermammographically,sonographically,andclinicallyoccultPathologicalexaminationofthebreastFinaldiagnosisofbreastlesionsOpenbiopsyCorebiopsyMammography-guidedUltrasound-guidedMRI-guidedFineneedleaspirationImprintClinicalIndicationsProblemsolving:equivocalmammogram,ultrasound,orphysicalexaminationfindingAxillarynodemalignancyandunknownsiteofprimarytumorMonitoringresponsetochemotherapyBreastcancerscreeninginwomenathighriskNippledischargeBreastcancerstagingCongenitalAbnormalitiesPolytheliaPolymastiaAmastiaAtheliaAcutemastitisEtiologyS.Aureus(金黄色葡菌球菌)Staphylococcusepidermidis(表皮葡萄球菌)Streptococcusspecies(链球菌)Patientspresentationpain,erythema,swelling,tenderness,orsystemicsignsofinfectionMorecommonlylactationalinfectionAcutemastitisBreastabscessLactationalbreastinfectionManagementAcutestageStoplactationorNotEmptymilkAntibioticsAbscessIncisionanddrainageMastopathyEtiologyImbalanceofestrogenandprogesteroneManifestationPainandmassSometimescorrelatedwithmensecyclesManagementDifferentiatewithbreastcancerFibroadenomaEtiologyHypersensitivitytoestrogenManifestationYoungwomenbreastmassPalpationManagementSurgeryFinalpathologyIntraductalpapillomaManifestationNippledischargeMassbeneathnipple-areolarcomplexDiagnosisCytologyexaminationDuctoscopy(乳管镜)MammographyUltrasoundMRIKun-WeiShen,etal.Cancer2000;89:1512–9.IntraductalpapillomaManagementSurgery(totalductexcision)Preoperaitvelocalization(hookwire)BreastSarcomaSarcomaPhyllodestumorClinicalmanifestationTreatmentPrognosisBreastCancerEvery12minutesawomaninAmericadiesofbreastcancerHistoryofbreastcancerBreastcancerincidence“Westernizing”Women’sRisks?BreastCancerinLower-IncomeCountriesDatasources：NEJM,2008,358(3):213-216Per100,000IncidenceofBreastCancer

inShanghaiTrendsofIncidencebyAgein5-year-IntervalPeriods,1978-2002Newpeakemerginginmiddle-agegroup–acurvewithtwopeaksPeakvaluemovingtoright(olderagegroups)Agegroups60to85hadrelativeconsistentconstituentratios111.51114.14DatafromShanghaiMunicipalCenterforDiseaseControl&PreventionEtiologyEtiologyGeneticfactors(BRCA1,BRCA2)RaceObesity,Radiation,DrugEndocrinerelatedfactorsAgeatmenarcheAgeatmenopauseParityAgeatfirstfulltermpregnancyBreastfeedingHormonereplacementtherapyPathologicalClassificationCarcinomainsituDuctalcarcinomainsitu(DCIS)Lobularcarcinomainsitu(LCIS)InvasivecarcinomaInvasiveductalcarcinoma(IDC)Invasivelobularcarcinoma(ILC)Medullarycarcinoma(髓样癌)Mucinouscarcinomas(粘液腺癌)NeuroedocrineCarcinomas(神经内分泌癌)Apocrinecarcinoma(大汗腺样癌)WayoftheDisseminationLocalinvasionRegionalmetastasisSystemicmetastasisClinicalManifestationMassCalcificationNippledischargeSkininvolvementNippleinversionAxillarylymphnodeenlargementSupraclavicularlymphnodeenlargementMetastasisLungBoneLiverBrainInflammatoryBreastCancerPaget’sDiseaseTNMClinicalStagingPrimaryTumor(T)TXPrimarytumorcannotbeassessedT0NoevidenceofprimarytumorTisCarcinomainsitu,Paget'sdiseaseofthenipplewithnotumorT1≤2cmT1micMicroinvasion≤0.1cmT1a>0.1cm,≤0.5cmT1b>0.5cm,≤1cmT1c>1cm,≤2cmT2>2cm,≤5cmT3>5cmT4Tumorofanysizewithdirectextensionto(a)chestwallor(b)skin,onlyasdescribedbelowT4aExtensiontochestwall,notincludingpectoralismuscleT4bEdemaorulcerationoftheskinofthebreast,orsatelliteskinnodulesconfinedtothesamebreastT4cBothT4aandT4bT4dInflammatorycarcinomaLpmphNode(N)andMetastasis(M)NXRegionallymphnodescannotbeassessedN0NoregionallymphnodemetastasisN1Metastasistomovableipsilateralaxillarylymphnode(s)N2Metastasesinipsilateralaxillarylymphnodesfixedormatted,orinipsilateralinternalmammarynodesintheabsenceofclinicallyevidentaxillarylymphnodemetastasisN3Metastasisinipsilateralsupraclavicular/infraclavicularlymphnode(s),orinbothipsilateralinternalmammarylymphnode(s)andaxillarylymphnode(s)MXDistantmetastasiscannotbeassessedM0NodistantmetastasisM1DistantmetastasisStageStageTNMStageIIIAT0N2M0T1N2M0T2N2M0T3N1M0T3N2M0StageIIIBT4N0M0T4N1M0T4N2M0StageIIICAnyTN3M0StageIVAnyTAnyNM1StageTNMStage0TisN0M0StageIT1N0M0StageIIAT0N1M0T1N1M0T2N0M0StageIIBT2N1M0T3N0M0PreventionComprehensiveTreatmentfor

BreastCancerTreatmentdependsonstageofcancerMorethanonetreatmentmaybeusedSurgeryChemotherapyRadiationtherapyHormonetherapyTargetedtherapyGoal:TreatmentIndividualization!Movingawayfromonesizefitsall!PateyDH,DysonWHBritishJournalofCancer1948;2:7-13ThePrognosisofCarcinomaoftheBreastinRelationtotheTypeofOperationPerformedPatientsHalstedmastectomy(45pts)Modifiedmastectomy(46pts)Result:3yearssurvivalrateLacourJ,BucalossiPCancer,1976;37:206-214RadicalMastectomyVersusRadicalMastectomyPlusInternalMammary1580patients(1963-1968)HalstedmastectomyExtendedmastectomyResult:NSin5yearssurvivalrateModifiedRadicalMastectomyPateyMaddenNodifferencesurvivalbetweenmodifiedandradicalmastectomy.Themostcommonlyperformedoperativetreatment.TurnerLAnnRCollSurgEngl,1981,63:239.MaddoxW.AnnSurg,1983,198:207.WilliamHalsted1852–1922FatherofBreastSurgeryNobleguysinthehistoryofbreastsurgery

UmbertoVeronesiHeadoftheNationalCancerInstituteinMilanThedirectoroftheEuropeanInstituteofOncologyLymphaticMappingandSentinelNodeBiopsyThe“sentinel”nodeisthefirstnodetoreceivelymphaticdrainagefromaprimarytumor.Thus,itisthefirstnodetowhichatumorwillmetastasize.Ifthesentinelnodeisnegativeformetastaticdisease,theremainingnodesinthelymphaticbasinarealsolikelytobenegative.Radicalmastecomy,HalstedMastectomy,VolkmanAxillarydissection,MooreExtensiveradicalmastecomy,Margottini19491866189418631951Lumpectomyplusaxillarydissection,VeronesiModifiedradicalmastecomy,Auchincloss1992Sentinellymphnodebiopsy,Krag1973HistoryofBreastCancerSurgery1949Modifiedradicalmastecomy,PateyFrom“Maximumtolerabletreatment”To“Minimumeffectivetreatment”Halstedvs.Systemic

TheoryofBreastCancerSpreadHalstedSystemicCancerTreatment:AdjuvantTherapyTreatmentgiveninadditiontosurgerytoreducetheriskofrecurrenceMayincluderadiationtherapy,chemotherapy,hormonetherapyandtargettherapy≥4LN(+)Chestwall+supraclavicularConsiderinternalmammarynodes1～3LN(+)Stronglyconsiderchestwall+supraclavicularConsiderinternalmammarynodesLN(-)T>5cmorpositivemarginChestwallLN(-)T≤5cmandmargin<1mmConsiderchestwallLN(-)T≤5cmandmargin≥1mmNoRTPost-mastectomyRadiationTherapy

IndicationsEBCTCG,Lancet,2005,2087-2106EBCTCG

Mastectomy±RadiotherapyEBCTCG,Lancet,2005,2087-2106Post-BCSRadiationTherapyAllpatientsshouldrecieveradiationtherapyCMFNoCT19704.2%improvementANTHRACYCLINES19804.3%improvementTAXANES20005.1%improvementAdjuvantChemotherapyandSurvivalImprovementOverPast40YearsCT+TT(trastuzumab)6%improvement2006ChemotherapycontinuestoimproveoutcomesinESBCandplaysaleadingroleintreatmentCMFNoCT19704.2%improvementANTHRACYCLINES19804.3%improvementTAXANES20005.1%improvementCT+TT(Trastuzumab)6%improvement2006ChemotherapycontinuestoimproveoutcomesinESBCandplaysaleadingroleintreatmentNotstandardtreamentnowFornearlyallptsForLN(+)orhighriskLN(-)ptsForHER2(+)ptsAdjuvantChemotherapyandSurvivalImprovementOverPast40YearsAdjuvantChemothearpy:IndicationsGoldhirschA,etal.AnnOncol.2009;20:1319-1329.BreastCancerRiskRiskAgeGradeHistologicalsubtypesER/PRandHER2statusVascularinvasionTumormarginsLymphnodestatusAdjuvantEndocrineTherapyPremenopausalwomenTamoxifenisviewedasastandardadjuvantOvarianfunctionsuppression(OFS)isacceptedasanalternativewhentamoxifeniscontraindicatedCombinationoftamoxifenplusOFSisacceptablePostmenopausalwomenanaromataseinhibitorshouldformpartoftherapytherewerecertainpatientsforwhomtamoxifenalonecanbeconsideredadequatearomataseinhibitorsasup-frontendocrinetreatmentparticularlyinpatientsathigherriskofearlyrelapseGoldhirschA,etal.AnnOncol.2009;20:1319-1329.5-yrTAMvsNotinER+BreastCancerEBCTCG,Lancet,2005:1687-717Targettherapy:RoleofHER2Aproto-oncogeneinvolvedinthedysregulationofcellproliferationAssociatedwithpoorprognosisandworsedisease-free/overallsurvivalPossiblypredictresponsetoparticulartherapyAnti-HER2Therapy:TrastuzumabforHER2(+)breastcancerHERAIHCor

FISH1v2年赫赛汀观察IHC:Immunohistochemistry

FISH:FluorescenceInSituHybridizationNCCTGN9831BCIRG006FISHNSABPB-31IHCor

FISHIHCor

FISHAnti-HER2Therapy:TrastuzumabTrastuzumab:ClinicalTrialsTrialsF/UNRecurrenceRiskReductionDeathRiskReductionReferenceHERA4y340124％15%NEJM2009B31/N98312.9y396951％37%ASCO2007BCIRG00665m322236%25%37%23%SABCS2009PACS0447m52814％HR=1.27JCO2009Gynecomastia(男性乳房发育症)Gynecomastianeedstobedifferentiatedfrom,cancer,andlesscommonlesionsS.Dali:SpaceVenus

(DaliUniverse,London)Welcometotheworldofbreast!EndocrineResponsivenessofBreastCancer(2007St.Gallen)HighlyendocrineresponsiveBothERandPRhighexpressionIncompletelyendocrineresponsiveBothERandPRhighexpressionER(+)andPR(-)ER(-)andPR(+)NoneendocrineresponsiveNoneERandPRexpressionCandidatesforendocrinetherapyModifiedRadicalMatectomyForphaseI,IIandpartofphaseIIIbreastcancerIsthemajorsurgicalapproachofbreastcancer

BreastConservingSurgery:IndcationsCouldreceivepostoperativeradiationtherapy

CouldensurenegativemarginsCouldensurepostoperativecosmeticeffectBreastConservingSurgery:ClinicalTrialsTrialsYearNSize(cm)F/U(y)OS%MastectomyBCSNSABPB-061976-198418514204746*/47MilanCancerInstitute1973-198070122058.858.3NCI1979-1987237