大四上期課件-外科學(xué)the breast

THEBREASTChongqingMedicalUniversitysuxinliangPARTONEHISTORICALASPECTSANATOMYandPHYSIOLOGYPHYSICALEXAMINATIONBREASTIMAGINGPATHOLOGICDIAGNOSISHISTORICALASPECTSBefore3000B.C.,EdwinSmith(surgicalpapyrus)describedserveralcasesofwomenwithtumorsofthebreast.Theseincludedtumorsthatwerehardandcooltotouchaswellasabscessesandinflammationsthatwerewarm.Therecoveryispossibleincaseofbreastabscessandinflammation,buttherewaslittlethatcouldbedonetoremedy.HISTORICALASPECTSBetween460-370B.C.,Hippocratesrecognizedthenatureofmalignantdisease,whichwascalled“Karkinos”or“Karkinoma”.Hebelievedthatitwasduetoasystemicimbalanceofcardinalhumoursoflivingbody.Hesaidthat“Itisbettertogivenotreatmentincasesofhiddencancer;treatmentcausesspeedydeath,buttoomittreatmentistoprolonglife.FatherofMedicine--HippocratesHippocrateswasaGreekphysicianbornin460BContheislandofCos,Greece.Hebecameknownasthefounderofmedicineandwasregardedasthegreatestphysicianofhistime.Hebasedhismedicalpracticeonobservationsandonthestudyofthehumanbody.Heheldthebeliefthatillnesshadaphysicalandarationalexplanation.Herejectedtheviewsofhistimethatconsideredillnesstobecausedbysuperstitionsandbypossessionofevilspiritsanddisfavorofthegods.HISTORICALASPECTSDuringthesixteenthandseventeenthcenturies,themodernanatomywasestablishedbysomefamousanatomistandsurgeons,suchasAndreasVesalius,AmbroisePare.Thenatureofcanceroustumorsandthelymphsystemweredicussed.In1757,HenryFrancoisLeDranofferedatheoryofthecentrifugalspreadofcancerforlocaltomoredistantsites.HISTORICALASPECTSIn1894,WilliamStewardHalsted,theGermenhistologistandsurgeon,presentedaformaldescriptionofthe‘completeoperation-RadicalMastectomy.ANATOMYandPHYSIOLOGYThesexualorganofadultwomenLocation:thebreastlocatedbetweenthelevelofthesecondandsixthrib.Inthecenterofthebreastisthenippleandareola.ANATOMYandPHYSIOLOGYFatMilkglandsMammaryductsFibrousconnectivetissue–Cooper’ligmentNervesBloodvesselsLymphvessels

ANATOMYandPHYSIOLOGY

Breastsdevelopatpubertyashormonesstimulatethesystemtoformandenlargelobulesandducts.Fulldevelopmentcanoccuranytimebetweentheagesof12and19.Awoman’smonthlymenstrualcyclecausesbreastgranularitytochange.Swellingandtendernessofbothbreastsmayoccurduringthesecondhalfofthemenstrualcycle.Cystsmaygrowandthenshrink.Duringpregnancy,thelobulesmultiplyandbegintoproducemilk.Whenababyisborn,milkisreleasedintotheductsforbreastfeeding(lactation)Duringmenopausethenumberoflobulesdecreasesandthoseremainingshrink.Alargerproportionofthebreastismadeupoffatsobreastdensitydecreases.ANATOMYandPHYSIOLOGYThelymphalicdrainageofthebreast

1.Themajorsiteofdraingeistothecentralaxillarygroup2.Theinternalmammarynode3.Theothersideofthebreast4.TheliverANATOMYandPHYSIOLOGYLocationoftheaxillarylymphnodeLevelⅠ：lateraltothelateralborderofthepectoralisminormuscle(PMM)LevelⅡ：underthePMMLevelⅢ：medialtothemedialborderofthePMMPHYSICALEXAMINATIONclinicalbreastexamination(CBE)

includesinspection(looking)andpalpation(feeling)oftheentirebreast/chestareaincludingthelymphnodeareasaboveandbelowthecollarboneandundereacharm.FortheCBE,thepatientundressesfromthewaistup.Usingthepadsofthefingers,theexaminerwillgentlypalpate(feel)eachbreast.Specialattentionwillbegiventotheshapeandtextureofthebreasts,locationofanylumps,andwhethersuchlumpsareattachedtotheskinortodeepertissues.PHYSICALEXAMINATIONTheinspection:theinspectionshouldbedonewiththepatientintheuprightsittingposition.Abnormalvariationinbreastsizeandcontour,minimalnippleretraction,andslightedema,redness,orretractionofskincanbeidentified.

PHYSICALEXAMINATIONTheinspection

theuseofindirectlightingcanunmasksubtle

dimplingoftheskinornipplecausedbythescirrhousreactionofacarcinomaplacingCooper’sligmentsundertension.

Simplemaneuverssuchasstretchingthearmhighabovethehead,tensingthepectoralismuscles,orgentleliftingthepatient’breastmayaccentuateasymmetriesanddimplingPHYSICALEXAMINATIONThepalpation:theaxillaandthebreast1.forthebreast,theexaminershouldpalpateeachquadrantofthebreastandthetissueundertheareolainlyingsupinepositionorsittingposition..

lump:location,diameter,texture,bordersandmovable,etc.2.fortheaxilla,theexaminershouldsupportthepatient’sarmandpalpateeachaxillatodetectthepresenceofenlargedaxillarylymphnodesinsittingposition.

PHYSICALEXAMINATIONBREASTIMAGINGMammographyB-ultrasoundComputedTomography(CT)orMRIMammographyAbnormalities(masses,asymmeties,andarchitectualdistortions)microcalcificationsB-ultrasound

CysticlumpBloodmarginsB-ultrasoundPATHOLOGICDIAGNOSISCoreneedlebiopsy(CNB):90—97%Fineneedleaspirationcytology(FNAC):70—90%,falsepositive:DissectedbiopsyPARTTWOAcutemastitisandthebreastabscessFibrocysticbreastdiseaseBraductalpapilloma3.breastcarcinomaAcutemastitisandthebreastabscessCausesofMastitis:

crackednipple,blockedmilkduct-staphylococcalbacteria–infectionSymptomsandsignsofMastitis:

Localized,red,painfularea,

Localhardness,

Swelling,

Obviousincreaseinlocalheat,

Fever,

Malaise

AcutemastitisandthebreastabscessTreatment:1.avoidthecrackednippleagainduringthebreastfeeding.2.localmeasuresuchasapplicationofheatpackoruseofamechanicalbreastpumpontheaffectedside.3.administrationofbroad-spectrumantibiotics,suchaspenicillin,4.ifthereisthelocalexpressionoffluctuance,theabscessisdiagnosis.Itispreferablydrainedbyacircumfeentialincisioninnaturalskinlines.Fibrocysticbreastdisease

Causes,incidence,andriskfactors

Thecauseisnotcompletelyunderstood,butthechangesarebelievedtobeassociatedwithovarianhormonessincetheconditionusuallysubsideswithmenopause,andmayvaryinconsistencyduringthemenstrualcycle.Theincidenceofitisestimatedtobeover60%ofallwomen.Itiscommoninwomenbetweentheagesof30and50,andrareinpostmenopausalwomen.Theincidenceislowerinwomentakingbirthcontrolpills.Theriskfactorsmayincludefamilyhistoryanddiet(suchasexcessivedietaryfat,andcaffeineintake),althoughthesearecontroversial.FibrocysticbreastdiseaseSymptomsAdense,irregularandbumpy"cobblestone"consistencyinthebreasttissueUsuallymoremarkedintheouterupperquadrantsBreastfortthatispersistent,orthatoccursoffandon(intermittent)Breast(s)feelfullDull,heavypainandtendernessPremenstrualtendernessandswellingBreastfortimprovesaftereachmenstrualperiodNipplesensationchanges,itchingFibrocysticbreastdiseaseSignsandtests

Physicalexamination

revealsthepresenceofmobile(non-anchored)breast"masses."Thesemassesareusuallyrounded,withsmoothborders,andeitherrubberyorslightlychangeableinshape.Densetissuemaymakethebreastexaminationmoredifficulttointerpret.FibrocysticbreastdiseaseMammographymaybedifficulttointerpretduetodensetissue.A

biopsyofthebreastmaybenecessarytoruleoutotherdisorders.Aspirationofthebreastwithafineneedlecanoftendiagnoseandtreatlargercysts.

FibrocysticbreastdiseaseTreatmentTheeffectivenessofVitaminE,VitaminB-6TraditionalchinesemedicineTamoxifenFibroadenoma-BreastDefinition

Fibroadenomaofthebreastisabenign(noncancerous)tumor.Causes,&RiskFactors

Fibroadenomaisthemostcommonbenigntumorofthebreastandthemostcommonbreasttumorinwomenlessthan30yearsofage.estrogenichormone.Maygrowinsize,especiallyduringpregnancyOftengetssmalleraftermenopause(ifnottakinghormones)Fibroadenoma-BreastSymptoms&SignsFibroadenomasareusuallyfoundassolitarylumps,butabout10-15%ofwomenhavemultiplelumpsthatmayaffectbothbreastsMaybefeltasaround,moveable,painless(nontender),firm,orrubberylumpwithwell-definedborders

FibroadenomaFibroadenomaFibroadenoma-BreastDiagnosis&TestsPhysicalexaminationMammographyUltrasoundFineneedleaspirationBiopsy(needleoropen)Fibroadenoma-BreastTreatmentExcisionThelumpmaybesurgicallyremovedatthetimeofanopenbiopsy.(Thisiscalledanexcisionalbiopsyorlumpectomy.)Mammotone

Mammotone

IntraductalPapillomaDefinition

Intraductalpapillomaisasmall,benign(non-cancerous)tumorthatgrowswithinamilkductofthebreast.IntraductalPapillomaPictures&Images

IntraductalPapillomaOverview,Causes,&RiskFactors

Intraductalpapillomaoccursmostfrequentlyinwomenbetweentheages35-55.Thecausesandriskfactorsareunknown.IntraductalPapillomaSymptoms&Signs

breastpain

nippledischarge,sometimesbloody,fromonebreastonly

stainingmaybenoticedinsidethebraand/orclothing

breastlump

breastenlargementIntraductalPapillomaDiagnosis&Tests

Intraductalpapillomaisthemostcommoncauseofspontaneousnippledischargefromasingleduct.Asmalllumpbeneaththenipplemaybefeltbytheexaminer,butitisnotalwayspalpable.Amammogramoftendoesnotshowpapillomas.Ultrasoundmaybehelpful.Anx-raywithcontrastinjectedintotheaffectedduct(ductogram)maybeperformed.Cellular(cytologic)examinationofdischargemaybeperformedtoidentifypotentiallymalignant(cancerous)cells.Abreastbiopsyisnecessarytomakeadefinitivediagnosisandruleoutcancer.

endoscopeIntraductalPapillomaTreatmentSurgicalremoval(excision)oftheinvolvedductandthemassofcellsisdoneforabiopsyandtoassurethatcancerisnotpresent.BreastCancer

Breastcanceristhemostcommoncancerinwomenandisestimatedtohaveaccountedfor203,500newcancerdiagnosesand39,600deathsin2002.Therehasbeenaperceptibledeclineinbreastcancermortalitysince1997,mostlikelytheresultoftherapywithtamoxifenandperhapsotherformsofchemotherapy.BreastCancerDefinition

Breastcancerisamalignantgrowththatbeginsinthetissuesofthebreast.Overthecourseofalifetime,oneineightwomenwillbediagnosedwithbreastcancerBreastCancerCauses,&RiskFactorsAge:45-50GeneticFactorsandFamilyHistoryofBreastCancer2-3timesEarlyMenstruationandLateMenopauseOralContraceptives(birthcontrolpills)HormoneReplacementTherapyAlcoholConsumptionObesityBreastbenigndiseaseBreastCancerSymptoms&SignsNoSymptoms&Signs:﹤1cmbreastmassnoteduponbreastexam--usuallypainless,firmtohardandusuallywithirregularbordersLumpormassinthearmpitAchangeinthesizeorshapeofthebreastAbnormalnippledischarge,Usuallybloodyorclear-to-yelloworgreenfluid,Maylooklikepus(purulent)Changeinthecolororfeeloftheskinofthebreast,nipple,orareolaBreastCancerSymptoms&SignsDimpled,puckered,orscalyRetraction,orangepeelskinRednessAccentuatedveinsonbreastsurfaceChangeinappearanceorsensationofthenipple,Pulledin(retraction),enlargement,oritchingBreastpain,enlargement,orfortononesideonlyAnybreastlump,pain,tenderness,orotherchangeinamanSymptomsofadvanceddiseasearebonepain,weightloss,swellingofonearm,andskinulcerationDimpled,RetractionofnippleSkinulcerationRedness,swellingofarm,

orangepeelskinSatelliteskinnodules,disappearofnippleBreastCancerDiagnosis1.Symptomsandsigns2.BreastimagingA.MammographyB.UltrasoundC.CTorMRI3.PathologicdiagnosisBreastCancerMammography

Screeningmammographyisalow-dosex-rayexaminationofthebreast.Thegoalofscreeningmammographyistodetectbreastcancerwhenitisstilltoosmalltobefeltbyaphysicianorthepatient.Mammographycandetectedapproximately85%ofbreastcancers.

Mammographicscreeningiskeytotheearlydetectionofbreastcancercranial-caudalview,CC

mediolateral-oblique,MLO

BreastCancerBreastCancerMammographicfeatureofbreastcancer1.Masses:stellate,irregularlydefined,surroundingspiculations2.Microcalcification:clusteredfineirregular3.Asymmetricdensity4.ArchitecturaldistortionThreecriteriahelptheclinciantodiscriminationbenignfrommalignantmasses:1.thepresenceofsymptoms:breastcancer-asymtomaticandpainlessfunctionalmass-associatedwithpainandtenderness2.age:breastcancer-usuallyanewmassinthepostmenopausalwomenorabout40-year,notcommonbelowtheageof30afibroadenoma-apainlessmassintheyoungwomanorteenagegirl

3.therelationofthemasstothesurroundingbreasttissue:fibroadenomaorcyst-amobilemassthatmovesfreelywithinthebreasttissueMucinous(colloid)Carcinomabreastcancer-anewmassthatfixedwithinthebreasttissueNon-invasiveCarcinomasoftheBreastIntraductalCarcinoma(DCIS)LobularCarcinomainsitu(LCIS)Paget’sdiseaseInvasiveCarcinomasoftheBreastInfiltratingDuctalCarcinomaInfiltratingLobularCarcinomaMedullaryCarcinomaMucinous(colloid)CarcinomaPapillaryCarcinomaTubularCarcinomaOthertypeTNMclassificationTX:PrimarytumorcannotbeassessedT0:NoevidenceofprimarytumorTis:CarcinomainsituintraductalcarcinomalobularcarcinomainsituPaget'sdiseaseofthenipplewithnoassociatedtumorNote:Paget'sdiseaseassociatedwithatumorisclassifiedaccordingtothesizeofthetumor.

TNMclassificationPrimarytumor(T):T1:Tumor2.0cmorlessingreatestdimensionT1mic:Microinvasion0.1cmorlessingreatestdimensionT1a:Tumormorethan0.1cmbutnotmorethan0.5cmingreatestdimensionT1b:Tumormorethan0.5cmbutnotmorethan1.0cmingreatestdimensionT1c:Tumormorethan1.0cmbutnotmorethan2.0cmingreatestdimension

TNMclassificationT2:Tumormorethan2.0cmbutnotmorethan5.0cmingreatestdimensionT3:Tumormorethan5.0cmingreatestdimensionTNMclassificationT4:Tumorofanysizewithdirectextensionto(a)chestwallor(b)skin,onlyasdescribedbelow.

Note:Chestwallincludesribs,intercostalmuscles,andserratusanteriormusclebutnotpectoralmuscle.

T4a:Extensiontochestwall

T4b:Edema(includingpeaud'orange)orulcerationoftheskinofthebreastorsatelliteskinnodulesconfinedtothesamebreast

T4c:Bothoftheabove(T4aandT4b)

T4d:Inflammatorycarcinoma*

TNMclassificationRegionallymphnodes(N):

NX:Regionallymphnodescannotbeassessed(e.g.,previouslyremoved)

N0:Noregionallymphnodemetastasis

N1:Metastasistomovableipsilateralaxillarylymphnode(s)

N2:Metastasistoipsilateralaxillarylymphnode(s)fixedtoeachotherorMetastasistoipsilateralinternalmammarylymphnode(s)

N3:Metastasistoipsilateralsubclavicularandornotaxillarylymphnodemetastasisormetastasistoipsilateralinternalmammaryandaxillarylymphnode(s)ormetastasistosupraclavicularlymphnodesandornotaxillaryorinternalmammarylymphnode(s)TNMclassificationDistantmetastasis(M):MX:Presenceofdistantmetastasiscannotbeassessed

M0:Nodistantmetastasis

M1:DistantmetastasispresentAJCCstagegroupingsStage0Tis,N0,M0

StageIT1,*N0,M0

StageIIAT0,N1,M0T1,*N1,M0T2,N0,M0

*T1includesT1micStageIIBT2,N1,M0

T3,N0,M0AJCCstagegroupingsStageIIIAT0,N2,M0T1,*N2,M0T2,N2,M0T3,N1,M0T3,N2,M0

StageIIIBT4,N0,M0T4,N1,M0T4,N2,M0

StageIIIC

Any

T,N3,M0

StageIVAnyT,AnyN,M1BreastCancerTreatment:

Breastcancertreatmentdependsonavarietyoffactorsincluding:

thesizeofthebreasttumor

locationofthetumor

thestageofthecancer

resultsoflaboratorytests(suchashormone

receptortests).

BreastCancerIntervention(operation):

1.

Lumpectomyandaxillarydissection(Conservativebreastsurgery):Lumpectomyreferstothesurgicalremovalofacancerouslump(ortumor)inthebreastalongwithasmallmarginofthesurroundingnormalbreasttissue.Indication:1.bigbreast2.stageI,II

3.partstageIII

tumor-freemargins!Breast-Conservingsurgery:

Conservativebreastsurgery(areorlarincision)Intervention(operation):

2.Mastectomy

Typesofmastectomyincludesimple,modifiedradical,radical,extensiveradicalmastectomy.(1)Radicalmastectomy:includingalloftheaffectedbreast,majorpectorlismajorandminormuscle,andthelevelone,two,threelymphnodeinaxilla.(2)Extensiveradicalmastectomy:inadditionofradicalmastectomy,dissectionofinternalvesselandlymphnode.BreastCancer(3)Modifiedradicalmastectomy(MRM):Patey(MRMone):preservesthepectoralismajormuscleandsacrificestheunderlyingpectoralisminormuscle.Auchincloss(MRMtwo):preservesthepectoralismajorandminormuscle.(4)simplemastectomy

Modifiedradicalmastectomy(MRM)BreastCancerIntervention:

3.Sentinellymphnodebiopsy(SLNB)

The“sentinel”nodeistheveryfirstlymphnode(s)toreceivedrainagefromacancer-containingareaofthebreast.BreastCancerSLNBrequirestheremovalofonlyonetothreelymphnodesforclosereviewbyapathologist.

Ifthesentinelnodesdonotcontaintumor(cancer)cells,thismayeliminatetheneedtoremoveadditionallymphnodesintheaxillaryarea.

BreastCancerIntervention(operation):

4.BreastreconstructionBreastCancerChemotherapy

1.

Neo-adjuvantchemotherapy

theaims:

controlthelocaltumorgrowthandgivethe

chancetohavetheoperation.

killthecancercells(micrometastasis)inthebody.

testthesensitiveofanticancerdrug2.AdjuvantchemotherapyBreastCancerChemotherapy

Examplesofchemotherapycombinationsusedtotreatbreastcancerinclude:1.cyclophosphamide(CTX),methotrexate(MTX),andfluorouracil(5-Fu)CMF2.CTX,Adriamycin,and5-FuCAF3.CTX,epirubicin(EPI),and5-FuCEF4.Adriamycin(EPI)andCTXwithpaclitaxel(Taxol)orDocetaxel(Taxotere)TAC5.vinorelbine(Navelbine),andgemcitabineBreastCancerEndocrinotherapyFORER(+)andPR（+），ER(+)orPR(+)

Togrowandreproduce,breastcancercellsrequirethefemalehormoneestrogen.

1.Surgicalcastration(bilateralOophorectomy):advancedbreastcancer,premenopausalpatient.2.TamoxifenTamoxifenisan"anti-estrogen"andworksbycompetingwithestrogentobindtoestrogenreceptorsinbreastcancercells.Tamoxifenisformallyknownasaselectiveestrogenreceptormodulator.Byblockingestrogeninthebreast,tamoxifenhelpsslowthegrowthandreproductionofbreastcancercells.

BreastCancerEndocrinotherapy2.Tamoxifesideeffects:endometrialcancer,deepveinthrombosis,pulmonaryembolism,possiblystroke.RegimenofTamoxifen:10mgbid.Maximanto5years.3.Aromataseinhibitor:Anastrozole(Arimidex)

Arimidexworksbyinterferingwiththebody’sabilitytosynthesizeestrogen.Arimidexisanon-steroidcompoundknownasaselectivearomataseinhibitor.SinceArimidexinhibitsthebody’sconversionofcertainsteroidhormones(androgens)toestrogenbytheenzymearomatase,Arimidexdecreasestheoverallconcentrationofestrogen,thusreducingthespreadofbreastcancerinpost-menopausalwomen.

BreastCancerEndocrinetherapy

3.Aromataseinhibitor:Anastrozole(Arimidex):

Arimidexdecreasesthebody’soverallestrogenlevel,womenathighriskofosteoporosismaynotbesuitedforArimidextherapy.sideeffects:osteoposis\fractureTheindiction:postmenopausalpatients

RegimenofAnastrozole:1mgqd5y