乳腺癌的預防

1BREASTCANCER:DIAGNOSIS

乳腺癌：診斷

整理課件2

OBJECTIVES目標：

·Listthesymptomsofabreastcancerpatient?列出乳腺癌患者的病癥Describescreeninganddiagnosticprocedures?描述篩查和診斷程序

·Explainhowmammographyisusedtodiagnosebreastcancer?釋如何用于診斷乳腺癌的乳房x光檢查整理課件3DIAGNOSTICPROCEDURES診斷程序PhysicalExamination體格檢查Inmostcases,breastcancerpresentsasalump.7Todeterminewhetherthelump(orlaboratoryinvestigationinthebreast)indicatesmalignancy,fineneedleaspiration,biopsy,andlaboratoryinvestigationareused.在大多數(shù)情況下,乳腺癌表現(xiàn)為腫塊。是否確定腫塊為惡性腫瘤,要通過細針吸取細胞學檢查(FNAC),和實驗室研究〔國際學術期刊〕。整理課件4Signsthatindicatealumpmaybemalignantinclude:跡象說明一個腫塊可能是惡性腫瘤包括：1)Findingsofaradiologicalopacity(microcalcification)withradiatingfibrousstrands發(fā)現(xiàn)輻射不透明度(鈣化)輻射纖維鏈2)Otherchangeswithinthebreastthatarenoticedbythepatient引起患者注意的乳房內的其他變化3)Signsoflocallyadvancedormetastaticdisease,includingalargemass,tetheringtotheskinand/orchestwall,lymphnodeenlargement,peaud’orange,nippleinversion,andskininfiltration。局部晚期或轉移性疾病的跡象，包括一個大腫塊，貼附于皮膚或胸壁，淋巴結腫大,呈現(xiàn)紅斑,乳頭內陷和皮膚侵潤。整理課件5Breastmass乳腺腫塊

Size(measured)大小

Location(clockpositionanddistancefromtheareola)位置（時鐘位置和乳暈的距離）

Consistency一致性

Fixationtoskin,pectoralmuscle,orchestwall皮膚、胸肌或胸壁的固定度Skinchanges皮膚的變化

Erythema紅斑

Edema水腫

Dimpling凹陷

Satellitenodules衛(wèi)星結節(jié)

Ulceration潰瘍Nipplechanges乳頭的變化

Retraction收縮

Discoloration變色

Erosion

侵蝕

Discharge流出血性Nodes節(jié)點

Axillary:size,number,fixation

腋窩:大小、數(shù)量、固定

Supraclavicular鎖骨上的

Infraclavicular鎖骨下的整理課件6Datafromalargerandomizedtrialofbreastself-examination(BSE)screeninghasshownthatinstructioninBSEhasnoeffectonreducingbreastcancermortality.21Nevertheless,womenshouldbeencouragedtobeawareoftheirbreastssincethismayfacilitatedetectionofintervalcancersbetweenroutinescreeningsbyaphysician.現(xiàn)階段的實驗隨訪中沒有發(fā)現(xiàn)乳腺自檢對降低乳腺癌死亡率有何益處。所以女性的乳腺自我檢查仍可作為一項常規(guī)的乳腺癌篩查手段。

整理課件7Notallwomenhavingbreastcancerpresentwithalump.Otherpossiblepresentingsignsandsymptomsinclude:不是所有女性有腫塊的就稱之為乳腺癌，其他可能呈現(xiàn)的病癥和體征表達為：

Breastpainortenderness乳房疼痛或壓痛

Changeinbreastshapeorsize乳房形狀或大小的改變

Dimpling,flaking,orthickeningoftheskinonthebreast凹陷、脫落或乳房皮膚增厚

Rednessorwarmthofthebreast乳腺乘紅色或發(fā)熱

Peaud’orange呈現(xiàn)紅斑

Nippleinversion,rash,ordischarge;and乳頭內陷，紅腫或有無分泌物

Swellingoftheupperarmorinthearmpit.上臂或腋窩有無腫脹整理課件8乳腺自我檢查〔BSE〕

乳腺自我檢查是一項以檢查者為中心,簡便易行、無需花費、平安無創(chuàng)的檢查方法。檢查者可以自己實施，無需任何設備支持。美國癌癥協(xié)會〔ACS〕在2003年發(fā)布的新的乳腺癌普查指南中建議：從20歲開始，應告知女性乳房自我檢查(BSE)的益處和局限性。應該強調及時向健康專家報告任何新的乳房病癥的重要性。選擇乳房自我檢查的女性應接受指導和在定期體檢時讓醫(yī)生檢查她們的手法是否正確。女性也可選擇不做或不定期做乳房自我檢查[2].乳腺自我檢查的優(yōu)缺點：乳腺自我檢查給婦女提供了一個認識乳房的時機，使婦女們增強了乳房保健意識，并促使她們一旦發(fā)現(xiàn)乳房腫塊就去醫(yī)院檢查。但過去20多年來,美國、加拿大、俄羅斯、英國、日本和中國都先后開展了關于乳腺自我檢查的研究，加拿大預防衛(wèi)生保健組織在比較了來自這些國家的7個國際性研究報告后發(fā)現(xiàn)，實施乳腺自檢與不實施乳腺自檢的婦女在乳腺癌的病死率上沒有差異，腫瘤在診斷時的分期和大小也無統(tǒng)計學意義。相反，干預組的良性病變的活檢率明顯高于對照組，就醫(yī)率也大大提高。從而得出結論,乳腺自我檢查有害無益[3]。整理課件9DIAGNOSTICPROCEDURES診斷程序Mammography乳房x光檢查Introduction介紹AmammogramisanX-rayimageofthebreast.Theprocedureusedtogenerateamammogramistermedamammography.30Mammographycandetecttumorsatanearlystage,whentheyarestillsmallandcan’tbedetectedbypalpation.31Basedonfairevidence,screeningmammographyinwomenaged40to70yearsdecreasesbreastcancermortality.32,33Thebenefitishigherforolderwomen,inpartbecausetheirbreastcancerriskishigher.34乳房x光片是乳腺癌的x射線圖像。程序用于生成一個乳房x光檢查稱為一個乳房x光檢查。在早期階段乳房x光檢查可以檢測腫瘤,當他們還小,不能被觸診?；诠降淖C據(jù),年齡在40-70歲的女性通過篩查性乳房x光檢查降低乳腺癌死亡率。尤其針對年長者,局部原因是他們患乳腺癌的風險高。整理課件10Transcript記錄Screeningbymammographycandetectsmalltumorsbeforethereisanynodalinvolvement.Thistechniqueisthereforeaneffectivetoolforearlydetectionofbreastcancer.Onamammogram,breastcarcinomastypicallydisplayfinecalcificationandareasofirregularity.Occasionally,fixationofdeeplesions,eithertothechestwallorskin,canalsobeseen.35Thereareseveraladvantagestousingmammographyasascreeningtechnique:小的腫瘤篩查通過乳房x光檢查可以發(fā)現(xiàn)之前有任何節(jié)點參與。這種技術是早期發(fā)現(xiàn)乳腺癌的一種有效工具。乳房x光檢查,乳房癌通常顯示鈣化和不規(guī)那么的地方。偶爾,深層病灶,固定胸壁或皮膚,也可以看到。使用乳房x光檢查作為篩查技術有如下幾個優(yōu)勢:

整理課件11

Theabilityofmammographytodetectcasesmuchearlierthanphysicalexaminationiswellestablished.36

TechnicaladvanceshaveenhancedtheutilityofmammographyinrecentyearsbyprovidingincreasedvisualizationofthebreastparenchymawhileusinglowerdosesofX-rayradiation.37

Combinedwithclinicalexamination,mammographycanbeatleast90%accurateinitsdiagnosis.Itshouldbenoted,however,thatthesuccessoflow-radiationmammographydependslargelyonthequalityofinterpretation.38＊乳房x光檢查檢測比體格檢查更早。

＊技術進步近年來加強了乳房X光檢查的應用提供可視化的乳腺實質而增加使用低劑量的X-射線輻射。

＊結合臨床檢查,乳房x光檢查至少到達90%準確的診斷。然而,值得注意的是,低輻射乳房x光檢查的成功很大程度上取決于interpretation的質量

整理課件12Thefindingthatscreeningreducesbreastcancermortalityhasimportantimplicationsregardingtheonsetandprogressionofthedisease.Evidencesuggeststhatmetastasesoccurveryearlyinthecourseofthediseaseandthatbreastcancershouldbeconsideredasystemicdiseasefromitsoutset.Therefore,thereductioninbreastcancermortalitybyscreening,anestimated10%to30%reduction,providescompellingevidencethatearlydiagnosisandtreatmentofbreastcancercanaverttheonsetofmetastasis.篩查可降低乳腺癌的死亡率對疾病的發(fā)病和進展有重要意義。證據(jù)說明,轉移病灶發(fā)生在發(fā)病早期，乳腺癌應該從一開始就被認為是一種全身性疾病。因此,通過篩查能夠降低乳腺癌的死亡率達10%到30%,提供了令人信服的證據(jù)說明,乳腺癌的早期診斷和治療可以防止轉移

整理課件13DIAGNOSTICPROCEDURES

診斷程序Confirmation確認Introduction

介紹Itisimportanttousemethodsotherthanmammographyandphysicalexaminationtoconfirmadiagnosisofbreastcancer.Thesemethodscanbeeithernon-invasiveorinvasive.除了乳房x光檢查和體格檢查還有其他方法來證實診斷為乳腺癌。這些方法可以是非侵入性或侵入性。整理課件14Transcript

記錄Ultrasoundisanon-invasivewaytodifferentiatewhetherapossibletumordetectedwithmammographyis,instead,afluid-filledcyst.Ultrasoundcanalsoaidintheevaluationoflumpsthataredifficulttovisualizewithmammography,andisoftenusedinconjunctionwithinvasivemethodssuchascorebiopsy,excisionbiopsy,aspirationcytology,andfineneedleaspiration(FNA).超聲波是一種非侵入性的方式來區(qū)分是否可能與乳房x光檢查發(fā)現(xiàn)腫瘤,相反,一個充滿液體的囊腫。超聲波還可以幫助評估腫塊與乳房x光檢查,很難想象,常用于結合核心活檢等侵入性方法,切除活檢,細胞學檢查和細針穿刺。

整理課件15STAGINGANDGRADING分期和分級10.TNMSystemTNM系統(tǒng)Introduction介紹Atthetimeofbreastcancerdiagnosis,thestageofdiseaseisroutinelydeterminedaspartofthemanagementplan.TheTumor,Node,Metastases(TNM)systemisnowthestandardmethodforclassificationofbreasttumors.Thefollowingoperativefindingsareusedintheclinicalstagingofbreastcancer:thesizeoftheprimarytumor,thepresenceofchestwallinvasion,andthepresenceorabsenceofregionalordistantmetastases.在乳腺癌診斷、疾病的階段經(jīng)常決定作為管理方案的一局部。腫瘤、節(jié)點轉移(TNM)系統(tǒng)現(xiàn)在是乳腺腫瘤分類的標準方法。以下手術結果用于乳腺癌的臨床分期:原發(fā)腫瘤的大小,胸壁入侵的存在,地區(qū)或遠處轉移的存在與否

整理課件16Thefirstfactorincategorizingtumors,T,describestheextentoftheprimarytumor.GradesforthefactorTare:第一個因子在腫瘤的分類上,T,描述了原發(fā)腫瘤的程度。T分級如下:

TX:Primarytumorcannotbeassessed原發(fā)腫瘤無法評估

T0:Noevidenceofprimarytumor沒有原發(fā)腫瘤證據(jù)

Tis:Carcinomainsitu–intraductalcarcinoma,lobularcarcinomainsitu,orPaget’sdiseaseofthenipplewithnotumor導管原位癌；小葉原位癌；乳頭page’s病，不伴有腫塊

T1:Lessthan20mmingreatestdimension腫瘤最大直徑<2cm

T2:Greaterthan20mmbutlessthan50mm腫瘤最大直徑>2cm，但<5cm

T3:Greaterthan50mm腫瘤最大直徑>5cm

T4:Tumorofanysizewithextensiontothechestwalland/oredemaorinflammatorycarcinoma不管腫瘤大小，直接侵犯胸壁或皮膚Nisbasedonthepresenceandlocationofinvolvedlymphnodes.區(qū)域淋巴結的位置和區(qū)域

NX:Unabletoassessstatus區(qū)域淋巴結無法評估

N0:Nonodespositiveforcarcinoma無區(qū)域淋巴結轉移

N1:Ipsilateral(samesideasprimarytumor)axillarynodesinvolved;movable同側腋窩淋巴結轉移，可活動整理課件17

N2:Ipsilateralaxillarynodesinvolved;fixed同側腋窩淋巴結轉移，固定和相互融洽

N3:Ipsilateralinternalmammarynodesinvolved

同側鎖骨下淋巴結轉移Misbasedonthepresenceofdistantmetastases.

M是基于存在遠處轉移

MX:Unabletoassess

遠處轉移無法評估

M0:Nodistantmetastases,and/orareasoftumorspreadarehistologicallysmallerthan0.2mmandfoundinnon-nodaltissue未見遠傳轉移及征象，而組織學或分子技術檢測到骨髓、血液或其他器官中<0.2mm轉移灶

M1:Distantmetastasespresent,and/orareasoftumorspreadarehistologicallylargerthan0.2mm發(fā)現(xiàn)遠處轉移，組織學發(fā)現(xiàn)>

0.2mm的轉移灶整理課件18T0:Noevidenceofprimarytumor

沒有原發(fā)腫瘤證據(jù)

Tis:CarcinomainsituorPaget’sdiseaseofthenipple

原位癌或伴有腫塊的paget’s病T1:

Tumorlessthan20mmingreatestdimension

腫瘤最大直徑≤2cmT2:

Tumorgreaterthan20mmbutlessthan50mmingreatestdimension腫瘤最大徑大2cm,

但≤5cm

T3:

Tumorgreaterthan50mmingreatestdimension腫瘤最大徑＞5cmT4:Tumorofanysizewithextensiontothechestwalland/oredemaorinflammatorycarcinoma無論腫瘤大小，直接侵及胸壁或皮膚/水腫或炎性乳腺炎N0:Nonodespositiveforcarcinoma

區(qū)域淋巴結無轉移N1:Ipsilateralaxillarynodesinvolved;movable

同側腋窩淋巴結轉移，可活動N2:Ipsilateralaxillarynodesinvolved;fixed

同側腋窩淋巴結轉移，固定

N3:IpsilateralinternalmammarynodesinvolvedM0:Nodistantmetastases同側鎖骨下淋巴結轉移伴或不伴有腋窩淋巴結轉移

M1:Distantmetastasespresent有遠處轉移整理課件19Tissuepathologyisanotherfactorinvolvedinclinicalstaging.Incontrast,pathologicalstagingismorecomprehensiveandincludesalldatausedforclinicalstagingandsurgicalresection,aswellasinformationgatheredfrompathologicalexaminationofbot