乳腺癌的預(yù)防

1BREASTCANCER:DIAGNOSIS

乳腺癌：診斷

整理課件2

OBJECTIVES目標(biāo)：

·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(xì)針吸取細(xì)胞學(xué)檢查(FNAC),和實(shí)驗(yàn)室研究〔國際學(xué)術(shù)期刊〕。整理課件4Signsthatindicatealumpmaybemalignantinclude:跡象說明一個(gè)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(nèi)的其他變化3)Signsoflocallyadvancedormetastaticdisease,includingalargemass,tetheringtotheskinand/orchestwall,lymphnodeenlargement,peaud’orange,nippleinversion,andskininfiltration。局部晚期或轉(zhuǎn)移性疾病的跡象，包括一個(gè)大腫塊，貼附于皮膚或胸壁，淋巴結(jié)腫大,呈現(xiàn)紅斑,乳頭內(nèi)陷和皮膚侵潤。整理課件5Breastmass乳腺腫塊

Size(measured)大小

Location(clockpositionanddistancefromtheareola)位置（時(shí)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(jié)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(diǎn)

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(shí)驗(yàn)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(xiàng)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(dá)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(nèi)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(xiàng)以檢查者為中心,簡便易行、無需花費(fèi)、平安無創(chuàng)的檢查方法。檢查者可以自己實(shí)施，無需任何設(shè)備支持。美國癌癥協(xié)會(huì)〔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(yīng)告知女性乳房自我檢查(BSE)的益處和局限性。應(yīng)該強(qiáng)調(diào)及時(shí)向健康專家報(bào)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(yīng)接受指導(dǎo)和在定期體檢時(shí)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(diǎn)：乳腺自我檢查給婦女提供了一個(gè)認(rèn)識(shí)乳房的時(shí)機(jī)，使婦女們增強(qiáng)了乳房保健意識(shí)，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(guān)于乳腺自我檢查的研究，加拿大預(yù)防衛(wèi)生保健組織在比較了來自這些國家的7個(gè)國際性研究報(bào)告后發(fā)現(xiàn)，實(shí)施乳腺自檢與不實(shí)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(shí)的分期和大小也無統(tǒng)計(jì)學(xué)意義。相反，干預(yù)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(jié)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(gè)乳房x光檢查稱為一個(gè)乳房x光檢查。在早期階段乳房x光檢查可以檢測腫瘤,當(dāng)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(fēng)險(xiǎn)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(diǎn)參與。這種技術(shù)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(shù)有如下幾個(gè)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(shù)進(jìn)步近年來加強(qiáng)了乳房X光檢查的應(yīng)用提供可視化的乳腺實(shí)質(zhì)而增加使用低劑量的X-射線輻射。

＊結(jié)合臨床檢查,乳房x光檢查至少到達(dá)90%準(zhǔn)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(zhì)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(jìn)展有重要意義。證據(jù)說明,轉(zhuǎn)移病灶發(fā)生在發(fā)病早期，乳腺癌應(yīng)該從一開始就被認(rèn)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(dá)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(zhuǎn)移

整理課件13DIAGNOSTICPROCEDURES

診斷程序Confirmation確認(rèn)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(shí)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(gè)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(jié)合核心活檢等侵入性方法,切除活檢,細(xì)胞學(xué)檢查和細(xì)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(diǎn)轉(zhuǎn)移(TNM)系統(tǒng)現(xiàn)在是乳腺腫瘤分類的標(biāo)準(zhǔn)方法。以下手術(shù)結(jié)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(yuǎn)處轉(zhuǎn)移的存在與否

整理課件16Thefirstfactorincategorizingtumors,T,describestheextentoftheprimarytumor.GradesforthefactorTare:第一個(gè)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(dǎo)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(jié)的位置和區(qū)域

NX:Unabletoassessstatus區(qū)域淋巴結(jié)無法評估

N0:Nonodespositiveforcarcinoma無區(qū)域淋巴結(jié)轉(zhuǎn)移

N1:Ipsilateral(samesideasprimarytumor)axillarynodesinvolved;movable同側(cè)腋窩淋巴結(jié)轉(zhuǎn)移，可活動(dòng)整理課件17

N2:Ipsilateralaxillarynodesinvolved;fixed同側(cè)腋窩淋巴結(jié)轉(zhuǎn)移，固定和相互融洽

N3:Ipsilateralinternalmammarynodesinvolved

同側(cè)鎖骨下淋巴結(jié)轉(zhuǎn)移Misbasedonthepresenceofdistantmetastases.

M是基于存在遠(yuǎn)處轉(zhuǎn)移

MX:Unabletoassess

遠(yuǎn)處轉(zhuǎn)移無法評估

M0:Nodistantmetastases,and/orareasoftumorspreadarehistologicallysmallerthan0.2mmandfoundinnon-nodaltissue未見遠(yuǎn)傳轉(zhuǎn)移及征象，而組織學(xué)或分子技術(shù)檢測到骨髓、血液或其他器官中<0.2mm轉(zhuǎn)移灶

M1:Distantmetastasespresent,and/orareasoftumorspreadarehistologicallylargerthan0.2mm發(fā)現(xiàn)遠(yuǎn)處轉(zhuǎn)移，組織學(xué)發(fā)現(xiàn)>

0.2mm的轉(zhuǎn)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(jié)無轉(zhuǎn)移N1:Ipsilateralaxillarynodesinvolved;movable

同側(cè)腋窩淋巴結(jié)轉(zhuǎn)移，可活動(dòng)N2:Ipsilateralaxillarynodesinvolved;fixed

同側(cè)腋窩淋巴結(jié)轉(zhuǎn)移，固定

N3:IpsilateralinternalmammarynodesinvolvedM0:Nodistantmetastases同側(cè)鎖骨下淋巴結(jié)轉(zhuǎn)移伴或不伴有腋窩淋巴結(jié)轉(zhuǎn)移

M1:Distantmetastasespresent有遠(yuǎn)處轉(zhuǎn)移整理課件19Tissuepathologyisanotherfactorinvolvedinclinicalstaging.Incontrast,pathologicalstagingismorecomprehensiveandincludesalldatausedforclinicalstagingandsurgicalresection,aswellasinformationgatheredfrompathologicalexaminationofbot