《乳腺癌课件70985.ppt》由会员分享，可在线阅读，更多相关《乳腺癌课件70985.ppt（46页珍藏版）》请在taowenge.com淘文阁网|工程机械CAD图纸|机械工程制图|CAD装配图下载|SolidWorks_CaTia_CAD_UG_PROE_设计图分享下载上搜索。
1、No.2 Affiliated Hospital Southern Medical UniversityGeneral Surgery 厉周厉周 Richard L1.Introduction 概论概论Western countries100/100,000stable incidencedeclined mortalityChina7-10%of all malignancies2nd most common Ca in 3%yearly increase rate(highest worldwide)2.Etiology 病因病因Exposure to estrogenAge at men
2、arche 54y/oAge at first pregnancy 30y/oFamily history and genetic disorder2-3 folds higher(first degree relatives)5-10%(BRCA1,BRCA2 genetic aberration)Previous benign breast disease:atypical hyperplasiaWestern life styleLipid dietObesitySexual concept主要与雌激素主要与雌激素(estrogen)有明显关有明显关系系 雌性激素与雌性激素受体结合雌性激
3、素与雌性激素受体结合-进入细胞核进入细胞核(nucleolus)-作用于作用于DNA的合成的合成-产生生物效应产生生物效应3.Pathological typing 病理类型病理类型Noninvasive breast carcinomaductal carcinoma in situ,lobular carcinoma in situ,Pagets diseaseEarly invasive breast carcinomaSpecial types of invasive breast cancerpapillary,medullary,tubular,mucinousOrdinary t
4、ypes of invasive breast cancerinvasive ductal,invasive lobular Others(1).非浸润性癌非浸润性癌:导管内癌导管内癌,小叶原位癌小叶原位癌-属早期属早期.(2).早期浸润性癌早期浸润性癌:(3).浸润性特殊癌浸润性特殊癌(4).浸润性非特殊癌浸润性非特殊癌(5).其他罕见癌其他罕见癌4.转移途径转移途径(1).Infiltrate,local invation 直接浸润直接浸润(2).lymphatic metastasis 淋巴转移淋巴转移经胸肌外缘经胸肌外缘-同侧腋窝同侧腋窝-锁骨上锁骨上-胸导管胸导管经胸骨旁经胸骨旁-锁
5、骨上锁骨上-胸导管胸导管(3).hematogenous metastasis 血行转移血行转移along inter-fascial spacealong ductulesLocal invasion invading Coopers ligamentsInvading skinInvading musclesSupraclavicular nodesSubclavicular nodesInternal mammary nodessubareolar plexusLymphatic metastasisHematogenous metastasis late stage and early
6、 stage via lymphatic drainage or directly5.Clinical Findings 临床表现临床表现5.1.好发部位好发部位:多见乳房外上象限多见乳房外上象限,次见乳晕乳头区次见乳晕乳头区(areola papillaris)5.2.局部临床体征局部临床体征:(1)乳房肿块乳房肿块(mass,lump,neoplasm)(2)皮肤凹陷皮肤凹陷(retraction)(3)乳头牵扯偏向或内陷乳头牵扯偏向或内陷 (4)皮肤桔皮样变皮肤桔皮样变 (5)盔甲状癌盔甲状癌 (6)乳癌破潰乳癌破潰(ulcer)Presentation in breast Palpab
7、le painless lumpLocal protrusionChanges in skin and nippleDelle and dimple signOrange-peel sign，peau dorange Nipple retraction and inverted nippleEczematoid change over areola or nippleHuge mass and ulcerationInflammatory breast cancerPalpable painless lumphard,irregular shape,rough surface,low mobi
8、lity80%in the upper half of the breastLocal protrusion assymetricity of Bil.Breasts change in shapeassymetric breastchange in shapeChange in skin-Delle and dimple signDelle:visible skin retractiondimple sign:pinched skin retraction invasion of Coopers ligaments and adjacent adipose incomplete fixati
9、on of skinChange in skin-orange-peel sign thickening of skindermal edema induced by invasion of lymphatic vesselsChange in nipple-nipple retraction and inversion differentiated from congenital nipple retraction invasion of mammary ducts Change in nipple&areola-eczematoid change(Pagets disease)low ma
10、lignant degree,slow development 90%accompanied by invasive cancerHuge mass and ulceration-locally advanced carcinoma 20%of all cases 50%in elderly women(70 yr)Inflammatory breast cancer high malignant degree,fast development,poor prognosis younger women5.3.Clinical presentation-distal metastasis 癌转移
11、癌转移Axillary Lymphadenectasis 腋下腋下LN肿大肿大 Bone metastasis 骨痛骨痛 local pain,fracture Liver metastasis 肝大肝大 liver enlargement,jaundiceLung metastasis 胸痛胸痛 Chest pain,dyspneaClinical presentation-axillary palpated movable,ipsilateral axillary nodes fixed or fused ipsilateral axillary nodes ulcerative ipsi
12、lateral axillary nodes6.Diagnosis 诊断诊断鉴别诊断鉴别诊断(differential diagnosis)特殊类型乳癌：特殊类型乳癌：1 炎性乳癌炎性乳癌 2 乳头湿疹样癌（乳头湿疹样癌（Paget病）病）Diagnosis-biopsyFine needle biopsyCytology70%accuracyCore needle biopsyHistology90%accuracyAvoid excisional biopsyDifferential diagnosisCystic fibrosis thickening lumpinessPapillom
13、a clear dischargeHow to differentiate?Ultrasound Mammography Ductal endoscopy Core needle biopsy Fine needle biopsyStagingRationalesGuidance for therapeutic approachesPrediction of recurrence riskPrediction of therapeutic responseStaging criteriaPrimary tumorsNumber of metastatic lymph nodesDistal m
14、etastasisStaging Primary tumorTis vs.T0T1:5cmT4:invasion to skin or chest wallStagingLymph nodesN0:no regional lymph node metastasisN1:movable ipsilateral axillary,1-3 axillaryN2:fixed or matted ipsilateral axillary,internal mammary alone,4-9 axillary N3:supra or infraclavicular,axillary and interna
15、l mammary,10 axillaryDistant metastasisM0:no distant metastasisM1:with distant metastasis7.Prevention 预防预防目前暂无确切方法防止癌肿形成目前暂无确切方法防止癌肿形成;预防的目的是早期诊断预防的目的是早期诊断,防止癌扩散防止癌扩散;早期诊断应重视早期诊断应重视易感因素易感因素(susceptible)和进行和进行普查普查(general investigation)。Susceptible 易感因素易感因素:1.乳癌家族史乳癌家族史(family history);2.大于大于35岁未育岁未育
16、(Nulliparous 35);3.行经超过行经超过45岁岁(late menarche 45);4.大于大于35岁头胎足月女性岁头胎足月女性(first full-term pregnancy 35);5.初次月经小于初次月经小于12岁岁(first menarche 12);6.乳头有血性溢液乳头有血性溢液(bloody discharge of nipple);7.乳腺有局限性增生乳腺有局限性增生(logical hyperplasia);8.乳癌术后病人另一侧乳房乳癌术后病人另一侧乳房.8.Treatment principle 治疗原则治疗原则:以手术治疗为主以手术治疗为主,化疗化
17、疗,放疗放疗,激素激素,免疫等免疫等综合综合(colligate,synthesize)措施的治疗为辅措施的治疗为辅;Surgery:radical mastectomy(Halsted)modified radical mastectomy Extensive radical mastectomy Breast conservative surgery Sentinel axillary LN biopsy8.1.Operation 手术治疗手术治疗(1)radical mastectomy乳腺根治切除术乳腺根治切除术 （切除内容及范围）（切除内容及范围）(2)Extended radica
18、l mastectomy乳癌扩大根治切除术乳癌扩大根治切除术 扩大切除的内容扩大切除的内容(3)Segmental mastectomy+axillary dissection 改良根治术改良根治术保留乳头的乳腺癌根治术保留乳头的乳腺癌根治术保留乳头的乳腺癌根治术保留乳头的乳腺癌根治术Sentinel axillary LN biopsyPercentage of LN metastasis is less than 10%for tumor size 1cmFor tumor size 1-2 cm,false negative SLNB is estimated to be less th
19、an 10%Isotope(Tc99 sulfur colloid),Blue dye injection Intratumor,subareolar,intraparenchymal injection Negative SLNB no radical axillary LN dissectionPositive SLND-radical axillary LN dissection8.2.化学药物治疗化学药物治疗常用方案：常用方案：5-氟脲嘧啶，氨甲蝶呤，环磷酰胺（氟脲嘧啶，氨甲蝶呤，环磷酰胺（CMF）8.3.放射治疗放射治疗时间时间:术后术后2-3周开始周开始目的：防止局部复发，常用于术
20、后辅助治疗目的：防止局部复发，常用于术后辅助治疗照射区域：锁骨上，胸骨旁，腋窝照射区域：锁骨上，胸骨旁，腋窝8.4.激素治疗激素治疗闭经闭经(menopause)前与闭经后的分界线前与闭经后的分界线:指月经终止后指月经终止后5年为绝年为绝经界线经界线(boundary,demarcation line)激素激素(hormone)治疗方法治疗方法:(1)卵巢切除卵巢切除(ovariotomy)(2)卵巢卵巢X线照射破坏线照射破坏(3)肾上腺切除肾上腺切除(adrenalectomy)(4)脑垂体切除脑垂体切除 (5)三苯氧胺三苯氧胺(tamoxifen)-雌激素吉抗剂雌激素吉抗剂 (6)雄激素雄
21、激素(androgenic hormone)应用应用 (7)激素激素+化学药联合治疗化学药联合治疗激素治疗的选择激素治疗的选择:（1）绝经前）绝经前:卵巢切除卵巢切除,雄激素雄激素,卵巢卵巢X线照射线照射 或三苯氧胺或三苯氧胺(雌激素受体阳性雌激素受体阳性)（2）绝经后）绝经后:三苯氧胺三苯氧胺,脑垂体切除脑垂体切除,肾上腺切除肾上腺切除9.Progonosis乳腺癌治疗预后乳腺癌治疗预后:取决于细胞生物学特性及其雌激素受体是取决于细胞生物学特性及其雌激素受体是否阳性否阳性 分化程度高则预后好分化程度高则预后好,分化程度底则预后差分化程度底则预后差雌激素受体阳性则预后好。雌激素受体阳性则预后好
22、。Reconstraction 隆乳术隆乳术Brief summary 总总 结结1.anatomy 乳腺解剖乳腺解剖2.examination乳房检查乳房检查3.乳腺癌乳腺癌 (1).Etiology 病因病因 (2).pathology病理病理 (3).lymph drain淋巴输出途经淋巴输出途经 (4.)clinical findings临床表现临床表现 (5).differential diagnosis乳腺癌诊断及鉴别诊断乳腺癌诊断及鉴别诊断 (6).treatment 治疗治疗:surgical treatment 外科治疗外科治疗 化疗化疗 放疗放疗 内分泌治疗内分泌治疗房房P左宽右高尖左宽右高尖宽深大宽深大Q有梗塞，有梗塞，ST抬高抬高T倒置倒置高高T低钾低钾U,地黄似鱼钩地黄似鱼钩