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 menarche 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 types 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 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 Palpable 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 mobility80% 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 fixation 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 malignant 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 ipsilateral 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 lumpinessPapilloma 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 metastasisStaging 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 internal 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(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