1、BREAST CANCER: DIAGNOSIS 乳腺癌：診斷乳腺癌：診斷OBJECTIVES 目標目標： List the symptoms of a breast cancer patient 列出乳腺癌患者的列出乳腺癌患者的癥狀癥狀 Describe screening and diagnostic procedures 描述描述篩查和診斷程序篩查和診斷程序 Explain how mammography is used to diagnose breast cancer 釋釋如何用于診斷乳腺癌的乳房如何用于診斷乳腺癌的乳房x x光光檢查檢查DIAGNOSTIC PROCEDURES 診

2、斷程序診斷程序Physical Examination 體格檢查體格檢查In most cases, breast cancer presents as a lump.7 To determine whether the lump (or laboratory investigation in the breast) indicates malignancy, fine needle aspiration, biopsy, and laboratory investigation are used.在在大多數(shù)情況下大多數(shù)情況下, ,乳腺癌表現(xiàn)為腫塊。是否確定腫塊為惡性腫乳腺癌表現(xiàn)為腫塊。是否確

3、定腫塊為惡性腫瘤瘤, , 要通過要通過細針吸取細胞學檢查細針吸取細胞學檢查(FNAC)(FNAC), ,和實驗室研究（國際和實驗室研究（國際學術(shù)期刊）。學術(shù)期刊）。Signs that indicate a lump may be malignant include:跡象表明一個腫塊可能是惡性腫瘤跡象表明一個腫塊可能是惡性腫瘤包括：包括：1) Findings of a radiological opacity (microcalcification) with radiating fibrous strands 發(fā)現(xiàn)發(fā)現(xiàn)輻射不透明度輻射不透明度( (鈣化鈣化) )輻射輻射纖維鏈纖維鏈2) O

4、ther changes within the breast that are noticed by the patient 引起患者注意的乳房內(nèi)的其他變化引起患者注意的乳房內(nèi)的其他變化3) Signs of locally advanced or metastatic disease, including a large mass, tethering to the skin and/or chest wall, lymph node enlargement, peau dorange, nipple inversion, and skin infiltration。局部局部晚期或轉(zhuǎn)移性疾病

5、的跡象，包括一個大腫塊，晚期或轉(zhuǎn)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(jié)腫大貼附于皮膚或胸壁，淋巴結(jié)腫大, ,呈現(xiàn)紅斑呈現(xiàn)紅斑, ,乳頭內(nèi)陷和皮膚侵潤。乳頭內(nèi)陷和皮膚侵潤。 Breast mass 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Skin changes 皮膚的變化 Erythema紅斑 Edema水腫 Dimp

6、ling凹陷 Satellitenodules衛(wèi)星結(jié)節(jié) Ulceration潰瘍Nipple changes 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Data from a large randomized trial of breast self-examination (BSE) screening has shown that instr

7、uction in BSE has no effect on reducing breast cancer mortality.21 Nevertheless, women should be encouraged to be aware of their breasts since this may facilitate detection of interval cancers between routine screenings by a physician. 現(xiàn)階段的實驗隨訪中沒有發(fā)現(xiàn)乳腺自檢對降低乳現(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腺癌死亡率有何益處。所以所

8、以女性的乳腺自我檢查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。仍可作為一項常規(guī)的乳腺癌篩查手段。 Not all women having breast cancer present with a lump. Other possible presenting signs and symptoms include: 不是所有女性有腫塊的就稱之為乳腺癌，其他可能呈現(xiàn)的癥不是所有女性有腫塊的就稱之為乳腺癌，其他可能呈現(xiàn)的癥狀和體征體現(xiàn)為：狀和體征體現(xiàn)為： Breast pain or tenderness 乳房疼痛或壓痛乳房疼痛或壓痛 Change in breast shape or

9、size 乳房形狀或大小的改變?nèi)榉啃螤罨虼笮〉母淖?Dimpling, flaking, or thickening of the skin on the breast 凹陷、脫落或乳凹陷、脫落或乳 房皮膚房皮膚增厚增厚 Redness or warmth of the breast 乳腺乘紅色或發(fā)熱乳腺乘紅色或發(fā)熱 Peau dorange 呈現(xiàn)紅斑呈現(xiàn)紅斑 Nipple inversion, rash, or discharge; and 乳頭內(nèi)陷，紅腫或有無分泌物乳頭內(nèi)陷，紅腫或有無分泌物 Swelling of the upper arm or in the armpit. 上臂或腋窩

10、有無腫脹上臂或腋窩有無腫脹1.乳腺自我檢查 （BSE）乳腺自我檢查是一項以檢查者為中心乳腺自我檢查是一項以檢查者為中心 , ,簡便易行、無需花費、安全無創(chuàng)的檢查方簡便易行、無需花費、安全無創(chuàng)的檢查方法法 。檢查者可以自己實施。檢查者可以自己實施 ，無需任何設備支持。，無需任何設備支持。美國癌癥協(xié)會（美國癌癥協(xié)會（ACSACS）在）在2003 2003 年年發(fā)布的新的乳腺癌普查指南中建議：從發(fā)布的新的乳腺癌普查指南中建議：從2020歲開始，應告知女性乳房自我檢查歲開始，應告知女性乳房自我檢查(BSE)(BSE)的益處和局限性。的益處和局限性。應該強調(diào)及時向健康專家報告任何新的乳房癥狀的重要性。選

11、擇應該強調(diào)及時向健康專家報告任何新的乳房癥狀的重要性。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。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女性也可選擇不做或不定期做乳房自我檢查22. .乳腺自我檢查的優(yōu)缺點乳腺自我檢查的優(yōu)缺點：乳腺自我檢查給婦女提供了一個認識乳房的機會：乳腺自我檢查給婦女提供了一個認識乳房的機會 ，使，使婦女們增強了乳房保健意識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，并促使她們一旦發(fā)現(xiàn)乳房腫塊就去醫(yī)院檢查。但過去去 20 20 多年來多年來

12、, ,美國、美國、 加拿大、加拿大、 俄羅斯、俄羅斯、 英國、英國、 日本和中國都先后開展了關(guān)于日本和中國都先后開展了關(guān)于乳腺自我檢查的研究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，加拿大預防衛(wèi)生保健組織在比較了來自這些國家的7 7個國際個國際性研究報告后發(fā)現(xiàn)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，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別沒有差別 ，腫瘤在診斷時的分期和大小也無統(tǒng)計學意義。相反，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，干預組的良性病變的活檢率明顯高于對照組變的活檢率明顯高于對

13、照組 ，就醫(yī)率也大大提高。從而得出結(jié)論，就醫(yī)率也大大提高。從而得出結(jié)論 , ,乳腺自我檢查乳腺自我檢查有害無益有害無益3 3 。DIAGNOSTIC PROCEDURES診斷程序 Mammography乳房x光檢查Introduction 介紹A mammogram is an X-ray image of the breast. The procedure used to generate a mammogram is termed a mammography.30 Mammography can detect tumors at an early stage, when they are

14、still small and cant be detected by palpation.31 Based on fair evidence, screening mammography in women aged 40 to 70 years decreases breast cancer mortality.32,33 The benefit is higher for older women, in part because their breast cancer risk is higher.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

15、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,部分原因是他們患乳腺癌的風險高。 Transcript 記錄Screening by mammography can detect small tumors before there is any nodal involvement. This technique is therefore an effective tool for early detection of breast cancer. On a mammogram, breast

16、 carcinomas typically display fine calcification and areas of irregularity. Occasionally, fixation of deep lesions, either to the chest wall or skin, can also be seen.35 There are several advantages to using mammography as a screening technique: 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(shù)是早期發(fā)現(xiàn)乳腺癌的一種有效工具。乳房x光檢查

17、,乳房癌通常顯示鈣化和不規(guī)則的地方。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)有如下幾個優(yōu)勢: The ability of mammography to detect cases much earlier than physical examination is well established.36 Technical advances have enhanced the utility of mammography in recent years by providing increased visualization of the breast paren

18、chyma while using lower doses of X- ray radiation.37 Combined with clinical examination, mammography can be at least 90% accurate in its diagnosis. It should be noted, however, that the success of low-radiation mammography depends largely on the quality of interpretation.38 乳房x光檢查檢測比體格檢查更早。技術(shù)進步近年來加強

19、了乳房X光檢查的應用提供可視化的乳腺實質(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光檢查至少達到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(zhì)量 The finding that screening reduces breast cancer mortality has important implications regarding the onset and progression of the disease. Evidence suggests that metastases occur very early

20、in the course of the disease and that breast cancer should be considered a systemic disease from its outset. Therefore, the reduction in breast cancer mortality by screening, an estimated 10% to 30% reduction, provides compelling evidence that early diagnosis and treatment of breast cancer can avert

21、 the onset of metastasis. 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)表明,轉(zhuǎn)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)表明,乳腺癌的早期診斷和治療可以避免轉(zhuǎn)移DIAGNOSTIC PROCEDURES 診斷程序Confirmation 確認Introduction 介紹It is important to use methods other than mammography and physical examination to confirm a dia

22、gnosis of breast cancer. These methods can be either non-invasive or invasive.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。Transcript 記錄Ultrasound is a non-invasive way to differentiate whether a possible tumor detected with mammography is, instead, a fluid-filled cyst. Ultrasound can also aid in th

23、e evaluation of lumps that are difficult to visualize with mammography, and is often used in conjunction with invasive methods such as core biopsy, excision biopsy, aspiration cytology, and fine needle aspiration (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(jié)合核心活檢等

24、侵入性方法,切除活檢,細胞學檢查和細針穿刺。STAGING AND GRADING分期和分級10. TNM System TNM系統(tǒng)Introduction介紹At the time of breast cancer diagnosis, the stage of disease is routinely determined as part of the management plan. The Tumor, Node, Metastases (TNM) system is now the standard method for classification of breast tumors

25、. The following operative findings are used in the clinical staging of breast cancer: the size of the primary tumor, the presence of chest wall invasion, and the presence or absence of regional or distant metastases.在乳腺癌診斷、疾病的階段經(jīng)常決定作為管理計劃的一部分。腫瘤、節(jié)點轉(zhuǎn)移(TNM)系統(tǒng)現(xiàn)在是乳腺腫瘤分類的標準方法。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

26、侵的存在,地區(qū)或遠處轉(zhuǎn)移的存在與否The first factor in categorizing tumors, T, describes the extent of the primary tumor. Grades for the factor T are: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: Primary tumor cannot be assessed 原發(fā)腫瘤無法評估 T0: No evidence of primary tumor 沒有原發(fā)腫瘤證據(jù) Tis: Carcinoma in situ intraductal carcinoma,

27、 lobular carcinoma in situ, or Pagets disease of the nipple with no tumor 導管原位癌；小葉原位癌；乳頭pages病，不伴有腫塊 T1: Less than 20 mm in greatest dimension腫瘤最大直徑 2cm，但 5cm T4: Tumor of any size with extension to the chest wall and/or edema or inflammatory carcinoma 不論腫瘤大小，直接侵犯胸壁或皮膚N is based on the presence and

28、location of involved lymph nodes. 區(qū)域淋巴結(jié)的位置和區(qū)域 NX: Unable to assess status 區(qū)域淋巴結(jié)無法評估 N0: No nodes positive for carcinoma 無區(qū)域淋巴結(jié)轉(zhuǎn)移 N1: Ipsilateral (same side as primary tumor) axillary nodes involved; movable 同側(cè)腋窩淋巴結(jié)轉(zhuǎn)移，可活動 N2: Ipsilateral axillary nodes involved; fixed 同側(cè)腋窩淋巴結(jié)轉(zhuǎn)移，固定和相互融洽 N3: Ipsilatera

29、l internal mammary nodes involved 同側(cè)鎖骨下淋巴結(jié)轉(zhuǎn)移M is based on the presence of distant metastases. M是基于存在遠處轉(zhuǎn)移 MX: Unable to assess 遠處轉(zhuǎn)移無法評估 M0: No distant metastases, and/or areas of tumor spread are histologically smaller than 0.2 mm and found in non-nodal tissue 未見遠傳轉(zhuǎn)移及征象，而組織學或分子技術(shù)檢測到骨髓、血液或其他器官中 0.2mm的

30、轉(zhuǎn)移灶T0: No evidence of primary tumor 沒有原發(fā)腫瘤證據(jù)Tis: Carcinoma in situ or Pagets disease of the nipple 原位癌或伴有腫塊的pagets病T1: Tumor less than 20 mm in greatest dimension 腫瘤最大直徑2cmT2: Tumor greater than 20 mm but less than 50 mm in greatest dimension腫瘤最大徑大2cm, 但5cmT3: Tumor greater than 50 mm in greatest di

31、mension腫瘤最大徑5cmT4: Tumor of any size with extension to the chest wall and/or edema or inflammatory carcinoma無論腫瘤大小，直接侵及胸壁或皮膚 /水腫或炎性乳腺炎N0: No nodes positive for carcinoma 區(qū)域淋巴結(jié)無轉(zhuǎn)移N1: Ipsilateral axillary nodes involved; movable 同側(cè)腋窩淋巴結(jié)轉(zhuǎn)移，可活動N2: Ipsilateral axillary nodes involved; fixed 同側(cè)腋窩淋巴結(jié)轉(zhuǎn)移，固定N

32、3: Ipsilateral internal mammary nodes involved M0: No distant metastases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: Distant metastases present 有遠處轉(zhuǎn)移Tissue pathology is another factor involved in clinical staging. In contrast, pathological staging is more comprehensive and includes all data used for clinical staging and surgical resection, as well as info