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1、Breast Cancer 2011.6.6 Introduction nMost common female cancer最常见的女 性癌症 nAccounts for 32% of all female cancer占 所有女性癌症的32 n211,300 new cases yearly and rising每年 新增211,300个病例 n40,000 deaths yearly每年40,000人死亡 Gross Anatomy大体解剖 Sappys plexus lymphatics under areolar complex 75% of lymphatics flow to ax
2、illa Microscopic Anatomy显微解剖 nStromal tissue基质组织 nConnective tissue, capillaries, lymphocytes, etc.结缔组织， 毛细血管，淋巴细胞等 nAdipose tissue脂肪组织 nDuctal tissue乳腺导管组织 nSquamous epithelium鳞状上皮细胞 nColumnar or cuboidal epithelium柱状或立方形 上皮 nLobular tissue小叶组织 Presentation nBreast lump乳房肿块 nAbnormal mammogram乳房X光检
3、查异常 nAxillary lympadenopathy腋窝淋巴结病变 nMetastatic disease转移性疾病 Screening Mammography乳房摄影 筛检 nRecommendations建议 nBiannually or annually in 40-49 y/o每半年或每年在40-49年 nAnnually in 50 y/o每年在“50 n15% relative risk reduction相对危险度减少15 nBirads分级 n0 - Incomplete assessment; need additional imaging evaluation n1 -
4、 Negative; routine mammogram in 1 year recommended n2 - Benign finding; routine mammogram in 1 year recommended n3 - Probably benign finding; short-term follow-up suggested (3%) n4 - Suspicious abnormality; biopsy should be considered (30%) n5 - Highly suggestive of malignancy; appropriate action sh
5、ould be taken (94%) Biopsy techniques活检技术 nFNA nDiagnostic and therapeutic in cystic lesions囊性病变的诊断和治 疗 nCore needle粗针 nU/S guided or sterotatic n90% effective in establishing diagnosis 90，在建立有效的诊断 nAtypia need excision异型性- 需要切除 nSterotatic nNeedle localization细针定位 nExcision biopsy切除活检 Risk of Futur
6、e Invasive Breast Carcinoma Based on Histologic Diagnosis from Breast Biopsies未来浸润性乳腺癌的风险基于活检病理诊断乳腺 癌 nNo Increase nAdenosis Apocrine metaplasia Cysts, small or large Mild hyperplasia (2 but 5cm nT4: invasion of skin or chest wall nNode nN1: 1-3 axillary nodes or int mam node nN2: 4-9 axillary nodes
7、 or palpalbe int mam node nN3: 10 nodes or combo of axillary and int mam nodes nmic micoroscopic posivitiy, mol molecular posiivity nMetastasis Modified Radical Mastectomy改良 根治术 nEntire breast tissue and Level I & II nodes整个乳房组织和I级和II节点 nSurvival at 10 yrs nNegative nodes 82% (5% local recurrence) n
8、Positive nodes 48% (5% local recurrence) Simple mastectomyModified radical Breast Treatment Trials乳腺癌治疗试验 nNSABP (1971 with B-04 update in 2002) nCompared radical, vs modified radical +/- radiation nNo survival diff for node neg or pos between three arms n75% of recurrences occur in 5 years 复发75发生在5
9、年 nTumor location not important Breast Treatment Trials乳腺癌治疗 试验 nOntario study nAll pts got lumpectomy, randomized to radiation or no radiation n25% failure rate without radiation, 5% with nNSABP B-06 nMastecomy vs lumpectomy vs lumpectomy with radiation nNo difference in survival n39% recur with lu
10、mpectomy, reduced to 14% with radiation, 3-4% with mastectomy n0.5-1% per year recurrence rate for life with BCT and radiation n2-5% complication rate with radiation (rib fx, pericarditis, cosmesis) Radiation after mastectomy?乳房切 除术后辐射？ nDanish studies and one Britsh study丹麦 研究和一Britsh研究 nRecommend
11、in: 3 nodes positive, aggressive/large tumors or extranodal invasion推 荐：“3节点积极，进取/大肿瘤或淋巴结外侵犯 nDecreased local or regional recurrence减少地方 或区域复发 n+/- survival benefit Sentinel node biopsy前哨淋巴结活检 nContraindications:禁忌 Clinically positive nodes, pregnant or nursing, prior axillary surgery, locally advan
12、ced disease临床淋巴结呈阳性，怀孕 或哺乳前，腋窝手术，局部晚期疾病 nFalse negative rate 3.1%假阴性率3.1 Macrometases (0.2cm) so recommended pathology cuts are 0.2 cm Micrometases (IHC staining) 37% death rate vs 50% of those with macrometases If sentinel node positive 43% will have other nodes positive and 24% will have 4 nodes p
13、ositive Treatment of DCIS n600% increase after mammography nOptions Mastectomy 1% breast ca mortality Large tumors, multicentric, positive margins after reexcision, Lumpectomy and radiation Radiation decreases local recurrence by 50% Of those that recur 50/50 DCIS vs Invasive 0-3% chance of dying of
14、 maligant breast ca for all DCIS Treatment of DCIS nNodal involvement n3.6% of DCIS pts have positive nodes in mastectomy specimins nBy definition DCIS has no access to lymphatics Size may matter (111 DCIS tumors evaluated) 55mm 48% microinvasion Tamoxifen in DCIS nNSABP (B-24) nDetermine benefit of
15、 tamoxifen in lumpectomy plus radiation pts n31% decrease in ipsilateral, 47% in contralateral, 31% decrease all together nRetrospectively looked at ER status 75% of DCIS is ER+ 59% reduction in ER+ pts No significant reduction in ER- Treatment for invasive breast ca nLocally advanced is likely alre
16、ady metastatic in most局部晚期很可能已经在大部分转移 nSurgery and radiation alone make no difference on survival nChemotherapy & +/- Tamoxifen nNeoadjuvant chemotherapy n7 randomized trials No survival benefit 50-80% response May allow for BCT in large tumors nSentinel node before chemo Tamoxifen他莫昔芬 nIndications
17、ER + breast ca LCIS BRCA1/2 Increased overall risk nBenefits Decreases risk of ca in other breast by 47-80% nDraw backs Increases endometrial ca risk by 2.5, PE 3.0, DVT 1.7 Source: NSABP P-1 trial Chemotherapy nEarly Breast Cancer Trialists Collaborative Group nDecreases recurrence (12%) and death
18、(11%) regardless of nodal status nIndications nAll patients except node negative, 10mm tumors nRegimens nMultidrug combination chemotherapy nTamoxifen or aromatse inhibitor - ER positive tumors nHerceptin (trastuzumab) HER2/neu positive tumors NSABP B-31 33% reduction in risk of death Other breast c
19、ancers nInflammatory ca nCarcinoma invading lymphatic ducts nChemotherapy, mastectomy, radiation n50% survival at 5 years Other breast cancers Pagets disease nIntraepithelial extesion of ductal ca导管上皮内 extesion约 nExcision with nipple-areolar complex nSentinel node if invasive ca如果CA的前哨淋巴结 侵袭 nMastec
20、tomy乳房切除术 Other breast cancers nPhyllodes tumor叶状肿瘤 n1% of breast tumors nAge 30-45 nSimilar in appearance to fibroadenoma n4% recurrence after excision n0.9% axillary spread nRadiation, chemotherapy, tamoxifen ?放疗，化疗，他 莫昔芬 Phyllodes tumorFibroadenoma Angiosarcoma 血管肉瘤 nRisk factors Radiation Lymphedema辐射 淋巴水肿 nTreatment Excision, radiation切除，放射 Male breast cancer男性乳腺癌 n90% are invasive at time of diagnosis90 在诊断时侵袭 n80% ER+, 75% PR+, 30% HER2/neu nMore invade into pectoralis更多侵入胸大 肌 nTreatment same as for female ca治疗女 性相同的CA 谢谢！