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1、乳腺癌诊断与分期1乳腺癌的三级预防l乳腺癌的一级预防病因预防：乳腺癌高危人群的确定 乳腺癌家族史，良性乳腺疾病史，初潮年龄小，首次生育年龄晚，绝经年龄晚。l乳腺癌的二级预防早期发现：乳房自查；高危人群普查，乳腺钼靶X线摄影或B型超声波检查。美国妇女40-50岁1-2年检查一次，50岁以上每年要求检查一次。l乳腺癌的三级预防对症治疗：当乳腺癌不可逆转时，对中、晚期患者尽量减少痛苦，提高生活质量，延长生存时间。 23乳腺癌的诊断-临床诊断（1）l全面体格检查l检查的最佳时间：月经来潮后的9-11天，此时雌激素对乳腺影响最小；临床疑为肿瘤的哺乳期乳房肿块，应在断乳后再进一步检查。l检查体位：坐位；对
2、肥胖、大乳房或乳房深部肿块者取卧位，使胸部隆起，乳房平坦，不遗漏小肿块。4乳腺癌的诊断-临床诊断（2）l检查步骤和内容l视诊乳腺发育情况双乳是否对称，大小是否一致，乳头是否回缩和凹陷，（若固定并逐渐加重是浅部肿瘤早期或深部肿瘤晚期）。乳头、乳晕有无糜烂（乳头湿疹样癌，Paget病的特征表现）。乳房皮肤色泽如何，有无水肿、橘皮样变（肿瘤广泛侵犯皮肤和皮下淋巴管，局部晚期）和红肿、浅表静脉怒张（炎性乳癌）乳腺侧下方和尾部（双手上举） 5乳腺癌的诊断-临床诊断（3）l触诊用指腹顺时针方向或按象限检查肿块大小、质地、边界和活动度。乳房皮肤粘连：托起乳房，乳房肿块处皮肤牵拉、皱缩、紧张和“酒窝征”（早期
3、乳癌，区别与良性肿瘤）胸肌粘连：双手叉腰，胸肌收缩，侵及胸肌筋膜和胸肌的肿瘤可使患侧乳房抬高，肿瘤活动度受限（肿瘤晚期）。乳头溢液：在乳晕及周边顺时针轻触或挤压，观察溢液性质记录肿瘤和排液管口的方位（早期导管内癌）。腋下淋巴结：托起患者手背，腋部放松，腋窝淋巴结大小、质地、活动度和与周边组织的关系。锁骨上淋巴结：站在患者背后，从锁骨头向上、向外检查淋巴结大小、质地、活动度和与周边组织的关系。 6乳腺癌的诊断-临床诊断（4）l乳腺癌的特殊检查方法l影像学检查 乳腺钼靶X线摄影术（软X线照相）：用于30岁乳腺癌患者的术前检查和高危人群的普查。乳腺癌的直接征象：肿块影，细纱样钙化。间接征象：血管异常
4、，透亮环，厚皮征，乳头内陷，导管扩张，塔尖征，乳房后间隙改变和乳房形态改变。乳腺彩色多普超声波检查： 在月经来潮后的9-11天检查，用于30岁乳腺癌患者的术前检查，鉴别乳腺肿块的良、恶性的敏感性和特异性均较高；对腋窝淋巴结的状况检查。亦可用于任何年龄患者的乳腺检查。超声波检查无放射性损害，但对1.0cm的乳腺癌、钙化点和毛刺样结构不能显示，受检查医师经验影响大。乳腺红外线检查 国际上应用极少，我国开展普遍7乳腺癌的诊断-临床诊断（5）l乳腺癌的特殊检查方法l细胞学检查： 三次以上的乳头溢液涂片细胞学检查或细针穿刺细胞学检查。阴性结果不能排除乳腺癌。l组织学检查： 粗针针吸活检和切除活检，是乳腺
5、癌诊断依据。8乳腺癌的诊断-临床诊断（6）l乳腺癌转移器官的检查骨转移检查： SPECT骨扫描，可疑转移骨骼的X线摄片。肺转移检查：肺X线摄片，胸部CT脑转移检查： MRI或螺旋CT造影检查腹腔脏器转移检查 腹腔脏器转移检查：腹部CT造影检查或B型超声波检查微转移检查： 骨髓细胞学检查，血、骨髓癌细胞微转移检查，PET检查。9乳腺癌的诊断-组织病理诊断（1）l非浸润性癌（原位癌）小叶原位癌 导管内癌l浸润性癌 非特殊性癌浸润性小叶癌 浸润性导管癌 单纯癌 硬癌 髓样癌 腺癌特殊性癌和罕见型癌乳头状癌 髓样癌伴淋巴细胞浸润 腺管样癌 腺样囊性癌 粘液性癌 大汗腺癌 鳞状细胞癌 Paget病 粘液
6、表皮样癌 类癌 未分化癌 分泌型癌l其它乳腺肉瘤 乳腺淋巴瘤10乳腺癌的诊断-组织病理诊断（2）l非特殊性癌比特殊性癌和罕见型癌预后差。 浸润性导管癌是最常见的乳腺癌； 小叶癌发病年龄小，多中心发生，常累及双侧乳腺，原位癌常不能扪及肿块； 硬癌常与其它癌并存，可钙化或骨化，生长慢，肿块小，浸润转移快，恶性度高； 髓样癌肿块大，位于组织深部，分界清楚，淋巴转移率低，有淋巴细胞浸润的预后好。乳头状癌部分有乳头血性溢液；腺管样癌双侧性和多中心发生，体积小；粘液性癌发病年龄大；Paget病常与其它乳腺癌伴发展慢，预后好。乳腺肉瘤发展慢局部扩展为主，淋巴转移少，有时血道转移。 11乳腺癌的诊断-免疫组化
7、免疫组化l四、乳腺癌免疫组织化学检查四、乳腺癌免疫组织化学检查l激素依赖性标记 雌激素受体（ER）,孕激素受体（PR）l人类表皮生长因子 （Her2）l其他 CEA, P53, PCNA, K-ras等12乳腺癌的诊断-血清标记物血清标记物l五、乳腺癌血清标记物检查五、乳腺癌血清标记物检查l乳腺癌血清标记物不是诊断的指标，可作为观察疾病的治疗和转归的参考指标。lCa-153, CEA, Ca-125等13乳腺癌的诊断-AJCC分期（1）lPrimary tumor (T)TX: Primary tumor cannot be assessed T0: No evidence of primar
8、y tumor Tis: Intraductal carcinoma, lobular carcinoma in situ, or Pagets disease of the nipple with no associated invasion of normal breast tissue Tis (DCIS): Ductal carcinoma in situ Tis (LCIS): Lobular carcinoma in situ Tis (Pagets): Pagets disease of the nipple with no tumor. Note: Pagets disease
9、 associated with a tumor is classified according to the size of the tumor.14乳腺癌的诊断-AJCC分期（2）T1: Tumor 2.0 cm in greatest dimension T1mic: Microinvasion 0.1 cm in greatest dimension T1a: Tumor 0.1 cm but 0.5 cm in greatest dimension T1b: Tumor 0.5 cm but 1.0 cm in greatest dimension T1c: Tumor 1.0 cm
10、 but 2.0 cm in greatest dimension T2: Tumor 2.0 cm but 5.0 cm in greatest dimension T3: Tumor 5.0 cm in greatest dimension15乳腺癌的诊断-AJCC分期（3）T4: Tumor of any size with direct extension to (a) chest wall or (b) skin, only as described below T4a: Extension to chest wall, not including pectoralis muscle
11、T4b: Edema (including peau dorange) or ulceration of the skin of the breast, or satellite skin nodules confined to the same breast T4c: Both T4a and T4bT4d: Inflammatory carcinoma 16乳腺癌的诊断-AJCC病分期（4）Pathologic classification (pN) pNX: Regional lymph nodes cannot be assessed pN0: No regional lymph no
12、de metastasis histologically, no additional examination for isolated tumor cells (ITC)pN0(I-): No regional lymph node metastasis histologically, negative IHCpN0(I+): No regional lymph node metastasis histologically, positive IHC, no IHC cluster 0.2 mmpN0(mol-): No regional lymph node metastasis hist
13、ologically, negative molecular findings (RT-PCR)*pN0(mol+): No regionally lymph node metastasis histologically, positive molecular findings (RT-PCR)* 17乳腺癌的诊断-AJCC分期（4）pN1: Metastasis in 1 to 3 axillary lymph nodes, and/or in internal mammary nodes with microscopic disease detected by sentinel lymph
14、 node dissection but not clinically apparent pN1mi: Micrometastasis (0.2 mm but 2.0 mm)pN1a: Metastasis in 1 to 3 axillary lymph nodespN1b: Metastasis in internal mammary nodes with microscopic disease detected by sentinel lymph node dissection but not clinically apparentpN1c: Metastasis in 1 to 3 a
15、xillary lymph nodes and in internal mammary lymph nodes with microscopic disease detected by sentinel lymph node dissection but not clinically apparent. (If associated with 3 positive axillary lymph nodes, the internal mammary nodes are classified as pN3b to reflect increased tumor burden)18乳腺癌的诊断-A
16、JCC分期（5)pN2: Metastasis in 4 to 9 axillary lymph nodes, or in clinically apparent * internal mammary lymph nodes in the absence of axillary lymph node metastasis to ipsilateral axillary lymph node(s) fixed to each other or to other structures pN2a: Metastasis in 4 to 9 axillary lymph nodes (at least
17、 1 tumor deposit 2.0 mm)pN2b: Metastasis in clinically apparent* internal mammary lymph nodes in the absence of axillary lymph node metastasis19乳腺癌的诊断-AJCC分期（6)pN3:pN3a: Metastasis in 10 or more axillary lymph nodes (at least one tumor deposit 2.0 mm), or metastasis to the infraclavicular lymph node
18、spN3b: Metastasis in clinically apparent ipsilateral internal mammary lymph nodes in the presence of 1 or more positive axillary lymph node(s); or in more than 3 axillary lymph nodes and in internal mammary lymph nodes with microscopic disease detected by sentinel lymph node dissection but not clini
19、cally apparentpN3c: Metastasis in ipsilateral supraclavicular lymph nodes20乳腺癌的诊断-AJCC分期（7)lDistant metastasis (M) MX: Presence of distant metastasis cannot be assessed M0: No distant metastasis M1: Distant metastasis 21乳腺癌的诊断-分期诊断（8）lTNM/AJCC分类组成临床分类组成临床/病理分期病理分期 0TisN0M0T1N0M0AT0-1N1M0,T2N0M0BT2N1
20、M0,T3N0M0AT0-2N2M0, T3N1-2M0 BT4或N3,M0 M1 22缩略语lER：(estrogen receptor)雌激素受体lPR：(progestin receptor)孕激素受体lHER-2/C-erbB-2：(human epidermal growth factor receptor 2) 人表皮生长因子受体-2lAJCC:American Joint Committee onCancer23Subtype Of Breast CancerlLuminal A :ER and/or PR positivelHER2 negative lKi-67 low (1
21、4%)lLuminal B (HER2 negative)lER and/or PR positivelHER2 negativelKi-67 high24lLuminal B (HER2 positive)lER and/or PR positivelAny Ki-67lHER2 over-expressed or amplifiedlErb-B2 overexpression lHER2 over-expressed or amplifiedlER and PR absent25lBasal-likelTriple negative (ductal)lER and PR absentlHER2 negativelSpecial histological types2627l题外话：l1.If there are three men walking together,one of them must be qualified to be my teacher.l2.Knowledge is infinite.2829
