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1、General Surgery DepartmentDr. Peng MiaoBreast DiseaseAnatomyModified sweat gland between the superficial and deep layers of the chest wallCoopers LigamentFibrous band of tissueAnatomyDuctsTerminal ductulesMilking forming glandsLobuleAnatomyAxillary lymph nodes defined by pectoralis minor muscleLevel
2、 1 lateralLevel 2 posteriorLevel 3 medialLong Thoracic NerveSerratus anteriorThoracodorsal NerveLatissimus DorsiIntercostalbrachial NerveLateral cutaneous Sensory to medial arm & axillaClinical ExamInspectionSkinSymmetryMassesPalpableGlandAxilla, Supraclavicular spacesNipple-areola complexBreast Cys
3、tsFluid-filled 1 out of every 14 women50% multiple and recurrentHormonally influencedNeedle aspiratedBreast MassBreast CystFibroadenomaStromal and epithelial elementsMost common in women 100/100,000stable incidencedeclined mortalityChina7-10% of all malignancies2nd most common Ca in 3% yearly increa
4、se rate (highest worldwide) 2. Etiology 病因病因Hormonal influence(激素影响激素影响):Long duration of reproductive life(育龄的长时间持续)Nulliparity(,nliprti未产妇)Late age at first child(老龄生育)Functioning ovariantumor(卵巢肿瘤影响) Fibrocystic disease(乳腺纤维囊性病乳腺纤维囊性病) Radiation exposure(射线照射射线照射) Obesity(肥胖肥胖) Genetic predisposi
5、tion遗传倾向遗传倾向)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 duc
6、tal, invasive lobular Others4. 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 invasionInvading Coopers ligamentsInvading skinInv
7、ading 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Site: Mostly in outer upper quadrant outer upper quadrant (外上四分之一区域外上四分之一区
8、域) 50%Central zone(中心区域中心区域) 20% 20% 10% outer lower quadrant (外外下四分之一区域下四分之一区域) 10% inner lower quadrant (内下四分之一区域内下四分之一区域) inner upper quadrant (内上四分之一区域内上四分之一区域) 10%Breast Anatomy Site(发病部位发病部位):Palpable painless lumpLocal protrusionChanges in skin and nippleDelle and dimple signOrange-peel sign，
9、peau dorange Nipple retraction and inverted nippleEczematoid change over areola or nippleHuge mass and ulcerationInflammatory breast cancerPresentation in breast Palpable painless lumphard, irregular shape, rough surface, low mobility80% in the upper half of the breastLocal protrusion assymetricity
10、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 skinderm
11、al 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 invasi
12、ve 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 met
13、astasis 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 nodesMammographyScreening
14、toolAge of 40Estimated reduction in mortality 15-25%10% false positive rateDensities & calcificationsUltrasoundBenignPure and intensely hyperechoicElliptical shape (wider than tall)LobulatedComplete tine capsuleMalignantHypoechoic, spiculatedTaller than wideDuct extensionmicrolobulationDiagnosis -bi
15、opsyFine 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 biopsyRationalesGuid
16、ance for therapeutic approachesPrediction of recurrence riskPrediction of therapeutic responseStaging criteriaPrimary tumorsNumber of metastatic lymph nodesDistal metastasisStagingStaging Primary tumorTis vs. T0T1: 5cmT4: invasion to skin or chest wallLymph nodesN0: no regional lymph node metastasis
17、N1: 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 metastasisStaging8. Treatment principle 治疗原
18、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 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
19、及范围）（切除内容及范围）(2) Extended radical 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乳腺癌诊断及鉴别诊断断(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内分泌治疗治疗Brief summary 总总 结结Thank You!
