術前系統(tǒng)治療指南圖文

1、NCCN Guidelines Version 3.2014,Preoperative Systemic Therapy Guideline of breast-conserving therapy,Absolute: Radiation therapy during pregnancy（注：鄰近分娩時，可先期手術，將放射治療延遲至分娩以后時才考慮保乳 ） Diffuse suspicious or malignant-appearing microcalcifications（彌漫可疑/癌性微鈣化灶） Widespread disease that cannot be incorporate

2、d by local excision through a single incision that achieves negative margins with a satisfactory cosmetic result（注：多灶、多中心為禁忌） Positive pathologic margin,Contraindications for breast-conserving therapy requiring radiation therapy include,Relative: Prior radiation therapy to the chest wall or breast A

3、ctive connective tissue disease involving the skin (especially scleroderma and lupus （注：因不能耐受放療，可能導致嚴重的纖維化和軟組織或骨的壞死) Tumors 5 cm (category 2B) Focally positive margin（注：顯微鏡下不伴有廣泛導管內癌成分的局灶性陽性切緣可選擇性保乳，更高劑量的瘤床推照） Women with a known or suspected genetic predisposition to breast cancer: 1）May have an inc

4、reased risk of ipsilateral breast recurrence（患側復發(fā)） or contralateral（對側） breast cancer with breast-conserving therapy 2）Prophylactic bilateral mastectomy for risk reduction may be considered（預防性雙乳切除,Contraindications for breast-conserving therapy requiring radiation therapy include,Stage IIA T2, N0,

5、M0 Stage IIB T2, N1, M0；T3, N0, M0 Stage lllA T3, N1, M0 Fulfills criteria for breast-conserving surgery except for tumor size,CLINICAL STAGE,History and physical exam CBC, platelets Liver function tests and alkaline phosphatase Bilateral mammogram（雙乳X線）; Ultrasound Pathology review Tumor ER/PR stat

6、us and HER2 status Genetic counseling if patient is high risk for hereditary(遺傳) breast cancer Breast MRI (optional), with special consideration for mammographically occult（鉬靶隱匿） tumors Fertility counseling if premenopausal（絕經前） Consider systemic staging (particularly if signs and symptoms are prese

7、nt): Chest diagnostic CT Abdominal（腹） pelvic（盆） diagnostic CT or MRI Bone scan or sodium fluoride（氟化鈉：主評骨） PET/CT (category 2B) FDG PET/CT (optional, category 2B,WORKUP,Desires breast preservation： Core biopsy with placement of image-detectable marker(s), if not previously performed, must be done to

8、 demarcate the tumor bed for post-chemotherapy surgical management. 即：術前需行瘤床定位 Does not desire breast preservation：See Locoregional(局部) Treatment of Clinical Stage I, IlA, or IlB Disease or T3, N1, M0,Preoperative Systemic Therapy Breast and Axillary Evaluation,Clinically negative : should have axil

9、lary ultrasound ; suspicious nodes should be sampled by FNA or core biopsy and clipped with image-detectable marker; positive clipped lymph nodes must be removed if FNA or core biopsy was positive prior to neoadjuvant therapy. Clinically positive:should be sampled by FNA or core biopsy and clipped w

10、ith image-detectable marker; positive clipped lymph nodes must be removed if FNA or core biopsy was positive prior to neoadjuvant therapy. 簡言之，淋巴結懷疑陽性的需活檢取樣，若證實，在新輔助治療前切除,Axillary lymph node(s,Preoperative systemic therapy,Endocrine therapy alone may be considered for receptor-positive disease in po

11、stmenopausal patients ; An aromatase inhibitor(芳香化酶抑制劑) is preferred,Those chemotherapy regimens recommended（化療方案推薦） in the adjuvant setting may be considered in the preoperative setting,Preoperative systemic therapy,A pertuzumab-containing regimen(含帕妥治療) may be administered preoperatively to patien

12、ts with T2 or N1, HER2-positive, early-stage breast cancer,Patients with HER2-positive tumors should be treated with preoperative system therapy incorporating trastuzumab(聯(lián)合曲妥) for at least 9 weeks of preoperative therapy,CR(Complete response)：S=0 PR(Partial response)：S 50%S SD(Stable disease): 50%S

13、 S 125%S PD(progressive disease):S125%S,Curative effect evaluation,腫塊,D,d,S = D d,RESPONSE,Mastectomy and surgical axillary staging reconstruction. If sentinel lymph node biopsy performed prechemotherapy and negative findings, may omit axillary lymph node staging 注意：化療前,Mastectomy,Lumpectomy with su

14、rgical axillary staging If sentinel lymph node biopsy performed prechemotherapy and negative findings, may omit axillary lymph node staging 注意：化療前,Lumpectomy,CLINICAL STAGE Stage IIIA T0, N2, M0；T1, N2, M0；T2, N2, M0；T3, N2, M0 Stage IIIB T4, N0, M0；T4, N1, M0；T4, N2, M0 Stage lllC Any T, N3, M0,Loc

15、ally advanced（局部晚期） invasive breast cancer(non-inflammatory,History and physical exam CBC, platelets Liver function tests and alkaline phosphatase Bilateral mammogram; Ultrasound Pathology review Tumor ER/PR status and HER2 status Genetic counseling if patient is at high risk for hereditary breast c

16、ancer Breast MRI (optional),with special consideration for mammographically occult tumors Fertility counseling if premenopausal Consider systemic staging (particularly if signs and symptoms are present): Chest diagnostic CT Abdominal pelvic diagnostic CT or MRI Bone scan or fluoride PET/CT (category

17、 2B) FDG PET/CT (optional, category 2B,WORKUP,Response: 1)Total mastectomy + level l/ll axillary dissection + radiation therapy to chest wall and infraclavicular(鎖骨下) and supraclavicular nodes (plus internal mammary nodes if involved(內乳淋巴結受累), strongly consider internal mammary nodes if not clinical

18、ly involved category 2B) delayed breast reconstruction(延遲性乳房重建). 2) Consider lumpectomy + level l/ll axillary dissection + radiation therapy to breast and infraclavicular and supraclavicular(鎖骨上) nodes (plus internal mammary nodes if involved,Preoperative systemic therapy,No response,For patients with skin and/or chest wall involvement (T4 non-inflammatory) prior to neoadjuvant therapy, breast conservation may be performed in carefully selected