醫(yī)學(xué)外科《乳腺疾患》課件（雙語）

DisordersoftheBreastcaseHistory:55歲女性，發(fā)現(xiàn)外上象限無疼性包塊3月PE:包塊最大直徑3cm，質(zhì)硬，固定，邊界不清Question:可能的診斷是什么，應(yīng)給與哪些檢查？應(yīng)該進行什么治療?

1AnatomyBreastlobesofmammaryglandlobuleofmammaryglandLactiferousduct12369BreastClaviclePectoralisminorsternumLobuleofmammaryglandLactiferousductnippleareolaAxillarylymphnodesribsfatPectoralismajorareolanippleMinorlobesofmammaryglandLactiferousductCoopersuspensoryligCooperligLactiferoussinuslobuleofmammaryglandPectoralismajorPectoralisfasciaribsreturn2Examinationofbreast

inspectionpalpationauxiliarytest：imagingtest(mammographyorultrasound)、pathologicaltestSelf-examinationofbreast（1）Step1：Beforemirror,pressinghandsonhip,inspecttheoutlineformofbreasts.Self-examinationofbreast（2）Step2：Liftingarmsorpressinghandsontopofthehead,inspectthenipple、skinandcontourofbreast.Self-examinationofbreast（3）Step3：Pressingnipplesbythumbandindexfinger.testingthedischargefromthem.Self-examinationofbreast（4）Step4：Lieonback,usingrighthandtotouchoppositeaxilla、tailofbreast.Self-examinationofbreast（5）

Step5：Touchingoppositebreastbysmallcirclet，trytooverjetallareas.3CancerofbreastCancerofbeast

乳腺癌是西方國家及我國城市女性發(fā)病率最高的惡性腫瘤6.epidemiology

moridityofbreastcanceriselevatedyearafteryear.male:female=1：100,theapexofincidenceisinthepopulationof40~60.Highinurbanareaordevelopedcountriesandlowinruralareaordevelopingcountries.highinCaucasianandlowinAfricanRiskfactorsincludeestrogeneffectbreastcancerinoneside(isapredisposingfactorforcontralateralbreastcancer)familieswithhistoryofbreastcancermenarche<ageof12,menopause>age50，ormenseslast>35years.Havingherfirstpregnancy>ageof35someofnon-malignantdietwithexcessivefationizationradiationNoninvasivebreastcancer(in-situ)Invasivebreastcancerspreadofbreastcarcinoma

Metastasesmayoccurveryearlyevenmicrometastasesarepresentinthenodeslongbeforetheyarepalpable.Mainwaysofmetastases：

directspread：skin,pleura，pectoralmuscleandchestwalllymphaticspread：ipsilateralaxillaryorparasternalnodes-subclavicularnodes-supraclavicularnodes-veinspreadofbreastcarcinomabloodstreamspread：occurearly,commonlyinlung、bone、liverclinicalpresentation

mass(mostwithoutpain)changeofskin:orangeskinsign、reddening、ulceration、satelliteganglioninskin、dilatedsuperficialvenousengorgementregionalenlargedlymphnodes:axillary、supraclavicularnodes、subclavicularnodesdistantmetastasesTypicalfindingsdimplingTypicalfindingsorange

non-painfulmass：single,localprotuberanceill-definedmargin,hard,fixative,growrapidly,clinicalpresentation

changeofsurface：skindimplingnippleretraction,driftmalformationsclinicalpresentation

dilatedsuperficialvenousengorgementandreddeningulcerationulcerationPaget’scarcinomaofbreasteczema，ulceration,anditchofnipple.Skinpresentwithreddening,erosionandwettingorcoveringscab.Thereisamarginalongit.Sometimesthenippledimplesorisdestroyedcompletely.Paget’scarcinomaofbreast

DiagnosisdependsonpathologicalexaminationMetastasisoccurlateandprognosisisgood.InflammatorybreastcarcinomaWithworstprognosis.Mostofthemwilldieinoneyearafterdiagnosed.Inflammatorybreastcarcinomapresentwithhyperemiaofskin,redness,localfever,enlargementofbreastwhichbecomeshard,similartothatinacuteinfection.nosystemicsigns.metastasizeearly6

Diagnosisofbreastcarcinoma

Typicalfindingsofhistory,physicalexaminationandimagingaresuggestiveforclinicaldiagnosis.Atypicalcancer:severaldiagnosticmethodsareused.mammographyirregularorlobular,ill-defined，highdenseincenter,somewithspiky.Skindimpleovercarcinomasornippleretract.CharacterofmammographyofbreastcancerSometimescoarsercalcificationisfoundclosetomasses.Especiallywhentherearemorethan15calcification/cm2,themassmustbecancer.CharacterofmammographyofbreastcancerUltrasonographyirregularorlobular,somewithspikyMRIMostaccurate,aspirationneedletumorbiopsydifferentialdiagnosis

纖維腺瘤fibroadenoma乳腺結(jié)核Tuberculosisofbreast脂肪壞死Fatnecrosis導(dǎo)管內(nèi)乳頭狀瘤Ductpapilloma囊性乳腺增生fibroadenosis漿細胞性乳腺炎Plasmacellmastitisstagingofbreastcancer

Thepurposeofstagingistohelpplanningtreatmentandtoestimateprognosis.

T:sizeandextentofprimarytumorN:ipsilaterallymphnodesM:distantmetastasisT(sizeandextentofprimarytumor)

T0：notumorTis：in-situstage（noninvasiveorPegat’scarcinomawithoutlump）

T1：length≤2cmT2：>2cm，≤5cmT3：>5cmT4：extensiontoskin,orchestwallorboth.Includeinflammatorybreastcarcinoma.N（ipsilateralaxillarylymphnodes）

N0：noipsilateralnodes

N1：mobileipsilateralnodes

N2：fixedandconfluentipsilateralnode

N3：ipsilateralsupraclavicularlymphnodesM（distantmetastases）

M0：nodistantmetastasesM1：distantmetastasesclinicalstaging

0stage：TisN0M0Ⅰstage：T1N0M0Ⅱstage：T0-1N1M0，T2N0-1M0，T3N0M0Ⅲstage：T0-2N2M0，T3N1-2M0，T4withanyNM0，anyTN3M0Ⅳstage：M1withanyTNtherapy

Comprehensivetherapy

Themaintherapyisoperation,withadjuvanttherapy：

chemotherapy、radiotherapy、endocrinetherapy、genetherapy最早描述乳腺癌（公元前460年-前377年）（最早是BC3000-2500埃及人）原發(fā)包塊的切除(公元1世紀)局部周圍組織的切除（皮膚、腺體，脂肪、肌肉10-16世紀）乳房全切術(shù)（19世紀之前）乳腺癌手術(shù)的發(fā)展復(fù)發(fā)率、死亡率仍然很高把可能轉(zhuǎn)移的和復(fù)發(fā)的地方都盡可能地切除，提高生存1898年發(fā)明根治術(shù)乳腺癌手術(shù)的發(fā)展根治術(shù)乳腺癌手術(shù)的發(fā)展改良根治術(shù)——胸大肌不切除乳腺癌手術(shù)的發(fā)展改良根治術(shù)——胸大肌不切除乳腺癌手術(shù)的發(fā)展●Modifiedmastectomysurgicaltherapy

Standard(Halsted)radicalmastectomySupra-radical(Urban)mastectomyModifiedradicalmastectomySimplemastectomyWidelocalexcision(lumpectomy)plusaxillarynodeclearance(breastconservingsurgery).Indulgentexcisionchemotherapy

Chemotherapycanimprovesurvival.mainscheme：CMF，CEF，ET。

course：6~8cyclesattentioninchemotherapy：systemicchanges，declineinplateletandWBC,hepaticandrenaldamage,abnormalECG.Indicationsforradiotherapy：

axillarylymphaticmetastasisparasternallymphaticmetastasis(confirmedbypathology）

primarytumor>T3(5CM)lesionoflocalrecurrenceorbonemetastasesbreastconservingsurgery6.radiotherapyendocrinetherapy

Cancerofbreastbearsestrogenreceptorsoitwillberesponsivetoanti-estrogentherapy.ButifER、PRisnegative,itisineffective.Tamoxifen20mg/day,5year4Benigndisordersofbreast4.1infectionofthebreast

Itistheacuteinflammationofthelobules.Theinfectionoccurmostcommonlyduringlatepregnancyandlactation.theorganismisalmostinvariablystaphylococcusaureuspathology

depositofmilkMalformationofthenipple；blockoflactiferousduct.accessbacteriumthroughcrackednippleskin,lymphtubeorviabloodstream.clinicalpresentationLocalsignofacute

inflammationredness、swelling、warmth、pain，ill-definedmargin,hard，fluctuant，swollennodesclinicalpresentation

Systemicsignsofacuteinflammation:sicknesswithatachycardiaandfeverLabtest：increasedWBCandNeutrophil，darkareainultrasonography,pusinaspirationButsomedeepabscesshasonlythepresentationofswollentreatment

Systemictherapy：

antibioticsmainlyforgrampositivebacteriae.g.penicillinLocaltherapy：Earlyphase:emptymilk；physicaltherapy:infrared；applyingofmedicine；Formofabscess：surgicaldrainagePrinciplesofsurgicaldrainage

Onceabscessform，surgicaldrainageisindicated.completeandunobstructeddrainageAttentionindrainageReducethedamageofduct：radiateincision；incisionalongareolainabscessnearbyareolaandacurvilinearincisionismadealonginferiorborderindeepabscess44.2

fibroadenosis

Itisannon-malignantdisorder.Thechangesresultfromdisorderandovergrowthofoneormorevariouscomponentsofbreast,namelytheduct,lobulesandsupportingfibroustissue.Itfrequentlyoccurbetween30-50yearsofage.itismorelikelytobearontheabnormalityofestrogenreceptorandaberrantlevelofestrogenorprogestogenpresentation

premenstrualswollenlumps：asingleormultiplemobilelumpswithill-definedoutline，itwillbecomeenlargedandrigidbeforemensesandgetsmallerandsoftaftermenses.axillarylymphnodes（-）

diagnosisClinicalfeaturesGoldstandard:pathologicexamination(usuallynotpractical)Differentialdiagnosis:Carcinomashouldbeexcludedbymammographyoraspirationtreatment

Thereisnospecialtreatmentreducethepainwhencarcinomacannotbeexcluded,excisionofthelesionisjustified.follow-upself-examinationofbreast（postmenstrual7