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 CystsFl
3、uid-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 increase rate
4、(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 predisposition遗传倾向遗传倾向)3
5、.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 ductal,invasive lobular
6、 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 skinInvading musclesSupraclavicul
7、ar 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域)50%Central zone(中心区域中心区域)2
8、0%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，peau dorange Nipple retraction and inv
9、erted 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 of Bil.Breasts change in shapeassymetric b
10、reastchange 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 skindermal edema induced by invasion of lymphatic vesse
11、lsChange 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 invasive cancerHuge mass and ulceration-locally advanced carc
12、inoma 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 metastasis 骨痛骨痛 local pain,fracture Liver metastasis 肝大肝大 liver en
13、largement,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 toolAge of 40Estimated reduction in mortality 15-25%10%false positiv
14、e rateDensities&calcificationsUltrasoundBenignPure and intensely hyperechoicElliptical shape(wider than tall)LobulatedComplete tine capsuleMalignantHypoechoic,spiculatedTaller than wideDuct extensionmicrolobulationDiagnosis-biopsyFine needle biopsyCytology70%accuracyCore needle biopsyHistology90%acc
15、uracyAvoid excisional biopsyDifferential diagnosisCystic fibrosis thickening lumpinessPapilloma clear dischargeHow to differentiate?Ultrasound Mammography Ductal endoscopy Core needle biopsy Fine needle biopsyRationalesGuidance for therapeutic approachesPrediction of recurrence riskPrediction of the
16、rapeutic responseStaging criteriaPrimary tumorsNumber of metastatic lymph nodesDistal metastasisStagingStaging Primary tumorTis vs.T0T1:5cmT4:invasion to skin or chest wallLymph nodesN0:no regional lymph node metastasisN1: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 princ
