乳房疾病课件

BreastDiseasesAnswer1.ShirleyTempleOscar:Winner7y8m45852.KylieMinogue:AustralianSinger3748-3.RonaldW.Reagan&NancyD.ReaganThefirstlady&The40thpresidentofUSA6694OutlineAnatomyDiagnosisBenignDiseasesMalignantDiseasesSurfaceanatomyBreast:anteriorandalsopartlythelateralaspectsofthethorax;betweenthesubcutaneousfatlayerandthesuperficialpectoralfascia.

superior:2ndrib.

inferior:6thcostalcartilage.

medial:lateralborderofsternum.

laterally:mid-axillaryline.Nipple–areolacomplex:4th~5thrib.Langerlines:extendoutwardscircumferentiallyfromthenipple–areolacomplex.Surfaceanatomy6thribLateralborderofthesternum2ndribmid-axillarylineLangerlinesBreastAnatomyParenchymaThreetissuetypesGlandularepitheliumFibrousstromaandsupportingstructuresFatCooper`sligaments（dimplesignincancer）Fibrouscontinuationsofthesuperficialfascia,whichspantheparenchymaofthebreasttothedeepfasciallayersProvideshapeandholdthebreastupward.fatCooper`sligamentSegmentalductTerminalductBreastAnatomyVasculatureArterialsupplyInternalmammaryarteryperforators(60%)Lateralthoracicartery(30%)IntercostalperforatorsVenousreturnIntercostalsAxillaryvein(primary)InternalmammaryveinBreastAnatomyNervesLongthoracicnerve(Serratusanteriormusle)Thoracodorsalnerve(Latissimusdorsimusle)MedialpectoralnerveLateralpectoralnerveIntercostalbrachialNerve

BreastAnatomyLymphatics

1.Axillarylymphnodes（85%）.2.Internalmammarylymphnodes.3.Rotter’snodes：betweenpectorialminorandmajormuscles.AxillaryLymphnodesAnteriorgroup:

alongthelateralthoracicvessels.Posteriorgroup:

alongthesubscapularvessels.Lateralgroup:

alongtheaxillaryvein.Centralgroup:

embeddedinfatinthecentreoftheaxilla.Apicalgroup:

abovethelevelofthepectoralisminortenden.Thecontinuitywiththelateralnodesandreceivetheefferentsofalltheothergroups.AnteriorgroupPosteriorgroupCentralgroupLateralgroupApicalgroupRotter’sLNInternalmammarychainLymphnodeslevelLevelI–LateralPectoralisMinorMuscleLevelII–DeepPectoralisMinorMuscleLevelIII–MedialPectoralisMinorMuscleⅡⅠⅢCommonDiseasesMass:CystandFibroadenoma：developwithinlobules.

Carcinomas:developintheterminalductlobularunit.Nippledischarge:

PapillomaandDuctEctasia:developinthesegmentalducts.Nippleadenoma:

developinthesegmentalducts,neartheiropeninginthenipple.Paget’sdisease:

referstoexcoriationoftheskininthenipple-aveolarcomplex.DiagnosisofthebreastdiseasesHistoryClinicalBreastExaminationBreastimagingTissuesamplingHistoryAgeMenarchePregnancy(Breastfeeding,1stpregnancyage)MenopauseFamilyHistoryPriorbiopsiesHormonereplacementtherapy(HRT)Clinicalbreast-examinationInspectionSkinSymmetryMassesPalpationGlandAxilla,SupraclavicularspacesNipple-areolacomplexClinicalbreast-examinationUseyourbellyofthemiddlethreefingers.Clinicalbreast-examinationNippledischargeYou’vefoundalump!PositionColourandtextureofoverlyingskinTemperatureTendernessShapeSizeSurfaceEdgeDifferentialdiagnosisDischargeDuctectasiaMastitisDuctpapillomabloodyDuctalcarcinomainsitu(DCIS)bloodyDifferentialdiagnosisLump

Cancer(75%ductal,25%lobular)FibroadenomaFibrocysticdiseaseCystAbscessFatnecrosisGalactocoeleEectopicbreasttissueBreastimagingUltrasonographyMammographyMRI:toosensitiveMammaryductoscopy:impracticalCT:entirebodyassessmentinABCPET-CT:entirebodyassessmentinABCUltrasoundSpeciallyusefulinyoungwomenwithdensebreast.DistinguishcystfromsolidlesionLocalizeimpalpablelesions

BUSguidedcoreneedlebiopsy.Notascreeningtool(operatordependent)UltrasoundBenignPureandintenselyhyperechoicEllipticalshape(widerthantall)LobulatedCompletetinecapsule

MalignantHypoechoic,spiculatedTallerthanwideDuctextensionmicrolobulationMammographyaveryusefultoolforbreastcancerscreeningMammographyPositionCC:craniocaudalML:mediolateralMLO:mediolateraloblique

Atleasttwopicturesaretakeofeachbreast.MammographyBreastcompressionEvensoutbreastthicknesssothatallofthetissuecanbeseenSpreadsoutthetissuesothatsmallabnormalitiesarelesslikelytobehiddenbyoverlyingbreasttissueAllowstheuseofalowerx-raydose.HoldsthebreaststilltominimizeblurringthepictureBI-RADSTheBreastImagingReportingandDataSystem(BI-RADS)oftheAmericanCollegeofRadiology(ACR).Itspurposeistostandardize:(1)theterminologyinamammographicreport,(2)theassessmentoffindings,and(3)theresultingrecommendationTypesofbreasttissuedensity

MassAmassisdefinedasalesionseenintwodifferentprojections.Ifalesionisseenonlyinasingleprojection,itshouldbecalledadensity.

Massesarefurtherclassifiedbyshape,margin,anddensityMassShape:round,oval,lobular,orirregular.Margin:circumscribed(well-definedorsharplydefined)microlobulated(undulationwithshortcycles)obscured(hiddenbysuperimposingadjacenttissue)indistinct(ill-defined)

spiculatedDensity:higher,equivalent(isodense),orlowerthanthesurroundingparenchymaorfatequivalent.↖不规则肿物，周围见毛刺↘类圆形肿物，边缘模糊外侧肿物局部加压，边缘模糊，其内见细点状钙化←偏内侧肿物，局部加压，见典型的毛刺征←

女，39岁，左乳外上扪及两个肿物，界限不清，Localpointamplification:2masses，手术：LIDC（多灶）。2.5×2cm、1.2×1cm。

女，68岁，右乳肿物，查体质硬，动度差。DR：不规则肿物，边缘略模糊浸润。皮肤广泛增厚，腋下淋巴结肿大。手术：浸润性导管癌，并腋下淋巴结转移。↗腋下淋巴结肿大、密度增高正常左乳↙

女，59岁，右乳肿物边缘模糊浸润，伴少许毛刺。病理：乳腺癌。

女，67岁，左乳外上肿物，边界不清，动度差。DR：肿物周围明显毛刺。左乳头赘生物。手术病理：左乳癌。

女，51岁，右乳肿物，边界不清，动度差，DR:右乳内下肿物，边缘模糊浸润。手术：浸润性导管癌。女70岁，手术左乳癌DR：左乳内下不规则肿物，边缘模糊，见毛刺影。女，53岁，DR：右乳中央区Patchdensity，内侧见类圆形结节，乳晕区为中心皮肤增厚，craternipple。手术病理为：乳腺炎并乳腺癌（肿块为癌灶）↑↙

不同病人，皆为高密度肿块，边缘模糊，第一个肿物周围见毛刺，不同程度皮肤增厚，手术：皆为乳腺癌

女，46，不规则肿物，边缘见毛刺征，手术：左乳癌↙↙局部加压毛刺明显↓↓↘↑局部点压放大摄影↙女，62岁，左乳癌术后一年，右乳发现小病灶，导丝定位手术病理：右乳小癌灶。sss

IrregualarmasswithpleomorphiccalcificationsIDC

右乳纤维腺瘤，左乳浸润性导管癌。左乳肿物周围见毛刺，并且密度明显高于右侧肿物。肿物周围致密浸润，边缘模糊，乳腺癌。CalcificationsBenignIntermediate-concerncalcificationsCalcificationssignifyingahighprobabilityofmalignancy)TypicallybenignSkincalcifications(dermal)VascularcalcificationsCoarseorpopcorn-likecalcificationsLargerod-likecalcificationsRoundcalcificationsLucent-centeredcalcifications“Eggshell”or“rim”calcificationsMilkorcalciumcalcificationsSuturecalcificationsDystrophiccalcificationsPunctatecalcificationsIntermediate-concerncalcificationsAmorphousIndistinctcalcificationsHigherprobabilityofmalignancyPleomorphicorheterogenouscalcifications(granular)Finelinear,finelinearbranching(casting)calcifications

Clusteredcalcificationstwocancercases：Finelinear,finelinearbranching,granular

↘

Pleomorphicorheterogenouscalcifications(granular)Large-scale:Finelinear,finelinearbranching,granular

典型恶性钙化，不同病例，tinypleomorphiccalcification，clusterorlineardistribution

女，50岁，右乳外上浸润性导管癌，区域分布细小多形性钙化。

女，30岁，乳头溃疡、湿疹一年余，在外地按皮肤病治疗欠佳，查体乳头鲜红，溃烂、缺失大半。（接下一幻灯片）↖腋窝淋巴结肿大

线状、小线虫状、细小多形性钙化，手术病理：浸润性导管癌。Paget’sdisease。女，46岁，右乳外上见区域性分布细小多形性钙化，手术病理：浸润性导管癌。女，45岁，手术病理浸润性导管癌↘

典型细小多形性钙化伴皮肤增厚，乳头凹陷

局限致密，结构不良，伴恶性钙化，皮肤增厚，乳头凹陷crater

nipple女、75岁，左乳肿物伴多发细小多形性钙化，手术乳腺癌。

右乳扪及肿物，质硬、界不清，DR：乳头后方，相当于临床扪及肿物部位见成簇细小钙化，最具特征的是钙化沿导管走行方向分布，手术：筛状癌。

不规则肿物伴多形性钙化，浸润性导管癌

大小不等不均质钙化及细小不定形钙化，病理：浸润性导管癌左乳癌，成簇细小多形性钙化，导管征阳性。

女，46岁，乳腺DR查体发现三簇模糊伴定形钙化，导丝定位手术，guidewirelocalizethecalcification（接下一幻灯片）←↙↙穿刺定位点↗

（接上）女，46岁，查体发现多簇模糊不定型钙化，needle-localization，病理：乳腺癌。↖↖↖↘↘↘↘似良性钙化

成簇钙化，形态较规则，边缘清晰，密度较高。手术病理：浸润性导管癌无定形钙化左乳细小浅淡不定型amorphous钙化，手术病理：浸润型导管癌。

女，45岁，乳腺DR体检发现右乳外上8mm范围成簇模糊不定形钙化。手术病理：浸润性导管癌.↘

位置偏上，容易漏诊←局部点压片↘无定形或粗糙不均质钙化手术病理：小管癌。ClusteredAmorphousheterogenouscalcifications

右乳浸润性导管癌，肿物似良性，密度浅淡，边缘较清。↙↘DR：肿物密度浅淡，边缘模糊似良性。手术病理：浸润性导管癌

女，39岁，多灶癌，部分病灶不规则肿物伴毛刺，部分病灶边缘模糊浸润。↘肿物伴毛刺肿物边缘模糊浸润↑

女，40岁，右乳外上结构不良伴钙化，局部加压可见毛刺改变，浸润性导管癌

女，67岁，左乳外上肿物，边界不清，动度差，DR见小病灶伴多发毛刺。手术病理：乳腺癌。

不规则肿物伴粗糙不均质钙化，周围见多发毛刺，手术乳腺癌。

不规则肿物伴多发毛刺，手术乳腺癌。致密浸润、结构不良↙↗不规则肿物，周围伴放射样毛刺，手术病理：左乳癌。

多发肿块，边缘见毛刺，周围腺体结构不良，伴成簇细点状钙化，手术病理：多灶癌。↙

不规则肿物伴多发细长毛刺，手术：左乳外上浸润性导管癌↙局部结构不良↙侧位切线位加压↙

localamplify女，44岁，MLO位发现结构不良，局部摸到肿物，侧位及局部点压，发现毛刺样改变，手术病理：浸润性导管癌女，45岁，手术病理浸润性导管癌。↘皮肤增厚女，53岁，手术病理为：乳腺炎并乳腺癌（肿块为癌灶）→皮肤增厚，乳头凹陷右乳炎性乳癌→皮肤广泛增厚，下部明显左乳炎性乳癌←皮肤广泛增厚，下部明显不同病人，同样高密度肿块，皮肤增厚，乳腺癌←皮肤广泛增厚↖乳晕区皮肤增厚

局限致密，结构不良，伴恶性钙化，皮肤增厚，脂肪层浑浊，乳头凹陷。浸润性导管癌。↘广泛皮肤增厚乳头凹陷nippleretraction，导管征conductsign、漏斗征hoppersign。左乳炎性乳癌，thickenskin左乳侧位X线片：乳头缺损。乳晕增厚，密度增高，乳晕后见三角形索条状影与深部腺体相连。未见肿块。乳晕后上部两个钙化点。标本切片X线片：乳头消失，乳头根本向后凹陷，乳晕增厚，乳晕下脂肪层内见三角形和索条状致密影与后部腺体相连。手术病理：Paget病。MRIHighriskpatientsPersonalhistoryofbreastcaLCIS,atypia1stdegreerelativewithbreastcancerVerydensebreastHighsensitivity(95-100%)10-20%willhaveabiopsyMRIMagneticresonanceimagingHighsensitivity,lowspecificitySpeciallyusefultofindthelesionsofoccultbreastcancer.3-Dimaging.MammaryductoscopyTissuesamplingFNA(fineneedleaspiration)CNB(coreneedlebiopsy)mammotomestereotacicbiopsyNeedle-LocalizedbiopsyOpenbiopsyFNACNBSamplesofCNBStereotacticBiopsyProcedurePositionpatientcomfortably!Patientneedstoremainstillforupto45minutesObtainimagesLocalizemassorcalcificationsPerformcalculationsTransmitX,Y,Zco-ordinatesFromKennethTomkovichMDStereotacticBiopsyProceduretechniquePlaceneedleintoincisionAdvanceneedletocorrectX,Y,ZpositionObtainpre-fireimagesConfirmpositionofneedleObtainpost-fireimagesPerformbiopsyNumberofpassesandlocationisdependentonlesionandneedlegaugeFromKennethTomkovichMDStereotacticBiopsyTableFromKennethTomkovichMDStereotacticBiopsyFromKennethTomkovichMDTripleAssessmentPathologyFNAImagingTriple

AssessmentAgeExamBUSMammographyClinicalCNBConfidentdiagnosisin99%ofcasesBenighdiseasesMastalgiaCyclicalpain–hormonalDull,diffuseandbilateralLutealphaseTreatmentReassuranceNSAIDSEveningprimroseoilNon-cyclicalpainNon-breastvsbreastImagingTreatmentReassuranceNSAIDSEveningprimroseoilMastalgiaCancermustbeexcludedthroughexamination,mammogram,andultrasoundifthepainislocalized.Cellulitis,mastitisUsuallyassociatedwithlactationTreatwith10-14daycourseantibioticstocoverStaphylococcusandStreptococcusAbscessTreatedbysurgicaldrainageChronicsubareolarabscessOccursatbaseoflactiferousduct,andsquamousmetaplasiaofductmayoccur.SinustracttoareoladevelopsTreatmentrequirescompleteexcisionofsinustractRecurrenceiscommonInfectiousandInflammatoryBreastDiseaseInfectiousandInflammatoryBreastDiseaseMondor’sdiseasePhlebitisofthethoracoepigastricveinPalpable,visible,tendercordalongupperquadrantsUltrasoundmaybehelpfulinconfirmingthisdiagnosis.Treatmentself-limited,canuseanti-inflammatoriesifnecessaryBreastInfectionsMastitisGeneralizedcellulitisofthebreastAscendinginfectionsubareolarductscommonlyoccursduringlactationAcuteinflammationErythema,pain,tendernessMastitisTreatmentAntibioticsStopbreastfeedEmptyofmilk(breastpump)RelievepainBreastAbscessInfectiondidnotresolvewithin48hours.Localizedinfection(erythematous,warm,andfluctuant)BUS:aarea“ripe”fordrainage.TreatmentAntibioticsNeedleaspiration（+antibioticsNoscar）Incisionanddrainageanincision

ismadedirectlyovertheabscess

cavity

CystCystsFluid-filled,epithelium-linedcavitiesInfluencedbyovarianhormonesCommonafterage35,andrarebefore25.Incidencedeclinesaftermenopause.ExcisiondependsonwhetherthecystcompletelyresolvesafteraspirationCompleteresolution,followuptoensureitdoesnotrecur.Incompleteresolution,Treatasbreastmassandexcise.Fluid-filled,epithelium-linedCystPalpable:needleaspirationNotpalpable:ultrasound-guidedThreecolorsbyneedleaspirationSimplecyst,clearorgreenfluidandisbenign.Milk-filledcyst,calledgalactoceleandisbenign.Bloodycystisacauseofconcernformalignancy.Bloodyfluid:cytologyevaluationBreastCystNippleDischargeDischargefromthesurfaceDischargefromasingleductDischargefrommorethanoneductDischargefromthesurfacePaget’sdiseaseSkindeseases(eczema,paoriasis)Rarecauses(chancre,syphilis)DischargefromasingleductBlood-stained

intraductcarcinomaintroductpapillomaductectasiaSerous(anycolour)

fibrocysticdiseaseductectasiacarcinomaDischargefrommorethanoneductBlood-stained

carcinoma,ectasia,fibrocysticdisease.GrumousductectasiaPurulentinfectionSerousfibrocysticdisease,ductectasia,carcinomaMilklactation,rarecausesNippleDischargePhysiologicBilateralInvolvesmultipleductsHeme(-)Non-spontaneousNippleDischargePathologicUnilateralSpontaneousHeme(+)MostcommoncauseintraductalpapillomaBenignBreastDiseasePathologicnippledischargeispersistentandspontaneousRequiresfurtherevaluationGalactorrheaBilateral,milkydischargeoccursObtainprolactinlevels,ifhighlyelevated,suspectpituitaryadenomaasoneofcauses.BloodynippledischargeMostcommoncauseisintraductalpapillomaCancerpresent10%oftime.CytologicexamondischargeMammogramtoruleoutassociatedmassIfdrainagefromisolatedduct,thenitshouldbeexcised.IntraductalPapillomaSingleductBenignMovableround/ellipsemassunderthenipple-areolarcomplex4%ofintraductalcarcinomalumpectomyFibroadenomaCommondiseasein15-30yStromalandepithelialelementsWell-defined,movablebenigntumorofbreastMostcommoninwomen15-25yearperiod.Indication:suspiciouscytologyorbecomeverylarge.patientsexpresslydesiresthelumptoberemoved.Giantfibroadenoma:over5cm,growrapidly.FibroadenomaPhyllodesTumorProliferationofconnectivetissuewithductalelementsFirm,lobulated2to40cminsizeBenign,borderlineandmalignantsubtypes10%malignantTreatment:wideexcisionBreastCarcinomaMagnitudeoftheproblemCancerStatisticsEstimatesfor2000inUSA

NewCases-1,220,100;Deaths-552,200Male-newcases:619,700Prostate180,400Lung89,500Colon/rectal63,600MaleDeaths:284,100Lung89,300Prostate31,900Colon/rectal27,800Female-newcases:600,400Breast182,800Lung74,600Colon/rectal66,600FemaleDeaths:268,100Lung67,600Breast40,800Colon/rectal28,5001:8womenwilldevelopbreastcancerinlifetime(USA)BREASTCANCEREPIDEMIOLOGY:Stageatdiagnosis:UnitedStatesvs.IndiaSTAGE

EXTENT

5year DISTRIBUTION SURVIVAL USA

INDIA

0 Noninvasive 100% 16%

I Earlystagedisease 100% 40%

1% II Earlystagedisease 86% 34%

23% III Locallyadvanced 57% 6% 52%

IV Metastaticdisease 20% 4% 24%

USA:90%DCISorearlystagedinvasivediseaseatdiagnosisINDIA:76%locallyadvancedormetastaticatdiagnosisSources:SEERSurvivalMonograph(NCI),2007;Chopra,CancerInstituteChennai,India,2001FromthereportofDr.G.V.NagarajRiskfactorsOestrogenexposureFemaleAgeatmenarche(earlierthan13yo)Ageatmenopause(laterthan50yo)Nulliparous（neverhavebaby）Ageoffirstpregnancy(>30yo)NobreastfeedingTakingHRT(hormonereplacementtherapy)OtherRadiationexposureAgeBRCA1+2FamilyhistoryBreastCancerRiskFactorsRRFirstPregnancy(>30yrs)1.48Bodymassindex(>29.68kg/m2)1.48Collegegraduate1.36Alcoholuse(>5g/d)1.16Delayedmenopause1.14(5yrs)HRT(current)1.12(5yrs)**basedondatafromCollaborativeGrouponHormonalFactorsinBreastCancer.Lancet.1997;350-1047.BreastCancerScreeningMethodsForHealthyWomen1.BreastSelfExam—StatusGuidingprincipal“Knowyourbreasts—theyarenotlandmines”2.ClinicalBreastExamAge20-39:every1-3yearsAgeafter40:everyyear3.MammographyAgeafter40:everyyearBenefitToScreeningFor50-74yearoldgroupthereisanestimated30%reductioninmortalityFor40-49yearoldgroup,thereisanestimated17%reductioninmortalityBottomLine“Apalpablecancerisalatecancer”IfyoucanfeelthecanceryourselfitlikelywillalreadyhavespreadGetyourpatientsscreenedSymptomsNewlumpsorathickeninginthebreastorunderthearmNippletenderness,discharge,orphysicalchangesSkinirritationorchanges,suchaspuckers,dimples,scaliness,ornewcreasesSymptomsWarm,red,swollenbreastswitharashresemblingtheskinofanorangePaininthebreast(usuallynotasymptomofbreastcancer,butshouldbereportedtoadoctor)Novisibleorobvioussymptoms(asymptomatic)ClinicalmanifestationsDimplingSignRetractionofthecooper’sligament.DimplingsignPeaud’orange

cutaneouslymphaticoedema,Peaud’orangeBloodydischargePaget’sDiseaseInflammatorybreastcarcinomaLocationofprimarybreastcancerDiagnosisFine-needleaspirationSensitivityis80-98%,specificity100%Falsenegativesare2-10%Core-needlebiopsyMoretissue,howeverstillpossibilityoffalse“negative”andcouldrepresentsamplingerrorIncisionalbiopsyForlarge(>4cm)lesionsforwhompre-opchemotherapyorradiationwillbedesirable.ExcisionalbiopsyRemovalofentirelesionandamarginofnormalbreastparenchymaStagingPrimaryTumorT1=Tumor<2cm.ingreatestdimensionT2=Tumor>2cm.but<5cm.T3=Tumor>5cm.ingreatestdimensionT4=TumorofanysizewithdirectextensiontochestwallorskinRegionalLymphNodesN0=NopalpableaxillarynodesN1=MetastasestomovableaxillarynodesN2=Metastasestofixed,mattedaxillarynodesDistantMetastasesM0=NodistantmetastasesM1=DistantmetastasesincludingipsilateralsupraclavicularnodesStagingHistologicGradeTreatmentSurgeryChemotherapyTargetTherapyRadiationTherapyEndocrineTherapyTreatmentTypesofTreatment:LocalandSystemicLocalSurgeryRadiationTherapySystemicChemotherapyEndocrineTherapyTargetTherapySurgeryBreastconservationtherapyStageI,stageII,andsometimestageIIIcarcinomasLumpectomy,axillarylymphadenectomy,andpostoperativeradiationtherapyContraindications:tumors>5cm,grossmultifocaldisease,anddiffusemalignantmicrocalcificationsLocalrecurrencemorethanmastectomysofollowupimportantModifiedradicalmastectomy(1948,mostcommonmastectomyprocedureforinvasivebreastcancer)EntirebreastandaxillarycontentsareremovedPectoralismusclesremainsSurgeryHalstedradicalmastectomy(1894)Removesbreast,axillarycontents,andpectoralismajormuscleCosmeticallydeformingOnlyindicatedwhenpectoralismuscleinvolvedSimplemastectomyAllbreasttissueisremoved,axillarycontentsnotremovedTreatmentfornon-invasivebreastcancerRadiationUtilizedforprimaryandmetastaticdiseaseUsefulinbreastconservationtherapytoreducerateofrecurrence.RadiateentirebreastChemotherapyChemotherapyEradicatesriskofoccultdistantdiseaseinstageIandstageIIpatients.Allpatientswithaxillarynodeinvolvementarecandidatesalongwithpatientswithnegativeaxillarynodeinvolvementwhoarehighriskbyotherprognosticindicators.Exampletreatmentis6monthsofcyclophosphamide,methotrexateoradriamycin,andflourouracilalongwithpaclitaxel.ImprovementindiseasefreeintervalandoverallsurvivalChemotherapyRegimensCMFCAFACTAC6–12CyclesChemotherapyEndocrineTherapyTamoxifenisaselectiveestrogenreceptormodulatorwhichbindstoandinhibitsestrogenreceptorsignalinginthebreast.Itiseffectiveinbothpre-andpost-menopausalwomen.5yearsofadjuvanttherapywithTamoxifen20mg/dhasbeenshowntoreducebreastcancerrecurrencesby47%andmortalityby22%.Aseffectiveaschemotherapyinpost-menopausalpatientswithestrogenreceptorpositivetumorsEndocrineTherapyAromatase

istheenzymefoundinfat,

adrenalglands,breasttissue,andtumorcells,responsibleforconvertingothersteroidhormonesintoestrogen.Itisthesourceofestrogeninpost-menopausalwomen.Aromataseinhibitors(AIs)havenoeffectonovarianestrogenproduction.AIs

arerecommendedforpost-menopausalwomen.Myalgias,bonelossandfracturecanoccur.TheexactdoseanddurationofAIsisbeinginvestigated.Drugs:Anastrozole,Exemestane,Letrozole.EndocrineTherapyTargettherapyHer-2:positiveHerceptinTargetTherapyThespreadofbreastcancerLocalspreadLymphaticmetastasisSpreadbythebloodstreamLocalizationoftherecurrenceatautopsyLocalizationofthe1stsiteofthemetastasesPrognosticFactorsSizeNodesStageGradePloidyS–PhaseNecrosisHER-2/neuPrognosticFeaturesTumorsizeimportantprognosticfactorPoorprognosticfeaturesoftumor:Presenceofedemaorulcerationofskin,massfixedtochestwallorskin,satelliteskinnodules,peaud’orange(dermallymphaticinvasion),skinretractionanddimpling,andinvolvementofmedialportionofinnerlowerquadrantinvolved.Axillarynodestatus:BestsourceofpredictingsurvivaloroutcomeN0has10yearsurvivalrateof60%N1has10yearsurvivalrateof50%N2has10yearsurvivalrateof20%If10ormorenodesarediseased(N3)10yrsurv.Rateis14%Poorprognosticfeatureofnodes:Capsularinvasion,extranodalspread,andedemaofarmDistantmetastasesisverypoorprognosticindicatorPostiveestrogenandprogesteronereceptorindicateslikelyresponsetohormonaltreatmentandisapositiveprognosticindicatorBreastCancerPathologyInsitubreastcancers：

85%DCIS(ductalcarcinomainsitu)15%LCIS(lobularcarcinomainsitu).Invasivebreastcancers.Otherspecialtypes.DuctalCarcinomainSituDC