Introduction:
Breast cancer(mammary cancer) is one of the most common malignant tumors in women. The incidence rate is 7-10% of all kinds of malignant tumors in the body. After women are second only to uterine cancer, it has become a major cause of threat to women's health. Its incidence is often related to heredity, and between 40 and 60 years old, the incidence of women before and after menopause is higher. It is one of the most common malignancies that usually occurs in breast glandular epithelial tissue, which seriously affects women's physical and mental health and even life-threatening. Breast cancer is rare in men, and only about 1-2% of breast patients are male.
Cause:
Several major factors known to induce breast cancer:
1 Age: In women, the incidence rate increases with age, is rare before menarche, and is rare before 20 years old, but the incidence rate rises rapidly after 20 years old, 45 to 50 years old, but relatively flat The incidence rate after menopause continues to rise, reaching the highest peak around 70 years old. Mortality also rises with age, and mortality increases gradually after age 25 and continues to rise until old age.
2 Genetic factors: Women in the family have a history of breast cancer in the first-degree family, and the risk of breast cancer is 2 to 3 times higher than that of the normal population.
3 Other breast diseases.
4 Menarche age: The risk of onset of menarche earlier than 13 years is 2.2 times that of those older than 17 years old.
5 Menopause age: The risk of menopause older than 55 years is greater than that of less than 45 years old.
6 First pregnancy age: The risk increases gradually with the delay of the primiparous age. The risk of primiparity after 35 years of age is higher than that of those without birth history.
7 Postmenopausal supplementation of estrogen: Long-term use of estrogen during menopause may increase the risk of breast cancer.
8 oral contraceptives.
9 Food: Especially a fatty diet can increase the risk of breast cancer.
10 Drinking alcohol.
11 Weight gain may be an important risk factor for breast cancer in postmenopausal women.
12 virus infection
13 radiation effects: easy to increase the risk of breast cancer
14 mental factors: anxiety, stress can inhibit the immunity of anti-cancer
(two) pathogenesis
(1) Genetic factors: Li (1988) reported that young people with soft tissue malignant tumors in the United States, and their children have breast cancer, which is breast cancer syndrome. Studies have shown that some patients in the female mammary gland are caused by the transmission of genetic genes, that is, the younger the age of onset, the greater the genetic predisposition. With the in-depth study of the pathogenesis of hereditary breast cancer, there may be some elaboration in the future. The characteristics of hereditary breast cancer are: 1 the age of onset is mild; 2 is easy to bilateral; 3 in the premenopausal breast cancer patients, their relatives are also prone to premenopausal disease.
(2) Gene mutations: Oncogenes can have two synergistic stages but differ in terms of the initiation phase and the initiation phase. At present, the relationship between oncogenes and their products and the occurrence and development of breast cancer has concluded that there are several oncogenes involved in the formation of breast cancer; the first introduction of oncogenes by normal cells does not necessarily cause tumors, which may involve multiple times. Carcinogenesis occurs; oncogenes not only participate in cell mutations during the initiation phase, but also play a role in the formation of breast cancer; in the process of normal breast epithelial-proliferative-carcinogenesis, different genes may be involved.
1 Radiation exposure can cause genetic damage, causing mutations in the chromosomes, leading to breast cancer.
2 endocrine hormones have a proliferative effect on mammary epithelial cells. Animal experiments show that estrogen mainly acts on the stage of cancer formation, while normal female endocrine hormones are in a state of dynamic equilibrium, so the occurrence of breast cancer is directly related to endocrine disorders.
Estrogen,ProgesteroneProlactin, androgen and thyroid hormone are related to the development of breast cancer. Estrogen levels in the mammary gland are several times higher than estrogen levels in the blood. Cholesterol and its oxidation products in the breast, cholesterol epoxide, induce hyperplasia of mammary epithelial cells, and cholesterol epoxide itself is a mutagenic, carcinogenic, cytotoxic compound.
3 exogenous hormones, such as oral contraceptives, therapeutic estrogen, androgen, etc., can cause imbalance of the above endocrine hormones in the body, resulting in a corresponding effect.
4 The relationship between dietary components and certain metabolites such as fat and breast cancer: The incidence of hypertrophic mice with mammary gland tumors caused by animal and vegetable oils increased. In the initial stage of the carcinogenic effect of carcinogens on mice, increasing the amount of fat does not work, but in the stage of triggering, the amount of fat is increased and the tumor growth is rapidly accelerated.
(3) Decreased immune function of the body: The body's immunity is reduced, and the carcinogens and carcinogen-induced mutant cells cannot be removed in time. It is one of the important factors in the host of breast cancer. With the increase of age, the immune function of the body is especially It is a decline in cellular immune function, which is one of the reasons why most tumors including breast cancer are prone to occur in middle-aged and old age.
(4) Neurological status: Many breast cancer patients have had trauma before the onset of the disease, indicating that the nervous system is over-stressed and may provide favorable conditions for the induced mutation of the carcinogen.
symptom:
1. Symptoms and signs Early onset of breast cancer can be asymptomatic, and may develop local and systemic symptoms as the disease progresses.
(1) Lump: It is the first symptom of breast cancer. According to foreign reports, most of the masses are located in the outer upper quadrant, followed by the inner upper and the nipple areola area, and the lower part is less. The size of the tumor is different, and it is more common in the size of 2 to 3 cm. Most of them are single-shot, and occasionally multiple. The masses are mostly round or oval, and the borders are unclear. They are generally indurated and have poor mobility.
(2) Pain: Most breast cancer patients lack pain symptoms. Breast cancer is not easily detected early because of less pain. Pain often manifests as tingling, pain or dull pain in the breast, such as periodic pain in the breast with cystic hyperplasia of the breast.
(3) Breast skin changes: The breast tissue is surrounded by a superficial fascia located under the skin, and the deep fascia is connected by a Cooper ligament. Because the superficial fascia is connected to the skin, when the breast cancer invades the Cooper ligament between the breasts to shorten it, it will pull the skin and make the local skin sag, like a dimple, called "dimple sign." In addition, adhesion of the tumor directly to the skin may also cause this condition. Dimples can appear earlier in breast cancer and are more pronounced when the affected arm moves up and down.
1 redness and swelling: tumors with faster growth and larger volume may have superficial venous engorgement and elevated local skin temperature. The skin may turn red when the tumor is close to the surface of the skin. If the cancer cells block the subcutaneous lymphatics, skin edema can occur and an "orange peel-like change" can occur.
Breast skin redness and swelling are most typical of inflammatory breast cancer. The skin color is light red or deep red, and the limited piece quickly spreads to most breasts and even whole milk. At the time of palpation, the whole breast thickened and hardened, the skin temperature increased, and it was swollen and rough, and there was obvious orange peel-like change.
2 skin ulceration: the tumor develops to the advanced stage, the tumor grows up, can make the skin bulge, such as insufficient blood supply, with the skin redness, thinning, can occur ulceration. Patients often have pain, sometimes severe pain. Because the wound has a large amount of necrotic tissue and bloody secretions exudation, patients often have signs of weight loss and anemia.
3 skin nodules: when the nodules are distributed around the skin of the lesion, it is called a satellite nodule, which is caused by the direct infiltration of cancer cells along the lymphatic vessels, mammary ducts or subcutaneous fascia. Satellite nodules can be single or several, and the latter are mostly distributed.
4 armor cancer: several skin nodules are fused into a piece, covering the entire affected side of the chest wall, and can extend to the back of the armpit to the back, even beyond the midline of the sternum, extending to the contralateral chest wall. The skin of thick and hard plates is like the armor worn by ancient soldiers, so it is called armor cancer.
(4) Maize wheel corridor change: When the mass is large, the mammary gland may have local uplift and the mammary gland enlarges. When the tumor affects the skin or the chest muscles, the breast can be hardened and shrunk. When the patient is sitting, the affected breast can be raised.
(5) Nipple areola changes:
1 nipple retraction and orientation change: the nipple is flat, retracted, sunken, and changed in orientation until it is completely retracted into the areola, and the nipple is not visible. The nipple depression caused by breast cancer is different from congenital nipple retraction. The latter can often be pulled by hand, and the nipple retraction caused by breast cancer cannot be pulled out, and the lumps can be swollen under or around the nipple.
2 Eczema-like changes in the nipple: initial nipple itching, nipple epithelial thickening, desquamation, exudate, gradual erosion, erosion and repeated scarring, sputum, red granulation after the exfoliation of the areola skin, the nipple can slowly flatten And finally disappeared.
(6) nipple discharge: nipple discharge with lumps, breast cancer accounted for a larger proportion. The discharge may be colorless, milky white, light yellow, brown, bloody, etc.; it may be watery, bloody, serous or purulent; the amount of overflow may be more or less, and the interval time is also inconsistent.
(7) Regional lymphadenopathy:
1 腋 lymph node metastasis: the most common, when the metastases are small, the lymph nodes are not swollen, or the swelling is not obvious, it is difficult to reach. Metastatic lesions generally involve the lateral lymph nodes of the pectoral muscles. The touch is hard, irregular, and the activity is poor.
2 supraclavicular lymph nodes: metastatic lymph nodes are mostly located in the left supraclavicular fossa or the right supraclavicular fossa, the lesion is hard, generally small.
3 internal mammary lymph nodes: metastasis is often not significant, there is no method of diagnosis before surgery, only when the tumor is born in the inner half of the breast, it can be found in the ultra-radical surgery.
4 Upper extremity edema is widely metastasized from axillary lymph nodes: palpation can reach the axillary fossa or metastatic lymph nodes with fixed and fusion swelling on the clavicle.
(8) Distant metastasis: Breast cancer can be metastatically transferred through the blood or lymphatic route. The most common sites are lung, pleura, bone, liver, brain and soft tissue.
1 lung and pleural metastasis: lung is a common metastatic site of breast cancer, often manifested as nodular multiple metastasis, mostly bilateral. Cough and dyspnea, hemoptysis, chest pain, etc. can occur. Pleural metastases are mainly cough, fatigue, weakness, difficulty breathing, and some patients have chest pain.
2 bone metastasis: the most vulnerable parts are spine, ribs, pelvis and long bones, and can also appear in the scapula, skull and so on. Mainly manifested as pain.
3 liver metastasis: When the liver metastases are small, there are no special symptoms. When the mass is larger, or more extensive, there may be hepatomegaly, pain in the liver area, loss of appetite, and bloating. In the advanced stage, jaundice ascites embolism can occur.
4 brain metastasis: brain metastasis is mainly manifested by meningeal and brain parenchymal metastasis, headache and mental state changes are common symptoms, and may appear brain dysfunction, visual impairment. If the spinal membrane is invaded, there may be back pain, sensory disturbance, bladder dysfunction, difficulty in urinating, and the like.
2. Clinical Staging The most commonly used international TNM classification staging is to design and analyze therapeutic effects for unified treatment, and to comply with international programs.
(1) The general rule of the TNM staging system: The TNM staging system is mainly based on the anatomical extent of the disease, and the classification is only applicable to cancer, and needs to be confirmed by histology.
T (Primary tumor): The scope of the primary tumor should have physical examination and imaging examination data.
N (regional nodes): regional lymph nodes, classified according to physical examination and imaging examination.
M (metastasis): The state of distant metastasis should be based on physical examination and imaging examination.
(2) International Anti-Cancer Alliance (UICC) classification and staging:
1 clinical classification:
T: primary tumor.
Tis invasive precancerous carcinoma (in situ carcinoma), non-invasive ductal carcinoma, non-invasive lobular carcinoma, Paget disease that is confined to the papilla mammary gland without significant mass
The tumor was not touched in the T0 breast.
The T1 tumor has a maximum diameter of ≤2.0 cm.
T1a has no adhesion to the pectoral fascia or chest muscles.
T1b has adhesion to the pectoral fascia or chest muscles.
The T2 tumor has a maximum diameter > 2.0 cm, but ≤ 5.0 cm.
T2a has no adhesion to the pectoral fascia or chest muscles.
T2b has adhesion to the pectoral fascia or chest muscles.
The T3 tumor has a maximum diameter > 5.0 cm, or two or more tumors.
T3a has no adhesion to the pectoral fascia or chest muscles.
T3b has adhesion to the pectoral fascia or chest muscles.
T4 regardless of tumor size, as long as directly invading the chest wall or skin, chest wall refers to the ribs, intercostal muscles and anterior serratus, excluding the pectoralis major.
T4a tumors were fixed with the chest wall.
T4b breast skin edema, infiltration or ulceration (including orange peel-like changes, or satellite nodules confined to the ipsilateral breast).
T4c includes both T4a and T4b.
T4d inflammatory breast cancer.
The Tx tumor has been removed and the data is unknown.
N: regional lymph nodes.
N0 ipsilateral axillary fossa did not touch the active enlarged lymph nodes.
There are active lymph nodes in the ipsilateral armpit of N1.
N1a considers no metastasis within the lymph nodes.
N1b considers metastasis within the lymph nodes.
N2 ipsilateral axillary lymph nodes fuse into a mass or adhere to other tissues.
N3 ipsilateral supraclavicular metastasis or upper limb lymph node metastasis or upper extremity edema (upper limb edema or obstruction due to lymphatic vessels).
The Nx lymph node status is unknown.
M: Transfer in the distance.
M0 has no evidence of distant transfer.
M1 has a distant metastasis, including skin infiltration more than the ipsilateral breast.
M1 further indicates the scope with the following signs:
Lung PUL: bone marrow MAR; bone OSS; pleural PEL; liver HEP; peritoneal PER; brain BRA; skin SKI; lymph node LYM;
2 clinical staging:
Tis carcinoma in situ: papillary Paget disease, non-invasive ductal carcinoma, non-invasive lobular carcinoma.
Phase I T1a N0-1aM0.
T1b N0-1bM0.
T0 N1bM0.
Phase II T1a-1bN1bM10.
T2a-2b N0-1aM.
T2bN1bM0.
Phase III any T3 and any NM0.
Any T and any N2M0.
Any T and any N3M0.
Phase IV any T, any N, M1.
(3) TNM classification and staging jointly developed by the American Cancer Association (TJCC) and the International Union Against Cancer:
1TNM classification:
T: primary tumor.
The primary tumor of Tx was not determined.
The primary tumor of T0 was not touched.
Tis primary cancer: intraductal carcinoma, lobular carcinoma in situ or untouched Paget's disease (some lumps are classified by size of the lumps).
The diameter of T1 tumor is ≤2.0cm maximum.
The maximum diameter of T1a tumor is ≤0.5cm.
The maximum diameter of T1b tumors is <1.0 cm, >0.5 cm.
The maximum diameter of the T1c tumor is >1.0 cm, but ≤2.0 cm.
The maximum diameter of T2 tumors is >2.0 cm, <5.0 cm.
The T3 tumor has a maximum diameter of >5.0 cm.
T4 Regardless of the size of the tumor, as long as it directly invades the chest wall and the skin (the chest wall refers to the ribs, the intercostal muscles and the anterior serratus, excluding the pectoral muscles).
T4a invades the chest wall.
T4b Breast skin edema (including orange peel-like changes), ulcers and satellite nodules on the ipsilateral breast.
T4c and above coexist (T4a+T4b).
T4d inflammatory breast cancer.
N: regional lymph nodes.
Nx cannot assess regional lymph nodes.
N0 no regional lymph nodes are accessible.
There are single or multiple metastatic lymph nodes in the i1 ipsilateral armpit.
N2 ipsilateral axilla has single or multiple metastatic lymph nodes that fuse with each other or with other tissues.
Single or multiple internal mammary lymph node metastases on the same side of N3.
M: Transfer in the distance.
Mx cannot determine if there is a distant transfer.
M0 has no distant transfer.
M1 has distant metastases (including single or multiple lymph node metastases on the ipsilateral clavicle). At M1, the specific part is marked with the corresponding symbol.
2TNM staging:
Phase 0 TisN0M0.
Phase I T1 N0M0.
Phase IIa T0N0M0.
T1N1M0.
T2N0M0.
Phase IIb T2N1M0.
T3N0M0.
Phase IIIa T0N2M0.
T2N2M0.
T2N3M0.
T3N1M0.
Phase IIIb T4 any NM0.
Any TN3M0.
Phase IV any T any NM1.
3 pathological classification (PTNM):
PT primary tumor (consistent with the above T classification).
PN regional lymph nodes.
Patients with PNx who are unable to make regional lymph nodes (including lymph nodes that have been removed before or without lymph nodes for pathological studies).
PN0 histology revealed no regional lymph nodes.
The ipsilateral axilla of PN1 can reach the transferred single or multiple lymph nodes.
PN1a has only a small shift (<0.2cm).
PN1b has one or more metastases (>0.2 cm).
PN1bi has a single or three lymph node metastases, either >0.2 cm, but the metastatic lymph nodes are <2.0 cm in diameter.
PN1bii 4 or more metastatic lymph nodes, any one of which was >0.2 cm, but the diameter of the metastatic lymph nodes was <2.0 cm.
One of the PN1biii metastases had invaded the lymph node capsule, but the maximum diameter of the lymph nodes was <2.0 cm.
The maximum diameter of the PN1biv metastatic lymph nodes is ≥ 2.0 cm.
The PN2 ipsilateral axillary metastatic lymph nodes fuse with each other or invade other tissues.
The lymph nodes in the ipsilateral inner breast zone are metastasizable.
PM has a distant transfer (consistent with the above classification).
4 pathological staging:
Phase 0 TisN0M0.
Phase I T1N0M0.
Phase II T0N1M0.
T1N1M0.
Phase IIa T0N1M0.
T1N1M0.
T2N0M0.
Phase IIb T2N1M0.
T3N0M0.
Phase IIIa T0N2M0.
T1N1M0.
T2N1M0.
T3N1-2M0.
Phase IIIb T4 any NM0.
Any TN3M0.
Phase IV any T any NM1.
diagnosis
There are many methods for the diagnosis of breast cancer. The most commonly used mammography is the pathological diagnosis. Generally, the image is checked first, and if there is any doubt, the pathological examination is performed. With the in-depth study of the close relationship between the pathological results of Western medicine and the syndrome type of TCM, the diagnosis of breast in Chinese medicine can not be underestimated. The ultimate goal of diagnosis is treatment. The combined diagnosis of Chinese and Western medicine will play a significant role in promoting the comprehensive treatment of Chinese and Western medicine.
First, the diagnosis of breast cancer - Western medical imaging
Early detection of breast cancer is important.
1 Ultrasound examination: microcalcification in the breast mass, marginal "burr" sign, aspect ratio greater than 1, the most likely cancer. Observing the peak flow velocity of cancer cells, the average density of color pixels, and the average density of blood vessels by semi-quantitative method and color capture technique are helpful for the differential diagnosis of benign and malignant tumors. The penetrating blood vessels and MVD are highly sensitive to the diagnosis of breast cancer.
2MRI examination: The positive rate of MIP reconstruction with paramagnetic contrast agent for breast cancer was 100%. MRS strongly suggests that the level of choline in breast cancer tissues is increased, and the water/fat ratio is significantly larger than that of normal tissues, which is an important criterion for diagnosing breast cancer.
3CT examination: thin-layer scanning can find a tumor with a diameter of 0.2 cm, and the related parameters of breast cancer increase are closely related to MVD. Better display of metastatic lymph nodes.
4X-ray examination: the most advantageous detection of breast cancer calcification, X-ray digital photography can help CAD. MWA and CMRP technology can improve the reliability of breast cancer.
5 infrared thermography: quantitative analysis of breast cancer hot zone temperature by digital quantitative system, calibration of the temperature difference between the lesion center and surrounding tissue, to determine the tumor good and malignant.
6 minimally invasive imaging: ultrasound guided biopsy for small lesions lacking image features, 3D CE PDU improved ultrasound imaging like CT guided biopsy
Second, the evaluation of Western medicine diagnosis of breast cancer
Comprehensive evaluation of needle aspiration cytology, analysis of cancer cell DNA content, carcinoembryonic antigen detection and mammography in the diagnosis of breast cancer; needle cytology has the highest diagnostic coincidence rate of 85.35 %; flow cytometry The false positive rate of DNA content in cells was the highest, being 34.20%; the false negative rate of mammography was the highest, being 44.54%; and the combined diagnosis of 4 indicators increased the diagnostic coincidence rate of breast cancer to 92.35%, and the false positive rate dropped. 1.96%, the false negative rate dropped to 5.93%. The combined diagnosis of 4 indicators can significantly improve the correct diagnosis rate of breast cancer and contribute to early diagnosis.
Breast aspiration cytopathology not only has important applicability to the diagnosis of breast diseases, but also has important value for early diagnosis and classification of breast cancer, especially for the identification of breast hyperplasia and breast fibroadenoma. The success rate of puncture is up to 100%, the early diagnosis rate is 16.9%, and the total diagnostic accuracy is as high as 98.6%. The needle aspiration cytopathology of the breast has the advantages of small trauma, simple and rapid, safe and reliable, economical and practical, accurate results, etc. Higher than the traditional diagnostic method, it is currently irreplaceable by any method, and has higher promotion and practical value.
3. Correlation between TCM Syndromes and Western Medicine Pathology
To study the characteristics of mammography of hepatic stagnation type breast cancer and to explore its pathological basis. In cases of liver stagnation and phlegm-type breast cancer, the breast type is mostly dense and mixed (78%). Abnormal vascular signs and perforation signs occur frequently (accounting for more than 80%). The frequency of axillary lymph node metastasis was low (12%).
diagnosis:
The main clinical diseases that need to be differentiated from breast cancer are:
1. Breast hyperplasia Mammary gland hyperplasia, also known as mammary gland malocclusion, is the most common non-inflammatory, non-neoplastic breast disease in women. More caused by women's endocrine dysfunction. The age of onset is mostly 20 to 40 years old. The incidence rate in developed countries is up to 1/3, and the domestic rate is about 50%. The main manifestation is the thickening of breast tissue. Later, it can touch the nodules of different sizes, with skin and breast. There is no adhesion at the rear. It happens in the upper quadrant of the breast, mostly bilateral. Patients are often accompanied by varying degrees of pain, which is obvious before menstruation and can be relieved or relieved after menstruation.
2. Breast duct dilatation This disease is also called plasma cell mastitis, which occurs mostly in middle-aged women aged 37-50. Mainly manifested as breast pain, nipple discharge, nipple can be invaginated, very similar to breast cancer.
The following points can be differentiated from breast cancer: 1 patients are younger, mostly around 40 years old. 2 nipple discharge is mostly serous or purulent, and a few can also be bloody. 3 thickened milk ducts are sometimes touched under the nipple or areola. 4 breast lumps are mostly located around the areola, accompanied by pain, and are closely related to large catheters. 5 The breast has an inflammatory manifestation or a history of inflammatory disease and a history of malnutrition, and the breast lumps may be reduced or enlarged. 6 ductography can show catheter dilation. 7 nipple discharge has a large number of inflammatory cells. 8 A large number of inflammatory cells or pus cells can be seen in the puncture of the breast mass. 9 Axillary lymph nodes are swollen, soft and tender.
3. Breast tuberculosis Breast tuberculosis has the following characteristics: 1 patients are mostly young and middle-aged women. 2 Most have a history of tuberculosis, or have tuberculosis in other parts. 3 lesions have a history of inflammation, when the mass is large and small, effective against anti-tuberculosis drugs. 4 The local part of the mass may have redness, rupture and other history, and some cysts are sac sexy. 5 swollen needles can be seen with cheese-like tissue, with thin pus. 6 has a history of nipple discharge, can be purulent. 7 A small number of patients with nipple discharge or pus aspirate, smear can be seen with tuberculosis. 8 Mammography X-ray examinations are mostly abnormal and have a light shadow. 9 There are breast tuberculosis and breast cancer coexist, accounting for about 5%.
4. The main differential analysis of breast fat necrosis is as follows: 1 lack of characteristic clinical manifestations, the disease is generally hard, irregular shape, similar to breast cancer. Generally divided into 2 types in clinical: glandular type, superficial, located in the subcutaneous of the breast, irregular shape, inflammatory changes, easy to diagnose as breast tuberculosis; glandular type, the mass is located in the mammary gland, lack of features, Easy to be misdiagnosed as breast cancer. 2 Lack of effective auxiliary examination, especially in middle-aged and elderly women, the mass is located under the skin, and the mass does not grow or shrink, and the breast has a history of trauma. Metastatic lymph nodes should be removed for biopsy.
5. Acute mastitis Acute mastitis is common in secretory breasts, especially 3 to 4 weeks after priming. Most of the pathogens are Staphylococcus aureus and a few are streptococcus, and the infection is mostly caused by retrograde infection of the nipple. It can also cause infection by directly invading the milk duct by the bacteria and ascending to the glandular lobules.
At the beginning, the mammary gland locally shows redness, swelling, heat, pain, and swelling of the surrounding lymph nodes. When necrosis occurs, there may be abscesses. The breast is swollen, active, hard and tender, and when the abscess is formed, the mass softens and fluctuates. At the same time, I feel general discomfort, chills, and high fever. X-rays show a clear blur of flaky dense shadows, thickened skin, subcutaneous fat showing disorder, more blood vessels and lymphatic shadows, and cord-like connective tissue blurring, sometimes accompanied by sediment Calcification lesions.
Acute mastitis compared with breast cancer: 1 breast skin without orange peel-like changes, no satellite nodules. 2 breast mass rarely occupies the whole milk, more than half of them have cystic sex. 3 breast mass is less common. 4 Most body temperature and white blood cell count increased. 5 anti-inflammatory treatment is effective. 6 needles are mostly pus or inflammatory cells, which is helpful for diagnosis.
6. Chronic mastitis and abscess often have abscess formation, touched into a lump, the edge is unclear, the capsule is sexy, may have mild tenderness, and has a slight adhesion to the surrounding tissue. X-rays are seen as locally dense lamellae with unclear borders and slightly thickened skin. The breast abscess can be characterized by a round or elliptical irregular dense shadow with a clear edge. The central part has no structure and the surrounding area can be lightly densified due to edema.
7. Simple cysts of the breast are more common in the middle of the breast, mostly due to the proliferation and enlargement of the ductal epithelial cells of the breast, leading to prolongation, distortion, and folding of the catheter. At the fold, the catheter can be necrotic due to ischemia, forming a cyst, and the wall is atrophied. The X-ray film shows a round, elliptical dense shadow with uniform density and smooth edges. The translucent halo appears due to the cyst's compression of the surrounding fat tissue. The single cyst is the original shape, the multiple cysts are oval, and the cyst wall is smooth and tidy.
8. Lactocyst cysts are rare. A cyst is formed during a lactation due to a blockage of the milk duct. The cyst can be single or multiple, grayish white, containing milk or cheese-like material. The wall thickness varies from one to another and can occur anywhere, with deeper breasts being the most common. The X-ray shows a circular or elliptical translucent area, which is small in size, generally 1 to 1.5 cm. Occasionally, there is >3 cm, the edge is smooth and sharp, and the density is slightly lower than fat.
9. Breast fibroma Breast fibroma occurs mostly in young women aged 20 to 25 years. It consists of glandular and fibrous tissues. There are two types of juvenile and giant fibroadenomas, but they are qualitatively different. The occurrence of this disease is closely related to estrogen, and there are two types of single and multiple. Single breast fibroma occurs in the upper quadrant of the breast, mostly small oval lumps, and the fibroids that grow before menarche can grow larger. The surface is smooth, the texture is tough, the tumor boundary is clear, and it has no adhesion to the skin and surrounding tissues. It is easy to push in the breast and has a sliding feeling. It grows slowly and does not change within a few years, but it can increase rapidly during pregnancy. Multiple breast fibromas are uniform, medium-hard, and vary in size. Larger lobulated, smooth, tough, well-defined, with calcified particles in the center of the tumor.
There is a capsule outside the breast fibroadenoma, the cut surface is grayish white, bright, not smooth, and the most visible irregular cracks in the cut surface are the expanded milk duct.
The giant fiber tumor X-ray film can be seen as a large mass of uniform mass, showing a lobulated shape. The surrounding tissue is compressed to form a translucent area, and the center of the tumor may have calcification, accompanied by thickening of blood vessels and varicose veins.
Although breast tumors are small, the chance of malignant transformation is large, so they must be treated seriously.
10. Intraductal papilloma The intraductal papilloma often occurs in women between the ages of 40 and 50, and 75% occur in large breast ducts close to the nipple, or in cysts connected to the milk duct near the nipple. Can be single or multiple. The tumor is small, but often with fluff and more thin-walled blood vessels, it is very easy to bleed.
There is no pain in the clinic. During the non-menstrual period, the bloody liquid overflows from the nipple, and the mass is not touched. If the lumps are found, it is usually a few millimeters in diameter and is located in the areola area. The breast tumor is often round, hard and does not stick to the skin. It can be pushed and gently pressed to the tumor, which can have a nipple bloody discharge.
About 6% to 8% of papillary tumors in the duct can be cancerous, so angiography should be performed before surgery to confirm the diagnosis. Surgery should be completely removed, and the diseased milk duct and its surrounding glandular tissue should be removed together to avoid future complications. Older women should be treated with simple breast resection.
complication:
A common complication of breast cancer is "tumor loss of appetite - cachexia syndrome." Loss of appetite is one of the causes of cachexia and a clinical manifestation of cachexia.
As with the cachexia of other advanced cancers, patients may experience loss of appetite or anorexia, weight loss, fatigue, anemia, and fever, severe failure and even death.
Common complications of breast cancer surgery
Breast cancer surgery is a surface surgery, but due to the wide range of surgery and trauma, there may be multiple complications after surgery. Common surgical complications associated with breast tumors are:
First, bleeding is one of the common complications after surgery. This complication can occur after a lumpectomy or radical resection. The cause of bleeding is often:
1, intraoperative hemostasis is not complete, leaving active bleeding points;
2, due to the application of continuous negative pressure drainage, position change or severe cough, etc., the electrocoagulated clots fall off or the ligated silk slips off, leading to drainage bleeding;
3, preoperative application of chemotherapy or hormone drugs to make the wound easy to ooze blood.
Complete hemostasis during operation, especially the intercostal vascular penetration of the sternum should be ligated; attention should be paid to the bleeding point of the muscle stump and section, ligation or electrocoagulation; the wound should be washed and the active bleeding should be checked carefully. Pay attention to the position of the drainage tube, proper pressure dressing can help prevent postoperative bleeding; in addition, pay attention to the patency of the negative pressure drainage tube and the drainage, the nature of the drainage fluid, for patients with poor coagulation mechanism should be targeted Timely symptomatic treatment.
Second, effusion refers to the accumulation of fluid between the flap and the chest wall or the armpit, resulting in the flap not being able to cling to the wound. It is also one of the common complications after breast tumor surgery. Common reasons are:
1. Poor drainage makes the exudate of the wound not accumulate in time and accumulate;
2, blood coagulation in the wound to form a clot, can not be drained, and later liquefied to form effusion;
3, when dissecting the lymphatic fat around the iliac vein, some small lymphatic vessels are not ligated with poor drainage to form effusion, which usually occurs outside the armpit;
4, the use of electric knife to dissect the iliac vein when the opportunity to accumulate more than the use of scalpel, may have a certain impact on the healing of the wound, and after the electrosurgical anatomy, some small lymphatic vessels are temporarily closed and under negative pressure After being attracted, it is open again, causing effusion;
5, In addition, the flap tension is too large to make the wound difficult to cover and the drainage tube is removed too early, etc. also have a certain relationship.
During the operation, the ankle anatomy should be ligated when there is a small exudate, reduce the tension of the flap, keep the negative pressure smooth, and proper pressure dressing will help reduce the occurrence of effusion. If there is effusion, if the amount is small, you can repeatedly use the empty needle to suck; if the amount is large or the multiple suction is invalid, it is recommended to reset the negative pressure suction or the skin drainage and pressure dressing.
Third, flap necrosis is also a common complication of postoperative breast cancer, due to delayed healing of skin necrosis may affect subsequent treatment. Radical mastectomy often requires more skin to be removed, and the range of separation of the flap is larger. The peeling of the flap is too thin or uneven, which may damage the capillary in the dermis and affect the blood supply of the postoperative flap; or When the flap is sutured, the tension is too large. When the wound is effusion, the ischemic necrosis of the flap may be caused. Sometimes the skin burn or vascular coagulative embolism may cause the flap to be necrotic due to improper operation with an electric knife. Skin flap necrosis generally showed that the ischemic skin became pale after 24 hours, and gradually showed blue-violet edema with small blisters on the surface. After 3 to 7 days, the boundary of the necrotic area gradually became clear, and the skin gradually became black and hard.
Reasonable design incision before surgery to avoid too long flap on one side; pay attention to the level of flap separation, reduce flap tension, and skin graft if necessary; avoid fluid accumulation, proper dressing and other measures will help reduce flap necrosis . If flap necrosis occurs, the necrotic flap can be removed after the boundary of the necrotic area is obvious. Such as marginal necrosis of the incision, the area is less than 2cm, after the debridement, wet dressing, dressing change, often self-healing; those with larger necrotic area should be skin grafted; if the necrotic area is large and the patient is unwilling to receive skin grafting, often The wound healing is delayed, and the epidermis that grows later is often white and thin, and is easily broken after rubbing.
Fourth, upper limb edema
After radical mastectomy, the upper limb edema is easily caused by the lymphatic and blood return of the upper limb. The incidence of upper extremity edema is reported from 5% to 40%. The incidence of severe upper extremity edema has decreased significantly in recent years, not exceeding 5%. Causes of severe reflux disorders in the upper limbs:
1. The axillary cleaning range is improper, destroying the local collateral circulation. In the past, the anatomy of the lymphatic fat around the iliac vein often deletes the tendon sheath at the same time, which also affects the lymphatic reflux after surgery. Therefore, if there is no obvious enlarged lymph node during operation, it is not necessary to remove the vascular sheath. If the upper axilla has a swollen lymph node that invades the tendon sheath, it is often completely non-surgical to achieve the goal of radical cure.
2, there is effusion or infection in the sputum area, causing local congestion, fibrosis, scar formation hindered the establishment of collateral circulation.
3, postoperative treatment of the upper and lower clavicle and sacral area, causing local edema, connective tissue hyperplasia, local fibrosis and then edema.
Upper extremity edema can occur several days after surgery, and several years later, the swelling is often in the upper arm, or in the forearm or back of the hand. Regular upper limb function after surgery, avoiding excessive physical exertion of the upper limbs and avoiding infection of the upper limbs can reduce the occurrence of upper extremity edema. Once edema occurs in the upper extremities, symptomatic treatment can only be applied to reduce edema.
Fifth, upper limbs and hand muscle atrophy are often caused by injury to the brachial plexus or its sheath during surgery, and there is often atrophy of the small fish muscle.
treatment:
Western medicine treatment
Surgical treatment is still one of the main treatments for breast cancer. There are many kinds of surgical procedures, and there is no consensus on their choice. The general development trend is to minimize the surgical damage and try to retain the breast shape for early breast cancer patients under the condition of equipment. Regardless of the type of surgery, you must strictly adhere to the principle of radical cure, retaining function and shape.
(1) Surgical indications Halsted's first radical surgery for breast cancer, due to reasonable operation and clear curative effect, has become the standard way for people to treat breast cancer in the past 100 years. In the past half century, a lot of exploratory revisions have been made to the breast cancer surgery. The general trend is not only conservative and expanding, but it is still debated. Local excision of the breast and total mastectomy are representative of conservative surgery. Postoperative need to be supplemented with radiotherapy, radiation dose is not the same, generally 30 ~ 70Gy, for the strict choice of limited early cancer, can receive better results. But whether it is a routine treatment for early breast cancer and how to choose such early cancer accurately, it is difficult to draw conclusions.
(two) surgical contraindications
1. Systemic contraindications:
1 distant metastasis of the tumor.
2 years old and frail can not tolerate the operator.
3 The general situation is poor, showing the septic quality.
4 important organ dysfunction can not tolerate the operator.
2. Contraindications for localized lesions: Patients with stage III have one of the following conditions:
1 breast skin orange-like edema is more than half of the breast area;
2 satellite-like nodules appear on the breast skin;
3 breast cancer invades the chest wall;
4 clinical examination of parasternal lymphadenopathy and confirmed as metastasis;
5 upper limb edema on the affected side;
6 The pathology of the supraclavicular lymph nodes was confirmed as metastasis;
7 inflammatory breast cancer. There are two of the following five situations:
1 tumor collapse;
2 breast skin orange-like edema accounts for less than l/3 of the total breast area;
2 cancer and pectoralis major muscle fixation;
4 The maximum length of the lymph nodes exceeds 2.5 cm;
5 腋 lymph nodes adhere to each other or to the skin, deep tissue.
(three) surgical methods
1. Radical mastectomy
2. Extensive radical mastectomy for breast cancer
3. Syndrome radical surgery (modified radical mastectomy)
4. Simple breast resection
5. less than the total breast resection
Radiation Therapy
Radiation therapy is a major component of breast cancer treatment and is one of the local treatments. Compared with surgical treatment, it is less restricted by anatomy, patient's physical condition and other factors, but the effect of radiation therapy is affected by the biological effects of radiation. It is more difficult to achieve the goal of "completely killing" tumors with the currently used radiotherapy facilities, and the effect is inferior to surgery. Therefore, most scholars do not advocate radiotherapy for curable breast cancer. Radiation therapy is often used for comprehensive treatment, including adjuvant therapy before or after radical surgery, and palliative treatment for advanced breast cancer. In the past 10 years, the comprehensive treatment of early breast cancer with local excision has been increasing, and there is no significant difference between curative effect and radical surgery. Radiation therapy plays an important role in narrowing the scope of surgery.
Relationship between hormone receptor assay and endocrine therapy
Hormone receptor measurement has a clear relationship with the efficacy of breast cancer: 1 estrogen receptor-positive patients with endocrine therapy are 50% to 60% effective, while negative patients are less than 10% effective. Simultaneous determination of progesterone receptors can more accurately estimate the effect of endocrine therapy, both of which are more than 77% effective. The relationship between the content of the receptor and the therapeutic effect is positively correlated, and the higher the content, the better the therapeutic effect. 2 Receptor-negative cells are often poorly differentiated. Recipient-negative patients are prone to recurrence after surgery. Regardless of lymph node metastasis, the negative prognosis of patients with negative receptors was worse than those with positive ones. Positive patients tend to have skin, soft tissue or bone metastases if they have recurrence, while negative ones tend to visceral metastases. 3 hormone receptor measurement has been used to develop postoperative adjuvant therapy. Receptor-positive patients, especially postmenopausal cases, can use endocrine therapy as a postoperative adjuvant therapy. Pre-menopausal or hormone receptor-negative patients are mainly adjuvant chemotherapy.
Fourth, endocrine therapy
Endocrine therapy for breast cancer is non-cure, but it can receive varying degrees of palliative effects for hormone-dependent breast cancer. The more estrogen receptor (ER) content in the cytoplasm and nucleus of cancer cells, the stronger the hormone dependence. It should also be borne in mind that breast cancer that occurs before amenorrhea differs from breast cancer that occurs after amenorrhea.
Chemical drug treatment
(I) Principles of adjuvant chemotherapy Most breast cancers are a systemic disease that has been confirmed by numerous experimental studies and clinical observations. When breast cancer develops to more than 1 cm, when it is clinically palpable, it is often a systemic disease, and there may be distant micrometastases, but it cannot be found by current examination methods. The purpose of surgical treatment is to maximize the local control of the primary tumor and regional lymph nodes, reduce local recurrence, and improve survival. However, after tumor resection, residual tumor cells still exist in the body. Based on the concept of breast cancer at the time of diagnosis, the purpose of systemic chemotherapy is to eradicate residual tumor cells in the body to improve the cure rate of surgery.
(two) preoperative adjuvant chemotherapy
1. The significance of preoperative chemotherapy
(1) Control micrometastases as soon as possible.
(2) Degenerate or partially kill cancer cells that spread in the primary cancer and its surroundings to reduce postoperative recurrence and metastasis.
(3) Progressive breast cancer and inflammatory breast cancer limit the implementation of surgical treatment. Preoperative chemotherapy can shrink the tumor for surgical resection.
(4) The effect of preoperative chemotherapy can be evaluated according to the resected tumor specimen as a reference for selecting a chemotherapy regimen after surgery or recurrence.
2. Methods of preoperative chemotherapy
(1) Preoperative systemic chemotherapy: Shanghai Medical University Cancer Hospital since 1996, 96 patients with breast cancer were treated with preoperative oral pyrimidine mustard, 15 mg daily, LD stopped for 2 days, and the total dose was 45 mg. Compared with the 94 control group, the 5-year survival rate of the stage III patients was 56.3% in the medication group and 39.3% in the control group.
(2) Preoperative arterial infusion chemotherapy: There are two methods of intubation of the internal thoracic artery and intubation of the subclavian artery.
(three) postoperative adjuvant chemotherapy
1. Indications for postoperative adjuvant chemotherapy
(1) Premenopausal women with positive axillary lymph nodes, regardless of estrogen receptor status, have prescribed chemotherapy, which should be used as a standard treatment.
(2) Anti-estrogen therapy should be preferred for postmenopausal women with axillary lymph node positive and estrogen receptor positive.
(3) Postmenopausal women with positive axillary lymph nodes and negative estrogen receptors may consider chemotherapy, but are not recommended as standard.
(4) Adjuvant treatment is not recommended for premenopausal women with negative axillary lymph nodes, but adjuvant chemotherapy should be considered for some high-risk patients.
(5) Postmenopausal women with axillary lymph node negative, regardless of their estrogen receptor levels, have no indication for adjuvant chemotherapy, but some high-risk patients should consider adjuvant chemotherapy.
The high risk of recurrence of lymph node-negative breasts is as follows:
1 hormone receptor (ER, PR) is negative.
2 The percentage of cells in the S phase of the tumor is high.
3 aneuploid tumors.
4 The oncogene CerbB-2 has overexpression or amplification.
2. Modern perspective on adjuvant chemotherapy
(1) Adjuvant chemotherapy should be applied early in the operation, and it should be applied 2 weeks after surgery. At the latest, it should not exceed one month after surgery. If the lesion is used obviously, it will reduce the curative effect.
(2) Combination chemotherapy in adjuvant chemotherapy is better than single-agent chemotherapy.
(3) Adjuvant chemotherapy needs to reach a certain dose, and the effect is better when it reaches 85% of the original planned dose.
(4) The treatment period should not be too long, and 6 cycles of chemotherapy are recommended for breast cancer surgery.
(5) Chemotherapy for central nervous system metastasis
1. If there is no brain edema, you can use the x-ray to scan the location and give radiation therapy. Patients with cerebral edema should first control cerebral edema with diuretic mannitol and high dose corticosteroids.
2. When the lesion is extensive or unable to locate, first use a fat-soluble chemotherapeutic drug that easily penetrates the blood-brain barrier, such as CCNU oral 100mg once every 3-4 weeks, MECCNul 25mg orally once every 4 to 6 weeks.
(6) Chemotherapy of cancerous pleural effusion should be done by pumping pleural effusion, and then using the following chemotherapeutic drugs to inject into the chest:
1 eliminating tumor mustard 40 ~ 60mg;
2 nitrogen mustard 10mg;
7 thiotepa 30mg;
4 mitomycin 6 ~ 8mg;
5 fluorouracil 1000mg;
6 cis ammonium chloride platinum 90 ~ 120mg. The above chemotherapeutic drugs, except for cisplatin platinum, are injected once every 3 weeks (at the same time, systemic hydration), and are usually injected intrathoracically once a week.
The above content is for reference only, please consult the relevant physician or relevant medical institution if necessary.
prevention:
Early detection of breast cancer is well known, cancer is not an "incurable disease", the key is whether early detection and early treatment can be achieved. For many years, clinical practice has confirmed that for most cancers, if you want to improve the cure rate, it is unsatisfactory to improve the treatment method alone. As far as breast cancer is concerned, although there have been many improvements in treatment methods at home and abroad in recent decades, the mortality rate has not decreased significantly. The main reason is still due to late treatment. Among the patients treated, the majority of cases were caused by the middle and late stages. This requires us to advocate the detection of early cancer to reduce the appearance of advanced cancer, which will be an effective way to improve the survival rate of breast cancer.
Modern requirements for early breast cancer should be that small cancers (diameter ≤ 0.5 cm) and To cancers that are clinically inaccessible to the mass are classified as early, because such cancers rarely metastasize. After surgery, the 10-year survival rate is generally more than 90%. A large number of such cancers will be detected, which may have a positive effect on survival rate. In order to detect such early cancer more, the following point.
1. Establish a new concept of early cancer: In the daily examination of patients, early cancer is not uncommon, and should be more than the common intermediate and advanced cancer, because in the natural course of breast cancer growth, the preclinical period accounts for about 2/ of the whole process. 3. Despite this, early cancer was rarely detected, indicating that most of the early cancer was missed by the examiner during the examination. The reason. Mainly because the examiner still lacks sufficient understanding of early cancer, the vast majority of the examiners still use the "breast lumps" as the traditional concept for diagnosing the primary signs of breast cancer, and the aforementioned early cancers do not necessarily form obvious lumps. Under the guidance of the concept, early cancer is inevitably difficult to detect. Therefore, we should re-recognize the new concept of early cancer.
2. Carefully query the predisposing factors of breast cancer: There are many predisposing factors for breast cancer, and the following are common: (1) Family history of breast cancer, especially whether the mother and sister of the subject have had the disease; (2) Menarche is too early (less than 12 years old), or late (more than 50 years old); (3) more than 40 years old; (4) one side of the breast has cancer, the contralateral breast is also a vulnerable part and so on. Anyone with these factors should be considered as susceptible to breast cancer and should be the focus of the examination.
3. The cause should be ascertained for any abnormalities in the breast.
(1) nipple discharge, especially bloody discharge, coexists with breast cancer, especially when there is bloody discharge in women over 50 years old, about half of them may be malignant.
(2) Localized thickening of the breast gland, which is a clinically common but not valued sign. Such a situation, if it occurs in women who are not menopausal, especially when the menstrual cycle changes in size, is mostly physiological. If thickened tissue persists for a long time, it has nothing to do with changes in the menstrual cycle, or it is increasing and increasing in scope, especially in postmenopausal women.
(3) nipple erosion after repeated local treatment is ineffective, should consider the disease, the positive rate of cell smear is high, should be promptly diagnosed.
(4) Breast pain, in premenopausal women, especially with menstrual cycle changes, the degree of pain also has light or heavy changes, mostly physiological. If the pain is limited, there are fixed sites, regardless of the menstrual cycle or postmenopausal women, the cause should be identified.
(5) Unexplained areola skin edema, nipple retraction and breast skin limitation depression, etc., all need to find out the reasons.
In short, early detection and early treatment are undoubtedly the development direction of breast cancer prevention and treatment. What is urgently needed is to popularize the knowledge of early breast cancer inspection, extensively conduct breast cancer screening and women's self-examination of the breast, in order to achieve the goal of improving survival rate and reducing mortality rate at an early date.
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