BreastBreast

高雄榮總一般外科主治醫師高雄榮總一般外科主治醫師葉名焮 葉名焮

DefinitionDefinition

• The word “breast” refers to the The word “breast” refers to the mammary glands, plus the additional mammary glands, plus the additional connective tissue elements and fat that connective tissue elements and fat that surround and support the gland.surround and support the gland.

DevelopmentDevelopment

• The breast develops as down-growth of skin into meThe breast develops as down-growth of skin into mesodermal tissue over ventral body wall along a line frsodermal tissue over ventral body wall along a line from axilla to medial aspect of the proximal thigh (om axilla to medial aspect of the proximal thigh (milmilk linek line). ).

• The adult breast comprises a collection of tuboalveoThe adult breast comprises a collection of tuboalveolar glandular tissue, which is arranged in 15-20 lobes. lar glandular tissue, which is arranged in 15-20 lobes. The breast gland is made of lactiferous ducts and, aftThe breast gland is made of lactiferous ducts and, after puberty (10-12 yrs), alveoli (terminal duct lobular er puberty (10-12 yrs), alveoli (terminal duct lobular unit). unit).

DevelopmentDevelopment

DevelopmentDevelopment

• 15-20 lactiferous ducts converge under the areola of 15-20 lactiferous ducts converge under the areola of the nipple, and expand into lactiferous sinuses. Each the nipple, and expand into lactiferous sinuses. Each of these sinuses constricts into a terminal duct, whicof these sinuses constricts into a terminal duct, which runs vertically upward to end at the papilla of nipplh runs vertically upward to end at the papilla of nipple at a visible but narrow orifice.e at a visible but narrow orifice.

• skin that surrounds the nipple is the areola. Beneath skin that surrounds the nipple is the areola. Beneath the areola and opening onto its surface are the large the areola and opening onto its surface are the large areolar glands of Montgomery. areolar glands of Montgomery.

DevelopmentDevelopment

• Marked changes occur during the early weeks Marked changes occur during the early weeks of pregnancy. Ductal sprouting and lobular prof pregnancy. Ductal sprouting and lobular proliferation occur by the 8th week of pregnancoliferation occur by the 8th week of pregnancy. After the 6th month, aveoli become distendy. After the 6th month, aveoli become distended with colostrums. True milk secretion does ed with colostrums. True milk secretion does not commence until a few days after parturitinot commence until a few days after parturition. on.

DevelopmentDevelopment

• After menopause, the glandular tissue of the After menopause, the glandular tissue of the breast atrophies, the connective tissue strombreast atrophies, the connective tissue stroma becomes less cellular, and shrinkage of the a becomes less cellular, and shrinkage of the breast tissue with marked fatty infiltration ocbreast tissue with marked fatty infiltration occurs.curs.

TopographyTopography

• The adult female breast extends from the 2nd rib or The adult female breast extends from the 2nd rib or upper border of the 3rd rib superiorly to the 6th rib bupper border of the 3rd rib superiorly to the 6th rib below. Its medial border extends to the lateral edge of elow. Its medial border extends to the lateral edge of the sternum or close to the mid-sternal plane. And itthe sternum or close to the mid-sternal plane. And its lateral border reaches the mid-axillary line. s lateral border reaches the mid-axillary line.

• Axillary tail of SpenceAxillary tail of Spence• Nipple: 4th intercostals space in man and nulliparouNipple: 4th intercostals space in man and nulliparou

s female. s female.

TopographyTopography

• The breast is contained within a pocket of superficial The breast is contained within a pocket of superficial fascia, connective tissue bands (fascia, connective tissue bands (the suspensory ligmthe suspensory ligments of Cooperents of Cooper) extend from the dermis of breast, are) extend from the dermis of breast, areola and nipple, into underlying tissue of breast (morola and nipple, into underlying tissue of breast (more developed over upper part). e developed over upper part).

• The deep layer of superficial fascia covers the underlThe deep layer of superficial fascia covers the underlying muscles and is separated by submammary spacying muscles and is separated by submammary space that enables the normal breast to move freely. e that enables the normal breast to move freely.

Blood supplyBlood supply

• The arterial supply of the breast forms a rich aThe arterial supply of the breast forms a rich anastomotic plexus derived fro the internal thonastomotic plexus derived fro the internal thoracic artery, axillary artery (thoracoacromial, lracic artery, axillary artery (thoracoacromial, lateral thoracic and subscupular artery) and inateral thoracic and subscupular artery) and intercostals artery. tercostals artery.

Lymphatic drainageLymphatic drainage

• A plexus of lymphatic vessels lies in the interlA plexus of lymphatic vessels lies in the interlobular connective tissue and communicates obular connective tissue and communicates with a subareolar plexus around the nipple. with a subareolar plexus around the nipple.

Lymphatic drainageLymphatic drainage ( (described by Haagensedescribed by Haagensen n et. alet. al.).) • Axillary drainage: external mammary nodes, scapulaAxillary drainage: external mammary nodes, scapula

r nodes, central nodes, interpectoral (Rotter’s) nodr nodes, central nodes, interpectoral (Rotter’s) nodes, axillary vein nodes and subclavian nodes. Axillary es, axillary vein nodes and subclavian nodes. Axillary nodes were classified in three levels according to thenodes were classified in three levels according to their location in relation to pectoralis minor. ir location in relation to pectoralis minor.

• Internal thoracic drainage:Internal thoracic drainage:• Others: intercostals, diaphragmatic and mediastinal Others: intercostals, diaphragmatic and mediastinal

nodes. nodes.

Prevalence of presenting Prevalence of presenting symptomssymptoms

Brest lumpBrest lump 36%36%

Painful lump or lumpinessPainful lump or lumpiness 33%33%

MastalgiaMastalgia 17.5%17.5%

Nipple dischageNipple dischage 5%5%

Nipple retractionNipple retraction 3%3%

Strong family history of breast cancerStrong family history of breast cancer 3%3%

Breast distortionBreast distortion 1%1%

Breast swelling or inflammationBreast swelling or inflammation 1%1%

Scaling nipple (eczema)Scaling nipple (eczema) 0.5%0.5%

Extra nipples and breastsExtra nipples and breasts

• 1%-5% of men and women have 1%-5% of men and women have supernumerary or accessory nipple or supernumerary or accessory nipple or breastsbreasts

• Most common site for accessory nipple: Most common site for accessory nipple: just below normal breastjust below normal breast

• Most common site for accessory breast: Most common site for accessory breast: lower axilla lower axilla

MastalgiaMastalgia

• Breast pain of any type is a rare symptom of bBreast pain of any type is a rare symptom of breast cancer , only 7% of breast cancer have reast cancer , only 7% of breast cancer have mastalgia as the only symptom.mastalgia as the only symptom.

• Most mastalgia is of minor to moderate severiMost mastalgia is of minor to moderate severity and accepted as part of the normal changety and accepted as part of the normal changes that occur in relation to menstrual cycle. s that occur in relation to menstrual cycle.

MastalgiaMastalgia

• Cyclic mastalgia: begin since average 34 y/o, rCyclic mastalgia: begin since average 34 y/o, relieved by menopause, physical activity can ielieved by menopause, physical activity can increase the pain, e.g. lifting and prolonged usncrease the pain, e.g. lifting and prolonged use of arm. e of arm.

• Non-cyclic mastalgia: affects older women (mNon-cyclic mastalgia: affects older women (mean age 43), arises from chest wall. Breast itseean age 43), arises from chest wall. Breast itself or outside the breast.lf or outside the breast.

Mastalgia - treatmentMastalgia - treatment

Useful response to Useful response to treatmenttreatment

Cyclic mastaCyclic mastalgialgia

Non-cyclic Non-cyclic mastalgiamastalgia

Side effectSide effect

DanazolDanazol 79%79% 40%40% 30%30%

Gamolenic aGamolenic acidcid

58%58% 38%38% 4%4%

BromocriptinBromocriptinee

54%54% 33%33% 35%35%

Mastalgia - treatmentMastalgia - treatment

• Danazol: (200-300 mg daily, slowly reduced to Danazol: (200-300 mg daily, slowly reduced to 100 mg daily or on alternative day, given on d100 mg daily or on alternative day, given on days 14-28 of menstrual cycle, after pain relief.ays 14-28 of menstrual cycle, after pain relief.

• Responses are usually seen within 3 monthsResponses are usually seen within 3 months• Weight gain, acne and hirsutism.Weight gain, acne and hirsutism.

Breast infectionBreast infection

Type of breast infectionType of breast infection organismorganism

neonatalneonatal S. aureus, E. ColiS. aureus, E. Coli

LactatingLactating S. aureus, S.epidermidis, SS. aureus, S.epidermidis, Streptococcitreptococci

Non-lactatingNon-lactating S. aureus, enterococcus, AS. aureus, enterococcus, Anaerobic streptococci, bacnaerobic streptococci, bacteroides spp.teroides spp.

Skin associatedSkin associated S. aureus, FungusS. aureus, Fungus

Lactating mastitisLactating mastitis

• Most frequently seen within first 6 weeks of breMost frequently seen within first 6 weeks of breast feedingast feeding

• History of cracked nipple or skin abrasionHistory of cracked nipple or skin abrasion• Antibiotic (oxacillin) + abscess drainageAntibiotic (oxacillin) + abscess drainage• Brest feeding is encouraged BroBrest feeding is encouraged Bro

mocriptin ( 2.5mg Bid)mocriptin ( 2.5mg Bid)• Symptom or mass lesion persist ---- Carcinoma?Symptom or mass lesion persist ---- Carcinoma?

Non-lactating mastitis- periareolar iNon-lactating mastitis- periareolar infectionnfection

• Commonly seen in mean age of 32Commonly seen in mean age of 32• Histologically, there is periductal mastitisHistologically, there is periductal mastitis• Smoking in 90% of periductal mastitisSmoking in 90% of periductal mastitis• Central breast pain, nipple retraction, nipple diseaseCentral breast pain, nipple retraction, nipple disease• 1/3 of cases develop mammary duct fistula (duct ect1/3 of cases develop mammary duct fistula (duct ect

asia)asia)• Recurrent cases should be treated by excision of the Recurrent cases should be treated by excision of the

diseased duct diseased duct

Non-lactating mastitis-Non-lactating mastitis-peripheral breast abscessperipheral breast abscess

• Less common.Less common.• Associated with underlying disease, such as DAssociated with underlying disease, such as D

M, RA, steroid treatment, trauma or granulomM, RA, steroid treatment, trauma or granulomatous mastitisatous mastitis

Benign breast tumorsBenign breast tumors

• FibroadenomaFibroadenoma• Fibrocystic diseaseFibrocystic disease• Cystic diseaseCystic disease• Sclerosis: sclerosing adenosis, radial scar, complex sclerosing Sclerosis: sclerosing adenosis, radial scar, complex sclerosing

lesionlesion• Duct ectasiaDuct ectasia• Epithelial hyperplasia (e.g. atypical hyperplasia)Epithelial hyperplasia (e.g. atypical hyperplasia)• Intraductal papillomaIntraductal papilloma• LipomaLipoma• Fat necrosisFat necrosis

FibroadenomaFibroadenoma

• Minor aberration of normal process of Minor aberration of normal process of lobular development. lobular development.

• 9-10% of all women in autopsy studies.9-10% of all women in autopsy studies.

• 10-15% of patients present multiple lesions10-15% of patients present multiple lesions

• Fine needle aspirationFine needle aspiration

• Excision biopsy: > 2-4cm, patient age > Excision biopsy: > 2-4cm, patient age > 40y/o, uncertain lesion 40y/o, uncertain lesion

FibroadenomaFibroadenoma

• Relative risk for breast cancer development in Relative risk for breast cancer development in patients with FA: 1.2-3.0 --- FA associated with patients with FA: 1.2-3.0 --- FA associated with cyst >3mm, sclerosing adenosis, epithelial calcyst >3mm, sclerosing adenosis, epithelial calcification and papillary apocrine change cification and papillary apocrine change

• The incidence of a carcinoma arising within a The incidence of a carcinoma arising within a FA is reported to be 0.002 to 0.125%. Among tFA is reported to be 0.002 to 0.125%. Among these, about 50% are lobular carcinoma in situ.hese, about 50% are lobular carcinoma in situ.

Fibrocystic disease Fibrocystic disease

• Physiologic change of mammary glandPhysiologic change of mammary gland

• Painful lumpsPainful lumps

• Cyclic changeCyclic change

Cystic breast lesionCystic breast lesion

• 15% of all women15% of all women

• 1-3% of breast cancer are associated with 1-3% of breast cancer are associated with cystscysts

Atypical hyperplasiaAtypical hyperplasia

• Increased risk of breast cancer developedIncreased risk of breast cancer developed Without family Hx of breast CA: 8% at 10 yearWithout family Hx of breast CA: 8% at 10 year With family Hx of breast CA: 20-25% at 15 yearWith family Hx of breast CA: 20-25% at 15 year• Risk decreases over timeRisk decreases over time

GynecomastiaGynecomastiaPubertyPuberty 25%25%

Idiopathic (senescent)Idiopathic (senescent) 25%25%

Drug (cimetidine, digoxin, androgen, lasix, Drug (cimetidine, digoxin, androgen, lasix, antioestrogen)antioestrogen)

10-20%10-20%

Liver cirrhosisLiver cirrhosis 8%8%

Primary hypogonadismPrimary hypogonadism 8%8%

Testicular tumorTesticular tumor 3%3%

Secondary hypogonadismSecondary hypogonadism 2%2%

HyperthyroidismHyperthyroidism 1.5%1.5%

Renal diseaseRenal disease 1%1%

• Mondor’s disease: throMondor’s disease: thrombophlebitis of thoracombophlebitis of thoracoepigastric veinepigastric vein

Breast Cancer - Breast Cancer - epidemiologyepidemiology

• Estimate 2000 new cases per year in Estimate 2000 new cases per year in TaiwanTaiwan

• Second most common women cancerSecond most common women cancer

• The single most common cause of death The single most common cause of death among women aged 40-50y/o among women aged 40-50y/o

• Mean age 45-50y/o Mean age 45-50y/o

Breast cancer – Breast cancer – risk factorsrisk factors

• AgeAge

• Geographical locationGeographical location

• Age at menarche < 11y/oAge at menarche < 11y/o

• Age at menopause > 54y/oAge at menopause > 54y/o

• Age at first pregnancy > 30y/oAge at first pregnancy > 30y/o

• Family history of breast cancer (first degree Family history of breast cancer (first degree relative): 5-10% (BRCA1, BRCA2, p53)relative): 5-10% (BRCA1, BRCA2, p53)

Breast cancer – Breast cancer – risk factorsrisk factors

• Previous benign breast disease: atypical Previous benign breast disease: atypical hyperplasia.hyperplasia.

• Radiation: teenageRadiation: teenage

• Post-menopause obesity (Body mass index Post-menopause obesity (Body mass index >35)>35)

• Alcohol consumptionAlcohol consumption

• Oral contraceptiveOral contraceptive

• Hormone replacement therapyHormone replacement therapy

Presenting symptoms of breast Presenting symptoms of breast cancercancer

• Painless breast mass _ 66% Painless breast mass _ 66%

• Painful breast mass _ _11 %Painful breast mass _ _11 %

• Nipple discharge _ _ _ _9 %Nipple discharge _ _ _ _9 %

• ScreeningScreening

Breast cancer - Breast cancer - screeningscreening

• Self breast examinationSelf breast examination

• Physical examinationPhysical examination

• Breast ultrasoundBreast ultrasound

• Mammography: Mortality can be reduced Mammography: Mortality can be reduced up to 40% in women, the benefit is up to 40% in women, the benefit is greatest in women aged over 50y/ogreatest in women aged over 50y/o

Breast cancer - Breast cancer - screeningscreening

• Age range: Reduction in mortality is greatest iAge range: Reduction in mortality is greatest in women aged 50-70%n women aged 50-70%

• Frequency of screening: propably between 18 Frequency of screening: propably between 18 months and 2 yearsmonths and 2 years

Breast Self-examination Breast Self-examination (BSE)(BSE)• Visual examination in Visual examination in

front of a mirror front of a mirror

• Examination while Examination while standing in the standing in the shower shower

• Examination while Examination while lying down lying down

What are you looking for in What are you looking for in BSEBSE

• Lumps that are hard, irregular in shape, not pLumps that are hard, irregular in shape, not painful, and not mobile (in breast or axilla)ainful, and not mobile (in breast or axilla)

• A change on the skin of breast A change on the skin of breast • Assymetricity of Bil. breasts or a change of shAssymetricity of Bil. breasts or a change of sh

ape of breastape of breast• Nipple dischargeNipple discharge• Eczematoid change over areola or nippleEczematoid change over areola or nipple

Breast cancer - Breast cancer - diagnosisdiagnosis

• Palpable lesions: sonography-quided fine neePalpable lesions: sonography-quided fine needle aspiration cytology or core needle biopsy, dle aspiration cytology or core needle biopsy, excisional biopsyexcisional biopsy

• Impalpable lesions: wire localization and exciImpalpable lesions: wire localization and excisional biopsy for microcalcification, stereotaxsional biopsy for microcalcification, stereotaxis is

Breast cancer - Breast cancer - classificationclassification

• Invasive breast cancerInvasive breast cancer Invasive ductal carcinomaInvasive ductal carcinoma Invasive lobular carcinomaInvasive lobular carcinoma Medullary carcinomaMedullary carcinoma Mucinous carcinomaMucinous carcinoma Papillary carcinomaPapillary carcinoma Tubular carcinomaTubular carcinoma

Breast cancer - Breast cancer - classificationclassification

• Non-invasive breast cancerNon-invasive breast cancer Ductal carcinoma in situ (DCIS)Ductal carcinoma in situ (DCIS) Lobular carcinoma in situ (LCIS)Lobular carcinoma in situ (LCIS)

Breast cancer - Breast cancer - stagestage• Early stages of breast cancerEarly stages of breast cancer

The term "early breast cancer" refers to stages of breast cancer labeled 0, I, The term "early breast cancer" refers to stages of breast cancer labeled 0, I, and II.and II.

Stage 0Stage 0Cancer cells are present in either the lining of a breast lobule or a duct, but tCancer cells are present in either the lining of a breast lobule or a duct, but they have not spread to the surrounding fatty tissue. This stage is also called hey have not spread to the surrounding fatty tissue. This stage is also called ductal carcinoma ductal carcinoma in situin situ, or DCIS., or DCIS.

Stage IStage ICancer has spread from the lobules or ducts to nearby tissue in the breast. ACancer has spread from the lobules or ducts to nearby tissue in the breast. At this stage and beyond, breast cancer is considered to be invasive. The tumt this stage and beyond, breast cancer is considered to be invasive. The tumor is 2 cm or less in diameter; the lymph nodes are not involved. or is 2 cm or less in diameter; the lymph nodes are not involved.

Stage IIStage IICancer has spread from the lobules or ducts to nearby tissue in the breast. ICancer has spread from the lobules or ducts to nearby tissue in the breast. In this stage, the tumor can range from about 2 cm to greater than 5 cm in din this stage, the tumor can range from about 2 cm to greater than 5 cm in diameter; sometimes the lymph nodes may be involved.ameter; sometimes the lymph nodes may be involved.

Breast cancer - Breast cancer - stagestage

• Advanced stages of breast cancerAdvanced stages of breast cancerThe term "advanced breast cancer" refers to stages of breast The term "advanced breast cancer" refers to stages of breast cancer labeled III and IV. cancer labeled III and IV.

Stage IIIStage IIIKnown as locally advanced cancer; tumor may be larger than Known as locally advanced cancer; tumor may be larger than 5 cm (2 inches) in diameter, and cancer may or may not have 5 cm (2 inches) in diameter, and cancer may or may not have spread to lymph nodes or other tissues near the breast.spread to lymph nodes or other tissues near the breast.

Stage IVStage IVKnown as metastatic; cancer has spread from the breast and Known as metastatic; cancer has spread from the breast and lymph nodes under the arm to other parts of the body, such alymph nodes under the arm to other parts of the body, such as bone, liver, lung, or brain. s bone, liver, lung, or brain.

Breast cancerBreast cancer - treatment - treatment

• Locoregional treatmentLocoregional treatment Surgery: Modified radical mastectomy (MRM) Surgery: Modified radical mastectomy (MRM) Breast conservative treatment (BCT)Breast conservative treatment (BCT) RadiotherapyRadiotherapy• Systemic treatment > 90% breast cancer (tumour sizSystemic treatment > 90% breast cancer (tumour siz

ee>> 1 cm, LN involved, grade >I carcinoma) 1 cm, LN involved, grade >I carcinoma) ChemotherapyChemotherapy Hormone therapyHormone therapy

Breast cancerBreast cancer - MRM - MRM

• Including removal of breast tissue and axillary Including removal of breast tissue and axillary LN dissectionLN dissection

• Complication (1)Complication (1) SeromaSeroma InfectionInfection Flap necrosisFlap necrosis Wing scapulaWing scapula

Breast cancerBreast cancer - MRM - MRM

• Complication (2)Complication (2) Numbness and paraethesiae over upper inner Numbness and paraethesiae over upper inner aspect of arm: intercostobrachial nerve injuraspect of arm: intercostobrachial nerve injur

yy Reduced range of movement: 5% frozen Reduced range of movement: 5% frozen shouldershoulder Lymphedema: 5%Lymphedema: 5%

Breast cancer – Breast cancer – sentinel axillary LN bisentinel axillary LN biopsy (SLNB)opsy (SLNB)• Initial group of LNs that basin cancer cellsInitial group of LNs that basin cancer cells• Isotope (Tc99 sulfur colloid), Blue dye injection Isotope (Tc99 sulfur colloid), Blue dye injection • Intratumor, subareolar, intraparenchymal injectIntratumor, subareolar, intraparenchymal inject

ion ion • Percentage of LN metastasis is less than 10 % foPercentage of LN metastasis is less than 10 % fo

r tumor size < 1cmr tumor size < 1cm• For tumor size 1-2 cm, false negative SLNB is estFor tumor size 1-2 cm, false negative SLNB is est

imated to be less than 10%imated to be less than 10%

Breast cancer – Breast cancer – sentinel axillary LN bisentinel axillary LN biopsy (SLNB)opsy (SLNB)• Negative SLNB– no radical axillary LN dissectiNegative SLNB– no radical axillary LN dissecti

onon• Positive SLND-radical axillary LN dissection Positive SLND-radical axillary LN dissection vs vs

Axillary radiation Axillary radiation vsvs FU FU• Reduced frequency of lymphedema, limited RReduced frequency of lymphedema, limited R

OM, and paresthesiaOM, and paresthesia

Breast cancer -Breast cancer - BCT BCT

+ Radiotherapy over diseased breast + Radiotherapy over diseased breast

Breast cancer - Breast cancer - radiotherapyradiotherapy

• Dose of 40-50 Gy delivered in daily fractions oDose of 40-50 Gy delivered in daily fractions over 3-5 weeksver 3-5 weeks

• IndicationIndication BCTBCT Tumour size >5cmTumour size >5cm Involvement of chest wall/skin, or Involvement of chest wall/skin, or inflammatory cancerinflammatory cancer LN involved > 3LN involved > 3

Breast cancer - Breast cancer - chemotherapychemotherapy

• Chemotherapy is indicated for most breast cancerChemotherapy is indicated for most breast cancer >1cm tumour>1cm tumour Cellular grade >1Cellular grade >1 ER(-), HER(+)ER(-), HER(+) LN metastasisLN metastasis Not well-differentiated cell type, e.g. mucinous, papillaryNot well-differentiated cell type, e.g. mucinous, papillary• Taxol, epirubicin (CEF), Taxol, epirubicin (CEF),

Breast cancer – Breast cancer – Hormone Hormone therapytherapy

• Hormone treatment is benefit for breast cancHormone treatment is benefit for breast cancer with ER(+) and/or PR(+): 80% response rateer with ER(+) and/or PR(+): 80% response rate

• Tamoxifen, Aromatase inhibitors (anastrozolTamoxifen, Aromatase inhibitors (anastrozole) e)

• Drug-related side effect: gynaecoloical probleDrug-related side effect: gynaecoloical problems, vascular events (DVT), arthralgia, fracture.ms, vascular events (DVT), arthralgia, fracture.

Breast cancer – Breast cancer – immunotherapyimmunotherapy

• Monoclonal antibody against HER-2/neu for HMonoclonal antibody against HER-2/neu for HER-2/neu overexpression breast cancerER-2/neu overexpression breast cancer

• FISH (+) or IHC (+++)FISH (+) or IHC (+++)

Breast cancer - Breast cancer - prognosisprognosis

Breast cancer –Breast cancer – follow up follow up

期別期別 治療後治療後 1-51-5 年年 滿滿 55 年年

第零期 第零期 每每 6-126-12 個月作理學檢查、乳房個月作理學檢查、乳房攝影或超音波 攝影或超音波

每十二個月作理學檢查、乳房攝影每十二個月作理學檢查、乳房攝影或超音波。 或超音波。

第第 1-31-3 期 期 每每 3-63-6 個月定期作理學檢查、血個月定期作理學檢查、血液檢查及腫瘤標記。每液檢查及腫瘤標記。每 6-126-12 個個月定期作乳房攝影或超音波，胸月定期作乳房攝影或超音波，胸部部 XX 光。腹部超音波及全身骨骼光。腹部超音波及全身骨骼掃描視病況而定。 掃描視病況而定。

每每 1212 個月定期作理學檢查、乳房攝個月定期作理學檢查、乳房攝影或超音波、血液檢查、腫瘤標記。影或超音波、血液檢查、腫瘤標記。胸部胸部 XX 光及腹部超音波視病況而定。光及腹部超音波視病況而定。

第四期 第四期 視病況而定視病況而定 視病況而定視病況而定

Breast cancer -Breast cancer - DCIS DCIS

• Pre-malignant lesionPre-malignant lesion

• Segmental resection versus MRMSegmental resection versus MRM

• SLNB is indicated in mastectomy or in BCT for SLNB is indicated in mastectomy or in BCT for high risk group ( tumor size >4cm, high grade, high risk group ( tumor size >4cm, high grade, younger patients)younger patients)

• Radiotherapy after BCS: recurrent rate reduced Radiotherapy after BCS: recurrent rate reduced from 39% to 14%, over survival improved up to 8-from 39% to 14%, over survival improved up to 8-9%9%

• Systemic therapySystemic therapy

Breast cancer -Breast cancer - LCIS LCIS

• Malignant tumor markerMalignant tumor marker• Multifocal and multicentricMultifocal and multicentric• Bilateral breast involvedBilateral breast involved• MRM and close FUMRM and close FU

Breast cancer - Breast cancer - pregnancypregnancy

• 1-2% of all breast cancers .1-2% of all breast cancers .

• Diagnosis is often delayed.Diagnosis is often delayed.

• Treatment: Treatment:

First and second trimester: MRMFirst and second trimester: MRM

Third trimester: delay and deliver baby Third trimester: delay and deliver baby at at

30-32 weeks30-32 weeks

Breast cancer - Breast cancer - malemale

• Less than 0.5% of all breast cancers.Less than 0.5% of all breast cancers.• 0.7 of all male cancers0.7 of all male cancers• Peak incidence: 5-10 years later than in femalePeak incidence: 5-10 years later than in female• Prognosis similar to female, however, diagnosis Prognosis similar to female, however, diagnosis

is delayedis delayed• Treatment: mastectomy, axillary LN clearance, rTreatment: mastectomy, axillary LN clearance, r

adiotherapy adiotherapy ++ chemotherapy/hormone therapy chemotherapy/hormone therapy

Paget’s disaese of the nipplePaget’s disaese of the nipple

• Eczematoid change of the nipple associated Eczematoid change of the nipple associated with an underlying breast cancerwith an underlying breast cancer

• 1-2% of all breast cancers1-2% of all breast cancers• Underlying mass lesion: 90% will have invasivUnderlying mass lesion: 90% will have invasiv

e cancer – MRM + radiotherapye cancer – MRM + radiotherapy• No mass lesion: 30% will later have invasive cNo mass lesion: 30% will later have invasive c

ancer - wide excision + SLNB + radiotherapyancer - wide excision + SLNB + radiotherapy• Adjuvant treatment Adjuvant treatment

Paget’s disaese of the nipplePaget’s disaese of the nipple

Phylloides tumorPhylloides tumor

• Range from benign to malignancy in behaviorRange from benign to malignancy in behavior• Up to 20% recur locally after excision.Up to 20% recur locally after excision.• Malignant lesion is the sarcomatousMalignant lesion is the sarcomatous• Wide excisionWide excision• The role of radiotherapy and chemotherapy is The role of radiotherapy and chemotherapy is

unclearunclear

Phylloides tumorPhylloides tumor