早期乳腺癌的诊断和外科治疗进展

乳腺癌是危害妇女生命和健康的恶性肿瘤一。近年来,欧美发达国家的乳腺癌发病率持续升高,但是乳腺癌的死亡率开始出现下降趋势[1],这归功于乳腺癌的早期诊断和规范化、个体化的综合治疗。我国乳腺癌诊治的总体水平落后于欧美国家,但是随着乳腺癌二级预防的广泛开展和各种早期诊断技术的应用,早期乳腺癌所占比例越来越多,促使我们更加重视早期乳腺癌的综合治疗,实现乳腺癌     

Potential Impact of USPSTF Recommendations on Early Diagnosis of Breast Cancer

Objective  

Current US Preventive Services Task Force (USPSTF) guidelines recommend against routine screening mammography in women aged 40–49 years. However, diagnosis of early-stage breast cancer relies on mammographic screening for detection. We hypothesized that screening at younger age may be important for detecting earlier and more treatable cancers for women in different demographic groups.     

触诊阴性乳腺病灶活检在乳腺癌早诊早治中的价值

目的探讨临床触诊阴性乳腺病灶的定位切除活检在乳腺癌早期诊断与治疗中的价值。方法141例女性患者，共158个由钼靶X线发现的触诊阴性乳腺病灶，采用金属线定位技术进行切除活检。结果全组158个临床触诊阴性乳腺病灶中，乳腺癌42个(42例患者)，占26．6％，根据美国癌症联合会第6版乳腺癌分期标准，0期12例(28．6％)，Ⅰ期24例(57．1％)，Ⅱ期2例(4．8％)，Ⅲ期4例(9．5％)。所有乳腺癌患者术后中位随访时间31个月，只有1例Ⅲ期患者于术后16个月出现对侧腋窝淋巴结转移，其余41例患者全部无癌生存。结论临床触诊阴性乳腺癌大多数为早期癌，预后良好，对于此类病灶，应当积极进行定位切除活检，以利于临床触诊阴性乳腺癌的早期诊断与治疗。     

Depression in Patients with Breast Cancer: Prevalence, Diagnosis, and Treatment

Abstract: Untreated anxiety and depression lead to increased costs for family members regarding work, overall medical expenses, greater physical symptomology, and possibly even decreased life expectancy. This article discusses early identification of those patients who are at high risk for developing depression during the course of breast cancer, and focuses on points in the disease course that render patients most vulnerable. Early diagnosis and treatment of depression are critical for a patient's physical, as well as emotional, wellbeing. Diagnosis can be challenging because the illness of cancer can produce the same somatic symptoms found in depression. Treatment should address psychological and family issues, and in many cases include evaluation for antidepressant medication. Psychosocial intervention in patients with breast cancer has been shown to effectively treat both psychological distress and physical symptoms, including pain, nausea, and fatigue. Pharmacological treatment of major depression in patients with breast cancer has been shown to treat depression effectively and to improve quality of life.     

Efficacy of Breast Conservation Therapy in Early Stage Bilateral Breast Cancer

The purpose of this study was to evaluate the outcome of patients with bilateral breast cancer as compared to unilateral breast cancer treated with breast conservation therapy. Sixty patients with bilateral breast cancer (BBC) and 1,080 unilateral breast cancer (UBC) patients treated with breast conservation therapy from 1977 to 1994 were analyzed for outcome. Of the 60 bilateral patients, 44 were metachronous bilateral breast cancer patients (MBBC) and 16 were synchronous bilateral breast cancer patients (SBBC). The majority of patients received lumpectomy, axillary node dissection, and localized radiation therapy. Median tumor size was 1.4 cm for BBC and 1.5 cm for UBC patients. Median total dose to the tumor bed was 60 Gy for both unilateral and bilateral patients. Of the 44 MBBC patients, 14 received breast conservation for both the first and second lesions, while 30 received breast conservation for only the second metachronous lesion. Thus 58 lesions in 44 patients were treated with breast conservation therapy. Of the SBBC patients, 13 of 16 patients received breast-conserving therapy for both breasts, while 3 received a mastectomy for the second synchronous primary. Median follow-up was 50 months for SBBC patients, 45 months for MBBC patients, and 52 months for UBC patients. Local control and survival were analyzed in patients with SBBC, MBBC, and UBC. The interval to development of local recurrence and survival were calculated from the time of development of the second breast lesion in patients with MBBC. No differences were found for survival and failure-free survival in patients with SBBC, MBBC, or UBC. Five-year overall survival by lifetable analysis was 76% for SBBC, 78% for MBBC, and 87% for UBC patients (p = 0.32 by log-rank analysis). The 5-year failure-free survival was 79% for SBBC, 73% for MBBC, and 85% for UBC patients (p = 0.28 by log-rank analysis). No significant differences were seen for median age, tumor size, pathologic node status, tamoxifen use, chemotherapy use, or median total radiation dose for SBBC, MBBC, or UBC patients. A significant difference was found in the incidence of family history of breast cancer in patients with unilateral versus bilateral breast cancer (p = 0.028 by chi-square analysis). However, there was no difference in outcome of patients by family history of breast cancer. The local control was identical in both BBC and UBC patients, with a local failure rate of 3%. Therefore, breast conservation therapy in local-regional, early stage breast cancer is a rational and efficacious treatment modality for patients with SBBC, MBBC, and UBC.     

Sentinel Lymph Node Biopsy in Early Breast Cancer

The role of axillary surgery for the treatment of primary breast cancer is in a process of constant change. During the last decade, axillary dissection with removal of at least 10 lymph nodes (ALD) was replaced by sentinel lymph node biopsy (SLNB) as a staging procedure. Since then, the indication for SLNB rapidly expanded. Today's surgical strategies aim to minimize the rate of patients with a negative axillary status who undergo ALD. For some subgroups of patients, the indication for SLNB (e.g. multicentric disease, large tumors) or its implication for treatment planning (micrometastatic involvement, neoadjuvant chemotherapy) is being discussed. Although the indication for ALD is almost entirely restricted to patients with positive axillary lymph nodes today, the therapeutic effect of completion ALD is more and more questioned. On the other hand, the diagnostic value of ALD in node-positive patients is discussed. This article reflects today's standards in axillary surgery and discusses open issues on the diagnostic and therapeutic role of SLNB and ALD in the treatment of early breast cancer.