Breast cancer is one of the most common malignant tumors in women. According to statistics, the incidence of breast cancer accounts for 7- 10% of all kinds of malignant tumors in the whole body. Its incidence rate is often related to heredity, and it is higher in women aged 40-60 and women before and after menopause. Only about 1-2% of breast patients are male. Malignant tumor that usually occurs in glandular epithelial tissue of breast. The breast part is related to female endocrine, which can be identified by immunohistochemical examination and is sensitive to some chemotherapy drugs related to hormone control.
Several main known factors inducing breast cancer: 1 age: In women, the incidence rate increases with age, which is rare before menarche and before the age of 20, but rises rapidly after the age of 20, and it is higher at the age of 45-50, but relatively flat. The incidence of postmenopausal women continues to rise, reaching its peak around the age of 70, and the mortality rate also increases with age. After the age of 25, the mortality rate gradually rises. Genetic factors: if the female in the family has a history of breast cancer in the first-degree immediate family members, the risk of breast cancer is 2~3 times that of the normal population; 3 other breast diseases; Age of menarche in April: the risk of menarche is 2.2 times that of people older than 13 years old; 5 menopausal age: the risk of menopause is 6 times higher than that of those under 45 years old. Age of second pregnancy: with the delay of the age of first delivery, the risk increases. The risk of primipara after the age of 35 is higher than that of those without childbearing history. 7. After menopause, long-term use of estrogen may increase the risk of breast cancer. 8. Take oral contraceptives. 9. Food: Especially eating a lot of fat will increase the risk of breast cancer. 10 Drinking alcohol 1 1 Weight gain may be an important risk factor for breast cancer in postmenopausal women. 12 Long-term smoking 13 The ovarian function of breast is regulated by ovarian hormones. Estrogen is the basic stimulator of breast development and one of the prerequisites for the onset of breast tumors. Some people think that the abnormal increase of estrone and estradiol and the lack of estriol are one of the causes of breast tumors, which has been supported by clinical examination and proved by animal experiments. Moreover, male patients with breast tumor are relatively rare, accounting for about 1% of female patients, which also indicates that it may be related to male ovarian hormone deficiency.
The treatment of joint lies in early detection: 1. Some patients with early breast cancer often feel local discomfort, especially postmenopausal women, sometimes feel mild pain and discomfort in one breast, or heavy shoulder and back, and even pull the upper arm. 2, the early breast can touch the broad bean-sized lump, which is hard and movable. Generally, there is no obvious pain, and a few have paroxysmal dull pain, dull pain or tingling. Morphological changes of breast: The skin at the lump is swollen, some local skin is orange peel-like, and even edema, discoloration and eczema-like changes appear. 4. There is nipple invagination near the center of nipple. Breast skin has slight depression (medically called "dimple disease"), nipple erosion, nipple asymmetry, or breast skin thickening and pore enlargement (medically called "orange peel disease"). 5, nipple discharge: when the discharge is bloody and serous, special attention should be paid to further inspection. 6. Regional lymphadenopathy, with ipsilateral axillary lymphadenopathy being the most common. Advanced supraclavicular lymphadenopathy.
treat cordially
surgical operation
Surgical treatment is still one of the main treatments for breast cancer. There are many surgical methods, but there is still no consensus on their choice. The general development trend is to minimize surgical injuries. When the equipment conditions permit, patients with early breast cancer should try their best to keep the breast shape. No matter which surgical method is chosen, radical treatment is the main method, supplemented by function and morphology.
1. Surgical indications
Radical mastectomy, initiated by halsted, has become the standard way to treat breast cancer for hundreds of years because of its reasonable operation and clear curative effect. In the past half century, people have made many exploratory improvements in the surgical methods of breast cancer. The general trend is nothing more than conservatism and amplification. There is still controversy about local mastectomy and total mastectomy, which is a representative conservative operation. Radiotherapy is needed after the operation. Generally, the radiation dose ranges from 30 to 70 Gy, which can achieve good results for the limited early cancer with strict selection. However, it is still difficult to draw a conclusion whether it is a routine treatment for early breast cancer and how to choose this one.
2. Contraindications for surgery
(1). General contraindications: ① patients with distant tumor metastasis, ② elderly and infirm patients who can't tolerate surgery, ③ patients with poor general condition and cachexia, ④ patients with major organ dysfunction who can't tolerate surgery, (2). Contraindications to local lesions: ① Patients with stage ⅲ have one of the following conditions: ① The orange-peel edema of breast skin exceeds half of the breast area; ② Satellite nodules appeared in breast skin; ③ Breast cancer invaded the chest wall; ④ Clinical examination showed that parasternal lymph nodes were enlarged and metastasis was confirmed; ⑤ Edema of the affected upper limb; ⑥ Supraclavicular lymph nodes were pathologically confirmed as metastasis; ⑦ Inflammatory breast cancer has two of the following five conditions: ① tumor ulceration; (2) The celluloid edema of breast skin accounts for less than1/3 of the total breast area; ② Cancer and fixation of pectoralis major; ④ The maximum diameter of axillary lymph nodes is larger than 2.5cm；; ⑤ Axillary lymph nodes adhere to each other or to deep skin tissue.
3. Surgical methods
(1). Radical mastectomy: In 1894, Halsted and Meger respectively published the surgical principles of radical mastectomy: ① The primary focus and regional lymph nodes should be removed together; ② Excision of all mammary glands and pectoral muscles; ③ Total axillary lymph node resection Haagensen improved radical mastectomy, emphasizing that the operation should be particularly thorough, mainly including ① careful peeling of skin flap; ② After the flap was completely separated, pectoralis major and pectoralis minor were cut off from the chest wall and turned outwards; (3) When dissecting armpits, the chest length and diameter should be preserved. If there are no obvious swollen lymph nodes in the armpit, the thoracodorsal nerve can also be preserved. ④ The common complications in skin grafting for chest wall defect are: ① axillary vein injury: it is mostly caused by unclear dissection of the fat and lymphatic tissue around the axillary vein or too close to the trunk of the axillary vein when cutting off its branches, so it is very important to clearly expose and keep a few broken ends of branches. (2) Extended radical mastectomy: Extended radical mastectomy includes radical mastectomy, that is, radical mastectomy and internal mammary lymph node dissection, that is, 1-4 intercostal lymph nodes need to be removed. The second, third and fourth costal cartilages need to be removed. There are intrapleural surgery and extrapleural surgery. The former has many traumatic complications, so the latter is often used. (3) Simulated radical mastectomy (modified radical mastectomy) is mainly used for non-invasive cancer or stage I invasive cancer with no obvious axillary lymph node enlargement in stage II, and (3.1) type I can also be selected: the principle of pectoralis minor skin incision and flap separation is the same as that of radical mastectomy, and total mastectomy (fascia resection in pectoralis major surgery) is performed first. The anatomy from breast to axillary side and axillary lymph nodes are basically the same as those of radical surgery. The diameter of the chest should be preserved, and the whole breast and axillary lymphatic tissue should be completely removed (3.2). Type ⅱ: the skin incision of pectoralis minor was removed, and the pectoralis major was preserved. Free the breast to the outer edge of pectoralis major, then cut off the attachment point of the 456th rib of pectoralis major, and turn it upward to expand the surgical field of vision. Cut off the attachment point of pectoralis minor muscle at the coracoid process of scapula. The following steps are the same as radical operation, but pay attention to preserving the thoracic nerve and accompanying blood vessels. Finally, the whole pectoralis minor and axillary lymph tissue (4) are cut off. Simple mastectomy: As an ancient operation, it was once replaced by radical mastectomy. In recent years, with the development of breast cancer biology, total mastectomy has aroused people's concern about its indications: first, early cases with non-invasive or axillary lymph node metastasis can be treated without radiotherapy after operation; 2. Simple mastectomy combined with radiotherapy for locally advanced breast cancer. If total mastectomy still needs complicated breast reconstruction according to the increasing aesthetic requirements, it is not suitable for young and middle-aged women. Early disease, therefore, its main indications should be limited to the elderly who can only be palliative resection or some advanced cases (5) are less than total mastectomy. In recent years, due to the progress of radiotherapy equipment, lesions were found earlier than before, and patients' requirements for postoperative quality of life were improved. Therefore, many conservative surgical methods less than total mastectomy were reported, ranging from local excision to L/4 mastectomy. Some breast-conserving operations with radiotherapy were not suitable for all breast cancer cases, nor could they replace all radical mastectomy. In order to avoid local recurrence, the indications are as follows: ① Small tumors are suitable for clinical T 1 and partial T2 (less than 4 cm) lesions; ② Peripheral tumors located under areola are often inappropriate; ③ Single lesion; ④ It is often inappropriate to see the tumor boundary clearly with naked eye or microscope; ⑤ The therapeutic effect of axillary lymph node metastasis is related to the following factors: ① The tumor margin must have a normal boundary, and if there is enough normal tissue at the margin, the prognosis will be better; ② The size and histological grade of the primary tumor; ③ The local recurrence rate is high without radiotherapy after operation.
Radiation therapy
There are many radiation complications, even resulting in partial loss of function. At the same time, it can be combined with Zhenqing powder to reduce the side effects of radiotherapy. Radiotherapy is the main part of breast cancer treatment and one of the local treatment methods. Compared with surgical treatment, it is less limited by anatomical factors such as the patient's physique. However, the effect of radiotherapy is influenced by the biological effects of radiation. It is difficult to achieve the goal of "completely killing" the tumor with the commonly used radiotherapy facilities at present, and the effect is not as good as that of surgery. Therefore, most scholars do not advocate radiotherapy alone for curable breast cancer. It is mostly used for comprehensive treatment, including adjuvant treatment before or after radical mastectomy. Palliative treatment of early breast cancer In recent 10 years, comprehensive treatment with local resection as the main method has been increasing, and the curative effect is not significantly different from that of radical surgery. Radiotherapy has played an important role in narrowing the scope of surgery. (1) preoperative radiotherapy 1. Indication (1) estimates that the primary focus is large, It is difficult to operate directly. (2) The tumor grows rapidly and obviously in a short time. (3) The primary focus has obvious skin edema or adhesion of pectoral muscles. (4) Axillary lymph nodes are large or obviously adhered to skin and surrounding tissues. (5) The tumor retraction is not ideal after preoperative chemotherapy. (6) Patients with inflammatory breast cancer who strive for surgical resection. (1) The role of preoperative radiotherapy can improve the surgical resection rate, so that some patients who cannot be operated can get another one. Because radiotherapy prolongs the preoperative observation time, some cases of subclinical distant metastasis can avoid unnecessary surgery. 3. The shortcomings of preoperative radiotherapy increase postoperative complications and affect the correct staging and hormone receptor determination. 4. The application method of preoperative radiotherapy should adopt high-energy radiation as much as possible, which can better protect normal tissues and reduce complications. At present, most radiation techniques use conventional fractionation and moderate dose, but they are generally not used. Surgery is ideal 4 ~ 6 weeks after rapid radiotherapy or hyperfractionation radiotherapy. (2) Whether postoperative radiotherapy is needed after radical surgery has always been the most controversial issue in the treatment of breast cancer. In recent years, many authors admit that postoperative radiotherapy can reduce the local recurrence rate. Since Fishor put forward a new viewpoint of breast cancer, the treatment of breast cancer has gradually shifted from local treatment to comprehensive treatment. Postoperative radiotherapy is no longer used as routine treatment after radical operation, but is used selectively.
1. instruction
(1) After simple mastectomy, (2) After radical mastectomy, the pathology reported that there was lymph node metastasis in the middle or upper armpit, (3) After radical mastectomy, it was confirmed by pathology that the metastatic lymph nodes accounted for more than half of the total number of lymph nodes examined, or there were more than 4 lymph nodes metastasis, (4) Cases of lymph node metastasis in breast were confirmed by pathology (irradiation in supraclavicular area), and (5) The primary lesion was located in the center or inside the breast, especially.
2. The principle of radiotherapy
(1) After radical mastectomy or sham radical mastectomy, patients whose primary focus is axillary lymph nodes in the outer quadrant of the breast will not receive radiotherapy after operation. When axillary lymph nodes were positive, the internal mammary region and supraclavicular region were irradiated after operation. When the pathological examination of axillary lymph nodes in the central area or the inner quadrant of the breast is negative, only the axillary lymph nodes in the inner area of the breast are irradiated after operation. When axillary lymph nodes are positive, they will irradiate the upper and lower clavicle areas. (2) After radical mastectomy for stage Ⅲ breast cancer, the medial breast region and the supraclavicular region will be irradiated regardless of whether axillary lymph nodes are positive or negative. (3) According to the positive number of axillary lymph nodes and the involvement of chest wall, chest wall irradiation can be considered or not. After radical mastectomy, axillary lymph nodes have been cleared. Under normal circumstances, axillary irradiation should not be performed unless the operation gap is incomplete or there are residual lesions. (4) Radiotherapy should be started within 4-6 weeks after operation, and it can be extended to 8 weeks if there is skin grafting. (3) Radiotherapy is the main treatment. In the past, radiotherapy was usually palliative for patients with locally advanced tumors without surgical indications. In recent years, with the improvement of radiotherapy equipment and technology and the progress of radiobiology research, radiotherapy can make local tumors get higher dose with less damage to surrounding normal tissues, and the therapeutic effect is obviously improved. At present, the study of minor surgery plus radiotherapy for early breast cancer has changed the treatment of breast cancer from palliative radiotherapy to radical radiotherapy. For patients whose primary focus is less than 3cmN0 or N 1, minor surgery plus radiotherapy is still an effective local treatment for locally advanced breast cancer. Resection of all tumors before radiotherapy or simple mastectomy can improve the curative effect (4). Postoperative radiotherapy for recurrent metastatic breast cancer is a bad sign, but it is not hopeless. Proper local treatment can improve the quality of life and prolong the survival time. In terms of irradiation, Oto irradiation is better than Xiaoye irradiation. For recurrent cases, comprehensive radiotherapy and chemotherapy should be used, especially for rapidly developing recurrent cases. When distant metastasis of breast cancer occurs, chemotherapy should be considered first to relieve symptoms and patients' pain. For example, in patients with bone metastases, the pain can be alleviated or disappeared after radiotherapy. For patients with thoracolumbar metastasis, radiotherapy can prevent or delay paraplegia.
endocrinotherapy
There is a clear relationship between the determination of hormone receptor and the curative effect of breast cancer: ① The effective rate of endocrine therapy for estrogen receptor positive patients is 50% ~ 60%, and that for negative patients is less than 65,438+00%. At the same time, the determination of progesterone receptor can more accurately estimate the effective rate of endocrine therapy in two positive patients, which can reach more than 77%. The relationship between receptor content and curative effect is that the higher the receptor content, the better the curative effect. ② Cells with negative receptors are often negative for poorly differentiated receptors. Patients are prone to recurrence after operation, and lymph node metastasis is not considered. The prognosis of negative patients is worse than that of positive patients. Positive patients are prone to skin, soft tissue or bone metastasis, while negative patients are prone to visceral metastasis. ③ The determination of hormone receptor has been used to formulate postoperative adjuvant therapy. Endocrine therapy can be used as postoperative adjuvant therapy for positive patients, especially postmenopausal patients, and adjuvant chemotherapy is mainly used for premenopausal or hormone receptor negative patients.
[Edit this paragraph] Chemotherapy
(A) the principle of adjuvant chemotherapy
Chemotherapy can inhibit the decline of bone marrow hematopoietic system, mainly white blood cells and platelets. At this time, it is necessary to take Zhenqing Powder to make up for the deficiency of chemotherapy and reduce the damage of chemotherapy to hematopoietic system. Most breast cancer is a systemic disease, which has been confirmed by many experimental studies and clinical observations. When breast cancer develops to a mass larger than the clinical palpable mass of lcm, it is often a systemic disease with distant micrometastasis, which can only be found by current examination methods. The purpose of surgical treatment is to control the primary tumor and regional lymph nodes to the maximum extent, reduce local recurrence and improve the survival rate. But after tumor resection, there are still residual tumor cells in the body. Breast cancer is a systemic disease when it is diagnosed. The purpose of systemic chemotherapy is to eradicate the residual tumor cells in the body and improve the surgical cure rate.
(2) preoperative adjuvant chemotherapy
1. Significance of preoperative chemotherapy (1) Control micrometastasis as soon as possible (2) Degenerate or partially kill primary cancer and its surrounding cancer cells, reduce postoperative recurrence and metastasis (3) Restrict the implementation of surgical treatment for advanced breast cancer and inflammatory breast cancer. Preoperative chemotherapy can shrink the tumor and facilitate surgical resection (4). The effect of preoperative chemotherapy can be evaluated according to the resected tumor specimens, which can be used as a reference for selecting chemotherapy schemes after operation or recurrence. 2. preoperative chemotherapy method (1) preoperative systemic chemotherapy: from 1978, the cancer hospital of Shanghai medical university gave 15mg pyrimidine nitrogen mustard to 96 breast cancer patients every day. After the operation, the total dose was 45 mg. Compared with 94 control groups, the 5-year survival rate of patients in the third stage was 56.3% in the drug group and 39.3% in the control group. (2) preoperative arterial infusion chemotherapy: there are two methods: intrathoracic arterial intubation and subclavian arterial intubation.
(3) postoperative adjuvant chemotherapy
1. Indications for postoperative adjuvant chemotherapy (1) Postmenopausal women with positive axillary lymph nodes should use prescription combined chemotherapy regardless of the status of estrogen receptor (2) Postmenopausal women with positive axillary lymph nodes and estrogen receptor should be the first choice for anti-estrogen treatment (3). Postmenopausal women with positive axillary lymph nodes and negative estrogen receptors can consider chemotherapy, but it is not recommended as a standard regimen (4) Premenopausal women with negative axillary lymph nodes generally do not recommend adjuvant therapy, but adjuvant chemotherapy should be considered for some high-risk patients (5). Postmenopausal women with negative axillary lymph nodes have no indication of adjuvant chemotherapy, but some high-risk patients should consider adjuvant chemotherapy. The high-risk recurrence factors of axillary lymph node negative breast are: ① hormone receptor (ERPR) negative; ② The proportion of S-phase cells in tumor is high; ③ aneuploid tumor; ④ Overexpression or amplification of oncogene CERBB-2; 2. Modern viewpoint of adjuvant chemotherapy (1). Adjuvant chemotherapy should be applied early after operation, at least within two weeks and not more than one month after operation. If the lesion is obvious, the curative effect will be reduced. (2) Adjuvant chemotherapy combined with chemotherapy is superior to single drug chemotherapy. (3) Adjuvant chemotherapy needs to reach a certain dose of 85% of the original planned dose. (4) The course of treatment should not be too long. We advocate 6 courses of chemotherapy after breast cancer surgery.
immunotherapy
1 activates immune cells such as phagocytes, natural killer cells and nociceptive T cells, and induces the secretion of cytokines such as leukocytes, interferon-γ and tumor necrosis factor-α. 2. Induce cancer cell apoptosis. 3. Combined with traditional chemotherapy drugs (mitomycin, carmustine, etc. ), which not only increases the curative effect, but also reduces the side effects of chemotherapy. 4. It has synergistic effect with immunotherapy drug (interferon -α2b). 5. Relieve the pain of patients with advanced cancer, increase their appetite and improve their quality of life.
Traditional therapy in China
Chinese medicine treatment of breast cancer has the following characteristics: 1, which does not affect the labor force. The local condition of breast cancer patients has improved, while the general condition has also improved. 2, the side effects are small. 3. Have a strong overall concept. Although breast tumor grows in a certain part of the body, it is actually a systemic disease. For most patients with breast tumors, local treatment can't solve the problem of radical cure. Based on the overall concept and the implementation of syndrome differentiation, Chinese medicine not only considers local treatment, but also adopts the method of strengthening the body resistance and strengthening the foundation, which plays an important role in improving patients' local symptoms and general condition. Although the tumor can be removed by surgery, there are still residual tumors, regional lymph node metastasis, or tumor thrombus in blood vessels. Long-term treatment with traditional Chinese medicine after operation can prevent recurrence and metastasis. Radiotherapy and chemotherapy have considerable side effects on digestive tract and hematopoietic system. Using traditional Chinese medicine can not only reduce the side effects of radiotherapy and chemotherapy, but also enhance the effect of radiotherapy and chemotherapy. For patients with inoperable advanced breast cancer, radiotherapy and chemotherapy can be performed with traditional Chinese medicine.
[Edit this paragraph] Prevention methods and health care
In order to avoid breast cancer, women should have some basic knowledge of "preventing breast cancer", as follows: 1, eat more foods rich in cellulose, obesity and weight gain may lead to breast cancer. Usually, we should consume less animal fat and more fiber food, vegetables, fruits, cereals and beans to reduce estrogen that may cause breast cancer in the body and reduce the incidence of breast cancer. 2. Develop good exercise habits According to the statistics of medical experts, the risk of breast cancer of women who exercise regularly is 30% lower than that of women who do not exercise. Doing more exercise is not only good for health, but also can prevent the occurrence of breast cancer. 3, regular breast examination ① Women aged 20-40 should do a breast self-examination within one week after the monthly holiday; Every two years, a professional doctor will have a clinical examination or mammogram. ② For women aged 40-49, besides regular breast self-examination every month, it is best to have a professional breast examination once a year. ③ Women over 50 years old should have regular breast self-examination every month, and have clinical breast examination and mammography once a year. Although all women are at risk of breast cancer, as long as you adhere to the above points, you will be able to stay away from the threat of breast cancer and achieve the effect of early detection and early treatment.