menopausal breast cancer
Introduction
Introduction to menopausal breast cancer Breast cancer is a serious threat to women of all ages. The incidence of breast cancer in women with severe obesity and central fat accumulation after menopause is significantly increased. Taking estrogen after perimenopause can increase the chance of breast cancer. Levels of prolactin also increase the incidence of breast cancer. basic knowledge The proportion of patients: 0.001%-0.002% (the prevalence of this disease is about 0.001%-0.002% for middle-aged and older women over 50 years old) Susceptible people: women Mode of infection: non-infectious complication:
Cause
Causes of menopausal breast cancer
(1) Causes of the disease
The underlying cause is not fully understood, but some factors may be an important factor in the induction of breast cancer. The incidence of postmenopausal breast cancer in adult women with severe obesity and central fat accumulation is significantly increased. Obesity may be through estrogen bioavailability and Lipid metabolism affects breast cells, and ovarian endocrine plays an important role in the pathogenesis of breast cancer. Estrogen and progesterone are important endocrine hormones closely related to the onset of breast cancer. Women with menarche ages earlier than 13 years and menopause for more than 40 years The risk of breast cancer is more than double that of the average woman. The incidence of breast cancer increases with the delay of the primiparous age. Breastfeeding can reduce the risk of breast cancer, and the total time of breastfeeding and the risk of breast cancer are Negative correlation, oral contraceptives do not increase the risk of breast cancer, but long-term use of estrogen after perimenopause can increase the incidence of breast cancer, high-fat diet, drinking can increase the incidence of breast cancer, and non-drinkers Compared with the risk of breast cancer increased by 11%, the risk of breast cancer in patients with breast fibrocystic disease can be increased by 2 to 4 times, genetic factors It plays an important role in the pathogenesis of breast cancer. With the development of molecular biology techniques and the development of the human genome project, at least two breast cancer susceptibility genes, BRCA1 and BRCA2, have been mapped to chromosomes 17 and 13, respectively. All of them are autosomal dominant tumor suppressor genes. The genetic mutation carriers of BRCA1 or BRCA2 have up to 90% of breast cancer risk in their lifetime, and about 5% to 10% of breast cancer and genetic susceptibility. related.
Phytoestrogen, Isoflavone, which has potential anticancer effects. The main source of isoflavones in the diet is soy. A study in Singapore says that premenopausal women consume 55g of legumes per day, breast cancer. The risk is reduced by 60%, and Japan has the same report.
Other factors such as environmental pollution, organochlorine pesticides, and radiation are carcinogenic, and more carcinogenic factors are still being explored.
(two) pathogenesis
1. Occurrence and growth
Breast cancer mainly originates from small ducts of the breast, but originated from small leaflets and terminal ductal carcinomas. In the past 40 years, the origin of breast cancer has been considered through large continuous sectioning of whole breasts and observation of its early development process and cancer tissues. Often more than one foci, but multiple foci, derived from a number of scattered atypical hyperplasia, that is, multifocal origin theory, under the effect of carcinogenic factors, breast duct response is different, cancer can be most susceptible The cell population occurs in one or more places. Clinically, the breast cancer is mostly on the right side, and the outer upper quadrant is more than the other quadrants. The reason is unknown.
The growth rate of breast cancer is between some fast-growing sarcomas and slow-growing squamous cell tumors. According to the doubling time of breast cancer, it is estimated that after an epithelial cell becomes cancer cells, it takes a long time to be clinically It is shown that when the tumor diameter reaches 1cm, half of them have metastasized 2 years ago. According to the patient's self-reported situation, the statistical analysis shows that the breast cancer increases by about 1cm in 3 months, at a certain level. In time, the faster the tumor grows, the worse the prognosis.
2. Infiltration and transfer
(1) Infiltration: When the epithelial cells of the mammary duct become cancerous, they first grow in the lumen. As the disease progresses, the cancer cells invade the surrounding glandular tissue or expand along the fascial space, causing the connective tissue to proliferate, and then invade the lymphatic vessels around the duct. As the tumor continues to grow, it finally affects the breast skin, the pectoralis major fascia and the chest muscle tissue and is fixed with it. Invasive cancers such as hard cancer can invade the ribs and intercostal muscles of the chest wall in the late stage.
(2) Lymphatic metastasis: Lymphatic metastasis has been confirmed to follow the lymphatic fluid flow to the lymph nodes in the way of cancer cell plugs. After the cancer cells invade the lymph nodes, they proliferate under appropriate conditions until the entire lymph nodes are involved, and the cancer tissue can be worn. Lymphatic sac membrane infiltrates into the membrane. In recent years, foreign scholars have studied the ability of regional lymph nodes to resist the spread of cancerous plugs. It is proved that regional lymph nodes can temporarily impede cancer cells, but there are some channels of mutual communication between lymphatic vessels that enter the input lymphatics. Lymph can sometimes bypass the front lymph nodes, which explains why sometimes the cancer will pass over a lymph node and move to the next lymph node, and sometimes directly into the blood channel without lymph nodes, and it is confirmed that it is circulating blood. The cancer cells can return to the lymphatic system, and then enter the blood circulation through the thoracic duct. In addition, there are many anastomotic branches between the lymphatic vessels and the veins. Therefore, it has been suggested that breast cancer is a systemic disease from the onset of the disease, and surgery alone has lost its radical significance. The most frequently metastatic lymph nodes of breast cancer are axillary lymph nodes, intramammary lymph nodes and clavicle Knot, whether the lymph node is involved, in addition to the degree of disease, is still affected by the location of the tumor, the tumor is only located in the inner side of the breast, prone to lymph node metastasis, supra-clavicular lymph node metastasis is late, cancer cells through the top of the axillary lymph nodes The filtering effect is then spread along the subclavian vein.
(3) blood transfer: advanced breast cancer, cancer can be transferred to distant organs through the bloodstream, mainly lung, liver and bone, its transfer route:
1 vascular invasion, cancer tissue invasion of the vein wall into the blood metastasis is the most common way, this metastasis has a certain relationship with the degree of tumor differentiation, the lower the differentiation, the higher the rate of venous invasion.
2 through the lymphatic pathway into the blood vessels, cancer cells invading the lymphatic vessels can flow into the thoracic duct or the right lymphatic duct with the lymph fluid, respectively, flowing into the body vein near the left and right jugular vein angles, causing bloodway metastasis, 3 infiltration into the blood channel, when the cancer Suffering from accidental trauma, the vessel wall in the tumor is defective, and when the extravascular pressure exceeds the intravascular pressure, the cancer cells can penetrate into the blood passage through the vascular wall. Others such as excessive cancer examination or improper biopsy can make Cancer cells enter the bloodstream, so during the examination, biopsy or surgery, the operation must be gentle and meticulous to avoid artificial spread.
Transfer of organs:
1 lung metastasis, the lung is the first metastatic organ of breast cancer, and after the lung has metastasized, multiple multiple metastases will occur.
2 pleural metastasis, multiple lung metastasis and invasion of the pleura, pleural pain and pleural effusion caused by pleural involvement are often the first symptoms of lung metastasis, and lung parenchyma may not be abnormal.
3 bone metastasis, breast cancer is prone to bone metastasis, the most common vertebrae and pelvis, followed by ribs, femur, scapula and skull, bone metastases at the distal end of the elbow and knee are extremely rare, generally speaking, breast cancer patients For those with bone metastases, firstly, the affected bones have obvious pain, tenderness or pain. The pain is persistent and gradually aggravated. Usually it is the most intense at night. The bone scan is a very sensitive method for the diagnosis of bone metastasis.
4 liver metastasis, a rare metastasis, difficult to find early, 5 contralateral breast metastasis, poor prognosis.
3. Staging of breast cancer
(1) TNM staging:
1T-primary tumor:
TX: The primary tumor cannot be determined (eg, removed).
T0: The primary tumor was not detected.
Tis: carcinoma in situ (intraductal carcinoma, lobular carcinoma in situ, papillary Paget disease without mass), with a nipple with a mass.
Paget disease is classified by size of the tumor:
T1: The maximum diameter of the primary lesion is <2cm.
T1mic: Tiny invasive cancer with a maximum diameter of 0.1cm.
T1a: The maximum diameter of the tumor is >0.1 cm, 0.5 cm.
T1b: tumor maximum diameter > 0.5 cm, 1.0 cm.
T1c: tumor maximum diameter > 1.0 cm, 2.0 cm.
T2: tumor maximum diameter > 2.0 cm, 5.0 cm.
T3: Maximum tumor diameter > 5.0 cm.
T4: Regardless of tumor size, directly invade the chest wall or skin (breast wall including ribs, intercostal muscles, anterior serratus, but not including pectoral muscles).
T4a: The tumor invades the chest wall.
T4b: skin edema of the affected side (including orange peel-like changes), ulceration or satellite nodules.
T4c: T4a and T4b coexist.
T4d: inflammatory breast cancer.
2N-regional lymph nodes:
Nx: Regional lymph nodes cannot be analyzed (eg, once removed).
N0: There is no metastasis in the regional lymph nodes.
N1: ipsilateral axillary lymph node metastasis, active.
N2: ipsilateral metastatic axillary lymph nodes fuse with each other or with other tissues.
N3: lymph node metastasis in the ipsilateral inner breast region.
3M-distant transfer:
MX: I am not sure if there is a distant transfer.
M0: No distant transfer.
ML: There is distant metastasis (including supraclavicular lymph node metastasis).
(2) Pathological stage (PTNM):
1PT-primary tumor: consistent with the T classification, it is required that there should be no visible tumors around the specimen, and the tumors that can be found under the microscope do not affect the classification.
2PN-regional lymph nodes: specimens requiring surgical resection need to include at least the lower lobe (Lovel I) lymph nodes, and generally need to include 6 or more lymph nodes.
PNx: Regional lymph nodes cannot be analyzed (surgery does not include this site or has been removed in the past).
PN0: no regional lymph node metastasis.
PN1: ipsilateral axillary lymph node metastasis, active.
PN1a: Only tiny metastases 0.2cm.
PNlb: lymph node metastasis > 0.2 cm.
PNlbI: 1 to 3 metastatic lymph nodes, metastatic lesions >0.2 cm, <2.0 cm.
PNlbII: metastatic lymph nodes 4, metastases > 0.2 cm, < 2.0 cm.
PNlbIII: Lymph node metastasis invaded the envelope, <2.0 cm.
PNlbIV: metastatic lymph nodes > 2.0 cm.
PN2: Multiple metastatic lymph nodes in the ipsilateral axilla merge with each other or with other tissues.
PN3: lymph node metastasis in the ipsilateral inner breast region.
3PM - distant metastasis: same as M for clinical TNM staging.
(3) Histopathological grade (G):
Gx: Can't judge the degree of differentiation.
G1: Highly differentiated.
G2: Moderate differentiation.
G3: Low differentiation.
(4) Classification of residual tumors after surgical treatment (R):
Rx: Unsure of whether there is residual tumor.
R0: no residual tumor.
R1: Remnant tumors are visible under the microscope.
R2: Remnant tumors are visible to the naked eye.
(5) Clinical stage:
Phase 0: TisN0M0.
Phase I: T1N0M0.
Phase IIA: T0NlM0 T1N1M0 T2NOM0.
Phase IIB: T2N1 M0 T3NOM0.
Phase IIIA: TON2Mo T1N2Mo T2N2M0 T3N1.2M0.
Stage IIIB: T4 any NM0 Any TN3M0.
Stage IV: Any T any NML.
Prevention
Menopausal breast cancer prevention
So far, although a lot of experimental research and investigations have been done in the field of breast cancer etiology, various etiological hypotheses have been proposed, but the true cause of breast cancer has not been found, and the breast is treated like a contagious infectious disease. It is difficult to achieve effective preventive measures for cancer. It is hoped that the breast cancer screening will be hoped for early detection and detection of early breast cancer patients who have not had clinically obvious symptoms in many people. Many countries have adopted their own practice. It is proved that secondary prevention of breast cancer is an effective way to reduce mortality and improve survival rate.
1. Prevention of etiology and pathology (primary prevention)
The etiology of breast cancer is related to many factors. How to carry out primary prevention? There are three feasible ways to consider at present: 1 The study identifies the cause of cancer and adopts corresponding blocking measures. Although it is the fundamental way to prevent cancer, it is feared. It can be done in a short period of time; 2 prevention of pathogenesis, it is believed that there are often cells in the human body that are mutated or cancerous, but not all can develop into cancer. Once cancer cells appear, they can be recognized by the immune surveillance system. It is rejected, so it can improve the immune function of the human body and prevent breast cancer. 3 timely and correct treatment of breast cancer precancerous diseases and precancerous lesions is of practical significance in preventing breast cancer. Compare proven ways.
At present, on the basis of the prevalent factors of breast cancer that have been obtained, women's anti-cancer knowledge and education work should be strengthened. The feasible measures are to control high-fat diet and weight loss. Epidemiology and laboratory data prove that Japan eats meat and protein every day. The incidence of breast cancer in women with butter and cheese should be increased by 1.1 to 2.83 times, and the correlation coefficient between pork intake and breast cancer per person per day is the highest, followed by fat intake, high (>155 cm) and obesity (> 65kg) Women with thinner women are 11.5 times more dangerous. The effect of diet on height, weight and age at menarche is obvious and may directly affect the onset of breast cancer. The mechanism may be affecting hormone secretion and metabolism. Intervention trials to reduce dietary fat intake in women with high risk factors for breast cancer, requiring participants to reduce food fat from 40% to 20%, the incidence of breast cancer at the end of observation, and the most difficult problem in food intervention trials How to make the subjects adhere to food interventions, and the more feasible way to do so now is to strengthen the test subjects by the anti-cancer census personnel. System and supervision, which in large-scale prevention trials is unrealistic, so to strengthen publicity and education, so that subjects adhere to cooperation.
2. Promote breast cancer "three early" (secondary prevention)
"Three mornings" means early detection, early diagnosis and early treatment, which play an important role in the prevention of breast cancer. With the development of health care, the establishment of a sound death reporting system and the strengthening of grassroots primary health care units are "three early mornings". The key to discovery is that primary health care should master the risky population of breast cancer and register it regularly for observation. The purpose is to improve the chance of three early and thus achieve the purpose of prevention.
Early detection of early breast cancer is the core and key of three early. In recent years, due to the popularity of health knowledge, a small number of early breast cancer patients have been found in outpatient clinics. However, due to conditions, many early breast cancer patients have not been diagnosed and treated. Therefore, it is necessary to carry out Anti-cancer census, extensive publicity to the masses, and the implementation of women's breast self-examination method, for the early detection of breast cancer, the use of mobile inspection vehicles to take pictures of breast dry plates, B-ultrasound, cytology equipment, etc., to the grassroots unit census, Discover and master high-risk breast cancer patients and follow up regularly. The American Cancer Society's census relies mainly on mammography. 48% of all breast cancer patients can be found by mammography alone. The association recommended in 1984:
1 Those with breast disease manifestations, regardless of age, should be regularly checked for breast examination;
Women aged between 235 and 40 should take basic breast slices. For those who have found suspicious lesions of the breast, it is hoped that the early diagnosis of stress will be based on X-ray guidance, needle aspiration cytology, B-ultrasound and histopathological examination. To improve the early diagnosis rate of breast cancer, early treatment can often obtain satisfactory results.
3. Promote patient rehabilitation (three levels of prevention)
Active surgery for early and mid-stage breast cancer, and carry out comparison, observation and research on indications, contraindications and efficacy of various breast cancers, active implementation and research, improvement of comprehensive treatment measures based on surgery, for advanced breast cancer Strengthen the application of comprehensive therapy to improve the survival rate of breast cancer, strengthen follow-up observation of patients who have survived, take measures to promote their rehabilitation, and carry out plastic surgery and psychological treatment to improve the quality of life of patients.
Complication
Menopausal breast cancer complications Complication
Bleeding <br /> is one of the common complications after surgery. The cause of bleeding after such a mass resection or radical resection is often: 1 intraoperative hemostasis is not completely left active Bleeding point; 2 due to the application of continuous negative pressure lead fluid changes or severe cough and other reasons, the electrocoagulated clots fall off or ligated silk slippage leads to drainage bleeding; 3 preoperative chemotherapy or hormone drugs make the wound easy to ooze blood.
The effusion <br /> refers to the accumulation of fluid between the flap and the chest wall or the armpit, which prevents the flap from clinging to the wound. It is also a common complication of breast tumor surgery. Common causes are: 1 poor drainage makes the wound seepage The fluid can not be extracted in time and accumulate; 2 blood coagulation in the wound surface can not be induced to liquefy and form effusion; 3 small lymphatic vessel damage is observed when the lymphatic fat around the iliac vein is dissected without ligation and drainage is formed. Generally occurs in the lateral side of the armpit; 4 the opportunity to use the electric knife to dissect the iliac vein is more likely to occur than the use of a scalpel. The electrocautery may have a certain effect on the healing of the wound and some small lymphatic vessels are temporarily closed after electrosurgical dissection. After the vacuum suction, it is open to cause fluid accumulation.
Skin flap necrosis <br /> is also a common complication of breast cancer surgery. Delayed healing of skin necrosis may affect the subsequent treatment of radical mastectomy. It is often necessary to remove more skin and the flap is separated. Excessive thinness or uneven thickness can damage the capillary in the dermis and affect the blood supply of the postoperative flap; or the tension of the flap after suturing can cause ischemic necrosis of the flap during the postoperative effusion; sometimes due to use Improper operation of the electrosurgical unit causes local skin burns or vascular coagulative embolization. It is also easy to cause necrosis of the skin flap necrosis. Generally, the ischemic skin becomes pale after 24 hours after surgery, and the surface of the blue-purple edema gradually has small blisters.
Symptom
Menopausal breast cancer symptoms Common symptoms Menopausal nipple discharge edema milk hair inflammation breast upper quadrant gland thickening
Breast cancer is most common in the outer upper quadrant of the breast (45% to 50%), followed by the nipple, areola (15% to 20%) and the upper upper quadrant (12% to 15%), and the lower inferior and lower inferior quadrants ( Each accounted for about 10%).
1. The main symptoms are painless in the breast, single-shot mass, hard mass, unsmooth surface, unclear boundary with surrounding tissues, and difficult to be promoted in the mammary gland.
2. Breast pain is not a common symptom of breast cancer. Most women's breast pain is physiological, and breast cancer patients who are only seen for breast pain are clinically very rare.
3. Nipple discharge may be bloody, serous, purulent, but many patients with benign lesions due to discharge, common in ductal dilatation and intraductal papilloma, but can not rule out intraductal papilla without surgical biopsy The possibility of malignant tumors.
4. Changes in nipple and breast skin are more common in advanced breast cancer, manifested as nipple invagination and abnormal orientation, skin edema and "orange peel-like" changes, and the "dimple sign" formed by breast skin invagination.
5. When the lymph nodes have metastasis, they can reach the swollen mass in the armpit, and patients with distant metastases such as lungs, bones, liver and brain will have corresponding symptoms.
Examine
Examination of menopausal breast cancer
The use of tumor markers for diagnosis has been widely studied, and many projects have been applied to the clinic. This diagnostic method requires high specificity and high sensitivity; the proliferation or reduction of tumors can directly affect the content of blood markers; It is simple and easy to perform, and the effect can be repeated. It is used for the diagnosis of breast cancer markers: carcinoembryonic antigen, calcitonin, chorionic gonadotropin, placental lactogen, monoclonal antibody, thrombin, glycoprotein, pregnancy-binding macroglobulin , lactalbumin, enzyme protein, ferritin, etc., is widely used in clinical, reference and practical value should belong to carcinoembryonic antigen (CEA), a variety of cancer can secrete CEA, elevated CEA content in advanced breast cancer, However, the application of radioimmunoassay in the determination of CEA levels in nipple discharges indicates that breast cancer patients have a large amount of CEA in the nipple discharge. It is of great significance to use this method to diagnose early breast cancer, especially ductal carcinoma.
1. X-ray diagnosis method
(1) Molybdenum target anode soft X-ray photography: The molybdenum target anode soft X-ray machine has been used in the past 10 years, which enhances the contrast of various tissues in the breast, thereby improving the display effect of the details of the breast lesion. The lesions located in the thicker part of the breast are poorly displayed.
(2) Dry-plate mammography: Compared with molybdenum target soft X-ray photography, dry-plate photography has the advantages of clear, low cost and high diagnostic rate for deep lesions, so it is especially suitable for breast cancer examination.
(3) Mammary duct angiography: suitable for patients with nipple discharge, for patients who have not touched the tumor and have an overflow, you can choose the corresponding breast tube angiography, it is best to check several breast tubes to improve the positive rate.
(4) CT and magnetic resonance examination: These two methods are superior to molybdenum target photography, but due to the high cost, it is difficult to popularize.
(5) Breast angiography: The contrast agent can be injected by intubation of the radial artery and internal mammary artery. Continuous radiography and angiography are of great value in identifying benign and malignant lesions of the breast.
2. Ultrasound examination
Due to the development of gray scale and real-time ultrasound, the diagnostic accuracy of ultrasound imaging for breast cancer is 80%-85%. In recent years, color Doppler ultrasound diagnosis has made the diagnosis sensitivity and specificity of breast cancer reach 95%. And 97%.
3. Computer near infrared scanning inspection
Using the characteristics of soft tissue density and hemoglobin content of the breast to be sensitive to infrared light, the soft tissue of the breast is scanned by infrared light, and after image processing, a clear image is obtained on the fluorescent screen, the positive rate is 90%, but the diagnostic value for early cancer is How to be discussed.
4. Other methods
Such as cold light transillumination examination, radionuclide examination, heat map examination and needle aspiration cytology examination have good value for breast cancer diagnosis.
Diagnosis
Diagnostic diagnosis of menopausal breast cancer
Diagnostic criteria
In the natural course of breast cancer growth, the preclinical stage accounts for about 2/3 of the total disease duration, and many early cancers are in the subclinical stage, and the breast is a surface organ, so breast tumors should be easily detected, but the current clinical More than 3% to 4% of cancers detected 1cm, indicating that most of them have been leaked from the hands of the examiners during the examination, mainly because the clinicians still use the "breast mass" as the traditional concept of the primary signs of diagnosis of the breast. Ignore some minor signs. Experienced surgeons can find tumors of 1cm through palpation, but any type of examination has its limitations. In recent years, the diagnosis of breast cancer has progressed from simple palpation to comprehensive diagnosis. At home and abroad, comprehensive diagnostic methods have been reported to make more than 95% of stage I cancer diagnoses. Therefore, comprehensive diagnosis has become the development trend of early breast cancer diagnosis. On the other hand, raising the awareness of women's self-examination is also important for early detection. .
Differential diagnosis
Traumatic fat necrosis
Local manifestations are very similar to breast cancer. The mass is hard and adheres to the skin, but there is a clear history of trauma, and the lesion is shallow.
2. Breast tuberculosis
There are fewer tuberculosis, and breast tuberculosis is rare. You should know whether there is a history of systemic tuberculosis, whether there is a chronic sinus, and if necessary, biopsy or cytology.
3. Plasma cell mastitis
There are also hard irregular masses that also adhere to the skin, but it often has multiple small abscesses, anti-infective treatment will improve, and its mass range is large, often in a quadrant.
4. Chronic cystic mammary gland hyperplasia
This disease is often bilaterally symmetrical, but it is often difficult to identify, especially those with early cancer, if necessary, by cytology or biopsy.
