乳腺癌诊断流程

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Click to edit Master title style,Click to edit Master text styles,*,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Name of Speaker,Title,University,City,Country,Click to edit Master title style,Click to edit Master text styles,*,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Click to edit Master title style,Name of Speaker,Title,University,City,Country,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Name of Speaker,Title,University,City,Country,*,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Click to edit Master title style,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Click to edit Master title style,Click to edit Master text styles,*,*,Name of Speaker,Title,University,City,Country,Click to edit Master title style,Click to edit Master text styles,*,*,Name of Speaker,Title,University,City,Country,*,Name of Speaker,Title,University,City,Country,Click to edit Master title style,Click to edit Master text styles,*,Click to edit Master title style,Click to edit Master text styles,*,Click to edit Master title style,Click to edit Master text styles,*,Click to edit Master title style,Click to edit Master text styles,*,Click to edit Master title style,Click to edit Master text styles,*,Click to edit Master title style,Click to edit Master text styles,*,Click to edit Master title style,Click to edit Master text styles,*,*,Name of Speaker,Title,University,City,Country,Click to edit Master title style,Click to edit Master text styles,*,Click to edit Master title style,Click to edit Master text styles,*,*,Name of Speaker,Title,University,City,Country,Click to edit Master title style,Click to edit Master text styles,*,*,Name of Speaker,Title,University,City,Country,Click to edit Master title style,Click to edit Master text styles,*,Click to edit Master title style,Click to edit Master text styles,*,Click to edit Master title style,Click to edit Master text styles,*,乳腺癌诊断流程中若干问题,彩超与钼靶选择,乳腺癌诊断流程的优化,彩超与钼靶选择,彩超与钼靶选择,共同点：,正常组织的影像特征,脂肪型乳腺：黑色背景为主,致密型乳腺：白色背景为主,不同点：,乳腺肿瘤,超声：低回声：黑色,钼靶：高密度：白色,彩超与钼靶选择,致密型乳腺：,彩超,脂肪型乳腺：钼靶,2011,版,中国抗癌协会乳腺癌诊治指南与规范,（以下简称,指南,）对于致密多量腺体型乳腺亦推荐采用,X,线联合,B,超检查，而对于脂肪少量腺体型乳腺则采用,X,线检查以节约成本。,小肠,GIST,彩超与钼靶选择,随访高危人群,13339,例，发现乳腺癌,30,例,彩超敏感性优于钼靶,彩超与钼靶选择,对彩超和钼靶结果与病理结果符合情况的比较,9,个中心参与,N=2631,，,其中恶性肿瘤,1142,例，良性病变,1489,例,彩超与钼靶选择,(N=2631),彩超,钼靶,P,值,敏感性,89.6%,84.1%,0.001,特异性,85.6%,90.3%,0.001,初诊：选择彩超,复诊：彩超不能明确性质，可联合钼靶,乳腺病变诊断流程的优化,传统乳腺病变诊断流程,传统的乳腺病变诊断流程中的不利因素,切开活检加术中冰冻占用外科医生时间，耗费医疗资源,导致患者无法行新辅助治疗,病理结果不明，可导致良性病变的过度治疗,术前无病理结果，不利于保乳或重建手术决策的制定,完全切除，不利于新辅助化疗的疗效观察,优化后乳腺病变诊断流程,术前穿刺活检现状,日本，使用率,90%,美国，使用率,87.5%,我国，相对较低，大城市，逐年上升,乳腺癌诊治指南与规范,2011,版,也指出，对于有条件的单位，积极提倡在术前进行影像学引导下的微创活检。,穿刺活检方式,细针抽吸细胞学（,FNA),空心针穿刺活检（,CNB),真空辅助微创活检（,VAB),细针抽吸细胞学（,FNA),可触及的肿物均适用,细胞学诊断，不能确定组织学类型,样本量少,假阴性率高,32%,不能鉴别原位癌与侵润癌,不能判断,ER,PR,HER2,空心针穿刺活检（,CNB),适用于不能手术的晚期乳腺癌需要病理证实和检查激素受体状态,需要新辅助化疗者,组织学标本，诊断更明确,创伤小，操作时间短，恢复快，局麻,小的不连续标本,需精确定位,多次进针出针,无法标记活检部位,空心针穿刺活检（,CNB),彩超引导下的,CNB,敏感性,97.7%,，特异性,100%,彩超引导下的,CNB,的标本与切除活检标本的诊断符合率,90-96%,真空辅助微创活检（,VAB),充足，连续的组织标本，降低诊断低估率,真空辅助，一次进针，减少针道种植和上皮移位,活检部位可放置标记夹,可完全切除较小的良性病灶,费用贵,穿刺活检引导方式,超声实时引导,钼靶立体定位引导,MRI,穿刺活检引导方式：超声,最准确，首选,BI-RADS 4-5,级乳腺及腋窝病灶均可使用,中国人，乳腺组织致密，更适合,穿刺活检引导方式：,X,线钼靶,钼靶评估,类及以上的钙化灶,、,结构扭曲及非对称致密影，临床触诊阴性，且超声在该部位未发现病灶,对于小乳房，表浅病灶，贴近胸肌病灶，腋窝病灶的活检有困难,穿刺活检引导方式：,MRI,敏感性高,特异性低：,22-50%,价格贵,操作耗时：,45-90,分钟,穿刺活检操作技术,标本量,应不低于,4,条组织,钙化灶推荐,10,条组织,放置标志夹,有助于手术定位,良性病变不必要再次活检,新辅助治疗,穿刺活检准确性,假阴性率：穿刺活检为阴性，或非高危良性病变，而最终被诊断为癌的比例,低估率：穿刺活检为高危病变，最后被诊断为癌,穿刺活检为导管原位癌，最后被证实为有间质浸润,低估率,ADH,DCIS,29.2-43.5%,24.4-35.5%,穿刺活检准确性,穿刺活检准确性,对于,CNB,结果为,DCIS,的患者，建议行,SLN,活检有助于提高诊断准确率,CNB,在多数情况下不能区分纤维腺瘤及分叶状肿瘤，故不被推荐作为分叶状肿瘤的诊断方法，建议行切除活检。,穿刺活检并发症,穿刺活检安全性,CNB,VAB:69%,33%,P,0.0001,针道种植阳性率与时间有关，可能说明种植的癌细胞难以成活,术前,CNB,对接受保乳和加放疗的患者局部复发和总生存无影响,时间,15,天,15-28,天,28,天,针道种植阳性率,42%,37%,15%,穿刺活检适应症,影像学,BIRADS3,级伴有临床可疑病灶，高危因素或主观意愿强烈者需要接受术前穿刺活检,总结,术前微创穿刺活检是影像发现乳腺异常的首选和最佳活检技术，适合所有影像发现的乳腺病变,影像引导下的空心针经皮穿刺技术安全可靠，不会增加局部复发,根据患者病情使用合适的影像学引导，可提供准确的诊断，避免不必要的手术，为制定乳腺癌的方案提供依据,穿刺活检有一定的假