Методички онкология / 5 курс / САРС / 6 РГЖ
.docMINISTRY OF HEALTH OF UKRAINE
Kharkiv National Medical University
Approved
on the methodical meeting Department of Oncology
Head of Department
MD, professor Styarikov VI
'28"August 2011
A methodical DEVELOPMENT
For independent work of students
Course 5
Faculty of Medicine (specialty "General Medicine", "Pediatrics", "Prophylactic medicine")
Study Subject: Oncology
Module number 1
Content module № 2
Subject: № 6. Breast cancer
number of training hours -5
Kharkiv 2011
Topic.
Breast cancer ranks first in Ukraine among malignant tumors in women. The incidence is 46-49 per 100 thousand female population. There is a constant increase in the incidence of this disease. Experimental data suggest that the occurrence of breast cancer, he must pass through a series of phasic changes. Similar morphological changes observed in women with different proliferative changes in the mammary glands. Those changes are known in the clinic called mastitis or dishormonal hyperplasia of mammary glands. A special form of hormonal hyperplasia is a fibroadenoma of the breast. Mastitis and fibroadenoma of the breast is a precancerous condition. Therefore, knowledge of risk factors of precancer and cancer of the breast (and they have a common basis) is important for early diagnosis and prevention of breast cancer. Treatment of mastitis and fibroadenoma is the prevention of cancer. Great value in this aspect becomes outreach dear doctor specialty population.
Although some progress has been made in the treatment of locally advanced breast cancer, this disease continues to be one of the most acute and urgent problems of modern medicine.
The need to further improve the treatment strategy for this disease is dictated to a large spread of this disease, lack of effectiveness of existing treatments and a high degree of disability.
Breast cancer in the structure of cancers in women ranked first and has a tendency to increase in incidence.
Study objective: Decomposing precancerous disease etiology and mechanism of their occurrence, clinical manifestations, diagnostic tools and treatment as well as risk factors for breast cancer (BC), the etiology of breast cancer, ways metastasis and clinic early breast cancer.
Know:
1. Etiology mastopathy and breast fibroadenomas.
2. Etiology, epidemiology, pathogenesis and pathological anatomy of breast cancer.
3. Classification of breast cancer in stages and in TNM.
4. Clinical picture of breast cancer.
5. Surgical, radiation, chemotherapy breast cancer and modern schemes of combined and complex treatment.
Be able to:
Collect and correctly interpret the history of patients with precancerous breast disease.
To conduct palpation of the breast, axillary and supraclavicular lymph nodes.
Palpation distinguish benign breast disease.
Work plan and examination of the patient, based on a survey of the patient, formulate clinical diagnosis and treatment plan in case of mastitis and fibroadenoma of the breast.
Mastitis - a hormonal hyperplasia of mammary glands. Mastitis is related to the action of estrogenic hormones. Hiperstrohenemiya can be caused by several factors: violation of the regulatory impact of the cerebral cortex, hypothalamus, pituitary, thyroid, adrenal cortex.
Clinical manifestations: breast engorgement, pain before menstruation. Palpable determined diffuse (usually) or nodal consolidation in the mammary glands. Varieties of mastitis: IDSA and lhiya, fibrous and fibro-ki stozn and breast disease (Shimmelbush a) adenosyl breast disease (Rec Liu), bleeding nipple (illness Ming tsa, intraductal papilloma). Treatment of mastitis in most cases - conservative, severe nodular - sometimes surgery. Depending on the histology of mastopathy divided into simple and proliferating (requiring surgical treatment).
Conservative treatment of mastitis: sedatives (valerian, pustyrn and k), progesterone (local shape in the form of a gel), m Al Todd and non (homeopathic medicine), normalization of hormonal levels in the body (including sexual activity, pregnancy, lactation ).
Fibroadenoma of the breast - a special form of hormonal hyperplasia. This is a good quality breast tumors. Clinically, fibroadenomas are limiting seal with sharp edges, painless, with a smooth or bumpy surface. No. Fibroadenomas are single and multiple. Sizes range from microscopic to large, when the tumor occupies most of the breast. For histological distinction intrakanalikulyarni, perykanalikulyarni and foliate (filoyidni) forms fibroadenomas. Recent growing rapidly and often reach huge sizes.
Diagnosis fibroadenomas: - breast palpation and ultrasonography with puncture biopsiyey, sometimes (age over 40 years) mammography.
Treatment fibroadenomas - removal of the tumor
Among the etiologic factors of breast cancer isolated violation endocrine relationships. Among ethnic groups, who come to marriage at an early age birth to 3-4 children and lasted breastfeeding, breast tumors occur less frequently.
Allocate 4 pathogenic forms of breast cancer:
1) hipoty reoyidna form (5%);
2) ovarian - in patients with severe ovarian function, with menstrual disorders and with a tendency to dishormonal hyperplasia of mammary glands;
3) adrenal - infiltrative tumors grow and prone to early Ener g ation process;
4) senile - (10% patients) developed over 60 years.
Risk factors for breast cancer;
1) deviation in time of first menstruation;
2) late first pregnancy
3) absence of pregnancy;
4) breast cancer in close relatives;
5) presence of a history of benign breast tumors;
6) smoking tobacco;
7) use of hormones (especially estrogen).
8) Surgery (radiation) menopause;
9) Early or late onset of menopause;
10) The presence of thyroid dysfunction (hypothyroidism);
11) Pituitary dysfunction;
12) Adrenal dysfunction;
13) Ovarian dysfunction, pancreas with the development of diabetes, dishormonal breast disease;
14) Sexual disorders (lack of sexual activity);
15) Hypertension;
16) Body weight over 80 kg.
17) Growth of more than 170 cm;
18) Weight at birth more than 5 kg.
Ways regional metastasis:
1) axillary lymph nodes and mizhpektoralni 3 levels. Level I - lymph nodes located outward from the outer edge of the small pectoral muscles, the second - between the outer and inner edges of the small chest muscle and lymph nodes mizhpektoralni, III - lymph nodes located inward from the inner edge of a small chest muscle, including with subclavian and apical (apical) lymph nodes;
2) internal nodes of the breast, along the edge of the sternum on the affected side.
By the common forms of breast cancer may include diffuse form, inflammatory tumors (beshyhopodibnyy, armor and mastytopodibnyy cancer).
Diffuse or edematous-infiltrative form differs increase breast cancer infiltration of the skin to form a "lemon peel". Infitrat has no clear boundaries. Metastasis to regional nodes limfotychni there often comes quite quickly.
Mastytopodibna form combines features of infiltrative symptoms of inflammation - flushing of skin, increased local temperature, rapid tumor growth and infiltration as the skin and underlying tissues. This unfortunate form of breast cancer. Quickly metastasizing.
Beshyhopodibna (eryzypeloyidna) form is characterized by internally cutaneous tumors spread to the lymph vessels of the skin and is manifested focal hyperemia, similar to erysipelas.
Crustacean cancer - is actually late stage of local spread of infiltrative breast cancer. It dominates the infiltration of the breast, skin and underlying tissues. Gradually shrinks breast and infiltrate extends into the chest wall, zakovuyuchy sick though in armor.
It must be emphasized that needle biopsy is the main method, which allows for a morphological assessment of breast tumors. Discussion of additional examination methods, rationale and preliminary clinical diagnoses kurovanyh patients conducted in educational rooms. Consists algorithm differential diagnosis between precancerous diseases and cancer of the breast. For patients examined characteristics defined etiology and pathogenesis of the clinical course of the disease. A discussion of the treatment of patients with precancerous diseases and early breast cancer observed students. In drawing up the plan of treatment the patient to emphasize that it should be differentiated. Tactics of treatment depends on the flow of precancerous diseases and breast cancer, stage of the process, concomitant diseases and age of patients.
Choice of treatment locally common forms of breast cancer should be individualized, preferably treatment is complex.
When tumor size T1-T2 in the absence of distant metastases spend mastectomy for Peyto-Dissonom with preoperative radiotherapy middle fractions (4-5 Gy) dose of 20-25 Gy., Or without it. Later spend postoperative radiotherapy dose fractionation classic 40-60 Gy. and chemotherapy with hormonoterapiyey.
When "inflammatory" forms of breast cancer radical surgery almost never used, preferred chemo-radiation and hormone therapy. After neoadjuvant chemotherapy in locally advanced breast cancer is sometimes possible forms of radical m astektomiyi for Halstead-Meyer.
Radiotherapy conduct small fraction (1.5-2 Gy), daily irradiated breast and regional lymph nodes. The total dose to the operation 40-50 Gy, the radical program for 60-70 Gy.
Monochemotherapy hardly used, preferred combinations of drugs with different mechanisms of action (tiofosfamid, cyclophosphamide, 5-fluorouracil, methotrexate, ftorafur, adriablastyn etc.).
Hormone therapy is determined hormonozalezhnistyu breast tumors. For this purpose, use surgical Owari at ektomiyu, less radiation, or designate antyes Trogen different action (tamoxifen, fareston, deferelyn, fazlodeks, aromazyn).
Materials control baseline (rising levels) of students: test questions, test items
Quiz:
1. Breast. Etiopathogenesis.
2. Classification mastopathy. The division into localized and diffuse forms.
3. Clinical mastopathy.
4. Medical treatment in localized forms of mastitis.
5. Technology Sector resection.
6. Principles of non-hormonal and hormonal therapy of diffuse mastopathy. Clinical supervision.
7. No. Fibroadenomas breast cancer. classification.
8. Clinic fibroadenomas.
9. Methods of diagnosis of fibroadenomas.
10. Differential diagnosis of fibroadenoma and breast cancer.
11.Pryntsypy surgical treatment of fibroadenomas.
12. Clinical forms of breast cancer. Classification system of T nm.
13. Peculiarities of "inflammatory" forms of breast cancer.
14. Three levels of breast cancer metastasis to the lymph nodes.
15. Additional diagnostic methods locally common forms of breast cancer.
16. Indications for combined and complex treatment.
17. Peculiarities of locally advanced breast cancer.
18. Modern circuits chemo-hormonal breast cancer.
Test Objectives (Correct answers are marked *)
1. Mastopatia this:
- dishormonal hyperplasia *
- dysplasia;
- version of the rules;
- metaplasia;
- malignancy.
2. Fibroadenoma clinically is:
- limited seal with sharp edges;
- painless seal with a smooth or bumpy surface *
- painful multiple seals;
- tumor not palpable
- Isolated painful seal with sharp edges.
3. Treatment fibroadenomas requires:
- use of hormones;
- administration of progesterone;
- resection;
- reception Mastodinon;
- removal of the tumor. *
4. Risk factors for breast cancer are:
- Hipoestrohenemiya;
- Hyperprolactinemia;
- Early first pregnancy;
- A history of benign tumors in the mammary gland;
- Occurrence of early or late menopause *
5. By locally common forms of breast cancer include.
- The initial form of cancer;
- Marginal form of cancer
- Tumor Paget
- nodular form of cancer;
- edematous infiltrative form of cancer. *
6. Enter the 2nd level of metastatic breast cancer in the lymph nodes.
- Lymph nodes, placing the middle of the inner edge of the small pectoral muscle;
- Lymph nodes placed in the subclavian anatomical area
- Parasternal lymph nodes
- Lymph nodes positioned outward from the outer edge of the small pectoral muscle;
- Lymph nodes between the outer and inner edges of the small pectoral muscle. *
7. The main treatment for locally advanced breast cancer
- Surgery;
- Chemical-ray *
- Radiation.
- Hormone
- Chemotherapy
8. To the anti-estrogenic drugs include
- Tamo ksyfen *
- Testosterone;
- Dexamethasone;
- Sinestrol.
- Omnadren
9. After irradiation, large factions operation conducted
- 2-3 weeks;
- After 1 day
- After 1 week
- immediately *
- 1 month.
1 0. What form of breast cancer occurs most often
- Junction *
- Diffuse;
- Paget's disease.
- Marginal form
- Primary multiple cancer
Clinical case studies
clinical case studies (Correct answers are marked *)
Task 1. Patient M., 28y.o., applied to the oncologist complaining of multiple seals in the left breast. Sick 3 months. Recognizes the frequency of seal. Patient and Nizam al zhnya, no children. In conversation with the doctor was spotted irritability patient, fear for health. What diagnosis can put patients?
A Fibroadenoma
B Cancer
C nodal mastopathy
Diffuse mastopathy D *
E Nelaktatsiynyy mastitis
Task 2. Patient L., 33 years appealed to the oncologist complaining of tumor in the right breast. Ill during the year. Recognizes tumor growth. Palpation marked swelling of the right breast (upper - inner quadrant) thick, 3-4cm, with sharp edges, moving the skin over it unchanged. What is the most likely diagnosis in this patient? With the help of methods of examination can confirm or reject the diagnosis?
Diagnosis:
A Breast Cancer
B Alopecia breast
C * Fibroadenoma
D cysts
E Mastitis
Survey:
A Percutaneous biopsy under ultrasound *
B Mammography
C Palpation
D Ultrasound
E CT
Problem 3. Appealed to the clinic dispensary 63rokiv ill, complaining of swelling in the left breast. Neoplasms noticed more than a year ago notes that the tumor increased in size. On palpation the tumor was observed 3 - 5 cm, firm, painless, mobile. Increased left accessories and polar nodes. What disease occurs in this situation?
A Mastitis
B nodal mastopathy
C Cancer *
D cysts
E Fibroadenoma
What methods of diagnosis shows use?
A mammography + ultrasound + puncture *
Ultrasound B + puncture
Palpation C + puncture
D ultrasound puncture + + CT
E Mammography palpation + + puncture
Problem 4. Patient admitted to the hospital 40 years with available tumor occupying almost the entire right mammary gland. Tumor palpation dense, immobile, painless, with uneven surface. On Mammogram: homogeneous eclipse that occupies almost the entire gland. Regional lymph nodes were not enlarged. What disease most likely?
A fibroadenoma Filoyidna *
B Diffuse form of cancer
C Diffuse mastopathy
D Mastitis
E Alopecia form of cancer
Problem 5. Applied to oncology patient K., 60 years old, according to the patient, 3 months ago she noticed a tumor in the left breast. From the history of life is known that the first menstruation began at age 10 and menopause occurred in 55 years. The patient was never married, no children birth. On examination, the tumor is determined 4 - 5 cm in the lower-inner quadrant of the left breast, firm, mobile, leather unchanged, retracted nipple. Alveolar lymph nodes were not enlarged. What is the most likely diagnosis in this patient?
A Mastitis
B Cancer *
C Fibroradenoma
D Sarcoma
E Cyst
Problem 6. Patient L., 50 years old, was admitted to hospital with a tumor of the right breast. Palpable tumor defined 6-7cm, immobile, firm, painless, enlarged axillary supraclavicular lymph nodes. On ultrasound determined multiple shadows in the liver (secondary lesions). What morbidity torque available in this patient?
A Fibroadenoma
B Cancer *
C Sarcoma
D Mastitis
E Mastopatia
Problem 7. The woman at age 38 complaining of pain in the mammary glands, serous discharge from the nipple. Pain appear before menstruation. What disease you suspect?
A Cancer
B Mastitis
C Fibroadenoma
D Mastopatia nodal
E Mastopatia diffuse *
Task 8. The woman in '28 in the left breast palpable tumor formation 5x3 cm, its surface smooth. The tumor is cemented to the skin, redness of the skin is not, as determined by fluctuations tion. What is your diagnosis?
A Fibroadenoma
B Mastitis
Cyst C *
D Mastopatia
E Cancer
Problem 9. Patient I., 33 years appealed to the oncology clinic with complaints about the presence of a tumor in the left breast. On examination - tumor 2x2 cm, dense, lymph nodes were not palpable. Twice did the needle biopsy of the tumor, malignant cells were not found. Your continued tactics?
A dynamic observation
B Mammography
C Removal of tumor and dynamic monitoring
D Sector resection with urgent histological examination *
E Hormone
VII. Literature
7.1. Summary:
1. Bilynsky BT Oncology. Lviv, 1998.
1. Bilynsky BT Oncology. Lviv, 1992.
2. Peterson BE CANCER. Moscow: Medicine, 1980.
3. Slynchak SM CANCER. Kiev, 1989.
4. Trapeznikov NN CANCER. Moscow: Medicine, 1981.
5. Lecture material.
Methodological development was by MD, assistant Muzhychuk O.