China Oncology ›› 2023, Vol. 33 ›› Issue (12): 1092-1187.doi: 10.19401/j.cnki.1007-3639.2023.12.004
• Guideline and Concensus • Previous Articles Next Articles
The Society of Breast Cancer China Anti-Cancer Association, Breast Oncology Group of the Oncology Branch of the Chinese Medical Association
Received:
2023-11-15
Revised:
2023-11-30
Online:
2023-12-30
Published:
2023-12-28
Contact:
SHAO Zhimin.
CLC Number:
The Society of Breast Cancer China Anti-Cancer Association, Breast Oncology Group of the Oncology Branch of the Chinese Medical Association. Guidelines for breast cancer diagnosis and treatment by China Anti-cancer Association (2024 edition)[J]. China Oncology, 2023, 33(12): 1092-1187.
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适应证 | 禁忌证 | 豁免前哨淋巴结活检 |
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早期浸润性乳腺癌 | 炎性乳腺癌 | 肿瘤完整切除并经石蜡包埋组织病理完全评估为DCIS |
性别不限 | 临床ALN阳性(cN+)并经穿刺活检证实 | ≥70岁(伴随疾病),cT1N0M0,HR阳性HER2阴性,辅助治疗不受腋窝状态影响g |
临床ALN阴性(cN0) a | cN+新辅助治疗后仍为阳性 | cT1N0且影像±穿刺活检评估腋淋巴结阴性、接受保乳手术及全乳照射h |
单灶或多中心性病变 | cN2-3新辅助治疗后临床阴性 | |
DCIS全乳切除手术或保乳手术原发肿瘤切除影响随后SLNB成功率和准确性b | ||
cN0新辅助治疗后临床腋窝阴性 | ||
穿刺证实的cN1新辅助治疗后临床腋窝阴性c | ||
妊娠患者d | ||
保乳联合SLNB术后同侧乳房复发/再发e | ||
腋窝淋巴结临床查体阴性但影像学1 ~ 2枚异常并穿刺活检证实转移(有争议的适应证)f |
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内在分子分型 | 基于IHC4的分子分型 | 备注 |
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Luminal A型 | Luminal A样 ER/PR阳性且PR高表达HER2阴性 Ki-67增殖指数低 | ER、PR表达及Ki-67增殖指数的判定值建议采用报告阳性细胞的百分比。 Ki-67增殖指数的判定值在不同病理实验中心可能不同,可采用20%~30%作为判断Ki-67增殖指数高低的界值;同时,以20%作为PR表达高低的判定界值*,可进一步区分Luminal A样和Luminal B样(HER2阴性) |
Luminal B型 | Luminal B样(HER2阴性) ER/PR阳性 HER2阴性 且Ki-67增殖指数高或PR低表达 | 上述不满足Luminal A样条件的Luminal样肿瘤均可作为Luminal B样亚型 |
Luminal B样(HER2阳性) ER/PR阳性 HER2阳性(蛋白过表达或基因扩增) 任何状态的Ki-67增殖指数 | ||
ERBB2+型 | HER2阳性 HER2阳性(蛋白过表达或基因扩增) ER阴性和PR阴性 | |
Basal-like型 | 三阴性(非特殊型浸润性导管癌) ER阴性 PR阴性HER2阴性 | TNBC和Basal-like型乳腺癌之间的吻合度约80%;但是TNBC也 包含一些特殊类型乳腺癌如分泌性癌和腺样囊性癌等 |
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复发风险度 | 激素受体阳性HER2阴性 | HER2阳性 | TNBC |
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低危 | 豁免化疗 | 不适用 | 不适用 |
中危且pN0b | ·T3及以上推荐化疗 ·T1b-T2:考虑多基因检测工具,目前指导辅助化疗的主要是21基因或70基因检测 - 21基因:年龄>50岁且RS>25 推荐化疗 - 21基因:年龄≤50岁日RS≥16 推荐化疗 - 70基因:临床高风险a且70基因高风险推荐化疗 - 70基因:临床高风险a且年龄≤50岁且70基因低风险考虑化疗 ·T1b~T2:未接受基因检测,具有如下特征之一的可考虑化疗:ER低表达组织学3级,LVI阳性,年龄≤35岁,高Ki-67增殖指数c ·T1a:原则上豁免化疗,除非同时伴有多个风险因素时个体化综合考虑 | ·T1c及以上推荐 ·T1a-b考虑d ·T1mic原则上不考虑,需个体化综合评估,如年龄、LVI、多灶与否等 | ·T1c及以上推荐 ·T1a-b考虑 ·T1mic原则上不考虑,需个体化综合评估,如年龄、LVI、多灶与否等 |
中危且pN1 | ·均推荐化疗 ·除非T1-2且接受21基因或70基因检测时,如下结果才考虑豁免化疗: - 21基因: RS≤11的患者e - 70基因:临床高风险a,70基因低风险且年龄>50岁的患者 | 不适用 | 不适用 |
高危 | 均推荐化疗 | 均推荐化疗 | 均推荐化疗 |
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推荐对乳腺癌患者进行BRCA基因检测的专家共识 |
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·家族中有已知的BRCA1/2基因有害突变 |
·乳腺癌病史符合以下条件: |
确诊年龄≤45岁 |
确诊年龄46 ~ 50岁 |
▲第二原发乳腺癌 |
▲≥1位直系亲属确诊乳腺癌,其确诊年龄不限 |
▲≥1位直系亲属确诊高级别前列腺癌(Gleason分值≥7分) |
▲有限或未知家族史 |
三阴性乳腺癌确诊年龄≤60岁 |
年龄不限,但符合以下一项条件 |
▲≥1位直系亲属且满足:乳腺癌确诊年龄≤50岁,或卵巢癌,或男性乳腺癌,或转移性前列腺癌,或胰腺癌 |
▲≥2位患者或直系亲属确诊乳腺癌 |
·卵巢癌病史 |
·男性乳腺癌病史 |
·胰腺癌病史 |
·转移性前列腺癌病史 |
·任何年龄的高级别前列腺癌病史(Gleason分值≥7分)并且符合以下1项条件: |
▲≥1位直系亲属确诊卵巢癌、胰腺癌或转移性前列腺癌,确诊年龄不限或乳腺癌确诊年龄≤50岁 |
▲≥2位直系亲属确诊乳腺癌、前列腺癌(任何级别),确诊年龄不限 |
·肿瘤中发现BRCA1/2有害突变且胚系突变状态未明 |
·无论家族史,BRCA突变相关癌症受益于靶向治疗(如卵巢癌/HER2阴性的转移性乳腺癌PARP抑制剂治疗,前列腺癌铂类药物化疗 |
·不符合以上标准但有≥1位一级或二级亲属符合以上任何一条的个体。对于未携带者(BRCA1/2有害突变)检测结果的解读是有局限性的,需要充分讨论 |
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患者姓名:××× | 性别:女 | 年龄:51岁 | 放射学检查号码:12345678 |
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门诊号: | 住院号:123456 | 科室:乳腺外科 | 病区: |
临床诊断:左乳肿块 | |||
检查日期:2023年10月10日前片无 | |||
投照体位: | |||
√ 左侧:头足(轴)位、侧斜位 | |||
检查设备GE2000D | |||
√ 右侧:头足(轴)位、侧斜位 | |||
影像学描述: | |||
双侧乳腺腺体不均匀致密型。 | |||
左乳腺外上方可见一大小2.8 cm×1.8 cm的肿块影,高密度,形态不规则并伴有边缘毛刺,内见多形性细小钙化。 | |||
右乳腺未见明显肿块与异常钙化。 | |||
双侧皮肤、乳头影正常。 | |||
双侧腋下可见小淋巴结,形态密度无异常。 | |||
影像学评估: | |||
左乳外上病灶,考虑为恶性,BI-RADS 5。 | |||
右乳未见异常,BI-RADS 1。 |
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患者姓名:××× | 年龄: | 性别: | 超声号: |
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住院/门诊号: | 临床诊断: | 使用仪器: | 探头频率: |
双侧(左侧、右侧)乳腺组织回声(不)均匀,结构清晰(紊乱)。 | |||
导管(未见)扩张(内径 mm),乳腺组织呈条索状(结节状、团块状)等回声。 | |||
左(右)乳腺外上象限(内上、内下、外下、乳晕区域)点(按时钟法)距乳头 cm,探及低(等、高)回声结节,大小 mm× mm× mm,形态(不)规则,边界(欠、不)清晰,边缘光整(毛刺、成角、分叶状),内部回声(欠、不)均匀,(未)见点状强回声,后方回声增强(无变化、衰减),周围组织(水肿、受压、变形、无变化),彩色多普勒超声显示内部(无)血流信号,呈点状(条状、网状、团状),RI 。 | |||
双(左、右)腋下见淋巴结,大小 mm× mm× mm,形态(不)规则,边界(欠、不)清晰,边缘光整(毛刺、成角、分叶状),内部回声(欠、不)均匀,(未)见点状强回声,后方回声增强(无变化、衰减),彩色多普勒超声显示内部(无)血流信号,呈点状(条状、网状、团状),RI 。 | |||
超声提示: | |||
1. 双(左、右)乳未见明显占位 | |||
2. 左(右)乳外上象限实性(混合性、囊性)占位(纤维瘤可能……) | |||
检查医师: | |||
检查日期: |
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患者姓名:××× | 性别:女 | 年龄:51 | 放射学检查号码:12345678 |
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门诊号: | 住院号:123456 | 科室:乳腺外科 | 病区: |
临床病史:右乳癌待排检 | |||
要求:常规动态增强扫描 | |||
检查日期: | |||
前片:无 | |||
检查部位和名称:双侧乳房(平扫+动态增强) | |||
检查设备:3 T/1.5 T,乳腺专用线圈 | |||
检查方法:平扫AxT1,AxT2;Ax+Sag C+;以速率2.5 mL/s注射轧对比剂(具体药名)15 mL,再用0.9%的生理盐水10 mL冲洗 | |||
临床简述: | |||
右乳外上扪及肿块,X线和超声检查提示病变性质不确定。末次月经时间: (或绝经后妇女)。 | |||
影像学描述: | |||
两侧乳房大小、形态基本对称,两侧纤维腺体呈不均质致密型,分布无异常,增强后实质背景轻度强化。右乳外上象限中带见一卵圆形肿块影,边缘模糊不清,T1WI上呈低信号,T2WI上高信号,增强后呈不规则环形强化,早期强化明显,延迟期强化降低,动态增强曲线呈廓清型。病变大小约3 cm×2 cm×2 cm。病灶在扩散加权上受限,ADC约0.9 mm2/s。病灶前缘距离乳头约3 cm。左乳内未见明确占位及异常强化影。所示两侧腋下未见明显肿大淋巴结,两侧胸壁肌肉未见异常。两侧乳头及皮肤未见明显异常。 | |||
影像学评估: | |||
右乳外上象限中带距离乳头约3 cm处肿块,高度怀疑其为恶性,建议活检,BI-RADS 5 | |||
左乳未见异常发现,BI-RADS 1 | |||
报告医师签名: | |||
审核医师签名: | |||
报告日期: |
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患者姓名:××× | 性别: | 年龄: | 送检日期: | 病理号: |
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住院号: | 床号: | 科室: | 送检医师: | 标本类型: |
肉眼所见:(左乳)乳腺改良根治标本,乳腺大小27.0 cm×20.0 cm×3.5 cm。皮瓣面积19.0 cm×9.0 cm,乳头直径0.9 cm,高出皮肤0.3 cm,未见明显异常。内上象限,距乳头2.5 cm,皮下1.0 cm见大小约3.5 cm×3.0 cm×2.5 cm质硬肿块,切面灰白灰红、界限不清。查见腋窝淋巴结23枚,最大径0.5 ~ 1.2 cm。 | ||||
病理学诊断:(左乳)浸润性癌,非特殊类型,2级(腺管形成2分、核级2分、核分裂象2分,总分6分),伴导管原位癌(约占20%,中核级,粉刺样坏死,含钙化)。浸润癌最大径3.5 cm,可见脉管侵犯。周围乳腺呈乳头状瘤及腺病改变。乳头、乳腺表面皮肤及基底切缘均未见癌累及。腋窝淋巴结(7/23)查见癌转移。 | ||||
免疫组织化学检测提示浸润性癌:ER(+)(强,阳性细胞约70%)、PR(+)(中等强度,阳性细胞约60%)、HER2(0)、Ki-67增殖指数约30%。 | ||||
病理学分期:pT2N2Mx | ||||
报告医师签名: | ||||
审核医师签名: | ||||
报告日期: |
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