Reviewing the clinical management of breast cancer surgery according to evidence-based medicine
Definition of Evidence-based Medicine: Clinical practice requires a comprehensive analysis of a large number of cases and prospective randomized comparative clinical trials, which is evidence-based medicine. Clinical practice should be reviewed in accordance with Evidence-based Medicine (EBM). As a continuous improvement of breast cancer treatment.
Evidence-based medicine categorizes clinical literature into 5 levels.
Level 1: refers to a rigorous and comprehensive analysis of the results of many prospective randomized comparative clinical trials that can lead to conclusions.
Level 2: A small number of prospective randomized comparative clinical trials that failed to reach a definitive conclusion;
Level 3: Prospective clinical case group studies;
Level 4: A clinical case comparison study, which does not have a strict prospective randomized clinical trial nature;
Level 5: A clinical case study analysis.
The clinical practice should be guided by strong evidence: the results determined by the level 1 clinical trials are in line with the requirements of evidence-based medicine.
Cancer treatment options that are fully suitable for our socioeconomic conditions: breast-conserving surgery, neoadjuvant chemotherapy, mammaplasty, etc. In China, except for patients without subjective aesthetic requirements, objective breast radiotherapy, follow-up and mammograms after breast preservation surgery are under continuous development. However, there is an urgent need for primary hospitals and patient awareness and requirements to propose reasonable principles for the development of breast cancer treatment plans according to the requirements of evidence-based medicine.
Suspicious points during self-examination of breast
The following suspicious points should be noted during breast self-examination.
1, through the examination of the mirror, the appearance of bilateral breasts are found to have changes, such as: localized breast elevation, whether the nipples are invaginated, changes in the color of the skin of the breast redness, etc.
2.Touching the breast with the hand, a single lump, or multiple lumps, or lumps of different sizes were found.
3.Pull the breast skin by hand, and the lump in the breast adhesions; or other changes.
4.In the case of normal nipples, there is a significant depression of the nipple; pulling the nipple when pulling does not move.
5, accumulation or non-accumulation of the nipple, there is overflow; the color of the overflow is darker, more red and black.
6.No obvious lumps in the breast, but breast lumps or nodules compared with the actual distribution of nodules, more than the usual part of the breast augmentation.
7. Enlarged lymph nodes can be found in the armpits; however, there is no pressure pain.
Precautions for doctors when examining breasts
When examining the patient, the doctor should strictly grasp the differences between normal and abnormal breasts.
1.Breast appearance: whether the appearance of bilateral breasts is symmetrical; whether there are changes in the appearance of the breasts; in general, there is not much change in the appearance of the breasts, but special attention should be paid to the following changes in the appearance of the breasts: abnormal skin of the breasts: protrusion, depression, redness, edema, wrinkles, etc.; abnormal range of breast skin.
2. Observe the nipples: whether the nipples are symmetrical bilaterally; whether the nipples are sunken; whether there is overflow from the nipples; the nature of the overflow; and the amount of overflow. The common overflow abnormalities are: bloody overflow, but other colors of overflow cannot be excluded.
3. Touch the breast: touch both breasts and compare the differences between them; pay particular attention to whether a lump can be palpated when touching the breast, paying special attention to: the size, border, mobility, adhesiveness, solidity, cysticity, pain or not, etc. of the lump. Pay attention to the difference between nodules of breast enlargement and microscopic swellings of the breast.
4.Pay attention to the parametrium: the size of the parametrium varies, but be sure to check for the presence of parametrium and changes within the parametrium.
5.Touch the lymph nodes in bilateral axillae and bilateral supraclavicular for enlargement, pressure pain and mobility.
6.According to the examination results, the patient will be given various special and different examinations: ultrasound, mammogram, MRI, mammogram, nuclear scan, breast puncture, etc.
Suspicious points of mammography
Subjects for mammography: breast accessible masses; ultrasound suspicious masses; age over 40 years; etc.
Common problems with mammograms of the breast.
Breast with variable sized masses, single or multiple; irregular shape of the mass; poorly defined edges of the mass; skin changes of the breast; changes in the breast parenchyma; bilateral asymmetry; signs such as thickened vascular shadows are more likely to be malignant lesions. Changes in lymph nodes, etc.
Microcalcifications visible on mammogram of the breast.
Calcification foci in the breast can vary in size: coarse calcification foci are often benign lesions of the breast, such as aging arteries within the breast tissue, old injuries, and inflammation, and generally do not require biopsy.
Small foci of calcification are usually located in areas of rapid cell growth and division. If there are multiple tiny localized calcifications clustered together in a cluster, it suggests the possible presence of small breast cancer lesions.
The value of microcalcifications in breast cancer diagnosis
1. Incidence of calcification in breast cancer: Calcification is one of the common imaging manifestations of breast cancer. Certain specific forms of calcification are risk factors for breast cancer.
2. The only X-ray sign of early breast cancer: Cluster-like microcalcifications are often the only mammography plain sign of early breast cancer. The nature and extent of the lesion can be reflected by the shape, size, number and density of the microcalcifications. Microcalcifications can be located in or around the lump, with a total number of 6 to 15, with uneven density and varying size. Mammogram can improve the diagnosis rate of occult cancer, microscopic cancer and early cancer.
3.The formation of microcalcifications in malignant lesions of breast: the number of microcalcifications per unit area of malignant lesions of breast is high, which may be caused by the combined effect of necrosis of cancer tissue and secretion of cancer cells and other reasons. The different densities and sizes among calcification points may be due to the different lengths of calcium salt deposition, and the calcifications formed first with time are relatively denser and larger in volume.
4, the difference between benign and malignant calcification: compared with benign calcification, the average density of malignant calcification group is lower, and the density and size are of greater value in differentiating benign and malignant breast diseases. The distribution of microcalcifications in mammograms seems to be irregular, but when pathology reveals that the cancer occurs in the terminal ducts, the calcifications may be located in a large area of necrotic tissue or among cancer cells, or they may exist in the superior ducts or in the bifurcation of the ducts or in the adjacent alveolar cavity.
5. Formation of regional calcification of cancer foci: Regional calcification of cancer foci can be of fine sand type or mixed type, and intra-ductal calcification of worm type, which may be related to abnormal secretion of tumor along duct drainage. When the cancer is located in larger ducts, calcifications away from the foci are often located in the peripheral next level ducts, and are mainly of fine sand type, which may be produced by abnormal metabolites of cancer cells or cancer cells reflux stimulating the terminal ducts and glandular vesicles. The large number, fine particles and rough edges can be located inside or outside the mass shadow suggesting malignancy.
Difference between microcalcifications and stones in the breast
1, mammogram plain examination of the breast, breast stones can be seen. The concept of breast stones is that the calcified masses are large and can be single or multiple. Breast stones and microcalcifications are completely distinguishable.
2. Breast stones are not commonly seen clinically, and they are neither mammary hyperplasia nor breast tumors. Usually, the patient can feel a hard lump in the breast intentionally or unintentionally, which is usually flat or round, with different sizes in diameter, the largest being about 1 to 3 cm. When the calcification is large, the surface of the lump in the breast is smooth and clearly defined, and can be pushed with fingers without pain or other discomfort.
3. Inflammation of the breast with or without obvious symptoms can cause narrowing or blockage of the milk ducts, which can also cause milk stagnation. When too much milk accumulates in the breast, it can break through the wall of the alveoli or the milk ducts and overflow. Many of the disrupted alveoli and ducts fuse to form a larger breast cyst. Over time, the water inside the cyst is gradually absorbed and hard breast stones are formed. Once formed, breast stones are very difficult to subside and can be detected on mammogram.
Analysis and biopsy of patients with clustered calcifications
1. Diagnostic methods for cluster calcification: For patients with cluster calcification in the breast that are not clinically palpable but are found on mammography, the main methods used to further clarify the diagnosis are: X-ray guided coarse needle aspiration biopsy; X-ray guided metal wire localization excision biopsy; ultrasound guided coarse needle aspiration biopsy; ultrasound guided metal wire localization excision biopsy.
The advantages of metal wire localization biopsy: accurate localization of microcalcifications in the breast; parallel to the chest wall in the direction of needle insertion; marking the calcification site with a metal localization wire with “inverted hook”; adjusting the entry direction of the puncture needle according to the location of the calcification site; the number of localization wires placed depends on the distribution of the calcification site. Special attention: after the positioning wire is placed, the position of the patient may change the position of the positioning wire and the calcification point.
3. Judgment of the completeness of excision of microcalcifications: the biopsy procedure is always performed under the guidance of metal positioning lines; more glandular tissues are excised at the front of the positioning lines; radiographs are performed after cutting down the specimen to understand whether all the calcification points have been excised. However, attention is paid to the intensity of the radiation when the photograph is taken.
The value of breast calcification in breast cancer diagnosis
1. Incidence of calcification in breast cancer: Calcification is a common imaging manifestation of breast cancer. The specific form of calcification is a risk factor for breast cancer.
2.Signs of calcification in early breast cancer: the nature and scope of lesions can be reflected according to the performance of microcalcifications in terms of shape, size, number and density. Microcalcifications can be located in or around the lump. The density is more concentrated and the total number of 6 to 15 is commonly used for diagnostic significance. It improves the diagnosis rate of occult cancer, microscopic cancer and early cancer.
3.The formation of malignant microcalcifications in breast: it may be caused by the combined effect of various reasons such as necrosis of cancer tissue and secretion of cancer cells. The different densities and sizes among the calcification points may be due to the different length of time of calcium salt deposition, and the calcification formed over time has relatively higher density and wider range.
Differential diagnosis of common breast lumps and breast cancer
1. Cystic adenomatous hyperplasia: this disease is a stage of abnormal proliferation of the breast, mostly in older people, and is prone to multiple occurrences, sometimes in the form of cord-like nodules with unclear borders, which are pre-cancerous lesions.
2. Breast pain: It is also a stage of abnormal breast hyperplasia, which is mainly manifested by most of the small unsmooth nodules palpable on the breast, and most of them have slight spontaneous pain. Especially before the onset of menstruation, breast swelling and pain is obvious, and even pain is not palpable, the patient is very painful.
3, papilloma: can be single or multiple. Most of the single-occurring cases are in older women, and 50% have bloody overflow. Multiple cases are diffuse nodules with no obvious masses. This tumor can become malignant.
4. Adenofibroma: It occurs in young women with endocrine disorders, mostly between the ages of 20 and 30. The masses are obvious, well-defined, smooth, mobile, soft and nodular. It grows slowly and is rarely painful, but there is a possibility of malignancy occurring.
5.Fat necrosis: It occurs in the lateral part of the breast of obese women, mostly with a history of trauma, and requires excisional biopsy to identify.
6, breast tuberculosis: most of the chest wall tuberculosis spread, can be ulcerated, and outflow of cheese-like pus. The presence of tuberculosis lesions from other sites is often found at the same time during the examination.
7, plasmacytoid mastitis: also known as non-lactating mastitis. Less common, mostly with a history of acute attacks, may have pain, fever, etc., but subsides quickly after anti-inflammatory treatment.
8.Lobular cystic sarcoma: Mostly seen in 35-40 years old, with slow development, the tumor is lobulated, partly hard like stone, and partly cystic in nature. The tumor is often huge, sometimes ulcerated, and rarely fixed with the chest. It is often mistaken for advanced breast cancer, but the outcome is excellent after radical surgery. Metastasis is uncommon and is usually hematogenous, with occasional lymphatic metastasis.