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1、NCCN Guidelines Version 3.2014,Preoperative Systemic Therapy Guideline of breast-conserving therapy,Absolute:Radiation therapy during pregnancy（注：邻近分娩时，可先期手术，将放射治疗延迟至分娩以后时才考虑保乳）Diffuse suspicious or malignant-appearing microcalcifications（弥漫可疑/癌性微钙化灶）Widespread disease that cannot be incorporated by
2、 local excision through a single incision that achieves negative margins with a satisfactory cosmetic result（注：多灶、多中心为禁忌）Positive pathologic margin,Contraindications for breast-conserving therapy requiring radiation therapy include:,Relative:Prior radiation therapy to the chest wall or breastActive
3、connective tissue disease involving the skin(especially scleroderma and lupus（注：因不能耐受放疗，可能导致严重的纤维化和软组织或骨的坏死)Tumors 5 cm(category 2B)Focally positive margin（注：显微镜下不伴有广泛导管内癌成分的局灶性阳性切缘可选择性保乳，更高剂量的瘤床推照）Women with a known or suspected genetic predisposition to breast cancer:1）May have an increased risk o
4、f ipsilateral breast recurrence（患侧复发）or contralateral（对侧）breast cancer with breast-conserving therapy 2）Prophylactic bilateral mastectomy for risk reduction may be considered（预防性双乳切除）.,Contraindications for breast-conserving therapy requiring radiation therapy include:,Stage IIA T2,N0,M0Stage IIB T2
5、,N1,M0；T3,N0,M0Stage lllA T3,N1,M0Fulfills criteria for breast-conserving surgery except for tumor size,CLINICAL STAGE,History and physical examCBC,plateletsLiver function tests and alkaline phosphatase Bilateral mammogram（双乳X线）;UltrasoundPathology reviewTumor ER/PR status and HER2 statusGenetic cou
6、nseling if patient is high risk for hereditary(遗传)breast cancerBreast MRI(optional),with special consideration for mammographically occult（钼靶隐匿）tumorsFertility counseling if premenopausal（绝经前）Consider systemic staging(particularly if signs and symptoms are present):Chest diagnostic CTAbdominal（腹）pel
7、vic（盆）diagnostic CT or MRIBone scan or sodium fluoride（氟化钠：主评骨）PET/CT(category 2B)FDG PET/CT(optional,category 2B),WORKUP,Desires breast preservation：Core biopsy with placement of image-detectable marker(s),if not previously performed,must be done to demarcate the tumor bed for post-chemotherapy sur
8、gical management.即：术前需行瘤床定位Does not desire breast preservation：See Locoregional(局部)Treatment of Clinical Stage I,IlA,or IlB Disease or T3,N1,M0.,Preoperative Systemic Therapy Breast and Axillary Evaluation,Clinically negative:should have axillary ultrasound;suspicious nodes should be sampled by FNA
9、or core biopsy and clipped with image-detectable marker;positive clipped lymph nodes must be removed if FNA or core biopsy was positive prior to neoadjuvant therapy.Clinically positive:should be sampled by FNA or core biopsy and clipped with image-detectable marker;positive clipped lymph nodes must
10、be removed if FNA or core biopsy was positive prior to neoadjuvant therapy.简言之，淋巴结怀疑阳性的需活检取样，若证实，在新辅助治疗前切除。,Axillary lymph node(s),Preoperative systemic therapy,Endocrine therapy alone may be considered for receptor-positive disease in postmenopausal patients;An aromatase inhibitor(芳香化酶抑制剂)is prefer
11、red.,Those chemotherapy regimens recommended（化疗方案推荐）in the adjuvant setting may be considered in the preoperative setting.,Preoperative systemic therapy,A pertuzumab-containing regimen(含帕妥治疗)may be administered preoperatively to patients with T2 or N1,HER2-positive,early-stage breast cancer.,Patient
12、s with HER2-positive tumors should be treated with preoperative system therapy incorporating trastuzumab(联合曲妥)for at least 9 weeks of preoperative therapy.,CR(Complete response)：S=0PR(Partial response)：S 50%SSD(Stable disease):50%S S 125%SPD(progressive disease):S125%S,Curative effect evaluation,肿块,
13、D,d,S=D d,RESPONSE,Mastectomy and surgical axillary staging reconstruction.If sentinel lymph node biopsy performed prechemotherapy and negative findings,may omit axillary lymph node staging注意：化疗前,Mastectomy,Lumpectomy with surgical axillary stagingIf sentinel lymph node biopsy performed prechemother
14、apy and negative findings,may omit axillary lymph node staging注意：化疗前,Lumpectomy,CLINICAL STAGEStage IIIA T0,N2,M0；T1,N2,M0；T2,N2,M0；T3,N2,M0Stage IIIB T4,N0,M0；T4,N1,M0；T4,N2,M0Stage lllC Any T,N3,M0,Locally advanced（局部晚期）invasive breast cancer(non-inflammatory),History and physical examCBC,platelet
15、sLiver function tests and alkaline phosphataseBilateral mammogram;Ultrasound Pathology reviewTumor ER/PR status and HER2 statusGenetic counseling if patient is at high risk for hereditary breast cancerBreast MRI(optional),with special consideration for mammographically occult tumorsFertility counsel
16、ing if premenopausalConsider systemic staging(particularly if signs and symptoms are present):Chest diagnostic CTAbdominal pelvic diagnostic CT or MRIBone scan or fluoride PET/CT(category 2B)FDG PET/CT(optional,category 2B),WORKUP,Response:1)Total mastectomy+level l/ll axillary dissection+radiation
17、therapy to chest wall and infraclavicular(锁骨下)and supraclavicular nodes(plus internal mammary nodes if involved(内乳淋巴结受累),strongly consider internal mammary nodes if not clinically involved category 2B)delayed breast reconstruction(延迟性乳房重建).2)Consider lumpectomy+level l/ll axillary dissection+radiati
18、on therapy to breast and infraclavicular and supraclavicular(锁骨上)nodes(plus internal mammary nodes if involved),Preoperative systemic therapy,No response,For patients with skin and/or chest wall involvement(T4 non-inflammatory)prior to neoadjuvant therapy,breast conservation may be performed in care
19、fully selected patients based upon a multidisciplinary assessment of local recurrence risk.Exclusion criteria for breast conservation include:inflammatory(T4d)disease before neoadjuvant therapy and incomplete resolution of skin involvement after neoadjuvant therapy.,The End,Thank you!,18自动发卡平台 http:/嫓廰掆,
