术前系统治疗指南.ppt

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 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 breast Active 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 of 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, M0 Stage IIB T2, N1, M0；T3, N0, M0 Stage lllA T3, N1, M0 Fulfills criteria for breast-conserving surgery except for tumor size CLINICAL STAGE History and physical exam CBC, platelets Liver function tests and alkaline phosphatase Bilateral mammogram（双乳X线）; Ultrasound Pathology review Tumor ER/PR status and HER2 status Genetic counseling if patient is high risk for hereditary(遗传) breast cancer Breast MRI (optional), with special consideration for mammographically occult（钼靶隐匿） tumors Fertility counseling if premenopausal（绝经前） Consider systemic staging (particularly if signs and symptoms are present): Chest diagnostic CT Abdominal（腹） ± pelvic（盆） diagnostic CT or MRI Bone 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 surgical 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 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 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 preferred . 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. Patients 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=0 PR(Partial response)：S 50%S SD(Stable disease): 50%S S 125%S PD(progressive disease):S125%S Curative effect evaluation 肿 块 D d S = D ×d RESPONSE Confirmed progressive disease at any time Partial response, lumpectomy not possible Mastectomy Partial response, Lumpectomy possible or Complete response Lumpectomy 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 staging If sentinel lymph node biopsy performed prechemotherapy and negative findings, may omit axillary lymph node staging 注意：化疗前 Lumpectomy CLINICAL STAGE Stage IIIA T0, N2, M0；T1, N2, M0；T2, N2, M0；T3, N2, M0 Stage IIIB T4, N0, M0；T4, N1, M0；T4, N2, M0 Stage lllC Any T, N3, M0 Locally advanced（局部晚期） invasive breast cancer(non- inflammatory ) History and physical exam CBC, platelets Liver function tests and alkaline phosphatase Bilateral mammogram; Ultrasound Pathology review Tumor ER/PR status and HER2 status Genetic counseling if patient is at high risk for hereditary breast cancer Breast MRI (optional),with special consideration for mammographically occult tumors Fertility counseling if premenopausal Consider systemic staging (particularly if signs and symptoms are present): Chest diagnostic CT Abdominal ± pelvic diagnostic CT or MRI Bone scan or fluoride PET/CT (category 2B) FDG PET/CT (optional, category 2B) WORKUP Response: 1)Total mastectomy + level l/ll axillary dissection + radiation 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 + radiation therapy to breast and infraclavicular and supraclavicular(锁骨上) nodes (plus internal mammary nodes if involved) Preoperative systemic therapy No response Consider additional systemic chemotherapy and/or preoperative radiation Response - See above pathway No response Individualized treatment For patients with skin and/or chest wall involvement (T4 non-inflammatory) prior to neoadjuvant therapy, breast conservation may be performed in carefully 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 EndThe End Thank you!Thank you!