Diagnosis

诊断

Testing is required to differentiate benign lesions from cancer. Because early detection and treatment of breast cancer improves prognosis, this differentiation must be conclusive before evaluation is terminated.

需通过化验检查鉴别良性病变和癌变。乳腺癌早发现、早治疗可改善预后，因此，只有鉴别结论出来后才可以结束评估。

If advanced cancer is suspected based on physical examination, biopsy should be done first; otherwise, the approach is as for breast lumps. A prebiopsy bilateral mammogram may help delineate other areas that should be biopsied and provides a baseline for future reference. However, mammogram results should not alter the decision to perform a biopsy. Biopsy can be needle or incisional biopsy or, if the tumor is small, excisional biopsy. Any skin with the biopsy specimen should be examined because it may show cancer cells in dermal lymphatic vessels. Routinely, stereotactic biopsy (needle biopsy during mammography) or ultrasound-guided biopsy is being used to improve accuracy.

若体检时怀疑有晚期癌症，应先做活检。否则就按乳房肿块处理。活检前行双侧乳房X线照相可帮助划定其他活检部位，并为将来提供参考依据。只是，乳房X线照相结果不应影响活检决定。活检分针吸活检或切开式活检，小肿瘤也可行切除活检。活检标本皮肤应作检查，因为它可以揭示皮肤淋巴管的癌细胞。按常规，趋实体活检（乳房X线照相时的针吸活检)或超声引导活检可提高准确率。

Evaluation after cancer diagnosis: Part of a positive biopsy specimen should be analyzed for estrogen and progesterone receptors and for HER2 protein. WBCs should be tested for BRCA1 and BRCA2 genes when family history includes multiple cases of early-onset breast cancer, when ovarian cancer develops in patients with a family history of breast or ovarian cancer, when breast and ovarian cancer occur in the same patient, when patients have Ashkenazi Jewish heritage, or when family history includes a single case of male breast cancer.

乳腺癌诊断后评估：部分阳性活检标本应作雌激素、黄体激素受体分析和HER2蛋白分析。下列情况应作白血球BRCA1和BRCA2基因检测：有多例早发乳腺癌家族史，卵巢癌病人有乳腺癌或卵巢癌家族史，同一病人患乳腺癌和卵巢癌，病人有北欧犹太教徒血统，有一例男性乳癌家族史。

Chest x-ray, CBC, and liver function tests should be done to check for metastatic disease. Generally, measuring serum carcinoembryonic antigen (CEA), cancer antigen (CA) 15-3, CA 27-29, or a combination is not recommended because results have no effect on treatment or outcome. Bone scanning should be done if patients have tumors > 2 cm, musculoskeletal pain, lymphadenopathy, or elevated serum alkaline phosphatase or Ca levels. Abdominal CT is done if patients have abnormal liver function results, hepatomegaly, or locally advanced cancer with or without axillary lymph node involvement.

应进行转移性疾病检查，包括胸部X检查、全血计数和肝功能检查等。一般不建议作血清癌胚抗原（CEA)、癌抗原（CA)15－3、CA 27－29、或上述结合测定，因为测定结果对治疗或结果并无影响。下列情况应作骨扫描：病人肿瘤> 2 cm、肌骨痛、淋巴结病、血清碱性磷酸酶或钙值增高。如病人出现下列情况则应作腹部CT：肝功异常、肝肿大、局部晚期癌症伴或无腋淋巴结受累。

Grading and staging follow the TNM classification (see Table 2: Breast Disorders: Staging and Survival of Breast Cancer). Staging is refined during surgery, when regional lymph nodes can be evaluated.

肿瘤淋巴结转移分类后的分组与分期（见表2：乳房疾病：乳腺癌的分期与存活)。肿瘤分期在手术期间进行，此时可对局部淋巴结作评估。

Screening: Screening includes mammography, clinical breast examination (CBE) by health care practitioners, and monthly breast self-examination (BSE).

筛查：筛查包括乳房X线照相术、保健医师临床乳房检查（CBE)和每月乳房自我检查（BSE)。

Mammography, done annually, reduces mortality rate by 25 to 35% in women ≥ 50 yr. However, there is considerable disagreement about screening for women 40 to 50 yr; recommendations include annual mammography (American Cancer Society), mammography every 1 to 2 yr (National Cancer Institute), and no periodic mammography (American College of Physicians).

乳房X线检查每年一次，这可使≥50岁妇女死亡率减少25－35%。不过，对40－50岁妇女作筛查仍有很大分歧，不同建议包括，每年一次乳房X线照相（美国癌症学会)、每1－2年一次乳房X线照相（国家癌症研究所)及不定期乳房X线照相（美国医师学院)。

CBE is usually part of routine annual care for women > 35; it can detect 7 to 10% of cancers that cannot be seen on a mammogram. In the US, CBE augments rather than replaces screening mammography. However, in some countries where mammography is considered too expensive, CBE is the sole screen; reports on its effectiveness in this role vary.

全血计数是＞35岁妇女常规年度保健内容之一，在乳房X线照相无法发现的乳腺癌中，有7－10%的病例可通过这种方法检出。不过，在有些国家，人们认为乳房X线照相太贵，因此，全血计数是唯一的筛查方法，但对其有效性也是看法各异。

BSE has not been shown to reduce mortality rate but is widely practiced. Because a negative BSE may tempt some women to forego mammography or CBE, the need for these procedures is reinforced when BSE is taught.

乳房自检似乎并未减少死亡率，但它用得很广。由于阴性BSE可诱使一些妇女放弃乳房X线照相检查或CBE检查，因此，在教育妇女做BSE时就应强调这些检查的必要性。

Prognosis

预后

Long-term prognosis depends on extent of lymph node involvement, number of axillary lymph nodes involved, size of primary tumor, tumor grade, stage, presence of estrogen and progesterone receptors, patient age, and presence of HER2 protein.医学.全.在线.网.站.提供

长期预后取决于淋巴结的受累程度、受累的腋淋巴结数量、原发性肿瘤的大小、肿瘤级别、分期、是否有雌激素和黄体激素受体、病人年龄及是否有HER2蛋白。

Nodal status correlates with disease-free and overall survival better than other prognostic factors. For node-negative patients, 10-yr disease-free survival rate is > 70%, and overall survival rate is > 80%. For node-positive patients, rates are about 25% and 40%, respectively.

与其他预后因素相比，结节状况与无病及总存活率关系更大。对结节阴性病人来说，10年无病存活率> 70%，总存活率> 80%，结节阳性病人分别为25%和40%。

Larger tumors are more likely to be node-positive and also confer a worse prognosis independent of nodal status. Patients with poorly differentiated tumors have a worse prognosis.

较大肿瘤的结节阳性可能性更大，预后更差，且与结节状况无关。低分化肿瘤病人预后较差。

Patients with ER+ tumors have a somewhat better prognosis and are more likely to benefit from hormone therapy. Patients with progesterone receptors on a tumor may also have a better prognosis.

ER＋肿瘤病人预后稍好，也更容易从激素治疗中受益。肿瘤有黄体激素受体的病人预后较好。

When the HER2 gene is amplified, HER2 is overexpressed, increasing cell growth and reproduction and often resulting in more aggressive tumor cells. Overexpression of HER2 may be associated with high histologic grade, ER– tumors, greater proliferation, larger tumor size, and thus a poor prognosis.

HER2基因放大，HER2就会表达过度，增加细胞生长繁殖，并经常导致更多的攻击性肿瘤细胞。HER2的过分表达可能与组织学等级高、ER-肿瘤、增生扩大、肿瘤较大及因此而致的预后不良有关。

For any given stage, patients with the BRCA1 gene appear to have a worse prognosis than those with sporadic tumors, perhaps because they have a higher proportion of high-grade, hormone receptor-negative cancers. Patients with the BRCA2 gene probably have the same prognosis as those without the genes if the tumors have similar characteristics. With either gene, risk of a 2nd cancer in remaining breast tissue is increased (to perhaps as high as 40%).

不管处于哪一阶段，BRCA1基因病人的预后似乎都要比散发性肿瘤病人差，这也许是因为他们高等级、激素受体阴性癌比率较高的缘故。在肿瘤特征接近的情况下，BRCA2基因病人与无此基因病人的预后大致相同。不管哪种基因，在其他乳房组织发生继发癌的危险都会增加（也许高达40%)。