Breast Disorders

乳房疾病

Breast symptoms (eg, pain, lumps, nipple discharge) are common, accounting for > 15 million physician visits/yr. Although > 90% of symptoms have benign causes, breast cancer is always a concern. Because breast cancer is common and may mimic benign disorders, the approach to all breast symptoms and findings is to conclusively exclude cancer.

乳房症状（如乳房痛、肿块、乳头排泄物)很普遍，每年就诊者>1500万。虽然>90%症状为良性，但乳腺癌始终是人们的一大担心。乳腺癌很常见，其症状也与许多良性乳房疾病相仿，因此，分析乳房症状及化验结果就是要完全排除乳腺癌。

History includes duration of symptoms; relation of symptoms to menses and pregnancy; presence and type of pain, discharge, and skin changes; use of drugs, including hormone therapy; personal and family history of breast cancer; and date and results of last mammogram.

病史询问包括症状持续时间，症状与月经和妊娠的关系，是否疼痛、有排泄物、皮肤变化及类型，用药（包括激素)情况、个人及家庭乳腺癌史、最后一次乳房拍片时间及结果等。

Breast examination: Principles of examination are similar for physician and patient. Breasts are inspected for asymmetry in shape, nipple inversion, bulging, and dimpling (see Fig. 1: Breast Disorders: Breast Cancer Risks A and B). Although size differential is common, each breast should have a regular contour. An underlying cancer is sometimes detected by having the patient press both hands against the hips or the palms together in front of the forehead (see Fig. 1: Breast Disorders: Breast Cancer Risks C and D). In these positions, the pectoral muscles are contracted, and a subtle dimpling of the skin may appear if a growing tumor has entrapped a Cooper's ligament.医学全在线www.med126.com

乳房检查：医生检查和病人自己检查的原则类似。应检查乳房大小是否对称、乳头是否内翻、膨出、凹陷（见图1：乳房疾病：乳房危险A、B)。乳房通常会在大小，但轮廓应规则，病人双手压在髋部或两手掌在额前相压有时就可检查出潜在的乳癌（见图1：乳房疾病：乳房危险C、D)。在这些位置时，胸部肌肉是收缩的，如果在库柏韧带陷有一生长肿瘤，皮肤就会微微的凹陷。

The axillary and supraclavicular lymph nodes are most easily examined with the patient seated or standing (see Fig. 1: Breast Disorders: Breast Cancer Risks E). Supporting the patient's arm during the axillary examination allows the arm to be fully relaxed so that nodes deep within the axilla can be palpated.

病人坐位或站位时最易检查腋下和锁骨上淋巴结（见图1：乳房疾病：乳房危险E)。腋下检查时，支撑病人手臂，使其充分放松，这样就可以摸到腋窝深处的淋巴结。

The breast is palpated with the patient seated and again with the patient supine, the ipsilateral arm above the head, and a pillow under the ipsilateral shoulder (see Fig. 1: Breast Disorders: Breast Cancer Risks F). The latter position is also used for breast self-examination; the patient examines the breast with her contralateral hand. Having the patient roll to one side, so that the breast on the examined side falls medially, may help differentiate breast and chest wall tenderness because the chest wall can be palpated separately from breast tissue.

扪诊病人乳房时，病人取坐位。也可取仰卧位，此时，受检乳房同侧胳膊上举过头，同侧肩下垫一枕头（见图1：乳房疾病：乳房危险F)。此位置也可用于乳房自我检查，检查乳房时病人使用对侧手。病人转向一侧，受检乳房向内侧靠拢，因为触摸时胸壁和乳房组织分离，故此位有助于鉴别乳房和胸壁触痛。

The breast should be palpated with the palmar surfaces of the 2nd, 3rd, and 4th fingers, moving systematically in a small circular pattern from the nipple to the outer edges (see Fig. 1: Breast Disorders: Breast Cancer Risks G). Precise location and size (measured with a caliper) of any abnormality should be noted on a drawing of the breast, which becomes part of the patient's record. A written description of the consistency of the abnormality and degree to which it can be distinguished from surrounding breast tissue should also be included. Detection of abnormalities during physical examination largely determines whether a biopsy is needed, even if a subsequent mammogram shows no abnormalities.

检查乳房用第2、3、4指的掌面扪由乳头向外作环形有序移动（见图1：乳房疾病：乳房危险G)。任何异常的准确位置和尺寸（用测径规测量)应记录于乳房说明图上，并成为病人医疗记录的一部分。应书面说明异常的变化情况及与周围乳房组织的差异程度。发现异物在很大程度上决定是否要作组织活检，即使后续乳房X线检查未显示异物时也是如此。

Testing: Imaging tests are used for screening and for evaluation of breast abnormalities. Annual screening mammography is recommended for women ≥ 50 yr and sometimes for women 40 to 50 yr. Mammography is more effective in older women because with aging, fibroglandular tissue in breasts tends to be replaced with fatty tissue, which can be more easily distinguished from abnormal tissue. Low-dose x-rays of both breasts are taken in 1 (oblique) or 2 views (oblique and craniocaudal). Only about 10% of abnormalities detected result from cancer. Accuracy of mammography depends partly on the techniques used and experience of the mammographer; false-negative results may exceed 15%. Some centers use computer analysis of digitized mammography images to help in diagnosis. Such systems are not recommended for stand-alone diagnosis, but they appear to improve sensitivity for detecting small cancers by radiologists.

检验：影像检查用于筛查和乳房异物的评估。≥50岁，或40－50岁妇女，每年应作乳房影像筛查。乳房X线检查对老年妇女较有效，因为随着年龄增长，乳房中的纤维腺体往往会被脂肪组织所替代，与异常组织鉴别更容易。检查乳房时采小剂量射线，一个（侧位)或两个（侧位及轴位)投照位置。在检测到的异物中，只有10%是由癌症引起的。乳房X线照相准确度部分取决于所用技术及X光师经验，假阴性率超过15%。有些影像中心采用数字照像图像电脑分析技术帮助诊断。这些系统在单独诊断时不建议使用，但可以提高放射科医师发现小型癌症的敏感度。

Mammography is also used diagnostically to evaluate lumps, pain, and nipple discharge. It can determine size and location of a lesion and provide images of surrounding tissues and lymph nodes. Diagnostic mammography requires more views than screening mammography. For biopsy of a lesion seen on a mammogram but not detectable during physical examination, 2 needles or wires can be inserted via radiologic guidance to localize the lesion. The excised specimen should be x-rayed, and the x-ray compared with the prebiopsy mammogram to determine whether the lesion has been removed. Mammography is repeated when the breast is no longer tender, usually 6 to 12 wk after biopsy, to confirm removal of the lesion.

乳房X线照相术也可用于诊断评估肿块、乳痛和乳头排泄物。它可以确定某个病灶部位的大小与位置，提供周围组织和淋巴结的图像。诊断性照相术所需投照位置应多于筛查性乳房X线照相。给照相时发现、体检又未曾查出的病灶作活检时，可在放射线指导下，插入两个针头或导线进行定位。切除的标本须拍X线片，并将其与活检前X片作比较，以确定此病灶已被切除。乳房不再触痛时再行乳房X线片检查，通常在活检后6－12周进行，以确认病灶已经清除。

MRI is thought to be more accurate than clinical breast examination or mammography for screening women with a high (eg, > 15%) risk of breast cancer, such as those with a BRCA gene mutation. It is not considered appropriate for screening women with average or slightly increased risk. Because MRI can accurately determine tumor size, chest wall involvement, and presence of multiple tumors, it is often used in evaluation after breast cancer is diagnosed. Use of MRI to identify axillary node involvement is under study.

在筛查乳腺癌高危妇女（如> 15%)时，如BRCA基因突变者，磁共振成像准确度应高于门诊乳房检查或乳房X线照相检查。但不适合危险性一般或略高的女性。由于磁共振成像可准确确定肿瘤大小、胸壁受累程度及是否有多发性肿瘤存在，它常被用于乳腺癌确诊后的评估。目前人们正在研究使用磁共振成像鉴别腋下淋巴结受累情况。