Ⅲ期浸润性乳腺癌NCCN指南2015v3

Stage III Invasive Breast Cancer

Ⅲ期浸润性乳腺癌

Staging and Workup

分期与检查

The staging evaluation for most patients with stage III invasive breast cancer is similar to the one for patients with T3, N1, M0 disease. The workup includes history and physical exam, a CBC, liver function and alkaline phosphatase tests, chest imaging, pathology review, and pre-chemotherapy determination of tumor ER/PR receptor status and HER2 status. Diagnostic bilateral mammogram and breast ultrasound should be performed as clinically warranted. Genetic counseling is recommended if the patient is considered to be at high risk for hereditary breast cancer as defined by the NCCN Guidelines for Genetic/Familial High-Risk Assessment: Breast and Ovarian.山东省肿瘤医院呼吸肿瘤内科张品良

对于大多数Ⅲ期浸润性乳腺癌患者来说分期评估类似于T3N1M0患者。检查包括病史与体检、全血细胞计数、肝功能与碱性磷酸酶检测、胸部影像、复阅病理以及化疗前肿瘤ER/PR受体状态和HER2状态测定。当临床需要时应该进行诊断性双侧乳房X线摄影和乳腺超声。如果该患者被认为符合遗传性/家族性高危性评估：乳腺与卵巢NCCN指南定义的高危遗传性乳腺癌建议遗传咨询。

The performance of other studies, such as a breast MRI, a bone scan (category 2B), and abdominal imaging with diagnostic CT (with or without pelvic CT) or MRI (all category 2A) are optional unless directed by symptoms or other abnormal study results. PET/CT scan is also included as an optional additional study (category 2B). Ultrasound is an alternative when diagnostic CT or MRI is unavailable.

其它检查的实施，如乳腺MRI、骨扫描(2B类)和诊断性腹部CT影像(±盆腔CT)或MRI(均为2A类)不是必需的除非有症状或其它异常的检查结果。PET/CT扫描也被作为一项可选择的辅助检查收入(2B类)。当不能进行诊断性CT或MRI时超声是一个可供选择的检查。

The consensus of the panel is that FDG PET/CT is most helpful in situations where standard imaging results are equivocal or suspicious. However, limited studies support a potential role for FDG PET/CT to detect regional node involvement as well as distant metastases in locally advanced breast cancer, including T3, N1, M0 disease.

小组共识是在正规的影像结果意义不明或可疑的情况下FDG PET/CT是最有帮助的。但是，有限的研究支持在局部晚期包括T3N1M0乳腺癌中FDG PET/CT对发现区域淋巴结受累以及远处转移有潜力。

A retrospective study comparing bone scan with integrated FDG PET/CT, in women with stages I-III breast cancer with suspected metastasis, observed a high concordance (81%) between the two studies for reporting osseous metastases.

The NCCN Panel suggests that bone scan may be omitted if FDG PET/CT results are positive for bone metastases.

一项回顾性研究在Ⅰ-Ⅲ期具有可疑转移灶的乳腺癌女性中比较骨扫描与集成的FDG PET/CT，观察到在这两项检查之间报告骨转移高度一致(81%)。NCCN小组建议如果FDG PET/CT结果是明确的骨转移骨扫描可以省略。

Equivocal or suspicious sites identified by PET/CT scanning should be biopsied for confirmation whenever possible and if the site of disease would impact the course of treatment. In the past decade, the advent of PET/CT scanners has significantly changed the approach to PET imaging. However, the terminology has also created confusion regarding the nature of the scans obtained from a PET/CT device. PET/CT scanners have both a PET and CT scanner in the same gantry that allows precise coregistration of molecular (PET) and anatomic (CT) imaging. Almost all current clinical PET imaging is performed using combined PET/CT devices.

通过PET/CT扫描发现的意义不明或可疑的部位只要有可能以及如果该病变部位将影响治疗过程就应该进行活检证实。在过去的十年中，PET/CT扫描的出现已显著改变了PET影像手段。但是，从PET/CT设备获得的扫描特征术语也已引起了混乱。PET/CT扫描在同一个吊架中兼备PET与CT扫描提供精确的分子(PET)与解剖学(CT)影像配准。当前几乎所有的临床PET影像都是使用组合的PET/CT装置完成的。

In PET/CT tomographs, the CT scanner has a second important role beyond diagnostic CT scanning. For PET applications, the CT scan is also used for photon attenuation correction and for anatomic localization of the PET imaging findings. For these tasks, the CT scan is usually taken without breathholding, to match PET image acquisition, and typically uses low-dose (non-diagnostic) CT. Radiation exposure for these non-diagnostic CT scans is lower than for diagnostic CT. Intravenous contrast is not needed for this task.

在PET/CT断层X线摄影装置中，CT扫描具有除了诊断CT扫描外的第二重要地位。关于PET应用，CT扫描也用于光子衰减校正和PET影像发现的解剖学定位。为了完成这些任务，获取CT扫描通常没有屏气以匹配PET图象获取，而且通常使用低剂量(非诊断性)CT。这些非诊断性CT扫描的辐射暴露低于诊断性CT。对于这项任务不需要静脉注射对比剂。

PET/CT scanners typically include a high-quality CT device that can also be used for stand-alone, optimized, and fully diagnostic CT. Diagnostic CT scans are acquired using breathholding for optimal chest imaging, and are often performed with intravenous contrast. For fully diagnostic CT, the CT beam current, and therefore patient radiation exposure, is considerably higher than for the low-dose CT needed for PET requirements. Radiation exposures for fully diagnostic CT are often greater than for the emission (PET) component of the study.

PET/CT扫描一般包括一台高质量的CT设备也可以独立、优化以及完全作为诊断性CT使用。为了得到最佳的胸部影像利用屏气获得诊断性CT扫描，并经常静脉注射对比剂来完成。因此对于全诊断性CT，CT射束电流和患者辐射暴露明显高于PET要求的低剂量CT所需。全诊断性CT的辐照常大于该检查的发射(PET)部分。

Currently, the approach to clinical PET/CT imaging varies widely across centers. Many centers perform low-dose CT as part of a PET/CT scan, and perform optimized, fully diagnostic CT only when diagnostic CT has also been requested in addition to PET/CT. Other centers combine diagnostic CT scans with PET on all of their PET/CT images. The CT scans described in the workup section of the guidelines refer to fully optimized diagnostic CT scans, while the PET or PET/CT scans refer to scans primarily directed towards the PET component, not necessarily using diagnostic-quality CT. It is important for referring physicians to understand the differences between PET/CT performed primarily for PET imaging and fully optimized CT performed as a stand-alone diagnostic CT examination. It may be convenient to perform PET/CT and diagnostic CT at the same time.

目前，临床PET/CT成像方法各中心间差异很大。许多中心将低剂量CT作为PET/CT扫描并进行优化的一部分，除了PET/CT外只有当诊断性CT也有要求时才实施全诊断性CT。其它中心所有的PET/CT成像均联合诊断性CT扫描与PET。在该指南的检查章节中描述的CT扫描完全参考优化的诊断性CT扫描，然而PET或PET/CT参考的扫描主要针对PET部分，不一定使用诊断级别的CT。重要的是咨询医师以了解在PET/CT最初完成的PET影像和作为一个独立的诊断性CT检查实施的充分优化的CT之间的差异。同时进行PET/CT和诊断性CT可能是方便的。