CPG มะเร็งเต้านม

§ ≥ – ºŸâ ‡ ™’Ë ¬ « ™ “ ≠ Peer Reviewers

»“ µ√“®“√¬å𓬷æ∑¬å∏πæ≈ ‰À¡·æß √Õß»“ µ√“®“√¬å𓬷æ∑¬°å √™‘ ‚æ∏ ‘ ÿ«√√≥
§≥–·æ∑¬»“ µ√å ¡À“«∑‘ ¬“≈—¬ ß¢≈“π§√‘π∑√å §≥–·æ∑¬»“ µ√å »√‘ √‘ “™æ¬“∫“≈
√Õß»“ µ√“®“√¬å·æ∑¬åÀ≠‘ß∫ÿ…≥’ «∫‘ ≈ÿ º≈ª√–‡ √‘∞ 𓬷æ∑¬å°‘µ‘ ®π‘ ¥“«‘®—°…≥å
§≥–·æ∑¬»“ µ√å ‚√ß欓∫“≈√“¡“∏‘∫¥’  ∂“∫π— ¡–‡√ßÁ ·Àßà ™“µ‘
√Õß»“ µ√“®“√¬å𓬷æ∑¬ªå √–‡ √‘∞ ‡≈‘» ß«π π‘ ™¬— √Õß»“ µ√“®“√¬·å æ∑¬åÀ≠‘ߥ√≥ÿ ’ ∫ÿ≠¬◊π‡«∑«≤— πå
§≥–·æ∑¬»“ µ√å ®Ãÿ “≈ß°√≥¡å À“«∑‘ ¬“≈—¬ §≥–·æ∑¬»“ µ√å ®Ãÿ “≈ß°√≥å¡À“«∑‘ ¬“≈—¬
√Õß»“ µ√“®“√¬å𓬷æ∑¬æå ‘‡™∞  ¡— ª∑“πÿ°ÿ≈ »“ µ√“®“√¬πå “¬·æ∑¬æå ∑‘ ¬¿¡Ÿ ‘ ¿∑— √π∏ÿ “æ√
§≥–·æ∑¬»“ µ√å ®ÿÓ≈ß°√≥¡å À“«∑‘ ¬“≈—¬ §≥–·æ∑¬»“ µ√å »√‘ √‘ “™æ¬“∫“≈
»“ µ√“®“√¬·å æ∑¬Àå ≠ß‘ ¡“≈¬— ¡µÿ µ“√—°…å »“ µ√“®“√¬·å æ∑¬Àå ≠‘ß≈—°…≥“ ‚æ™πÿ°Ÿ≈
§≥–·æ∑¬»“ µ√å ¡À“«∑‘ ¬“≈¬— ‡™¬’ ß„À¡à §≥–·æ∑¬»“ µ√å ‚√ß欓∫“≈√“¡“∏∫‘ ¥’
𓬷æ∑¬¬å ߬∑ÿ ∏ §ß∏π“√—µπå »“ µ√“®“√¬å𓬷æ∑¬å«√™¬— √—µπ∏√“∏√
‚√ß欓∫“≈√“™«‘∂’ §≥–·æ∑¬»“ µ√å ‚√ß欓∫“≈√“¡“∏∫‘ ¥’
æπ— ‡Õ°π“¬·æ∑¬å«‘™—¬ «“ π √‘ ‘ »“ µ√“®“√¬·å æ∑¬åÀ≠ß‘  ¡ÿ ‘µ√“ ∑Õߪ√–‡ √∞‘
«∑‘ ¬“≈¬— ·æ∑¬»“ µ√åæ√–¡ß°Æÿ ‡°≈“â §≥–·æ∑¬»“ µ√å ¡À“«∑‘ ¬“≈—¬‡™’¬ß„À¡à
√Õß»“ µ√“®“√¬å𓬷æ∑¬å«™‘ “≠ À≈Õà «‘∑¬“ æ≈µ√π’ “¬·æ∑¬ å ÿ√æß…å  ¿ÿ “¿√≥å
§≥–·æ∑¬»“ µ√å ¡À“«‘∑¬“≈¬— ‡™¬’ ß„À¡à «∑‘ ¬“≈—¬·æ∑¬»“ µ√æå √–¡ß°ÿƇ°≈â“
ºŸ™â «à ¬»“ µ√“®“√¬å𓬷æ∑¬«å ‡‘ ™¬’ √ »√’¡ÿπ‘π∑√åπ¡‘ µ‘ ·æ∑¬åÀ≠‘ßÕ∞— ≥«’ √√≥ ™«π‡°√°‘ °ÿ≈
§≥–·æ∑¬»“ µ√å »‘√√‘ “™æ¬“∫“≈ ‚√ß欓∫“≈æ≠“‰∑ 2
√Õß»“ µ√“®“√¬å·æ∑¬Àå ≠ß‘ «‘‰≈æ√ ‚æ∏‘ «ÿ √√≥
§≥–·æ∑¬»“ µ√å »‘√‘√“™æ¬“∫“≈
𓬷æ∑¬ å ∂“æ√ ≈’≈“ππ— ∑°‘®
 ∂“∫π— ¡–‡√ßÁ ·Àßà ™“µ‘
𓬷æ∑¬Õå “§¡ ‡™¬’ √»‘≈ªá
 ∂“∫π— ¡–‡√ßÁ ·Àßà ™“µ‘

§≥–∑”ß“π

𓬷æ∑¬å ¡¬» ¥√’ »— ¡’ 𓬷æ∑¬Õå “§¡ ‡™¬’ √»≈‘ ªá
°√¡°“√·æ∑¬å °√–∑√«ß “∏“√≥ ¢ÿ  ∂“∫π— ¡–‡√ßÁ ·Àßà ™“µ‘
𓬷æ∑¬å∏√’ «ÿ≤‘ §ÀŸ –‡ª√¡– 𓬷æ∑¬Õå “§¡ ™¬— «’√–«≤— π–
 ∂“∫π— ¡–‡√ßÁ ·Àßà ™“µ‘  ∂“∫π— ¡–‡√ßÁ ·Àßà ™“µ‘
𓬷æ∑¬å°µ‘ ‘ ®π‘ ¥“«®‘ —°…≥å π“ß “« πÿ π— ∑“ ®√‘¬“‡≈‘»»°— ¥Ï‘
 ∂“∫π— ¡–‡√ßÁ ·Àßà ™“µ‘  ∂“∫π— ¡–‡√ßÁ ·Àßà ™“µ‘
·æ∑¬åÀ≠ß‘ ™«π滑 ∫ÿ≥¬–√—µ‡«™ π“ß»‘√æ‘ √√≥ æ‘…“¿“æ
 ∂“∫π— ¡–‡√ßÁ ·Àßà ™“µ‘  ∂“∫π— ¡–‡√ßÁ ·Àßà ™“µ‘
»“ µ√“®“√¬å·æ∑¬åÀ≠‘ß ÿ¡µ‘ √“ ∑Õߪ√–‡ √‘∞
¡–‡√Áß«∑‘ ¬“ ¡“§¡·Ààߪ√–‡∑»‰∑¬
æ≈Õ“°“»µ√’𓬷æ∑¬‡å Õ°™—¬ «‡‘ »…»√‘ ‘
 ¡“§¡√ß—  √’ °— …“·≈–¡–‡√Áß«∑‘ ¬“·Ààߪ√–‡∑»‰∑¬
»“ µ√“®“√¬§å ≈π‘ ‘°‡°¬’ √µ§‘ ≥ÿ 𓬷æ∑¬ å “‚√®πå «√√≥惰…å
√“™«‘∑¬“≈¬— √ß—  ’·æ∑¬·å Àßà ª√–‡∑»‰∑¬
𓬷æ∑¬∑å «’ ‡≈“Àæπ— ∏å
√“™«∑‘ ¬“≈¬— 欓∏·‘ æ∑¬å·Ààߪ√–‡∑»‰∑¬
𓬷æ∑¬å«™— √æß»å æÿ∑∏ ‘ « — ¥‘Ï
√“™«∑‘ ¬“≈¬— »≈— ¬·æ∑¬å·Ààߪ√–‡∑»‰∑¬
™¡√¡»≈— ¬·æ∑¬¡å –‡√ßÁ (ª√–‡∑»‰∑¬)
𓬷æ∑¬å ÿ‡¡∏ √π‘  ÿ√ߧ«ß»å
 ∂“∫π— ¡–‡√ßÁ ·Àßà ™“µ‘

§”π”

¡–‡√Á߇µâ“π¡‡ªìπÀπ÷Ëß„π‚√§¡–‡√Áß∑’ËÕ¬Ÿà„π·ºπ°“√ªÑÕß°—π·≈–§«∫§ÿ¡‚√§¡–‡√ÁߢÕߪ√–‡∑» (National Cancer Control Program) ¥—ßπÈ—π ‡æË◊Õ
„Àâ¡’√Ÿª·∫∫À√◊Õ·ºπ°“√¥Ÿ·≈√—°…“∑’ˇÀ¡“– ¡ ”À√—∫ºâŸªÉ«¬¡–‡√Á߇µâ“π¡„πª√–‡∑»‰∑¬ ®÷ß®”‡ªìπµâÕ߉¥â√—∫§«“¡√à«¡¡◊Õ®“°ºâŸ‡™Ë’¬«™“≠·≈–ºâŸ™”π“≠
°“√‡°¬Ë’ «°∫— °“√√—°…“¡–‡√ßÁ ‡µ“â π¡À≈“¬ “¢“¡“√«à ¡ª√–™ÿ¡‡æ◊ËÕ®¥— ∑”§¡àŸ Õ◊ ‡«™ªØ‘∫—µ‡‘ °Ë¬’ «°∫— ¡–‡√ßÁ ‡µ“â π¡ (CPG) ©∫—∫∑®’Ë –„™„â πª√–‡∑»‰∑¬

 ∂“∫—π¡–‡√Áß·Ààß™“µ‘‡ªìπÀπ૬ߓπ¢Õß√—∞∑Ë’¡’Àπâ“∑’Ë√—∫º‘¥™Õ∫‡°Ë’¬«°—∫°“√ªÑÕß°—π·≈–§«∫§ÿ¡‚√§¡–‡√ÁߢÕߪ√–‡∑»·≈–‡ªìπ°√√¡°“√ ºâŸ™à«¬
‡≈¢“πÿ°“√¢Õߧ≥–°√√¡°“√ªÑÕß°—π·≈–§«∫§ÿ¡‚√§¡–‡√Áß·Ààß™“µ‘ ®÷ß∑”Àπâ“∑Ë’‡ªìπ·°ππ”„π°“√®—¥∑”§Ÿà¡◊Õ‡«™ªØ‘∫—µ‘ ”À√—∫¡–‡√Á߇µâ“π¡ ‚¥¬‰¥â
¥”‡ππ‘ °“√µ“¡¢π—È µÕπ¥ß— π’È

1. «“ß·ºπ„π°“√®¥— ∑”§¡àŸ Õ◊ ‡«™ªØ∫‘ µ— ‡‘ °¬Ë’ «°∫— ¡–‡√ßÁ ‡µ“â π¡ ‚¥¬‡™≠‘ º·âŸ ∑π¢Õß√“™«∑‘ ¬“≈¬— √ß—  ·’ æ∑¬·å Àßà ª√–‡∑»‰∑¬, √“™«∑‘ ¬“≈¬— 欓∏·‘ æ∑¬å
·Àßà ª√–‡∑»‰∑¬, √“™«∑‘ ¬“≈¬— »≈— ¬·æ∑¬·å Àßà ª√–‡∑»‰∑¬,  ¡“§¡√ß—  √’ °— …“·≈–¡–‡√ßÁ «∑‘ ¬“·Àßà ª√–‡∑»‰∑¬,¡–‡√ßÁ «∑‘ ¬“ ¡“§¡·Àßà ª√–‡∑»‰∑¬
·≈–™¡√¡»≈— ¬·æ∑¬¡å –‡√Áß (ª√–‡∑»‰∑¬) ‡æ◊ËÕ殑 “√≥“‡ πÕ™◊ËÕº‡Ÿâ ™Ë¬’ «™“≠„π°“√®¥— ∑”§àŸ¡Õ◊ ‡«™ªØ∫‘ µ— ‘ ”À√—∫¡–‡√Á߇µâ“π¡

2. ª√–™¡ÿ ®¥— ∑”§¡àŸ Õ◊ ¥ß— °≈“à «√«à ¡°∫— º‡Ÿâ ™¬Ë’ «™“≠¢Õß·µ≈à –Õߧ°å √∑‡Ë’ °¬Ë’ «¢Õâ ßµ“¡√“¬™Õ◊Ë ∑‡Ë’  πÕ‡ªπì §≥–º‡âŸ ™¬’Ë «™“≠‚¥¬„™Àâ ≈°— ‡°≥±åBreastCancer
: CPG version 1.2004 ¢Õß National Comprehensive Cancer Network (NCCN) ¢Õß À√∞— Õ‡¡√‘°“ ·µªà √—∫ª√ÿߥ¥— ·ª≈ß„À‡â À¡“– ¡°∫—
°“√ªØ∫‘ µ— ß‘ “π„πª√–‡∑»‰∑¬ ‚¥¬º“à π¢∫«π°“√殑 “√≥“·≈–‡ πÕ·π–®“°º¡âŸ ª’ √– ∫°“√≥„å π°“√¥·Ÿ ≈√°— …“ºªŸâ «É ¬¡–‡√ßÁ ‡µ“â π¡„πª√–‡∑»‰∑¬
(Expertûs opinion)

3.  ∂“∫—π¡–‡√Áß·Ààß™“µ‘∑”°“√√«∫√«¡¢âÕ¡Ÿ≈∑È—ßÀ¡¥·≈–¥”‡π‘π°“√®—¥∑”‡ªìπ§Ÿà¡◊Õ‡«™ªØ‘∫—µ‘‡°Ë’¬«°—∫¡–‡√Á߇µâ“π¡©∫—∫√à“ß ‡æ◊ËÕ àß„Àâ
º‡âŸ ™¬’Ë «™“≠·µ≈à – “¢“µ√«®·≈–·°‰â ¢‡æË‘¡‡µ¡‘ °àÕπ®– àß„Àºâ ∑⟠∫∑«π (Peer reviewers) 殑 “√≥“·≈–«‘‡§√“–Àå«®‘ “√≥å

4. „Àºâ Ÿ∑â ∫∑«π¥”‡ππ‘ °“√«æ‘ “°…å§¡àŸ Õ◊ ‡«™ªØ∫‘ µ— ‡‘ °¬’Ë «°—∫¡–‡√Á߇µâ“π¡

5.  ∂“∫π— ¡–‡√ßÁ ·Àßà ™“µ¥‘ ”‡ππ‘ °“√·°‰â ¢·≈–®¥— æ¡‘ æ‡å ªπì √ªŸ ‡≈¡à ‡æÕË◊ „™‡â ªπì ‡Õ° “√Õ“â ßÕß‘ „π°“√¥·Ÿ ≈√°— …“ºªŸâ «É ¬¡–‡√ßÁ ‡µ“â π¡„πª√–‡∑»‰∑¬µÕà ‰ª

§≥–ºŸâ®¥— ∑”¡’§«“¡‡ÀÁπ«“à §Ÿà¡◊Õ‡«™ªØ‘∫—µ‘ ”À√—∫¡–‡√Á߇µ“â π¡ §«√¡’°“√∑∫∑«π·≈–ª√—∫ª√ßÿ ·°‰â ¢„À∑â —π ¡¬— ∑ÿ°ªï ‡πÕË◊ ß®“°¢Õâ ¡≈Ÿ ‡°¬’Ë «°—∫°“√¥·Ÿ ≈
√°— …“ºâªŸ «É ¬¡–‡√Á߇µ“â π¡¡’°“√‡ª≈ˬ’ π·ª≈ßÕ¬µàŸ ≈Õ¥‡«≈“

¢Õ¢Õ∫§ÿ≥∑ÿ°∑à“π∑’Ë¡’ à«π√à«¡„π°“√®—¥∑”§Ÿà¡◊Õ‡≈à¡π’È·≈–§≥–∑”ß“π¬‘π¥’√—∫§”«‘®“√≥åµà“ßÊ∑Ë’®–™à«¬„Àâ§àŸ¡◊Õπ’ȉ¥â√—∫°“√æ—≤π“·≈–ª√—∫ª√ÿß·°â‰¢
Õπ— ®–‡ªπì ª√–‚¬™π„å π°“√¥·Ÿ ≈√—°…“ºªâŸ «É ¬¡–‡√ßÁ ‡µâ“π¡„πª√–‡∑»‰∑¬µÕà ‰ª

  “ √ ∫— ≠ Àπ“â
1
·π«∑“ß°“√¥·Ÿ ≈√°— …“ºªâŸ É«¬¡–‡√Á߇µâ“π¡ (·ºπ¿Ÿ¡‘) 4
·π«∑“ß°“√µ√«®§—¥°√Õß·≈–«‘π‘®©—¬¡–‡√Á߇µâ“π¡ (·ºπ¿Ÿ¡)‘
·π«∑“ß°“√√°— …“¡–‡√ßÁ ‡µâ“π¡ (·ºπ¿Ÿ¡‘) 19
- Noninvasive Breast Cancer 25
- Invasive Breast Cancer 39
·π«∑“ß°“√µ√«®µ¥‘ µ“¡°“√√—°…“¡–‡√Á߇µâ“π¡ 41
TNM Staging System for Breast Cancer (AJCC)

·π«∑“ß°“√¥Ÿ·≈√°— …“ºŸâªÉ«¬¡–‡√Á߇µ“â π¡ 1

·π«∑“ß°“√¥Ÿ·≈√°— …“ºŸâª«É ¬

¡–‡√Á߇µ“â π¡

2 ·π«∑“ß°“√µ√«®«π‘ ®‘ ©¬— ·≈–√°— …“欓∫“≈‚√§¡–‡√Á߇µ“â π¡ ªï 2546-2547

·ºπ¿¡Ÿ ‘· ¥ß·π«∑“ß°“√¥Ÿ·≈ √°— …“ ºŸâª«É ¬¡–‡√Á߇µ“â π¡

ºâªŸ É«¬‡¢“â √—∫∫√°‘ “√∑’Ë OPD

¡“ Screening ¡’Õ“°“√

History + CBE History + CBE

¡¢’ Õâ ∫ßà ™∑È’ ” ‰¡à ·π–π” BSE ·≈–  ß —¬‡ªìπ¡–‡√Áß ‰¡à
Mammogram °“√µ√«® Screening ‡µâ“π¡ „À°â “√√°— …“∑Ë’
‡À¡“– ¡
„™à ‰¡à Refer ‰ª „™à
Center ‰¡à
¡’§«“¡ “¡“√∂„Àâ ¡¢’ ’¥§«“¡ “¡“√∂ Refer ‰ª
∫√°‘ “√ ∑Ë’®–µ√«®«‘π‘®©—¬ center

Mammogram 㪈
„Àâ°“√µ√«®«‘π®‘ ©¬—
㪈
∑” Mammogram

BIRAD O BIRAD I BIRAD ll BIRAD lll BIRAD IV ·≈– l BIRAD VI

·π–π”∂à“¬¿“æ√—ß ’ ·π–π” BSE ·≈– ·π–π”µ√«®´È”* ·π–π”µ¥— ™π‘È √°— …“¡–‡√ßÁ µ“¡ 殑 “√≥“º≈°“√ ‰¡à „À°â “√√°— …“∑’Ë
µ√«®‡ªπì ¡–‡√ßÁ ‡À¡“– ¡

À√◊Õµ√«®Õ—≈µ√“- °“√µ√«® Screening ∑°ÿ 6 ‡¥◊Õ𠇪πì ‡πÕÈ◊ µ√«® √–¬–¢Õß‚√§∑’Ë À√◊Õ‰¡à

´“«¥å‡æ¡Ë‘ ‡µ¡‘ ‡«≈“ 2 ªï ‡À¡“– ¡

·π«∑“ß°“√¥Ÿ·≈√°— …“ºâŸªÉ«¬¡–‡√Á߇µ“â π¡ 3

·ºπ¿Ÿ¡·‘  ¥ß·π«∑“ß°“√¥·Ÿ ≈ √°— …“ ºâŸª«É ¬¡–‡√ßÁ ‡µ“â π¡ (µàÕ)

殑 “√≥“º≈°“√
µ√«®‡ªìπ¡–‡√ßÁ

À√◊Õ‰¡à
㪈

·®âߺ≈°“√«‘π‘®©—¬·°àºªâŸ É«¬

æ‘®“√≥“¡¢’ ’¥§«“¡ ‰¡à
 “¡“√∂„π°“√ Refer ‰ª
√—°…“
Center
㪈
BIRADS = Breast imaging reporting and data system
BIRADS O = Incomplete Study ®—¥·∫àß√–¬–¢Õß‚√§¡–‡√ßÁ
BIRADS I = Negative (No detectable pathology)
BIRADS II = Benign finding «“ß·ºπ°“√√°— …“
BIRADS III = Probably benign
BIRADS IV = Suspicious abnormality √°— …“µ“¡·ºπ°“√√°— …“
BIRADS V = Highly suggestive of malignancy
BIRADS VI = Known biopsy proven malignancy æ‘®“√≥“ àß°≈—∫‰ª „™à Refer °≈∫— ‰ª
BSE = Breast self exammination „°≈â∫â“π‡¡Ë◊Õ√—°…“ Primary Care Unit
CBE = Clinical breast exammination
* ∂“⠺⪟ «É ¬µâÕß°“√„Àâµ√«®™‘πÈ ‡π◊ÕÈ À√◊Õ·æ∑¬¬å ß— ¡’§«“¡ ß ¬— ·≈– §√∫µ“¡·ºπ

‰¡ à “¡“√∂·¬°®“°¡–‡√Á߉¥â Õ“®æ®‘ “√≥“µ¥— ™È‘π‡πÕ◊È ‰¡à

µ√«®µ¥‘ µ“¡

4 ·π«∑“ß°“√µ√«®«‘π®‘ ©¬— ·≈–√°— …“欓∫“≈‚√§¡–‡√ßÁ ‡µ“â π¡ ªï 2546-2547

·π«∑“ß°“√µ√«®§—¥°√Õß·≈–«‘π®‘ ©—¬

¡–‡√ßÁ ‡µ“â π¡

(µ“¡À≈—°‡°≥±å¢Õß NCCN V1.2003)

·π«∑“ß°“√µ√«®§¥— °√Õß·≈–«π‘ ®‘ ©¬— ¡–‡√ßÁ ‡µâ“π¡ 5

°“√µ√«®§—¥°√Õß·≈–«‘π®‘ ©¬— ¡–‡√Á߇µâ“π¡

°“√µ√«®§—¥°√ÕßÀ√Õ◊ Õ“°“√· ¥ß

Lump/mass Age < 30 yr °“√µ√«®¢—ÈπµàÕ‰ª
Age > 30 yr (¥ÀŸ π“â ∂¥— ‰ª)
°“√µ√«®¢—ÈπµàÕ‰ª
Nipple discharge, (¥ŸÀπâ“ 12)
no palpable mass
°“√µ√«®§¥— °√Õߢ—πÈ µàÕ‰ª
Physical Positive findings (¥ÀŸ πâ“ 4)
exam on physical exam
°“√µ√«®§¥— °√Õߢ—πÈ µÕà ‰ª
Asymmetric (¥ÀŸ πâ“ 5)
thickening/
nodularity °“√µ√«®§—¥°√Õߢ—ÈπµÕà ‰ª
(¥ÀŸ π“â 6)
Skin changes:
peau dûorange
erythema
nipple excoriation
scaling, eczema

6 ·π«∑“ß°“√µ√«®«‘π®‘ ©¬— ·≈–√—°…“欓∫“≈‚√§¡–‡√Á߇µ“â π¡ ªï 2546-2547

Õ“°“√ / Õ“°“√· ¥ß °“√µ√«®§—¥°√Õß·≈–«π‘ ‘®©—¬¡–‡√Á߇µâ“π¡

°“√µ√«®¢πÈ— µπâ °“√µ√«®¢Èπ— µÕà ‰ª

Lump/mass Ultrasound No fluid ¥Ÿº≈°“√µ√«® ultrasound (Àπâ“∂—¥‰ª)
Age < 30 yr (preferred) Fluid (cyst)
¥ºŸ ≈°“√µ√«® aspirate (Àπâ“ 10)
À√Õ◊ Mass resolves ¥Ÿº≈°“√µ√«® aspirate (Àπ“â 11)
Mass persists
Needle Biopsy ¥·Ÿ π«∑“ß°“√µ√«®§¥— °√Õß¡–‡√Á߇µâ“π¡
Ultrasound (see appropriate pathway above)
À√◊Õ À√◊Õ
Needle biopsy
Observe for
1-2 menstrual
cycles (option
for low clinical
suspicion

·π«∑“ß°“√µ√«®§¥— °√Õß·≈–«π‘ ®‘ ©¬— ¡–‡√ßÁ ‡µ“â π¡ 7

°“√µ√«®§—¥°√Õß·≈–«π‘ ‘®©¬— ¡–‡√Á߇µ“â π¡ ¥ºŸ ≈°“√
µ√«®
Õ“°“√ / Õ“°“√· ¥ß °“√µ√«®¢πÈ— µπâ Indeterminate °“√µ√«®¢π—È µàÕ‰ª aspirate
or suspicious (Àπ“â 11)
Solid ¥ºŸ ≈°“√µ√«® ultrasound ¥·Ÿ π«∑“ß
Probably benign (Àπ“â ∂—¥‰ª) °“√µ√«®§¥—
Lump/mass Ultrasound Cyst finding °√Õß¡–‡√ßÁ
Age < 30 yr (preferred) ¥Ÿº≈°“√µ√«® ultrasound ‡µâ“π¡
Symptomatic or (Àπ“â 9)

non-simple cyst* Aspiration if symptomatic
or indeterminate (surgical
Asymptomatic excision preferred if
and simple cyst(s) sonographic findings of
irregular cyst wall or
intracystic mass)

Observe for
stability

Lesion not Consider Tissue biopsy
visualized Mammogram
À√◊Õ
Observe, depending
on level of clinical
suspicion

* Round, circumscribed mass containing low level echoes without vascular flow, fulfilling most but not all criteria for simple cyst.

8 ·π«∑“ß°“√µ√«®«π‘ ‘®©—¬·≈–√°— …“欓∫“≈‚√§¡–‡√Á߇µ“â π¡ ªï 2546-2547

°“√µ√«®§¥— °√Õß·≈–«π‘ ®‘ ©—¬¡–‡√ßÁ ‡µâ“π¡

º≈°“√µ√«® ultrasound °“√µ√«®¢È—πµÕà ‰ª

LUMB / MASS Benign and image
concordant
Physical exam + ultrasound every 6-12

mo for 1-2 yrs to assess stability***

Benign ¥·Ÿ π«∑“ß°“√µ√«®§¥—
°√Õß¡–‡√Á߇µâ“π¡

Needle Indeterminate or Surgical Atypical ¥·Ÿ π«∑“ß°“√µ√«®§¥—
atypical ductal excision hyperplasia °√Õß¡–‡√ßÁ ‡µ“â π¡
Biopsy* hyperplasia (ADH)
or benign and ¥Ÿ·ºπ¿¡Ÿ ·‘  ¥ß·π«
(preferred)
image discordant**
LCIS ∑“ß°“√√—°…“¡–‡√Áß
‡µ“â π¡Àπâ“ 21

Solid; Malignant
Indeterminate
or suspicious Mammo- Tissue À√Õ◊
gram biopsy

Malignant ¥Ÿ·ºπ¿¡Ÿ ·‘  ¥ß·π«∑“ß°“√√—°…“
¡–‡√ßÁ ‡µ“â π¡ (Àπ“â 22-38)

Excision Benign ¥Ÿ·π«∑“ß°“√µ√«®§—¥°√Õß¡–‡√ßÁ ‡µâ“π¡
Atypical
hyperplasia ¥·Ÿ π«∑“ß°“√µ√«®§¥— °√Õß¡–‡√ßÁ ‡µâ“π¡

LCIS ¥·Ÿ ºπ¿Ÿ¡‘· ¥ß·π«∑“ß°“√√°— …“
¡–‡√Á߇µ“â π¡ (Àπ“â 21)

Malignant ¥Ÿ·ºπ¿Ÿ¡‘· ¥ß·π«∑“ß°“√√°— …“
¡–‡√ßÁ ‡µâ“π¡ (Àπ“â 22-38)
* ∑”‰¥∑â —ßÈ FNA ·≈– core biopsy, FNA µâÕßÕ“»¬— cytologic expertise
** Am J Roentgenol 1999;173:291-299
*** Follow-up may be considered at earlier time intervals, if clinically indicated.

·π«∑“ß°“√µ√«®§¥— °√Õß·≈–«π‘ ®‘ ©¬— ¡–‡√ßÁ ‡µâ“π¡ 9

º≈°“√µ√«® ultrasound °“√µ√«®§—¥°√Õß·≈–«‘π®‘ ©¬— ¡–‡√ßÁ ‡µ“â π¡

LUMB / MASS °“√µ√«®¢Èπ— µÕà ‰ª

Excision Benign ¥Ÿ·π«∑“ß°“√µ√«®§¥— °√Õß¡–‡√Á߇µ“â π¡
Atypical
Benign Physical exam+ hyperplasia ¥·Ÿ π«∑“ß°“√µ√«®§¥— °√Õß¡–‡√ßÁ ‡µ“â π¡
ultrasound every LCIS
6-12 mo for 1-2 yrs ¥Ÿ·ºπ¿Ÿ¡·‘  ¥ß·π«∑“ß°“√√°— …“
Malignant ¡–‡√Á߇µâ“π¡ (Àπ“â 21)
to assess stability***
¥Ÿ·ºπ¿Ÿ¡·‘  ¥ß·π«∑“ß°“√√—°…“
Solid: Needle Indeterminate or Surgical ¡–‡√ßÁ ‡µâ“π¡ (Àπâ“ 22-38)
Probably Atypical Ductal excision
benign Biopsy** Hyperplasia
(ADH)
finding* (preferred)

Malignant ¥Ÿ·ºπ¿¡Ÿ ‘· ¥ß·π«∑“ß°“√√—°…“ Increase ¥ÀŸ πâ“ 8
¡–‡√Á߇µâ“π¡ (Àπ“â 22-38) in size ¥·Ÿ π«∑“ß°“√µ√«®§—¥°√Õß¡–‡√ßÁ ‡µ“â π¡
Observation (only
if < 2 cm with low Physical exam + Stable
clinical suspicion ultrasound every
3-6 mo for 1-2 yrs

to assess stability***

* Radiology 1995; 196: 123-124.
** ∑”‰¥â∑ß—È FNA ·≈– core biopsy, FNA µÕâ ßÕ“»—¬ cytologic expertise
*** Follow-up may be considered at earlier time interval, if clinically indicated.

10 ·π«∑“ß°“√µ√«®«π‘ ®‘ ©¬— ·≈–√°— …“欓∫“≈‚√§¡–‡√Á߇µ“â π¡ ªï 2546-2547

°“√µ√«®§—¥°√Õß·≈–«‘π®‘ ©—¬¡–‡√Á߇µ“â π¡

º≈°“√µ√«® aspirate °“√µ√«®¢π—È µàÕ‰ª

LUMB / MASS, AGE < 30 YR

No fluid Histology/ Fibroadenoma Consider Observe (only if < 2 cm)
Cytology ultrasound/ À√Õ◊
Nondiagnostic mammogram Surgical excision
À√Õ◊
indeterminate Core biopsy + image guidance
À√Õ◊ surgical excision + image
Cancer guidance

¥·Ÿ ºπ¿Ÿ¡‘· ¥ß·π«∑“ß°“√√—°…“
¡–‡√Á߇µ“â π¡ (Àπ“â 22-38)

·π«∑“ß°“√µ√«®§—¥°√Õß·≈–«π‘ ‘®©—¬¡–‡√ßÁ ‡µ“â π¡ 11

°“√µ√«®§¥— °√Õß·≈–«π‘ ®‘ ©¬— ¡–‡√Á߇µ“â π¡

º≈°“√µ√«® aspirate °“√µ√«®¢—πÈ µàÕ‰ª

LUMB / MASS, AGE < 30 YR Benign and ¥·Ÿ π«∑“ß°“√µ√«®§¥—
image °√Õß¡–‡√Á߇µâ“π¡
Mass concordant
persists or Ultrasound Indeterminate or Surgical
bloody fluid + image- ADH or benign Excision
guided and image
biopsy discordant Benign ¥Ÿ·π«∑“ß°“√µ√«®§¥— °√Õß
¡–‡√Á߇µâ“π¡
À√Õ◊ Malignant
¥·Ÿ π«∑“ß°“√µ√«®§—¥°√Õß
¥·Ÿ ºπ¿Ÿ¡·‘  ¥ß·π«∑“ß Atypical ¡–‡√Á߇µâ“π¡
°“√√—°…“¡–‡√Á߇µâ“π¡ hyperplasia
(Àπ“â 22-38) ¥·Ÿ ºπ¿Ÿ¡‘· ¥ß·π«∑“ß°“√
√—°…“¡–‡√Á߇µ“â π¡ (Àπâ“ 21)
Surgical LCIS
excision Malignant ¥Ÿ·ºπ¿¡Ÿ ·‘  ¥ß·π«∑“ß°“√
Fluid √—°…“¡–‡√ßÁ ‡µâ“π¡ (Àπâ“ 22-38)
(cyst)

Mass resolves µ¥‘ µ“¡º≈ Mass recurs ¥Ÿ ultrasound (Àπ“â 7)
2-4 ‡¥◊Õπ Negative exam
and nonbloody À√◊Õ

fluid* Surgical
excision

¥·Ÿ π«∑“ß°“√µ√«®§—¥°√Õß¡–‡√ßÁ ‡µ“â π¡

* ‰¡à·π–π”„À â àßµ√«® cytology ‡ªìπ routine

12 ·π«∑“ß°“√µ√«®«‘π‘®©—¬·≈–√°— …“欓∫“≈‚√§¡–‡√ßÁ ‡µâ“π¡ ªï 2546-2547

°“√µ√«®§¥— °√Õß·≈–«‘π‘®©¬— ¡–‡√Á߇µâ“π¡

Õ“°“√ / Õ“°“√· ¥ß °“√µ√«®¢π—È µπâ °“√µ√«®¢π—È µÕà ‰ª

Solid Indeterminate or ¥Ÿº≈°“√µ√«® ultrasound (Àπâ“∂—¥‰ª)
suspicious
¥Ÿº≈°“√µ√«® ultrasound (Àπ“â 9)
Compatible with
fibroadenoma

Symptomatic or Aspiration if symptomatic ¥ºŸ ≈°“√µ√«®
non-simple cyst or indeterminate (surgical aspirate (Àπ“â 8)
excision preferred if
radiographic findings of
irregular cyst wall or
intracystic mass)

Final Ultrasound Cyst

Assessment

category 1-3*

Asymptomatic Observe for ¥·Ÿ π«∑“ß°“√µ√«®
and simple cyst(s) stability §¥— °√Õß¡–‡√Á߇µ“â π¡

Lump/mass Mammogram
Age > 30 yr

Lesion not Tissue biopsy
visualized
À√◊Õ
Final Observe, depending on
level of clinical suspicion
Assessment
¥ŸÀπâ“ 18
category 4-5*

* ¥Ÿ·π«∑“ß°“√∂à“¬¿“æ√—ß ’‡µ“â π¡

·π«∑“ß°“√µ√«®§¥— °√Õß·≈–«π‘ ®‘ ©—¬¡–‡√Á߇µâ“π¡ 13

°“√µ√«®§—¥°√Õß·≈–«‘π‘®©¬— ¡–‡√Á߇µ“â π¡

º≈°“√µ√«® ultrasound °“√µ√«®¢Èπ— µÕà ‰ª

Benign and Physical exam + ultrasound every 6-12
image
concordant mo for 1-2 yrs to assess stabiliby*

Benign ¥Ÿ·π«∑“ß°“√µ√«®§—¥°√Õß
¡–‡√Á߇µâ“π¡

Atypical ¥·Ÿ π«∑“ß°“√µ√«®§¥— °√Õß

hyperplasia ¡–‡√Á߇µâ“π¡

FNA or lndeterminate or Surgical
Core ADH or benign excision
biopsy and image
discordant

LCIS ¥Ÿ·ºπ¿¡Ÿ ‘· ¥ß·π«∑“ß°“√
Malignant √—°…“¡–‡√ßÁ ‡µâ“π¡ (Àπ“â 21)

Solid: Tissue À√◊Õ
Indeterminate biopsy
or suspicious

Malignant ¥·Ÿ ºπ¿¡Ÿ ·‘  ¥ß·π«∑“ß°“√√°— …“¡–‡√Á߇µâ“π¡ (Àπ“â 22-38)

Excision Benign ¥Ÿ·π«∑“ß°“√µ√«®§—¥°√Õß¡–‡√ßÁ ‡µ“â π¡
Atypical hyperplasia ¥·Ÿ π«∑“ß°“√µ√«®§—¥°√Õß¡–‡√Á߇µâ“π¡
LCIS ¥·Ÿ ºπ¿¡Ÿ ‘· ¥ß·π«∑“ß°“√√°— …“¡–‡√ßÁ ‡µ“â π¡ (Àπâ“ 21)

Malignant ¥Ÿ·ºπ¿¡Ÿ ·‘  ¥ß·π«∑“ß°“√√°— …“¡–‡√ßÁ ‡µâ“π¡ (Àπ“â 22-38)

* Follow-up may be considered at earlier time interval, if clinically indicated

14 ·π«∑“ß°“√µ√«®«π‘ ‘®©¬— ·≈–√°— …“欓∫“≈‚√§¡–‡√ßÁ ‡µâ“π¡ ªï 2546-2547

°“√µ√«®§¥— °√Õß °“√µ√«®§¥— °√Õß·≈–«π‘ ®‘ ©—¬¡–‡√ßÁ ‡µ“â π¡
À√Õ◊ Õ“°“√· ¥ß
°“√µ√«®§—¥°√Õߢ—πÈ µπâ

Bilateral Pregnancy Negative Consider endocrine
Milky test Positive evaluation

Refer to obstetrician

Nipple Non- Age < 40 yr Observation
discharge, spontaneous Educate to stop compression of the breast
no palpable Multiduct Age > 40 yr and report any spontaneous discharge
mass
Persistent, Mammogram Mammogram
spontaneous, Guaiac or Educate to stop compression of the breast
unilateral, cytology and report any spontaneous discharge
single duct, optional
or serous Final Ductogram Duct excision
sanguinous (preferred)
Assessment

category 1-3*

Benign/
indeterminate

Final ¥ÀŸ πâ“ 18 Malignant ¥·Ÿ ºπ¿¡Ÿ ‘· ¥ß·π«∑“ß
°“√√—°…“¡–‡√Á߇µâ“π¡
Assessment (Àπâ“ 22-38)

category 4-5*

* ¥·Ÿ π«∑“ß°“√∂à“¬¿“æ√ß—  ‡’ µâ“π¡ (mammography)

·π«∑“ß°“√µ√«®§¥— °√Õß·≈–«‘π‘®©¬— ¡–‡√Á߇µ“â π¡ 15

°“√µ√«®§¥— °√Õß·≈–«π‘ ®‘ ©¬— ¡–‡√Á߇µâ“π¡

°“√µ√«®§—¥°√Õß °“√µ√«®§¥— °√Õߢπ—È µπâ
À√Õ◊ Õ“°“√· ¥ß

Stable Annual
Screening
Clinically
Asymmetric < 30 yr Ultrasound+ Final assessed Physical Progression ¥¢Ÿ πÈ— µÕπ
thickening > 30 yr mammogram Assessment as benign exam at Lump/mass (Àπâ“ 5)
if clinically category 1-2 3-6 mo
À√Õ◊ indicated and/or negative Clinically Reassess,consider consult
nodularity ultrasound or suspicious Benign with breast specialist
Bilateral simple cyst(s)
mammogram Needle Atypical ¥·Ÿ π«∑“ß°“√µ√«®§¥— °√Õß¡–‡√Áß
+ ultrasound, Final biopsy Hyperplasia ‡µâ“π¡
if clinically Assessment À√Õ◊
indicated category 3-5 Surgical
and/or solid or excision
¥Ÿ·ºπ¿¡Ÿ ·‘  ¥ß·π«∑“ß°“√√°— …“
non-simple cyst* ¡–‡√Á߇µ“â π¡ (Àπ“â 21)

LCIS ¥·Ÿ ºπ¿¡Ÿ ·‘  ¥ß·π«∑“ß°“√√—°…“
Malignant ¡–‡√Á߇µâ“π¡ (Àπâ“ 22-38)

* Round, circumscribed mass containing low level echoes without vascular flow, fulfilling most but not all criteria for simple cyst.

16 ·π«∑“ß°“√µ√«®«‘π®‘ ©¬— ·≈–√°— …“欓∫“≈‚√§¡–‡√Á߇µ“â π¡ ªï 2546-2547

°“√µ√«®§—¥°√Õß °“√µ√«®§—¥°√Õß·≈–«‘π‘®©¬— ¡–‡√ßÁ ‡µâ“π¡
À√Õ◊ Õ“°“√· ¥ß
°“√µ√«®§—¥°√Õߢπ—È µπâ
Skin changes :
peau dûorange Final Skin Benign Reassess, Consider
erythema Assessment Malignant repeat biopsy
nipple excoriation category 1-2 biopsy** Consider consult with
scaling, eczema and/or negative breast specialist
ultrasound or
simple cyst(s) ¥·Ÿ ºπ¿¡Ÿ ‘· ¥ß·π«∑“ß°“√√°— …“¡–‡√ßÁ
‡µâ“π¡ (Àπâ“ 22-38)
Final
Mammogram Assessment Benign Punch Repeat biopsy,
+ ultrasound category 3-5 Malignant biopsy Reassess,
and/or solid or of skin Consider
consult with
non-simple cyst* Needle breast
biopsy specialist

À√◊Õ ¥·Ÿ ºπ¿¡Ÿ ·‘  ¥ß·π«∑“ß°“√√—°…“¡–‡√Áß
Surgical ‡µâ“π¡ (Àπ“â 22-38)
excision

* Round, circumscribed mass containing low level echoes without vascular flow, fulfilling most but not all criteria for simple cyst.
** if clinically of low suspicion, a short trial of antibiotics for mastitis may be indicated

·π«∑“ß°“√µ√«®§¥— °√Õß·≈–«π‘ ‘®©¬— ¡–‡√ßÁ ‡µ“â π¡ 17

°“√µ√«®§—¥°√Õß·≈–«‘π‘®©¬— ¡–‡√Á߇µâ“π¡

ASSESSMENT DIAGNOSTIC MAMMOGRAM FOLLOW-UP See appropriate FINAL
CATEGORY* ASSESSMENT category.
Diagnostic workup including
BI-RADSTM Category 0 comparison to prior films
Need additional and/or diagnostic mammogram
imaging evaluation + ultrasound as indicated

BI-RADSTM Category 1 ¥·Ÿ π«∑“ß°“√µ√«®§—¥°√Õß¡–‡√Á߇µâ“π¡
Negative
¥·Ÿ π«∑“ß°“√µ√«®§—¥°√Õß¡–‡√Á߇µâ“π¡
BI-RADSTM Category 2
Mammographic Benign finding Diagnostic mammogram Stable or ¥·Ÿ π«∑“ß°“√µ√«®
evaluation at 6 mo, then every 6-12 resolving §¥— °√Õß¡–‡√Á߇µâ“π¡
BI-RADSTM Category 3 mo for 1-2 yrs.
Probably benign finding if return visit uncertain or Increased ¥Ÿ¢È—πµÕπ¢Õß Category 4-5
patient highly anxious, suspicion (Àπ“â ∂¥— ‰ª)
may include biopsy

BI-RADSTM Category 4 ¥ÀŸ π“â ∂¥— ‰ª
Suspicious abnormality

BI-RADSTM Category 5
Highly suggestive of
malignancy

* ¥·Ÿ π«∑“ß°“√∂à“¬¿“æ√—ß ‡’ µâ“π¡ (mammography)

18 ·π«∑“ß°“√µ√«®«π‘ ®‘ ©¬— ·≈–√°— …“欓∫“≈‚√§¡–‡√Á߇µâ“π¡ ªï 2546-2547

°“√µ√«®§—¥°√Õß·≈–«‘π‘®©—¬¡–‡√ßÁ ‡µ“â π¡

FINAL DIAGNSTIC MAMMOGRAM
ASSESSMENT FOLLOW-UP

CATEGORY* Pathology/ Benign Diagnostic ¥·Ÿ π«∑“ß°“√µ√«®§¥—
image mammogram °√Õß¡–‡√Á߇µâ“π¡
BI-RADS concordant ADH in 6-12 mo Benign
Category 4 À√◊Õ
Suspicious Surgical Malignant
abnormality Radial scar excision

BI-RADSTM Needle À√Õ◊
Category 5
Highly biopsy** Other
suggestive pathological
of (preferred)
malignancy findings***

Pathology/

image

Reassess, concordant ¥Ÿ·ºπ¿¡Ÿ ‘· ¥ß·π«∑“ß
°“√√—°…“¡–‡√Á߇µâ“π¡
Pathology (Àπ“â 22-38)

reimage + malignant ¥·Ÿ ºπ¿¡Ÿ ·‘  ¥ß·π«∑“ß
°√Õß¡–‡√Á߇µâ“π¡
pathology/ obtain
¥·Ÿ π«∑“ß°“√µ√«®§¥—
À√◊Õ image additional °“√√—°…“¡–‡√Á߇µâ“π¡
concordant tissue, as (Àπâ“ 22-38)

indicated Benign
Malignant
Pathology/

image Surgical
remains excision
discordant

Needle localization

excisional biopsy

(specimen

radiograph if Benign Mammogram ¥·Ÿ π«∑“ß°“√µ√«®§¥—
microcalcifications in 6-12 mo °√Õß¡–‡√ßÁ ‡µ“â π¡

À√◊Õ

mammographically Malignant ¥Ÿ·ºπ¿Ÿ¡·‘  ¥ß·π«∑“ß°“√√°— …“¡–‡√Á߇µ“â π¡
evident mass) (Àπ“â 22-38)

* ¥·Ÿ π«∑“ß°“√∂à“¬¿“æ√ß—  ’‡µâ“π¡ (mammography) ** ∑”‰¥∑â ß—È FNA ·≈– Core biopsy, FNA µÕâ ßÕ“»¬— cytologic expertise *** ¥·Ÿ π«∑“ß°“√µ√«®«π‘ ‘®©—¬∑“ß欓∏«‘ ‘∑¬“

·π«∑“ß°“√√—°…“¡–‡√ßÁ ‡µ“â π¡ 19

·π«∑“ß°“√√—°…“

¡–‡√Á߇µ“â π¡

·ºπ¿¡Ÿ ‘· ¥ß·π«∑“ß°“√√°— …“¡–‡√ßÁ ‡µ“â π¡
(µ“¡À≈—°‡°≥±¢å Õß NCCN V1.2004)
Noninvasive Breast Cancer
·ºπ¿Ÿ¡‘· ¥ß·π«∑“ß°“√√°— …“¡–‡√Á߇µâ“π¡
(µ“¡À≈°— ‡°≥±å¢Õß NCCN V1.2004)
Invasive Breast Cancer

20 ·π«∑“ß°“√µ√«®«‘π®‘ ©¬— ·≈–√—°…“欓∫“≈‚√§¡–‡√ßÁ ‡µâ“π¡ ªï 2546-2547

·ºπ¿¡Ÿ ‘· ¥ß·π«∑“ß°“√√°— …“¡–‡√ßÁ ‡µâ“π¡
(µ“¡À≈—°‡°≥±¢å Õß NCCN V1.2004)

Noninvasive Breast Cancer

·π«∑“ß°“√√°— …“¡–‡√ßÁ ‡µâ“π¡ 21

Noninvasive Breast Cancer ·π«∑“ßµ‘¥µ“¡
º≈°“√√°— …“
°“√«π‘ ®‘ ©¬— ‚√§ ¢—πÈ µÕπ°“√µ√«® ·π«∑“ß°“√√°— …“ ¢âÕ·π–π”„π°“√√—°…“
«‘π®‘ ©¬— ‚√§

Lobular carcinoma H&P Counseling regarding Interval history and physical
in situ (LCIS)* Diagnostic bilateral consideration of tamoxifen exam every 6-12 mo
Stage 0 mammogram Mammogram every 12 mo,
Tis, N0, M0 Pathology review for risk reduction unless postbilateral
mastectomy
À√Õ◊
In special circumstances, ∂“â √—°…“¥â«¬ tamoxifen,
bilateral mastectomy +,
reconstruction may be ªØ‘∫µ— ‘µ“¡°“√√°— …“‡ √¡‘
considered for risk
reduction ¢Õß¡–‡√ßÁ ‡µâ“π¡√–¬–·√°

* ¥Ÿ·ºπ¿Ÿ¡·‘  ¥ß·π«∑“ß°“√µ√«®§—¥°√Õß·≈–«‘π‘®©¬— ¡–‡√Á߇µ“â π¡ (Àπâ“ 4 - 16)

22 ·π«∑“ß°“√µ√«®«‘π‘®©¬— ·≈–√°— …“欓∫“≈‚√§¡–‡√Á߇µ“â π¡ ªï 2546-2547

‚√§∑’Ë√—∫°“√ Noninvasive Breast Cancer
«‘π‘®©—¬
¢∫«π°“√«π‘ ‘®©¬— º≈°“√µ√«®«‘π®‘ ©—¬

Ductal carcinoma H&P Widespread ¥Ÿ·π«∑“ß°“√√—°…“
in situ (DCIS) Diagnostic bilateral disease (2 or (Àπâ“∂—¥‰ª)
Stage 0 mammogram more quadrants)
Pathology review Excisional
Tis, N0, M0* Determination of Margins positive***
tumor estrogen Biopsy**
receptor (ER) Margins negative***
status

* ¥·Ÿ ºπ¿¡Ÿ ·‘  ¥ß·π«∑“ß°“√µ√«®§¥— °√Õß·≈–«π‘ ®‘ ©¬— ¡–‡√ßÁ ‡µ“â π¡ (Àπ“â 4-16)
** „πºâªŸ «É ¬∑µË’ âÕß°“√√—°…“·∫∫‡°∫Á ‡µâ“π¡‰«Õâ “®∑” resection ´È”‡æËÕ◊ „À‰â ¥â negative margins

 ”À√∫— ºªâŸ É«¬∑’‰Ë ¡à “¡“√∂∑” margin-free excision ‰¥â §«√∑” tatal mastectomy
*** Margin status

Margins greater than 10 mm are widely accepted as nagative.
Margins less than 1 mm are considered inadequate.
There are insufficient data to make definitive statements regarding margins between 1 and 10 mm.

·π«∑“ß°“√√—°…“¡–‡√ßÁ ‡µâ“π¡ 23

º≈°“√«‘π‘®©—¬ Noninvasive Breast Cancer

Widespread ·π«∑“ß°“√√—°…“
disease (2 or
more quadrants) Total mastectomy without lymph

Margins positive* node dissection + reconstruction**
Margins negative*
Excision** + RT***

À√◊Õ ¥°Ÿ “√√°— …“À≈ß— ºà“µ¥—
Total mastectomy without lymph (Àπâ“∂—¥‰ª)

node dissection + reconstruction**

Excision** + RT***

Small (< 0.5 cm) À√◊Õ
unicentric, low grade Total mastectomy without lymph node

dissection + reconstruction**

À√Õ◊

Excision alone**

* „πºâªŸ É«¬∑µ’Ë Õâ ß°“√√°— …“·∫∫‡°Á∫‡µ“â π¡‰«Õâ “®∑” resection ´”È ‡æ◊ÕË „À≥â negative margins
 ”À√∫— ºâŸªÉ«¬∑’ˉ¡ à “¡“√∂∑” margin-free excision ‰¥â §«√∑” total mastectomy

** ¥·Ÿ π«∑“ß°“√√°— …“¡–‡√ßÁ ‡µâ“π¡‚¥¬°“√ºà“µ¥—
*** ¥Ÿ·π«∑“ß√—ß ’√—°…“„πºâŸª«É ¬¡–‡√ßÁ ‡µ“â π¡

24 ·π«∑“ß°“√µ√«®«π‘ ‘®©¬— ·≈–√°— …“欓∫“≈‚√§¡–‡√ßÁ ‡µ“â π¡ ªï 2546-2547

DCIS À≈—ß°“√ºà“µ¥— Noninvasive Breast Cancer

·π«∑“ßµ¥‘ µ“¡º≈°“√√°— …“

Adjuvant treatment: Interval history and physical exam every 6 mo
Consider tamoxifen for 5 years for: for 5 yr, then annually
Mammogram every 12 mo
Patients treated with breast-conserving therapy ∂â“√°— …“¥«â ¬ tamoxifen §«√ªØ‘∫µ— ‘µ“¡°“√
√—°…“‡ √¡‘ ¢Õß¡–‡√ßÁ ‡µ“â π¡√–¬–·√°
(lumpectomy) and RT*
Patients treated with excision alone*

Risk reduction therapy:
Counseling regarding consideration of tamoxifen
for risk reduction.

* ¥·Ÿ π«∑“ß°“√√°— …“‡ √‘¡¢Õß¡–‡√Á߇µâ“π¡√–¬–·√°

·π«∑“ß°“√√°— …“¡–‡√Á߇µ“â π¡ 25

·ºπ¿Ÿ¡‘· ¥ß·π«∑“ß°“√√—°…“¡–‡√Á߇µâ“π¡
(µ“¡À≈—°‡°≥±¢å Õß NCCN V1.2004)

Invasive Breast Cancer

26 ·π«∑“ß°“√µ√«®«π‘ ®‘ ©¬— ·≈–√—°…“欓∫“≈‚√§¡–‡√Á߇µ“â π¡ ªï 2546-2547

√–¬–¢Õß‚√§ Invasive Breast Cancer

¢È—πµÕπ°“√µ√«®«π‘ ®‘ ©¬— ‚√§

Stage I H&P ¥ŸÀπâ“∂¥— ‰ª
T1,N0,M0 CBC, platelets
À√Õ◊ Liver function tests (LFTs)
Stage llA Chest x-ray
T0,N1,M0 Diagnostic bilateral mammogram, ultrasound as necessary
T1,N1,M0 Pathology review
T2,N0,M0
À√◊Õ Determination of tumor ER/PR status and HER-2 status*
Stage IIB
T2,N1,M0 Breast MRI with dedicated breast coil for cases equivocal for
T3,N0,M0 breast conserving therapy (optional)
À√◊Õ Bone scan (optional) (Indicated if localized symptoms or
T3,N1,M0 elevated alkaline phosphatase or it T3,N1,M0)
Abdominal CT or US or MRI (optional for stage IIA or IIB,
indicated if elevated alkaline phosphatase, abnormal LFTs,
or if T3,N1,M0)

*°“√µ√«®À“ HER-2 §«√„™«â ∏‘ ’ IHC ·≈–/À√◊Õ FISH ∂“â º≈ IHC 2+ §«√µ√«®¬◊π¬—π¥â«¬«∏‘ ’ FISH

·π«∑“ß°“√√°— …“¡–‡√Á߇µ“â π¡ 27

Invasive Breast Cancer

LOCOREGIONAL TREATMENT OF CLINICAL STAGE I,IIA, OR IIB DISEASE OR T3,N1,M0

> 4 positive RT to whole breast with boost (by photons, brachytherapy,
or electron beam) to tumor bed and supraclavicular area.
axillary nodes** consider RT to internal mammary node (controversy is çno
RTé vs çconsideré for internal mammary nodes). RT may be
given concurrent with CMF or follow chemotherapy when

chemotherapy indicated.***

RT to whole breast with boost (by photons, brachytherapy, ¥Ÿ·π«∑“ß

Lumpectomy with or electron beam) to tumor bed and supraclavicular area. °“√√°— …“

level l,ll 1-3 positive Consider RT to supraclavicular area and to internal ‡ √‘¡
axillary nodes mammary nodes (controversy is çno RTé vs çconsideré for
axillary dissection*
internal mammary nodes). RT may be given concurrent (Àπâ“ 24)
with CMF or follow chemotherapy when chemotherapy

indicated.***

À√◊Õ RT to whole breast with boost (by photons, brachytherapy,
Negative axillary or electron beam) to tumor bed. RT may be given
nodes concurrent with CMF or follow chemotherapy when

Total mastectomy with level l,ll chemotherapy indicated.***

axillary dissection* + ¥ŸÀπâ“∂¥— ‰ª

reconstruction æ‘®“√≥“„À⇧¡∫’ ”∫—¥°Õà π°“√ºà“µ¥— (Àπ“â 31)

À√Õ◊

if T2 or T3 and fulfills criteria for breast
conserving therapy except for size

* ¥Ÿ·π«∑“ß°“√√°— …“¡–‡√Á߇µ“â π¡‚¥¬°“√ºà“µ—¥
** Õ“®æ‘®“√≥“„Àâ∑” bone scan, abdominal CT/US/MRI, Chest CT ‡æÕ◊Ë µ√«®À“√–¬–¢Õß‚√§„Àâ·π™à —¥
*** ¥·Ÿ π«∑“ß°“√√°— …“¥â«¬√ß—  ’·≈–‡§¡∫’ ”∫—¥

28 ·π«∑“ß°“√µ√«®«π‘ ®‘ ©—¬·≈–√—°…“欓∫“≈‚√§¡–‡√ßÁ ‡µ“â π¡ ªï 2546-2547

Invasive Breast Cancer

LOCOREGIONAL TREATMENT OF CLINICAL STAGE I,IIA, OR IIB DISEASE OR T3,N1,M0

> 4 positive Postchemotherapy RT to chest wall + supraclavicular area;
axillary consider RT to internal mammary node (controversy is çno RTé

nodes** vs çconsider ç for internal mammary nodes*) ¥Ÿ·π«∑“ß°“√√°— …“

1-3 positive ¥â«¬√ß—  ’
axillary
nodes Consider postchemotherapy RT to chest wall +supraclavicular

Tumor > 5 cm area; if RT is given, consider internal mammary RT
À√Õ◊
margins positive (controversy is çno RTé vs çconsideré for internal mammary ¥°Ÿ “√√°— …“
nodes*) ¥·Ÿ π«∑“ß°“√√°— …“¥â«¬√—ß ’
Negative axillary nodes ‡ √‘¡ (Àπ“â ∂¥—
Total mastectomy with and tumor < 5 cm and
margins close (<1mm) Postchemotherapy RT to chest wall + supraclavicular area ‰ª)
level l,ll axillary
Negative nodes and
dissection* tumor < 5 cm and
margins > 1 mm
+ reconstruction

Consider RT to chest wall
No RT

* ¥Ÿ·π«∑“ß°“√√—°…“¡–‡√Á߇µâ“π¡‚¥¬°“√º“à µ¥—
** Õ“®æ‘®“√≥“„Àâ∑” bone scan, abdominal CT/US/MRI, chest CT ‡æÕ◊Ë µ√«®À“√–¬–¢Õß‚√§„À·â π™à ¥—

·π«∑“ß°“√√°— …“¡–‡√ßÁ ‡µâ“π¡ 29

Invasive Breast Cancer

SYSTEMIC ADJUVANT TREATMENT

Histology : < 1 cm No adjuvant therapy**
Tubular 1-2.9 cm
Colloid > 3 cm Consider adjuvant therapy***
Adjuvant therapy***
pT1,pT2, or Tumor < 0.5 cm or pN0
pT3 and pN0 or Microinvasive or pN1mi No adjuvant therapy*
pN1mi (< 2mm Tumor 0.6-1.0 cm, well differentiated,
axillary node Consider adjuvant
metastasis) no unfavorable features*
tamoxifen***
Adjuvant Histology : ER-positive Tumor 0.6-1.0 cm, moderate/poorly differentiated
Ductal, NOS and/or Adjuvant tamoxifen +
chemotherapy** Lobular PR-positive or unfavorable features*
Mixed adjuvant chemotherapy***
Metaplastic ER-negative Tumor > 1 cm
and Adjuvant tamoxifen +
PR-negative Tumor < 0.5 cm or pN0
Microinvasive pN1mi adjuvant chemotherapy***

Tumor 0.6-1.0 cm No adjuvant therapy*
Consider chemotherapy***
Node positive (one or Tumor > 1 cm
more metastasis > 2 mm Consider chemotherapy***
to one or more ER-positive and/or PR-positive
ipsilateral ER-negative and PR-negative Adjuvant chemotherapy***
axillary lymph nodes)
Adjuvant tamoxifen +

adjuvant chemotherapy***
Adjuvant chemotherapy***

* Unfavorable features : angiolymphatic invasion, high nuclear grade, high histologic grade, HER-2 overexpression, hormone receptor-negative.
** ∂“â ER+ §«√æ‘®“√≥“„Àâ tamoxifen ‡æËÕ◊ ≈¥‚Õ°“ ‡ ’ˬߵÕà °“√°≈∫— §π◊ ¢Õß‚√§
*** ¥·Ÿ π«∑“ß°“√√°— …“¥«â ¬¬“ŒÕ√å‚¡π·≈–¬“‡§¡∫’ ”∫—¥

ºªŸâ É«¬∑‰Ë’ ¥â√∫— tamoxifen §√∫ 5 ªï ·≈–À¡¥ª√–®”‡¥◊Õπ·≈«â §«√殑 “√≥“„À°â “√√°— …“µàÕ¥«â ¬ letrozole

30 ·π«∑“ß°“√µ√«®«‘π‘®©—¬·≈–√°— …“欓∫“≈‚√§¡–‡√Á߇µ“â π¡ ªï 2546-2547

Invasive Breast Cancer

SYSTEMIC ADJUVANT TREATMENT

Node Positive (one or Hormone-receptor negative Adjuvant ¥Ÿ°“√µ‘¥µ“¡
more metastasis > 2 mm Hormone-receptor positive º≈°“√√—°…“
to one or more ipsilateral Chemotherapy* (Àπâ“ 36)
axillary lymph nodes
Tamoxifen, 20 mg/d

for 5 years**+

adjuvant
chemotherapy*

* ¥Ÿ·π«∑“ß°“√√—°…“‡ √‘¡¥â«¬¬“ŒÕ√å‚¡π·≈–¬“‡§¡∫’ ”∫¥—
** ºŸªâ «É ¬∑‰’Ë ¥√â —∫ tamoxifen §√∫ 5 ªï ·≈–À¡¥ª√–®”‡¥◊Õπ·≈«â §«√æ‘®“√≥“„À°â “√√—°…“µÕà ¥â«¬ letrozole

·π«∑“ß°“√√°— …“¡–‡√Á߇µâ“π¡ 31

Invasive Breast Cancer

·π«∑“ß°“√„À⇧¡∫’ ”∫—¥°Õà π°“√ºà“µ—¥

√–¬–‚√§ ¢—ÈπµÕπ°“√µ√«®«π‘ ®‘ ©—¬‚√§

Stage llA History and physical examination ¥Ÿ·π«∑“ß
T2, N0, M0 CBC, platelets °“√√—°…“
Stage IIB Liver function tests (Àπâ“∂—¥‰ª)
T2, N1, M0 Chest x-ray
T3, N0, M0 Diagnostic bilateral mammogram, ultrasound as necessary
Stage IIlA Pathology review
T3, N1, M0 Determination of tumor ER/PR status and HER-2 status*
Breast MRI with dedicated breast coil for cases equivocal for
and breast conserving therapy (optional)
Bone scan (optional) (Indicated if localized
Fulfills criteria for breast symptoms or elevated alkaline phosphatase or if T3, N1, M0)
conserving surgery except for Abdominal CT or US or MRI (optional for stage IIA or IIB,
tumor size indicated if elevated alkaline phosphatase, abnormal LFTs,
or if T3, N1, M0)

* °“√µ√«®À“ HER-2 §«√„™â«‘∏’ IHC ·≈–/À√Õ◊ FISH ∂“â º≈ IHC 2+ §«√µ√«®¬π◊ ¬—π¥«â ¬«‘∏’ FISH

32 ·π«∑“ß°“√µ√«®«‘π®‘ ©—¬·≈–√—°…“欓∫“≈‚√§¡–‡√ßÁ ‡µ“â π¡ ªï 2546-2547

Invasive Breast Cancer

·π«∑“ß°“√√°— …“¥â«¬¬“‡§¡∫’ ”∫—¥°Õà π°“√º“à µ¥—

·π«∑“ß°“√√°— …“

No response after ¥Ÿ Mastectomy
3-4 cycles and level I/II
À√Õ◊ axillary dissection
Progressive (Àπâ“∂—¥‰ª)
disease

Desires Core biopsy of Localization of Preoperative Partial response, ¥Ÿ Mastectomy
breast breast, consider tumor bed for lumpectomy not and level I/II
preservation FNA of clinically future surgical chemotherapy* possible axillary dissection
positive axillary management (Àπâ“∂—¥‰ª)
lymph node(s)

Partial response, ¥Ÿ Lumpectomy
lumpectomy with level I/II
possible axillary dissection
À√Õ◊ (Àπ“â ∂¥— ‰ª)
Complete response

Does not desire ¥Ÿ stage l and ll breast cancer (Àπ“â 26 ·≈– 27)
breast preservation

* ¥Ÿ·π«∑“ß°“√√°— …“¥«â ¬¬“‡§¡∫’ ”∫—¥

·π«∑“ß°“√√°— …“¡–‡√Á߇µâ“π¡ 33

Invasive Breast Cancer ¥Ÿ·π«∑“ß
°“√µ‘¥µ“¡º≈°“√√—°…“ (Àπâ“ 36)
·π«∑“ß°“√√°— …“¥«â ¬¬“‡§¡’∫”∫—¥°Õà π°“√º“à µ—¥

°“√√°— …“‡√‘Ë¡µâπ °“√√—°…“‡ √¡‘

Mastectomy and level Consider additional Chest wall + supraclavicular area RT;
I/II axillary dissection chemotherapy
+ reconstruction consider RT to internal mammary nodes*

(controversy is çno RTé vs çconsideré
for internal mammary nodes) (If patient
is T2, N0 and pN0 postmastectomy RT is
optional)
and
Tamoxifen if ER-positive
¥Ÿ·π«∑“ß°“√√°— …“‡ √¡‘ ¥«â ¬¬“ŒÕ√å‚¡π

Lumpectomy with level Consider additional Breast + supraclavicular area RT*
I/ll axillary dissection chemotherapy
consider RT to internal mammary nodes
(controversy is çno RTé vs çconsideré
for internal mammary nodes)
and
Tamoxifen if ER-positive
¥Ÿ·π«∑“ß°“√√—°…“‡ √‘¡¥â«¬¬“ŒÕ√‚å ¡π

* ¥·Ÿ π«∑“ß°“√√—°…“¥«â ¬√—ß ’

34 ·π«∑“ß°“√µ√«®«‘π®‘ ©¬— ·≈–√—°…“欓∫“≈‚√§¡–‡√Á߇µ“â π¡ ªï 2546-2547

Invasive Breast Cancer

LOCALLY ADVANCED INVASIVE BREAST CANCER

√–¬–¢Õß‚√§ ¢∫«π°“√«π‘ ‘®©¬—

Stage lllA H&P ¥Ÿ Preoperative
T0, N2, M0 CBC, platelets Chemotherapy and
T1, N2, M0 Liver function tests Local-Regional
T2, N2, M0 Chest CT scan + chest x-ray Treatment (Àπ“â ∂¥— ‰ª)
T3, N2, M0 Pathology review
Prechemotherapy determination
(Stage lllA patients with T3, of tumor ER/PR receptor status
N1, M0 disease, ¥ÀŸ π“â 26)
and HER-2 status*
Stage lllB
T4, N0, M0 Diagnostic bilateral
T4, N1, M0 mammogram, ultrasound as
T4, N2, M0 necessary
Bone scan
Stage lllC Abdominal CT or US or MRI
Any T, N3,M0
¥Ÿ pathway for systemic recurrence (Àπâ“ 36)
Stage IV
Any T, any N, M1

* °“√µ√«®À“ HER-2 §«√„™«â ∏‘ ’ IHC ·≈–/À√Õ◊ FISH ∂“â º≈ IHC 2+ §«√µ√«®¬π◊ ¬π— ¥«â ¬«∏‘ ’ FISH

·π«∑“ß°“√√°— …“¡–‡√ßÁ ‡µ“â π¡ 35

Invasive Breast Cancer

‡§¡’∫”∫—¥°àÕπ°“√ºà“µ¥— „π LOCAL REGIONAL TREATMENT °“√√—°…“‡ √¡‘
ºªâŸ É«¬∑¡’Ë ’ locally advanced
invasive breast cancer Total mastectomy + level l/ll axillary Additional chemotherapy +
dissection + RT to chest wall and tamoxifen, 20 mg/d for 5 years
Response supraclavlcular nodes (plus internal if estrogen receptor positive
mammary nodes if involved) + delayed or unknown
Anthracycline-based cosmetic reconstruction
preoperative À√Õ◊ ¥Ÿ·π«∑“ß
chemotherapy Consider lumpectomy + level l/ll °“√µ¥‘ µ“¡
axilary dissection + RT to breast and º≈°“√√—°…“
No response supraclavicular nodes (plus internal (Àπâ“∂—¥‰ª)
mammary nodes if involved)
À√◊Õ Response-See above pathway
High does RT alone

Consider additional systemic
chemotherapy and/or preoperative
radiation

No response Individualized
treatment

36 ·π«∑“ß°“√µ√«®«π‘ ®‘ ©¬— ·≈–√°— …“欓∫“≈‚√§¡–‡√Á߇µâ“π¡ ªï 2546-2547

·π«∑“ßµ‘¥µ“¡º≈°“√√—°…“ Invasive Breast Cancer

Interval history and physical ¢—ÈπµÕπ°“√µ√«®«π‘ ®‘ ©¬—
exam every 4-6 mo for 5 yr,then ‡¡Õ◊Ë ¡’√Õ¬‚√§°≈∫— §π◊
every 12 mo À√◊Õ‡¡◊ËÕ‚√§‡ªìπ√–¬–∑’Ë 4
Mammogram every 12 mo (and 6
mo post-RT if breast conserved) H&P Local
Women on tamoxifen: pelvic CBC, platelets disease
exam every 12 mo if uterus Live function tests only
present Chest x-ray
Bone scan ¥°Ÿ “√√°— …“
X-rays of symptomatic bones and ‡¡ËÕ◊ ‚√§°≈—∫§◊π/√–¬–∑Ë’ 4
long and weight-bearing bones
abnormal on bone scan (Àπâ“∂—¥‰ª)
Consider chest and
abdominal CT and MRI Systemic
Biopsy documentation of first
recurrence, if possible disease**
If not previously performed,
determination of tumor ER/PR

and HER-2 status*

Pet scan (optional)

* °“√µ√«®À“ HER-2 §«√„™«â ‘∏’ IHC ·≈–/À√◊Õ FISH ∂“â º≈ IHC 2+ §«√µ√«®¬π◊ ¬π— ¥â«¬«∏‘ ’ FISH
** §«√„Àâ pamidronate À√◊Õ zoledronic acid (°∫— calcium citrate 500 mg ·≈–‡ √‘¡¥â«¬ vitamin D 400 IU) √à«¡°∫— °“√„À⇧¡’∫”∫—¥

À√◊ÕŒŒ√‚å ¡π∫”∫¥— ∂“â ¡°’ “√≈°ÿ ≈“¡‰ª¬ß— °√–¥Ÿ° (bone metastasis), expected survival > 3 ‡¥◊Õπ ·≈– creatinine < 3.0 mg/dl

·π«∑“ß°“√√—°…“¡–‡√ßÁ ‡µâ“π¡ 37

Invasive Breast Cancer

°“√√°— …“‡¡◊ËÕ¡’√Õ¬‚√§°≈—∫§π◊ /‚√§√–¬–∑Ë’ 4

Local Initial treatment with mastectomy Surgical resection (if possible) Consider systemic therapy
disease
only + RT (if possible)

Initial treatment with lumpectomy + RT Mastectomy Consider systemic therapy

Prior antiestrogen Second-line hormonal therapy***
within 1 yr

ER/PR positive or Postmenopausal Non-steroidal ¥ŸÀπâ“
bone/soft tissue only or aromatase inhibitor ∂—¥‰ª
asymptomatic visceral À√Õ◊
Antiestrogen

Systemic No prior antiestrogen or Premenopausal Antiestrogen + LHRH
> 1 yr off antiestrogen agonist
disease**
HER-2* Trastuzumab + Chemotherapy Consider no
ER/PR negative À√Õ◊ further cytotoxic
symptomatic visceral over-expressed Chemotherapy No response to 3 therapy.
À√◊Õ hormone refractory sequential regimens or ¥Ÿ·π«∑“ß°“√¥·Ÿ ≈
HER-2* not ECOG performance
status > 3 ºâŸªÉ«¬·∫∫
over-expressed
ª√–§—∫ª√–§Õß

* °“√µ√«®À“ HER-2 §«√„™â«‘∏’ IHC ·≈–/À√Õ◊ FISH ∂“â º≈ IHC 2+ §«√µ√«®¬π◊ ¬—π¥«â ¬«‘∏’ FISH
** §«√„Àâ pamidronate À√Õ◊ zoledronic acid (°—∫ calcium citrate 500 mg ·≈–‡ √‘¡¥â«¬ vitamin D 400 IU) √à«¡°—∫°“√„À‡â §¡’∫”∫—¥

À√◊ÕŒÕ√å‚¡π∫”∫¥— ∂“â ¡’°“√≈°ÿ ≈“¡‰ª¬ß— °√–¥Ÿ° (bone metastasis), expected survival > 3 ‡¥Õ◊ π ·≈– creatinine < 3.0 mg/dl
*** ¥·Ÿ π«∑“ß°“√√—°…“¥â«¬¬“ŒÕ√‚å ¡π

¥Ÿ·π«∑“ß°“√√°— …“¥â«¬¬“‡§¡∫’ ”∫¥—

38 ·π«∑“ß°“√µ√«®«‘π®‘ ©—¬·≈–√°— …“欓∫“≈‚√§¡–‡√Á߇µ“â π¡ ªï 2546-2547

Invasive Breast Cancer

°“√µ¥‘ µ“¡º≈°“√√°— …“‡¡ÕË◊ „À¬â “ŒÕ√‚å ¡π„πºªŸâ «É ¬∑Ë¡’ √’ Õ¬‚√§°≈—∫§π◊ /‚√§√–¬–∑’Ë 4

Continue hormonal Progression No clinical benefit after 3 Yes Chemotherapy*
therapy until consecutive hormonal No
progression À√Õ◊ therapy regimens Trial of new
unacceptable toxicity À√◊Õ
Symptomatic visceral hormone therapy**
disease

No response to Chemoterapy*

hormonal

therapy**

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µ“√“ß∑Ë’ 2 Breast Cancer Surveillance Testing - Not Recommended

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Complete blood cell ‰¡·à π–π”„Àâµ√«®‡ªπì routine „π°“√∑” surveillance ‡Õ° “√Õ“â ßÕß‘
Automated chemistry studies ·µ„à Àâµ√«®‡æÕ◊Ë ™«à ¬¬π◊ ¬π— recurrence À√◊Õ¡Õ’ “°“√ ß —¬ 1. Smith TJ, Davidson NE, Schapira DV, et al.
Chest Roentgenography «“à ®–¡’ recurrence
Bone scan American Society of Clinical Oncology 1998
Ultrasound of the liver and Computed Tomography update of recommended breast cancer
Tumor markers : CA 15-3, CEA surveillance guidelines. J Clin Oncol 1999;
17: 1080 - 1082.

TNM Staging System for Breast Cancer (AJCC) 41

TNM Staging System for Breast Cancer

(AJCC)

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Staging T3 Tumor more than 5 cm in greatest dimension
T4 Tumor of any size with direct extension to (a) chest
American Joint Committee on Cancer (AJCC) wall or (b) skin, only as described below
TNM Staging System For Breast Cancer T4a Extension to chest wall, not including pectoralis muscle
Primary Tumor (T) T4b Edema (including peau dûorange) or ulceration of the
skin of the breast or satellite skin nodules confined to
Definitions for classifying the primary tumor (T) are the same for clinical T4c the same breast
and for pathologic classification. If the measurement is made by the physical T4d Both T4a and T4b
examination, the examiner will use the major headings (T1, T2, or T3). If other Inflammatory carcinoma
measurements, such as mammographic or pathologic measurements, are used,
the subsets of T1 can be used. Tumors should be measured to the nearest 0.1 Regional Lymph Nodes (N)
cm increment. Clinical

TX Primary tumor cannot be assessed NX Regional lymph nods cannot be assessed (e.g.,
T0 No evidence of primary tumor previously removed)
Tis Carcinoma in situ
Tis (DCIS) Ductal carcinoma in situ N0 No regional lymph node metastasis
Tis (LCIS) Lobular carcinoma in situ N1 Metastasis to movable ipsilateral axillary lymph node (s)
Tis (Pagetûs) Pagetûs disease of the nipple with no tumor N2 Metastases in ipsilateral axillary lymph nodes fixed or

Note : Pagetûs disease associated with a tumor is classified according to matted, or in clinically apparent* ipsilateral internal
the size of the tumor. mammary nodes in the absence of clinically evident
axillary lymph node metastasis
T1 Tumor 2 cm or less in greatest dimension N2a Metastases in ipsilateral axillary lymph nodes fixed to
T1mic Microinvasion 0.1 cm or less in greatest dimension one another (matted) or to other structures
T1a Tumor more than 0.1 cm but not more than N2b Metastasis only in clinically apparent* ipsilateral
0.5 cm in greatest dimension internal mammary nodes and in the absence of
T1b Tumor more than 0.5 cm but not more than 1 cm in clinically evident axillary lymph node metastasis
greatest dimension N3 Metastasis in ipsilateral infraclavicular lymph node(s)
T1c Tumor more than 1 cm but not more than 2 cm in with or without axillary lymph node in volvement, or in
greatest dimension clinically apparent* ipsilateral internal mammary lymph
T2 Tumor more than 2 cm but not more than 5 cm in node(s) and in the presence of clinically evident
greatest dimension axillary lymph node metastasis; or metastasis in

TNM Staging System for Breast Cancer (AJCC) 43

ipsilateral supraclavicular lymph node(s) with or aClassification is based on axillary lymph node dissection with or without
without axillary or internal mammary lymph node sentinel lymph node dissection. Classification based solely on sentinel lymph
involvement node dissection without subsequent axillary node dissection is designated (sn)
N3a Metastasis in ipsilateral infraclavicular lymph node(s) for çsentinel node,é e.g., pN0(i+) (sn).
N3b Metastasis in ipsilateral internal mammary lymph
node(s) and axillary lymph node(s) bRT-PCR: reverse transcriptase/polymerase chain reaction.
N3c Metastasis in ipsilateral supraclavicular lymph node(s)
pN1 Metastasis in 1 to 3 axillary lymph nodes, and/or in
*Clinically apparent is defined as detected by imaging studies (excluding internal mammary nodes with micro scopic disease
lymphoscintigraphy) or by clinical examination or grossly visible pN1mi detected by sentinel lymph node dissection but not
pathologically. pN1a clinically apparent**
pN1b Micrometastasis (greater than 0.2 mm, none greater
Pathologic (pN)a pN1c than 2.0 mm)
pNX Regional lymph nodes cannot be asessed (e.g., Metastasis in 1 to 3 axillary lymph nodes
previously removed, or not removed for pathologic pN2 Metastasis in internal mammary nodes with microscopic
study) pN2a disease detected by sentinel lymph node dissection
pN0 No regional lymph node metastasis histologically, no pN2b but not clinically apparent**
additional examination for isolated tumor cells (ITC) Metastasis in 1 to 3 axillary lymph nodes and in
Note : Isolated tumor cells (ITC) are defined as single tumor cells or small internal mammary nodes with microscopic disease
detected by sentinel lymph node dissection but not
cell clusters not greater than 0.2 mm, usually detected only by immunohisto- clinically apparent.** (If associated with greater than
chemical (IHC) or molecular methods but which may be verified on H&E stains. 3 positive axillary lymph nodes, the internal mammary
ITCs do not usually show evidence of malignant activity e.g., proliferation or nodes are classified as pN3b to reflect increased tumor
stromal reaction. burden)
Metastasis in 4 to 9 axillary lymph nodes, or in clinically
pN0(i-) No regional lymph node metastasis histologically, apparent* internal mammary lymph nodes in the
negative IHC absence of axillary lymph node metastasis
Metastasis in 4 to 9 axillary lymph nodes (at least
pN0(i+) No regional lymph node metastasis histologically, one tumor deposit greater than 2.0 mm)
positive IHC, no IHC cluster greater than 0.2 mm Metastasis in clinically apparent* internal mammary
lymph nodes in the absence of axillary lymph node
pN0(mol-) No regional lymph node metastasis histologically, metastasis
negative molecular findings (RT-PCR)b

pN0(mol+) No regional lymph node metastasis histologically,
positive molecular findings (RT-PCR)b

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pN3
Metastasis in 10 or more axillary lymph nodes, or in STAGE GROUPING M0 Stage IIIB T4 N0 M0
pN3a infraclavicular lymph nodes, or in clinically apparent* Stage 0 Tis N0 M0 T4 N1 M0
pN3b ipsilateral internal mammary lymph nodes in the Stage I T1* N0 M0 T4 N2 M0
presence of 1 or more positive axillary lymph nodes; Stage IIA T0 N1 M0 Stage IIIC Any T N3 M0
pN3c or in more than 3 axillary lymph nodes with clinically M0 Stage IV Any T Any N M1
negative microscopic metastasis in internal mammary T1* N1 M0
lymph nodes; or in ipsilateral supraclavicular lymph T2 N0 M0 Note: Stage designation may be
nodes Stage IIB T2 N1 M0 changed if post-surgical imaging
Metastasis in 10 or more axillary lymph nodes (at T3 N0 M0 studies reveal the presence of
least one tumor deposit greater than 2.0 mm), or Stage IIIA T0 N2 M0 distant metastases, provided that
metastasis to the infraclavicular lymph nodes T1* N2 M0 the studies are carried out within 4
Metastasis in clinically apparent* ipsilateral internal T2 N2 M0 months of diagnosis in the absence
memmary lymph nodes in the presence of 1 or more T3 N1
positive axillary lymph nodes; or in more than 3 T3 N2 of disease progression and
axillary lymph nodes and in internal mammary lymph *T1 includes T1mic provided that the patient has not received
nodes with microscopic disease detected by sentinel neoadjuvant Therapy.
lymph node dissection but not clinically apparent.**
Metastasis in ipsilateral supraclavicular lymph nodes

* Clinically apparent is defined as detected by imaging studies (excluding
lymphoscintigraphy) or by clinical examination.

** Not clinically apparent is defined as not detected by imaging studies
(excluding lymphoscintigraphy) or by clinical examination.

Distant Metastasis (M)
MX Distant metastasis cannot be assessed
M0 No distant metastasis
M1 Distant metastasis

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