医学院外科乳腺疾病教案.docx

医科大学第二医院教案首页装订线课程名称外科学授课题目第二十三章乳腺疾病breastdiseases授课对象临床医学本科时间分配共80分钟解剖及生理4分钟乳腺的检查方法-8分钟急性乳腺炎病因、发病机制8分钟急性乳腺炎的治疗4分钟乳腺癌的发病原因及影响因素8分钟乳腺癌的临床病理分型及转移途径10分钟乳腺癌的临床表现及主要体征：10分钟乳腺癌的诊断及鉴别珍断8分钟乳腺癌的手术治疗8分钟乳腺癌的综合性治疗及进展一-12分钟课时目标1,了解急性乳腺炎病因、发病机制.2,掌握急性乳腺炎的治疗。3、掌握乳腺癌的临床病理分型及转移途径.4、熟悉乳腺癌的发病原因及影响因素、手术治疗5、掌握乳腺癌的诊断及鉴别诊断。授课重点乳腺癌的临床表现、诊断及鉴别诊断授课难点乳腺癌的临床表现授课形式大班授课授课方法讲授法参考文献1、外科学（第七版）吴在德主编，人民卫生出版社出版2、黄家驷外科学（第六版）裘法祖主编，人民卫生出版社出版思考题乳腺癌肝转移的途径是什么教研室主任及课程负责人签字教研室主任（签字）课程负责人（签字）年月日.年月日基本内容注解（进展、辅助手段）BreastdiseaseANATOMYThematurebreastliescushionedinadiposetissuebetweenthesubcutaneousfatlayerandthesuperficialpectoralfascia.Betweenthebreastandthepectoralism<yormuscleliestheretromammaryspace.Thenumberoflymphnodesfoundintheaxilladependsontheextentofdissectionandthediligenceusedtoidentifythesenodes.AnupperlimitisestablishedbytheworkofDurkinandHaagensenusingethanolclearing.LevelInodesarelocatedintheexternalmammary,scapular,axillaryvein,andcentralaxillarygroups,whichlielateraltothelateralborderofthepectoralisminormuscle.LevelIlnodesareinthecentralaxillarygrouplocatedunderthepectoralisminormuscle.LevelIIInodesincludetheSubclavicularnodesmedialtothepectoralisminormuscle.Theapexoftheaxillaisdefinedbythecostoclavicularligament.Lymphnodesinthespacebetweenthepectoralismajorandminormusclesareknownastheiterpectoralgroup,orRotternodes.Lymphaticchannelsareabundantinthebreastparenchymaanddenis.Specializedlymphaticchannelscollectunderthenippleandareola.Lymphflowsfromtheskintothesubareolarplexusandthenintointerlobularlymphaticsofthebreastparenchyma.Seventy-fivepercentoflymphaticflowfromthebreastisintotheaxillarylymphnodes,andaminoramountgoesthroughthepectoralismuscleandintomoremediallymphnodegroups.Knowledgeofmajornervousstructuresintheaxillaisrequiredtoavoidtheirsacrificeduringsurgery.Thismuscleisimportantforfixatingthescapulatothechestwallduringadductionoftheshoulderandextensionofthearm,anditsdivisionmayresultinthewingedscapuladefbity.Thisnervearisesfromtheposteriorcordofthebrachialplexusandenterstheaxillaryspaceundertheaxillaryvein.Itthencrossestheaxillatothemedialsurfaceofthelatissimusdorsimuscle.Althoughanatomistshavecalledthesenervesthemedi3pectoralnerves,manysurgeonsrefertothemasthelateralpectoralne*ves,reflectingtheirpositionduringsurgery.Exposureofthepectoralneurovascularbundleisagoodlandmark,indicatingthepositionoftheaxillaryveinjustaboveanddeepto借助图片讲解借助图片讲解基本内容注解（进展、辅助手段）Thenipplesareinspectedandcomparedforthepresenceofretraction,nippleinversion,orexcoriationofthesuperficialepidenisinPaget,sdisease.TheuseofindirectlightingcanunmasksubtledimplingoftheskinornipplecausedbythescirrhousreactionofacarcinomaplacingCooper'sligamentsundertension.Simplemaneuverssuchasstretchingthearmshighabovethehead,tensingthepectoralismuscles,orgentlyliftingthepatient'sbreastmayaccentuateasymmetriesanddimpling.Itisamisconceptiontoequateskindimplingwithadvancedcancer.Thissignisfrequentlyfoundinsmall,scirrhoustumorsthatdonotproducealargemasseffect.Ifcarefullysought,dimplingoftheskinornippleretractionisasensitiveandspecificsignofunderlyingcancer.Edemaoftheskin,frequentlyaccompaniedbyerythema,producesaclinicalsignknownaspeaud,orange.Whencombinedwithtendernessandwarmth,thesesignsandsymptomsarethehallmarkofinflammatorycarcinomaandmaybemistakenforacutemastitis.Althoughtheseclinicalsignsareoftendramatic,theycanbeoverlookedinwomenwithdarkerskinpigmentinaroomwithinadequatelighting.Theinflammatorychangesandedemaarecausedbyobstructionofdennallymphaticchannelswithemboliofcarcinomacells.Occasionally,abulkytumormayproduceobstctionoflargelymphchannelsthatresultsinoverlyingskinedema.Thisisnot,strictlyspeaking,aninflammatorycarcinoma,inwhichthevisiblesignsareoutofproportiontothepalpablemass.In40patientswithinflammatorycarcinomawhounderwenttreatmentwithHaagensen,allcasespresentedwitherythemaandedemaoftheskin;apalpablemassorlocalizedindurationwaspresentin19;and,in21patients,nolocalizedtumorwaspresent.Involvementofthenippleandareolaisacommonhistologicfindinginbreastsremovedforcarcinoma.Directinvolvementmayaccompanytumorsoriginatinginbreasttissueundertheareolaandmayresultinretractionoftheusuallyprotrudingnipple.Flatteningoractualinversionofthenipplecanbecausedbyfibrosisincertainbenignconditions,especiallysubareolarductectasia.Inthesecases,thefindingisfrequentlybilateralandthehistoryconfirmsthattheconditionhasbeenpresentformanyyears.Unilateralretractionorretractionthatdevelopsoverweeksormonthsismoresuggestiveofcarcinoma.Centrallylocatedtumorsmaydirectlyinvadeandulcerate配合图片了解乳腺的检查方法基本内容注解（进展、辅助手段）ThesecondclinicalfeatureofcarcinomathatdirectlyinvolvesthenipplewasdescribedbySirJamesPagetin1874andnamedPaget'sdisease.Histologically,thisdiseaseisproducedbyintraductalcarcinomaoccurringinthelargesinusesjustunderthenipple.Carcinomacellsinvadeacrosstheepidermoepi