B超医生通过观察是乳腺内组织的不同回声和血流情况

B超医生通过观察是乳腺内组织的不同回声和血流情况 B超医生通过观察是乳腺内组织的不同回声和血流情况，来做综合判断的，(1)有无肿块?如有肿块，形状是否规则、是否呈分叶状或蟹足状?肿块边界清不清?回声是否均匀?肿块后方回声是否衰减?(2)有无钙化?尤其注意有无细点样、砂粒样、簇状钙化?(3)有无血流?血流是否丰富?(4)如B超下弹性成像分级高，红色为主，提示肿块质地较硬。 下列情形往往提示有恶性可能 (1)肿块形状:不规则、分叶、蟹足状;(2)边界不清，回声不均匀，后方回声衰减 ;(3)细点样、砂粒样、簇状钙化;(4)血流丰富II-III级，高阻高速，阻力指数(RI)>0.70;(5)弹性成像分级高，提示肿块质地较硬。但也不能完全肯定，医生要根据病人年龄、月经状况、体检结果、钼靶情况、过去史、家族史综合考虑，必要时穿刺或小手术活检。 B超医生参照美国放射学会提出的乳腺影像和数据系统(BI-RADS报告系统)做如下报告: BI-RADS 0级 :需要结合其他检查 BI-RADS 1 级 :阴性 BI-RADS 2 级 :良性 BI-RADS 3 级 :良性可能,需短期随访(3-6个月就诊一次) BI-RADS 4 级 :可疑恶性,建议活检 4A: 低度可疑(<2%恶性可能) 4B: 中度可疑 4C: 高度但不肯定 BI-RADS 5 级: 高度恶性 BI-RADS 6 级: 已经病理证实恶性 临床经验提示:由于乳腺彩超有其固有的缺点，带有很大的人为因素，受医生专业水准、认真程度的限制，彩超结果往往多个医生出的报告不一致，这就需要临床医生综合判断，反复和彩超医生结合才能得出一个准确的诊断。所以如果彩超提示一个不能触及的结节，一定不要惊慌，多找医生会诊可能会避免不必要的惊慌和手术。医生经常遇到一些被诊断肿瘤或要手术的患者，经过医生仔细分析复查，排除了肿瘤，避免了不必要的手术。 ncluding based life support (BLS), and senior heart life support (ACLS), and based trauma life support (BTLS) and senior trauma life support (ATLS) of based knowledge; common emergency technology of application; common emergency of causes identification, and clinical performance and the processing specification; common emergency auxiliary check of select refers to levy, and results judge and the clinical meaning; Indications, effects of common emergency drugs, side effects, as well as specific applications (medicine, for expansion of vasoactive drugs, cardiac diuretic, antispasmodic and anti-asthmatic drugs, analgesic drugs, Hemostatic, antiarrhythmic drugs, such as Cortina). Understand: the new development of the theory of life support; cardiac respiratory and cardiopulmonary resuscitation after cardiac syndrome etiology, pathophysiology, clinical manifestations, diagnosis, and treatment. 2. basic requirements (1) species and cases of study requirements: disease disease fever acute abdominal pain chest pain and difficulty breathing faint coma shock in acute poisoning with cardiac respiratory arrest bleeding (hemoptysis, hematemesis, hematuria, etc) requires at least 45 cases of arrhythmia. (2) basic skills requirements name name heart lung 乳腺癌普查x线诊断 复旦大学肿瘤医院放射科 顾雅佳 乳腺癌是妇女中最常见的恶性肿瘤，发病率增加最快，早期诊断是控制乳腺癌的重要策略，普查是早期发现乳腺癌的重要手段。乳腺X线检查是目前唯一被证实有效的乳腺癌普查工具。 诊断标准 m年美国放射学会提出的乳腺影像报告和数据系统(Breast Imaging Reporting And DataSystem, BI-RADS )，至今已是第四版((2003)。这个系统对规范乳腺X线报告、减少影像描写的混淆，以及对普查的监侧均起着很大的作用。 (一)影像现 1、常见征象 肿块:在两个不同投照位置均可见的占位性病变，有鼓出的边缘，以边缘征象对判断肿块的性质最为重要。仅在一个投照位置上见到的可疑肿块影称“致密影”:无明显鼓出边缘的称“不对称”。肿块的描述包括三个方面:形态、边缘和密度。 形态有圆形、卵圆形、分叶形和不规则形，不规则形态多为恶性表现，前三种形态要结合其他征象综合考虑 边缘对诊断病变的性质最为重要，包括以下五种描述:清晰、模糊、小分叶、浸润和星芒状。边缘清晰是指超过75%的肿块边界与周围正常组织分界清晰、锐利，剩下的边缘可被周围腺体遮盖，但无恶性证据;模糊是指肿块被其上方或临近的正常组织遮盖而无法对其作进一步判断，一般用在报告者认为这个肿块的边界是清晰的，仅仅是被周围腺体遮住的情况下;小分叶表现为边缘呈小波浪状改变;浸润是由病灶本身向周围浸润而引起的边界不规则，而不是由于周围腺体遮盖所为;星芒状可见从肿块边缘发出的放射状线影。小分叶、浸润和星芒状边缘为恶性征象。对鉴别边缘模糊和漫润有时会有一定困难，但却是非常重要的，前者多为良性改变，而后者是恶性征象，通过局部加压摄影、辗平摄影技术对鉴别边缘征象有帮助。 密度是以肿块与其周围相同体积的乳腺组织相比，分为高、等、低(不包括脂肪密度)和脂肪密度四种描述。大多数乳腺癌呈高或等密度;极少数乳腺癌可呈低密度;乳腺癌不含脂肪密度，脂肪密度为良性表现。 钙化:良性钙化常比恶性钙化大，呈较粗糙或边缘清晰的圈形钙化。恶性钙化常较小，需要放大镜来帮助显示。对钙化的描述从形态和分布两方面进行。良性钙化可不描写，但当这些钙化可能会引起另外医生误解时，这些良性钙化需要描述。 形态上分为典型良性钙化、中间性钙化(可疑钙化)、高度恶性可能的钙化三种。 典型良性钙化有以下十种典型表现。皮肤钙化较粗大，典型者呈中心呈透亮改变，不典型者可借助切线投照予以鉴别;血管钙化表现为管状或轨道状;粗糙或爆米花样钙化直径常大于2 - 3mm，为纤维腺瘤钙ncluding based life support (BLS), and senior heart life support (ACLS), and based trauma life support (BTLS) and senior trauma life support (ATLS) of based knowledge; common emergency technology of application; common emergency of causes identification, and clinical performance and the processing specification; common emergency auxiliary check of select refers to levy, and results judge and the clinical meaning; Indications, effects of common emergency drugs, side effects, as well as specific applications (medicine, for expansion of vasoactive drugs, cardiac diuretic, antispasmodic and anti-asthmatic drugs, analgesic drugs, Hemostatic, antiarrhythmic drugs, such as Cortina). Understand: the new development of the theory of life support; cardiac respiratory and cardiopulmonary resuscitation after cardiac syndrome etiology, pathophysiology, clinical manifestations, diagnosis, and treatment. 2. basic requirements (1) species and cases of study requirements: disease disease fever acute abdominal pain chest pain and difficulty breathing faint coma shock in acute poisoning with cardiac respiratory arrest bleeding (hemoptysis, hematemesis, hematuria, etc) requires at least 45 cases of arrhythmia. (2) basic skills requirements name name heart lung 化的特征表现:粗棒状钙化连续呈棒杆状，偶可分支状，直径通常大于1mm，可能呈中央透亮改变，边缘光整，沿着导管分布，聚向乳头，常为双侧乳腺分布，多见于分泌性病变;圆形和点状钙化，小于lmm甚至0. 5.，常位于小叶腺泡中，簇状分布者要引起等惕;“环形”或“蛋壳样钙化”，环壁很薄，常小于lmm，为球形物表面沉积的钙化，见于脂肪坏死或囊肿;中空状钙化大小可从lmm到1cm甚至更大，边缘光滑呈圆形或卵圆形，中央为低密度，壁的厚度大于“环形”或“蛋壳样”钙化，常见于脂肪坏死、导管内钙化的残骸，偶可见于纤维腺瘤;牛奶样钙化为囊肿内钙化，在头足轴位(CC)表现不明显，为绒毛状或不定形状，在90度侧位上边界明确，根据囊肿形态的不同而表现为半月形、新月形、曲线形或线形，形态随体位而发生变化是这类钙化的特点:缝线钙化是由于钙质沉积在缝线材料上所致，尤其在放疗后常见，典型者为线形或管形，绳结样改变常可见到;营养不良性钙化常在放疗后或外伤后的乳腺上见到，钙化形态不规则，多大于0. 5.，呈中空状改变。 中间性钙化(可疑钙化)包括不定形或模糊钙化和粗糙不均质钙化两种，前者形态上常小而模糊无典型特征，弥漫性分布常为良性表现，而簇状分布、区域性分布、线样和段样分布需提请临床活检。后者的钙化多大于0. 5mm，形态不规则可能为恶性改变，也可出现在良性的纤维化、纤维腺瘤和外伤后的乳腺中，需结合分布情况考虑。 高度恶性可能的钙化也有两种表现形式，细小的多形性钙化(颗粒点状钙化)和线样或线样分支状钙化(铸形钙化)。颗粒点状钙化较不定形钙化更可疑，大小形态不一，直径常小于0. 5}。线样分支状钙化表现为细而不规则的线样，常不连续，直径小于0. 5.，这些征象提示钙化是从被乳腺癌侵犯的导管腔内形成的。 钙化分布常对提示乳腺病变的病理类型有帮助，包括以下五种分布方式。弥没或散在分布指钙化随意分散在整个乳腺，这样分布的点样和多形性钙化多为良性改变，常为双侧性;区域状分布是指较大范围内(>2cc)分布的钙化，但又不能用导管样分布来描写，常超过一个象限的范围，这种钙化分布的性质需结合形态综合考虑;簇状分布是指至少有5枚钙化占据在一个较小的空间内< lcc)，良恶性病变都可以有这样的表现;线样分布的钙化排列成线形，可见分支点，提示源于一支导管，多为恶性改变;段样分布常提示病变来源于一个导管及其分支，也可能发生在一叶或一个段叶上的多灶性癌，尽管良性分泌性病变也会有段样分布的钙化，但如果钙化的形态不是特征性良性时，首先考虑其为恶性钙化。 结构扭曲:是指正常结构被扭曲但无明确的肿块可见，_包括从一点发出的放射状影和局灶性收缩，或者在实质的边缘扭曲二结构扭曲也可以是一种伴随征象，可为肿块、不对称致密或钙化的伴随征象。如果没有局部的手术和外伤史，结构扭曲可能是恶性或放射状疤痕的征象，应提请临床切取活检。 2、特殊征象 非对称性管状结构/单个扩张的导管:管状或分支样结构可能代表扩张或增粗的导管。如果不同时伴有其他可疑的临床或影像征象，其意义不大。 乳腺内淋巴结:典型表现为肾形，可见有淋巴结门脂肪所致的透亮切迹，常小于lcm。当淋巴结较大，但其大部分为脂肪替代时，仍为良性改变。可以是多个，也可能是一个淋巴结由于明显的脂肪替代看上去像多个圆形结节影。对于乳腺外上部的特征性改变可以做出正确诊断。偶尔也可出现在其他区域。 局灶性不对称:不能用其他形状精确描述的致密改变.两个投照位置均显示，但缺少真性肿块特有的边缘改变，较球形不对称范围要小。它可能代表的是一个正常的乳腺岛，尤其当其中含有脂肪时。但由于其ncluding based life support (BLS), and senior heart life support (ACLS), and based trauma life support (BTLS) and senior trauma life support (ATLS) of based knowledge; common emergency technology of application; common emergency of causes identification, and clinical performance and the processing specification; common emergency auxiliary check of select refers to levy, and results judge and the clinical meaning; Indications, effects of common emergency drugs, side effects, as well as specific applications (medicine, for expansion of vasoactive drugs, cardiac diuretic, antispasmodic and anti-asthmatic drugs, analgesic drugs, Hemostatic, antiarrhythmic drugs, such as Cortina). Understand: the new development of the theory of life support; cardiac respiratory and cardiopulmonary resuscitation after cardiac syndrome etiology, pathophysiology, clinical manifestations, diagnosis, and treatment. 2. basic requirements (1) species and cases of study requirements: disease disease fever acute abdominal pain chest pain and difficulty breathing faint coma shock in acute poisoning with cardiac respiratory arrest bleeding (hemoptysis, hematemesis, hematuria, etc) requires at least 45 cases of arrhythmia. (2) basic skills requirements name name heart lung 缺乏特征性的良性征象，往往需要对其作进一步检查，由此可能会显示一个真性肿块或明显的结构扭曲改变。 3、合并征象 常与肿块或钙化征象合并，或为不伴有其他异常征象的单独改变。包括:皮肤凹陷、乳头凹陷、皮肤增厚、小梁增粗、皮肤病变投照在乳腺组织中、腋淋巴结肿大、结构扭曲和钙化。 (二)总体评估 1、评估是不完全的 0级:需要其他影像枪查进一步评估或与前片比较 常在普查情况下应用，在完全的影像学检查后以及与前片比较后则很少用。推荐的其他影像检查包括局部加压摄影、放大摄影、特殊投照体位摄影、超声等 2.评估是完全的 1级:阴性。无异常发现。 2级:良性发现。包括钙化的纤维腺瘤、多发的分泌性钙化、含脂肪的病变(脂性囊肿、脂肪瘤、输乳管囊肿及混合密度的错构瘤)、乳腺内淋巴结、血管钙化、植入体、有手术史的结构扭曲等等。但总的来说并无恶性的X线征象。 3级:可能是良性发现，建议短期随访。有很高的良性可能性，期望此病变在短期(小于1年，一般为6个月)随访中稳定或缩小来证实判断。这一级的恶性率一般小于2%。无钙化边界清晰的肿块、局灶性的不对称、簇状圆形或/和点状钙化这三种征象被认为良性改变可能大。 对这一级的处理，首先X线片短期随访((6月)，再6月、再12月随访至2年甚至更长稳定来证实他的判断。2或3年的稳定可将原先的3级判读(可能良性)定为2级判读(良性)。 这一分级用在完全的影像评价之后，一般不建议用在首次的普查中;对临床扣及肿块的评价用这一分级也不合适;对可能是良性的病变在随访中出现增大，应建议活检而不是继续随访。 4级:可疑异常，要考虑活检。这一级包括了一大类需临床干预的病变，此类病变无特征性的乳腺癌形态学改变，但有恶性的可能性。再继续分成4A, 4B, 4C，临床医生和患者可根据其不同的恶性可能性对病变的处理做出最后决定。/p> 4A:包括了一组需活检但恶性可能性较低的病变。对活检或细胞学检查为良性的结果比较可以信赖，可以常规随访或半年后随访。将可扣及的X线表现边缘清晰而B超提示可能为纤维腺瘤的实质性肿块、可扣及的复杂囊肿和可扣及的脓肿均归在这一亚级。 4B:中度恶性可能。对这组病变穿刺活检结果可信度的认识，放射科医生和病理科医生达成共识很重要。对边界部分清晰、部分浸润的肿块穿刺为纤维腺瘤或脂肪坏死的可以接受，并予随访。而对穿刺结果为乳头状瘤的则需要进一步切取活检予以证实。 ncluding based life support (BLS), and senior heart life support (ACLS), and based trauma life support (BTLS) and senior trauma life support (ATLS) of based knowledge; common emergency technology of application; common emergency of causes identification, and clinical performance and the processing specification; common emergency auxiliary check of select refers to levy, and results judge and the clinical meaning; Indications, effects of common emergency drugs, side effects, as well as specific applications (medicine, for expansion of vasoactive drugs, cardiac diuretic, antispasmodic and anti-asthmatic drugs, analgesic drugs, Hemostatic, antiarrhythmic drugs, such as Cortina). Understand: the new development of the theory of life support; cardiac respiratory and cardiopulmonary resuscitation after cardiac syndrome etiology, pathophysiology, clinical manifestations, diagnosis, and treatment. 2. basic requirements (1) species and cases of study requirements: disease disease fever acute abdominal pain chest pain and difficulty breathing faint coma shock in acute poisoning with cardiac respiratory arrest bleeding (hemoptysis, hematemesis, hematuria, etc) requires at least 45 cases of arrhythmia. (2) basic skills requirements name name heart lung 4C:更进一步怀疑为恶性，但还未达到5级那样典型的一组病变。形态不规则、边缘浸润的实质性肿块和簇状分布的细小多形性钙化可归在这一亚级中. 对影像判读为4级的，不管哪个亚级，在有良性的病理结果后均应定期随访。而对影像为4C级、病理穿刺为良性结果的，则应对病理结果作进一步的评价以明确诊断。 5级:离度怀疑恶性，临床应采取适当措施(几乎肯定的恶性)。这一类病变有高度的恶性可能性。检出恶性的可能性大于等于95。形态不规则星芒状边缘的高密度肿块、段样和线样分布的细小线样和分支状钙化、不规则星芒状边缘肿块伴多形性钙化均应归在这一级中。 6级:己活检证实为恶性，应采取适当措施。这一分级用在活检已证实为恶性但还未进行治疗的影像评价上。主要是评价先前活检后的影像改变，或监侧手术前新辅助化疗的影像改变。 良性。统称为乳腺增生。 结节就是疙瘩、小肿块的意思。 乳腺增生、乳腺纤维瘤的病因相同:是内分泌失调，或是体内雌激素分泌高造成的。中医认为是易躁易怒易忧，思想压力大，多愁善感，焦虑上火，肝火太盛，肝脾之气淤结而成。这与西医不矛盾，肝火太盛必然影响内分泌等。 乳腺疾病往往伴随月经不调、腋窝淋巴结肿大、便秘等症状。 平时要注意别吃辛辣的，以及油炸的、烧烤的，这些属燥热类的食品。还要戒烟酒，调节情绪，生气上火对这病不利。别吃蜂王浆、激素喂养的动物肉，因内含雌激素成分。年轻女性还不要吃避孕药，避免人工流，因为那样会导致体内雌激素紊乱。 多吃蔬菜水果、豆制品。因大豆中含有异黄酮，异黄酮既能代替雌激素和雌激素受体蛋白的结合从而发挥雌激素作用，又能干扰雌激素和雌激素受体蛋白的结合，发挥抗雌激素作用，这主要取决于人体内的激素状况:异黄酮对低雌激素者，发挥雌激素活性;对高雌激素者，发挥抗雌激素作用。 乳腺疾病看似是不大的病,但至今医院中及药厂生产的药物效果不能令人满意。中药可充分考虑。用化瘀散结、解毒消肿，针对疙瘩、肿块、炎症的中药丸来治。只要找对了药则是会者不难。笔者因工作关系，深知中药的魅力，亲眼目睹了大量乳腺增生、乳腺炎、乳腺纤维瘤及淋巴结炎、淋巴结核等被中药治得很典型的病例，验证了祖国中医药的独特之处。只单纯手术切除结节、疙瘩的话，因病根尚在，治标不治本，复发率很高。 4 在乳腺专科门诊过程中，经常会有患者拿着钼靶报告来咨询。经常患者很紧张拿着报告单到处问，甚至因为看不懂那么多英文而胡思乱想，惶惶不可终日。现提供一点科普参考。 但需要强调的是:报告一定要给医生看，而且放射报告仅仅提供医生参考，诊断、治疗应该以医生的意见为主。仅仅凭一张钼靶报告很难全面了解乳腺疾病，临床医生需要结合体检、病史、B超等能够全面了解乳腺的整体情况。 ncluding based life support (BLS), and senior heart life support (ACLS), and based trauma life support (BTLS) and senior trauma life support (ATLS) of based knowledge; common emergency technology of application; common emergency of causes identification, and clinical performance and the processing specification; common emergency auxiliary check of select refers to levy, and results judge and the clinical meaning; Indications, effects of common emergency drugs, side effects, as well as specific applications (medicine, for expansion of vasoactive drugs, cardiac diuretic, antispasmodic and anti-asthmatic drugs, analgesic drugs, Hemostatic, antiarrhythmic drugs, such as Cortina). Understand: the new development of the theory of life support; cardiac respiratory and cardiopulmonary resuscitation after cardiac syndrome etiology, pathophysiology, clinical manifestations, diagnosis, and treatment. 2. basic requirements (1) species and cases of study requirements: disease disease fever acute abdominal pain chest pain and difficulty breathing faint coma shock in acute poisoning with cardiac respiratory arrest bleeding (hemoptysis, hematemesis, hematuria, etc) requires at least 45 cases of arrhythmia. (2) basic skills requirements name name heart lung 一、乳腺钼靶检查的基本常识 利用软X线对乳腺组织进行投照成像，过去常用胶片直接成像，目前已经少用，现在由于数字化成像技术的迅速发展，乳房钼靶基本上是数字化成像后胶片冲印，图像质量有了质的飞跃。比如目前我院使用的最新一代数字化钼靶机，增加了许多新功能(如立体定位穿刺)，其所形成的乳腺X线摄影片高清晰度，是以往钼靶片所无法比拟的，可以发现的0.2 cm直径乳腺结节。 乳房钼靶与普通的X线检查不同。一般的X线机，球管的阳极钯面是钨，产生的波长为0.008---0.031nm,波长短，穿透力强，为硬射线。而钼钯产生的波长为0.063---0.071nm,波长长，穿透力弱，为软射线，对软组织的细微密度差别分辨率高，可以获得良好的乳腺图像，清晰显示乳腺的腺体、导管、纤维间隔、皮肤、皮下组织、血管结构和病变的肿块、细微钙化等。 二、检查体位及投照位置 一般取立位。常用轴位(CC)、侧斜位(MLO)投照方向，所以一般要拍四次。在片子上会有以下字母标注L(left 左侧乳房)、R(right 右侧乳房)、CC(轴位)、MLO(侧斜位)。 (MLO)(CC) 三、掌握钼靶报告的大方向 1.什么是BI—RADS 这是钼靶报告最常出现的英文缩写，许多人不清楚代表什么含义。1992年，美国放射学院(American College of Radiology)出版了指导性的文件:乳腺影像报告数据系统(Breast Imaging – Reporting And Data System，BI-RADS)。 对乳腺作为一个整体器官的所有影像学正常与异常情况的诊断报告进行规范，使用统一的专业术语、标准的诊断归类及检查程序，使放射科医生的诊断有章可循，同时，也加强了放射科和临床其他有关科室的协调与默契，使临床治疗医师一看放射科医师的报告即知道下一步该做什么。 2.BI-RADS分类(不是分级) BI,RADS 0类:需要结合其他检查。 BI,RADS 1类:阴性。 BI,RADS 2类:良性。 BI,RADS 3类:良性可能，需短期随访。 BI,RADS 4类:可疑恶性，建议活检。 4A:低度可疑。 4B:中度可疑。 4C:高度但不肯定。 BI,RADS 5类:高度恶性。 BI,RADS 6类:已经病理证实恶性。 四、大概理解钼靶报告上描述文字 乳腺癌钼靶摄影片的征象包括肿块、钙化、癌周围的改变、乳头及皮肤的改变等。一般将肿瘤本身所成的影像(肿块影、钙化)称为乳腺癌的X线直接征象;将癌周围继发性改变所成的影像称为间接征象。 乳腺癌在X线片中的直接征象主要包括肿块结节影和微小钙化。恶性肿块影常不规则，边缘有毛刺，密度较周围腺体高。微小钙化灶在乳腺癌早期诊断中具有十分重要的临床意义。但是，并非所有的乳腺X线片上的微小钙化灶都是恶性的。乳腺癌的钙化点一般表现为泥沙样，成簇或沿导管区段分布。若在每平方米中有15个以上的细小钙化点时，常需要考虑为乳腺癌。 ncluding based life support (BLS), and senior heart life support (ACLS), and based trauma life support (BTLS) and senior trauma life support (ATLS) of based knowledge; common emergency technology of application; common emergency of causes identification, and clinical performance and the processing specification; common emergency auxiliary check of select refers to levy, and results judge and the clinical meaning; Indications, effects of common emergency drugs, side effects, as well as specific applications (medicine, for expansion of vasoactive drugs, cardiac diuretic, antispasmodic and anti-asthmatic drugs, analgesic drugs, Hemostatic, antiarrhythmic drugs, such as Cortina). Understand: the new development of the theory of life support; cardiac respiratory and cardiopulmonary resuscitation after cardiac syndrome etiology, pathophysiology, clinical manifestations, diagnosis, and treatment. 2. basic requirements (1) species and cases of study requirements: disease disease fever acute abdominal pain chest pain and difficulty breathing faint coma shock in acute poisoning with cardiac respiratory arrest bleeding (hemoptysis, hematemesis, hematuria, etc) requires at least 45 cases of arrhythmia. (2) basic skills requirements name name heart lung 五、几点建议 为了实现乳腺癌的早期发现，定期的进行乳腺钼靶检查是行之有效的方法。由于35岁以下的妇女乳腺较致密，钼靶检查常不易发现病灶;而且此时的乳腺组织对放射线的损伤较敏感。故乳腺X线摄影一般不适于35岁以下的普查妇女。对于50岁以上的妇女，我们建议每年一次双侧乳腺钼靶检查。若有乳腺癌高危因素的妇女，如家族乳腺癌病史、既往乳腺癌史、良性肿瘤及活检史，或者月经初潮13岁以前、第一胎足月生产30岁以后、绝经在55岁以后等，建议40,49岁阶段就应该开始每年一次的乳腺钼靶检查。在定期乳腺钼靶摄影的同时，还可以结合每月一次的自我检查和定期的临床体检。 BI-RADS 0级 超声检查不能全面评价病变，需要进一步其他影像学检查诊断。 临床有体征者，超声检查无征象者 乳腺检查临床有体征 l1.临床扪及肿块或团块 l2.临床未扪及肿块或团块的乳头溢液 l3.不对称性增厚 l4.皮肤及乳头改变 ? 乳腺疼痛是自觉症状，不纳入为临床有体征者，按临床无体征的筛查流程 , , 3楼 BI-RADS 1级 l超声检查未见异常表现，如无肿块、无结构紊乱、无皮肤增厚、无微钙化等 l?每年定期超声复查 ncluding based life support (BLS), and senior heart life support (ACLS), and based trauma life support (BTLS) and senior trauma life support (ATLS) of based knowledge; common emergency technology of application; common emergency of causes identification, and clinical performance and the processing specification; common emergency auxiliary check of select refers to levy, and results judge and the clinical meaning; Indications, effects of common emergency drugs, side effects, as well as specific applications (medicine, for expansion of vasoactive drugs, cardiac diuretic, antispasmodic and anti-asthmatic drugs, analgesic drugs, Hemostatic, antiarrhythmic drugs, such as Cortina). Understand: the new development of the theory of life support; cardiac respiratory and cardiopulmonary resuscitation after cardiac syndrome etiology, pathophysiology, clinical manifestations, diagnosis, and treatment. 2. basic requirements (1) species and cases of study requirements: disease disease fever acute abdominal pain chest pain and difficulty breathing faint coma shock in acute poisoning with cardiac respiratory arrest bleeding (hemoptysis, hematemesis, hematuria, etc) requires at least 45 cases of arrhythmia. (2) basic skills requirements name name heart lung (对多腺体型诊断比较可靠) , , 4楼 BI-RADS 2级 良性征象，基本上可以排除恶性 ?单纯囊肿 ?乳腺内淋巴结(也可能属于1级) ?乳腺假体植入 ?年龄<40岁，考虑纤维腺瘤 ?脂肪小叶(注意与纤维腺瘤鉴别) ?6-12个月超声定期复查 , , 5楼 BI-RADS 3级 可能良性征象 ?年龄<40岁的实性椭圆形、边界清、纵横比<1的肿块，良性可能， 恶性的危险性<2% ?多发性复杂囊肿或簇状小囊肿 ?瘤样增生结节(属不确定一类) ncluding based life support (BLS), and senior heart life support (ACLS), and based trauma life support (BTLS) and senior trauma life support (ATLS) of based knowledge; common emergency technology of application; common emergency of causes identification, and clinical performance and the processing specification; common emergency auxiliary check of select refers to levy, and results judge and the clinical meaning; Indications, effects of common emergency drugs, side effects, as well as specific applications (medicine, for expansion of vasoactive drugs, cardiac diuretic, antispasmodic and anti-asthmatic drugs, analgesic drugs, Hemostatic, antiarrhythmic drugs, such as Cortina). Understand: the new development of the theory of life support; cardiac respiratory and cardiopulmonary resuscitation after cardiac syndrome etiology, pathophysiology, clinical manifestations, diagnosis, and treatment. 2. basic requirements (1) species and cases of study requirements: disease disease fever acute abdominal pain chest pain and difficulty breathing faint coma shock in acute poisoning with cardiac respiratory arrest bleeding (hemoptysis, hematemesis, hematuria, etc) requires at least 45 cases of arrhythmia. (2) basic skills requirements name name heart lung ? 3,6个月超声定期检查及其他进一步检查 BI-RADS 3级 l年龄在35-39岁初次超声检查为3级: *有家族史 *患者焦虑 *不愿定期检查 *实性肿块 *不能确定囊实性 肿块 *簇状小囊肿 ?建议活检 尽管多中心数据证实:超声此级短期随访是安全的，但作为处理 的策略或方法正在增加，部分此级者也需要活检 例如:35-39Y，超声考虑纤维腺瘤可能，患者焦虑，不愿随诊，可 考虑活检 , , 6楼 BI-RADS 3级 复查后的评估 年龄在35-39岁的实性肿块初次超声检查为3级，无家族史，3,6个 月超声复查 l1.肿块缩小、消失?2级 l2.肿块无变化，3,6个月再次复查，仍无变化?2级 l3.肿块增大，向恶性征象变化?4级(活检) , 7楼 ncluding based life support (BLS), and senior heart life support (ACLS), and based trauma life support (BTLS) and senior trauma life support (ATLS) of based knowledge; common emergency technology of application; common emergency of causes identification, and clinical performance and the processing specification; common emergency auxiliary check of select refers to levy, and results judge and the clinical meaning; Indications, effects of common emergency drugs, side effects, as well as specific applications (medicine, for expansion of vasoactive drugs, cardiac diuretic, antispasmodic and anti-asthmatic drugs, analgesic drugs, Hemostatic, antiarrhythmic drugs, such as Cortina). Understand: the new development of the theory of life support; cardiac respiratory and cardiopulmonary resuscitation after cardiac syndrome etiology, pathophysiology, clinical manifestations, diagnosis, and treatment. 2. basic requirements (1) species and cases of study requirements: disease disease fever acute abdominal pain chest pain and difficulty breathing faint coma shock in acute poisoning with cardiac respiratory arrest bleeding (hemoptysis, hematemesis, hematuria, etc) requires at least 45 cases of arrhythmia. (2) basic skills requirements name name heart lung , BI-RADS 4级 可疑异常 此级恶性的危险性3,94, ?不符合全部超声声像的纤维腺瘤和其他良性病变(良恶性鉴别表中 恶性表现1-3项) ? 40岁以上超声良性征象的实性肿块病变，此病变可能无特征性乳 腺癌形态，但属高发年龄，有恶性的可能性。4A ?建议活检:针吸细胞学检查、空芯针穿刺活检、手术活检等 , , 8楼 , BI-RADS 5级 高度可能恶性 超声有特征性异常征象(良恶性实性肿块鉴别表中恶性征象>3项)， 恶性的危险性>95, l应开始进行确定性治疗。考虑前哨淋巴结显像和新辅助化疗时，宜 进行空芯针穿刺活检 , , 9楼 BI-RADS 6级 已活检证实为恶性 用在活检已证实为恶性，治疗前的影像学评价 l主要是评价先前活检后的影像改变，或监测手术切除前和新辅助化ncluding based life support (BLS), and senior heart life support (ACLS), and based trauma life support (BTLS) and senior trauma life support (ATLS) of based knowledge; common emergency technology of application; common emergency of causes identification, and clinical performance and the processing specification; common emergency auxiliary check of select refers to levy, and results judge and the clinical meaning; Indications, effects of common emergency drugs, side effects, as well as specific applications (medicine, for expansion of vasoactive drugs, cardiac diuretic, antispasmodic and anti-asthmatic drugs, analgesic drugs, Hemostatic, antiarrhythmic drugs, such as Cortina). Understand: the new development of the theory of life support; cardiac respiratory and cardiopulmonary resuscitation after cardiac syndrome etiology, pathophysiology, clinical manifestations, diagnosis, and treatment. 2. basic requirements (1) species and cases of study requirements: disease disease fever acute abdominal pain chest pain and difficulty breathing faint coma shock in acute poisoning with cardiac respiratory arrest bleeding (hemoptysis, hematemesis, hematuria, etc) requires at least 45 cases of arrhythmia. (2) basic skills requirements name name heart lung 疗前后的影像改变 , , 10楼 BI-RADS分级应注意的问题(四) 主要是按乳腺有无探及肿块来划分 1.无探及肿块者:0级;1级;6级 2.可探及肿块者:2级;3级;4级;5级;6级 3.2-5级主要以乳腺良恶性肿块的鉴别要点来划分 BI-RADS分级应注意的问题(五) l0级是指超声的评价是不完全的，需要其他影像检查方法，但不包括 病理检查。如有临床症状无超声异常征象者 l6级是指病理已证实为恶性者 乳腺肿块超声彩色血流的数量(Adler分级) 0 级 病灶内无血管 ?级 少量血流，1,2个点状、棒状血管 ?级 中量血流，3,4个点状或一条血管 ncluding based life support (BLS), and senior heart life support (ACLS), and based trauma life support (BTLS) and senior trauma life support (ATLS) of based knowledge; common emergency technology of application; common emergency of causes identification, and clinical performance and the processing specification; common emergency auxiliary check of select refers to levy, and results judge and the clinical meaning; Indications, effects of common emergency drugs, side effects, as well as specific applications (medicine, for expansion of vasoactive drugs, cardiac diuretic, antispasmodic and anti-asthmatic drugs, analgesic drugs, Hemostatic, antiarrhythmic drugs, such as Cortina). Understand: the new development of the theory of life support; cardiac respiratory and cardiopulmonary resuscitation after cardiac syndrome etiology, pathophysiology, clinical manifestations, diagnosis, and treatment. 2. basic requirements (1) species and cases of study requirements: disease disease fever acute abdominal pain chest pain and difficulty breathing faint coma shock in acute poisoning with cardiac respiratory arrest bleeding (hemoptysis, hematemesis, hematuria, etc) requires at least 45 cases of arrhythmia. (2) basic skills requirements name name heart lung ?级 丰富血流，5个以上点状或2条长血管 ncluding based life support (BLS), and senior heart life support (ACLS), and based trauma life support (BTLS) and senior trauma life support (ATLS) of based knowledge; common emergency technology of application; common emergency of causes identification, and clinical performance and the processing specification; common emergency auxiliary check of select refers to levy, and results judge and the clinical meaning; Indications, effects of common emergency drugs, side effects, as well as specific applications (medicine, for expansion of vasoactive drugs, cardiac diuretic, antispasmodic and anti-asthmatic drugs, analgesic drugs, Hemostatic, antiarrhythmic drugs, such as Cortina). Understand: the new development of the theory of life support; cardiac respiratory and cardiopulmonary resuscitation after cardiac syndrome etiology, pathophysiology, clinical manifestations, diagnosis, and treatment. 2. basic requirements (1) species and cases of study requirements: disease disease fever acute abdominal pain chest pain and difficulty breathing faint coma shock in acute poisoning with cardiac respiratory arrest bleeding (hemoptysis, hematemesis, hematuria, etc) requires at least 45 cases of arrhythmia. (2) basic skills requirements name name heart lung