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01-53_pc22.pmd 1 19/2/2551, 20:58

01-53_pc22.pmd
2
Lobular Carcinoma in Situ
2
DIAGNOSIS WORKUP RISK REDUCTION SURVEILLANCE
Biopsy was core Perform Ductal carcinoma Manage per
needle biopsy surgical in situ (DCIS) or appropriate
(less than surgical excision invasive cancer Guideline
biopsy)
Lobular · History and

carcinoma in physical
situ (LCIS) · Diagnostic
identified on bilateral
breast biopsy mammogram
Stage 0 · Pathology
Tis, N0, M0 review
á¹Ç·Ò§¡ÒÃµÃÇ¨¤Ñ´¡ÃÍ§ ÇÔ¹Ô¨©ÑÂ áÅÐÃÑ¡ÉÒâÃ¤ÁÐàÃç§àµÒ¹Á
Initial biopsy was LCIS without Surveillance
19/2/2551, 20:58
surgical biopsy other cancer ´ÙË¹Ò 19
· Breast cancer risk
Counseling regarding reduction guidline
risk reduction ´ÙË¹Ò 31
· Breast cancer
screening and
diagnosis guideline
01-53_pc22.pmd
Ductal Carcinoma in Situ
3
DIAGNOSIS WORKUP PRIMARY TREATMENT
Lumpectomya without lymph node

surgery whole breast radiation
· History and physical exam therapyb (category 1)
Ductal carcinoma · Diagnostic bilateral mammogram or ´Ù
in situ (DCIS) · Pathology review Total mastectomy with or without Postsurgical
Stage 0 · Determination of tumor estrogen sentinel node biopsy ± reconstruction Treatment
Tis, N0, M0 receptor (ER) status or Ë¹Ò 4
Lumpectomya without lymph node
surgery without radiation therapyb
(category 2B)
a
Margins greater than 10 mm are widely accepted as negative (but may be excessive and may lead to a less optimal cosmetic outcome).
Margins less than 1 mm are considered inadequate.
With pathologic margins between 1-10 mm, wider margins are generally associated with lower local recurrence rates. However, close surgical margins (< 1 mm) at
19/2/2551, 20:58
the fibroglandular boundary of the breast (chest wall or skin) do not mandate surgical re-excision but can be an indication for higher boost dose radiation to the involved
lumpectomy site. (category 2B)
b
Whole breast radiation therapy following lumpectomy reduces recurrence rates in DCIS by about 50%. Approximately half of the recurrences are invasive and half DCIS.
A number of factors determine that local recurrence risk; palpable mass, larger size, higher grade, close or involved margins, and age under 50 years. If the patient and
physician view the individual risk as "low", some patients may be treated by excision alone. All data evaluating the three local treatments show no differences in
patient survival.
3
01-53_pc22.pmd
4
Ductal Carcinoma in Situ
4
DCIS POSTSURGICAL TREATMENT SURVEILLANCE/FOLLOW-UP
· Risk reduction therapy for ipsilateral breast

following breast conserving surgery:
Consider tamoxifen for 5 years for:
· Patients treated with breast-conserving therapy · Intervalhistory and physical exam every 6-12 mo for
(lumpectomy) and radiation therapyc (category 1) , 5 y, then annually
especially for those with ER-positive DCIS. The · Mammogram every 12 mo (and 6-12 mo postradiation
benefit of tamoxifen for ER-negative DCIS is uncertain therapy if breast conserved [category 2B])
· Patients treated with excision alonec
Risk reduction therapy for contralateral breast:
· Counseling regarding consideration of tamoxifenc
for risk reduction (category 2B).
19/2/2551, 20:58
c
Available data suggest tamoxifen provides risk reduction in the ipsilateral breast treated with breast conservation and in the contralateral breast in patients with
mastectomy or breast conservation with ER-positive primary tumors. Since a survival advantage has not been demonstrated, individual consideration of risks and
benefits is important
01-53_pc22.pmd
Invasive Breast Cancer
5
CLINICAL STAGE WORKUP
General workup including:

· History and physical exam
Stage I · CBC, platelets
T1, N0, M0 · Liver function tests and alkaline phosphatase
or · Diagnostic bilateral mammogram, ultrasound as necessary
Stage IIA · Pathology review
T0, N1, M0 · Determination of tumor estrogen/progesterone receptor (ER/PgR) status and
T1, N1, M0 HER2 status
T2, N0, M0 Optional studies for breast imaging:
or · Breast MRI ´Ù Locoregional
Stage IIB If clinical stage lllA (T3, N1, M0) consider: Treatments Ë¹Ò 6
T2, N1, M0 · Bone scan (category 2B)
T3, N0, M0 · Abdominal ± pelvis CT or US or MRI
or · Chest imaging
Stage IIIA
19/2/2551, 20:58
Additional studies as directed by signs or symptoms:
T3, N1, M0 · Bone scan indicated if localized bone pain or elevated alkaline phosphatase
· Abdominal ± pelvis CT or US or MRI if elevated alkaline phosphatase, abnormal
liver function tests, abdominal symptoms, abnormal physical examination of
the abdomen or pelvis
· Chest imaging (if pulmonary symptoms are present)
· Consider fertility counseling if indicated

5
01-53_pc22.pmd
6
6
LOCOREGIONAL TREATMENT OF CLINICAL STAGE I, IIA, OR IIB DISEASE OR T3, N1, M0
³ 4 positive Radiation therapyd to whole breast with or without boost

axillary nodes to tumor bed (category 1), and supraclavicular area . (category 3).
Lumpectomy with Radiation therapy to whole breast with or without boost

1-3 positive to tumor bed (category 1) , consider radiation therapy to ´Ù
surgical axillary staging axillary nodes supraclavicular area (category 2B). Ë¹Ò 8
(category 1) Radiation therapy should follow chemotherapy
or Negative Radiation therapy to whole breast with or without boost to tumor bed.
axillary nodes
Total mastectomy with surgical axillary See Locoregional Treatment (Ë¹Ò 8)
19/2/2551, 20:58
staging (category 1) ± reconstruction
or
If T2 or T3 and fulfills criteria for breast Consider Preoperative Chemotherapy Guideline (Ë¹Ò 15)
conserving therapy except for size
d
Radiation therapy should follow chemotherapy when chemotherapy indicated.
01-53_pc22.pmd
7
LOCOREGIONAL TREATMENT OF CLINICAL STAGE I, IIA, OR IIB DISEASE OR T3, N1, M0
³ 4 positive Postchemotherapy radiation therapy to chest wall

axillary nodes (category 1) + supraclaviculare
Strongly consider postchemotherapy radiation therapy
1-3 positive to chest wall + supraclavicular areas;e
axillary nodes (category 3).
Total mastectomy with Negative axillary nodes
surgical axillary and tumor > 5 cm Radiation therapy to chest wall ´Ù
staging (category 1) or and. Consider radiation therapy to supraclavicular nodese Ë¹Ò 8
± reconstruction margins positive
Negative axillary nodes
and tumor 5 cm and Consider postchemotherapy radiation therapy to chest walle
close margins (< 1-2 mm)
19/2/2551, 20:58
Negative axillary nodes
and tumor 5 cm and No radiation therapy
margins 1-2 mm
e
Radiation therapy should be given to the internal mammary lymph nodes that are clinically or pathologically positive, otherwise the treatment to the internal mammary
nodes is at the discretion of the treating radiation oncologist. CT treatment planning should be utilized in all cases where radiation therapy is delivered to the internal
7
mammary lymph nodes

01-53_pc22.pmd
8
8
HISTOLOGY HORMONE HER2 STATUS SYSTEMIC ADJUVANT TREATMENT
RECEPTOR STATUS
HER2 positive See Systemic Adjuvant Treatment - Hormone

ER-positive Receptor Positive - HER2 Positive Disease Ë¹Ò 9
and/or
PgR positive HER2 negative See Systemic Adjuvant Treatment - Hormone
· Ductalf Receptor Positive - HER2 Negative Disease Ë¹Ò 10
· Lobular
· Mixed
· Metaplastic HER2 positive See Systemic Adjuvant Treatment - Hormone
ER-negative Receptor Negative - HER2 Positive Disease Ë¹Ò 11
and
PgR-negative HER2 negative See Systemic Adjuvant Treatment - Hormone
Receptor Negative - HER2 Negative Disease Ë¹Ò 12
ER-positive
and/or
19/2/2551, 20:58
PgR positive
· Tubular See Systemic Adjuvant Treatment -
· Colloid ER-negative Favorable Histologies Ë¹Ò13
and
PgR-negative
f
This includes medullary and micropapillary subtypes.
01-53_pc22.pmd
9
SYSTEMIC ADJUVANT TREATMENT - HORMONE RECEPTOR POSITIVE - HER2 POSITIVE DISEASE
Tumor £ 0.5 cm or pN0 No adjuvant therapy

pN1mi
pT1, pT2, or pT3;
and pN0 or pN1mi Tumor 0.6-1.0 cm
(£ 2 mm axillary Adjuvant endocrine therapy
node metastasis)
Histologyg:
· Ductal Tumor > 1 cm Adjuvant endocrine therapy
· Lobular ± adjuvant chemotherapyh
· Mixed
· Metaplastic
Node positive (one or more Adjuvant endocrine therapy

metastases > 2 mm to one or more + adjuvant chemotherapy
19/2/2551, 20:58
ipsilateral axillary lymph nodes) + trastuzumab (category 1)h
g
Mixed lobular and ductal carcinoma as well as metaplastic carcinoma should be graded based on the ductal component and treated based on this grading.
The metaplastic or mixed component does not alter prognosis.
h
Chemotherapy and endocrine therapy used as adjuvant therapy should be given sequentially with endocrine therapy following chemotherapy. The benefits of
chemotherapy and of endocrine therapy are additive. However, the absolute benefit from chemotherapy may be small. The decision to add chemotherapy to endocrine
therapy should be individualized, especially in those with a favorable prognosis where the incremental benefit of chemotherapy may be smaller.
9
Available data suggest sequential or concurrent endocrine therapy with radiation therapy is acceptable.
01-53_pc22.pmd
10
10
SYSTEMIC ADJUVANT TREATMENT - HORMONE RECEPTOR POSITIVE - HER2 NEGATIVE DISEASE
Tumor £ 0.5 cm or pN0 No adjuvant therapy (category 2B)

pN1mi
pT1, pT2, or pT3;
(£ 2 mm axillary Adjuvant endocrine therapy
node metastasis)
Histologyg:
· Ductal Tumor > 1 cm Adjuvant endocrine therapy
· Lobular ± adjuvant chemotherapyh
· Mixed
· Metaplastic
Node positive (one or more Adjuvant endocrine therapy

metastases > 2 mm to one or more + adjuvant chemotherapy
19/2/2551, 20:58
ipsilateral axillary lymph nodes) (category 1)
g
Mixed lobular and ductal carcinoma as well as metaplastic carcinoma should be graded based on the ductal component and treated based on this grading. The
metaplastic or mixed component does not alter prognosis.
h
therapy should be individualized, especially in those with a favorable prognosis where the incremental benefit of chemotherapy may be smaller. Available data suggest
sequential or concurrent endocrine therapy with radiation therapy is acceptable.
01-53_pc22.pmd
11
SYSTEMIC ADJUVANT TREATMENT - HORMONE RECEPTOR NEGATIVE - HER2 POSITIVE DISEASE

pN1mi
pT1, pT2, or pT3;
(£ 2 mm axillary Consider adjuvant chemotherapy
node metastasis)
Histologyg:
· Ductal Tumor > 1 cm Adjuvant chemotherapy
· Lobular (category 1)
· Mixed
· Metaplastic
Node positive (one or more Adjuvant chemotherapy
19/2/2551, 20:58
metastases > 2 mm to one or more + trastuzumab (category 1)
ipsilateral axillary lymph nodes)
g
11
01-53_pc22.pmd
12
12
SYSTEMIC ADJUVANT TREATMENT - HORMONE RECEPTOR NEGATIVE - HER2 NEGATIVE DISEASE

pN1mi
pT1, pT2, or pT3;
(£ 2 mm axillary Consider adjuvant chemotherapy
node metastasis)
Histologyg:
· Ductal Tumor > 1 cm Adjuvant chemotherapy
· Lobular (category 1)
· Mixed
· Metaplastic
Node positive (one or more Adjuvant chemotherapy
19/2/2551, 20:58
metastases > 2 mm to one or more (category 1)
ipsilateral axillary lymph nodes)
g
01-53_pc22.pmd
13
SYSTEMIC ADJUVANT TREATMENT - FAVORABLE HISTOLOGIES
< 1 cm No adjuvant therapy

pT1, pT2, or pT3;
and pN0 or pN1mi 1-2.9 cm Consider adjuvant
(£ 2 mm axillary endocrine therapy
node metastasis)
ER-positive ³ 3 cm Adjuvant endocrine therapy
and/or
PgR-positive Node positive (one or more
metastases > 2 mm to one or more Adjuvant endocrine therapy ±
Histology: ipsilateral axillary lymph nodes) adjuvant chemotherapy
· Tubular
· Colloid
· Mucinous
ER-positive Follow appropriate pathway
19/2/2551, 20:58
and/or above
ER-negative Repeat determination of PgR-positive
and tumor estrogen/progesterone
PgR-negative receptor (ER/PgR) status ER-negative Treat as usual breast cancer
and histology (´ÙË¹Ò 11 áÅÐË¹Ò 12)
PgR-negative
13
01-53_pc22.pmd
14
14
Preoperative Chemotherapy Guideline
· History and physical
· CBC, platelets
Stage IIA · Liver function tests and alkaline phosphatase
T2, N0, M0 · Diagnostic bilateral mammogram, ultrasound as necessary
· Pathology review
· Determination of tumor ER/PgR status and HER2 status
Stage IIB
T2, N1, M0 Optional additional studies for breast imaging:
T3, N0, M0 · Breast MRI Preoperative
Chemotherapy
If clinical stage lllA (T3, N1, M0) consider: Ë¹Ò 15
Stage lllA · Bone scan (category 2B)
T3, N1, M0 · Abdominal ± pelvis CT or US or MRI
· Chest imaging
19/2/2551, 20:58
and Optional studies as directed by signs and symptoms:
· Bone scan indicated if localized bone pain or elevated alkaline phosphatase
Fulfills criteria for breast · Abdominal ± pelvis CT or US or MRI if elevated alkaline phosphatase,
conserving surgery abnormal liver function tests, abdominal symptoms, abnormal physical
except for tumor size examination of the abdomen or pelvis
· Chest imaging (if pulmonary symptoms are present)
01-53_pc22.pmd
15
PRIMARY TREATMENT
No response after
No response after 3-4 cycles
3-4 cycles or
or Progressive disease
Progressive disease MRM
Consider Partial response,
alternative lumpectomy not possi
chemotherapy
Preoperative Partial response,
chemotherapy lumpectomy not Complete response or ´Ù
possible partial response, Lumpectomy
lumpectomy possible Ë¹Ò 16
19/2/2551, 20:58
Partial response,
lumpectomy possible ´Ù
or Lumpectomy
Complete response Ë¹Ò 16
15
01-53_pc22.pmd
16
16
LOCAL TREATMENT ADJUVANT TREATMENT
· Adjuvant radiation therapy post-mastectomy is
based on prechemotherapy tumor characteristics
and
Consider additional · Endocrine therapy if ER-positive and/or PgR-
MRM chemotherapy in the positiveh (category 1)
± reconstruction
context of a clinical trial · Complete up to one year of trastuzumab therapy
if HER2-positive (category 1). May be administered
concurrent with radiation therapy and with endocrine
therapy if indicated. ´Ù
Surveillance/
· Adjuvant radiation therapy post-lumpectomy based Follow-up
on prechemotherapy tumor characteristics Ë¹Ò19
and
Lumpectomy with Consider additional · Endocrine therapy if ER-positive and/or PgR-positiveh
surgical axillary chemotherapy in the (category 1)

context of a clinical trial
19/2/2551, 20:58
staging · Complete up to one year of trastuzumab therapy if
HER2-positive (category 1). May be administered
concurrent with radiation therapy and with endocrine
therapy if indicated.
h
therapy should be individualized, especially in those with a favorable prognosis where the incremental benefit of chemotherapy may be smaller.
Available data suggest sequential or concurrent endocrine therapy with radiation therapy is acceptable.
01-53_pc22.pmd
LOCALLY ADVANCED INVASIVE BREAST CANCER (NON-INFLAMMATORY)
17
· History and physical
· CBC, platelets
Stage IIIA · Liver function tests and alkaline phosphatase
T0, N2, M0 · Diagnostic bilateral mammogram, ultrasound as necessary
T1, N2, M0 · Pathology review
T2, N2, M0 · Determination of tumor ER/PgR status and HER2 status
T3, N2, M0 Optional additional studies for breast imaging:
(Stage IIIA patients with T3, · Breast MRI ´Ù Preoperative
N1, M0 disease, ´ÙË¹Ò 13 If clinical stage lllA (T3, N1, M0) consider: Chemotherapy and
· Bone scan (category 2B) Locoregional
· Abdominal ± pelvis CT or US or MRI Treatment Ë¹Ò 18
· Chest imaging
Optional studies as directed by signs and symptoms:
Stage IIIB · Bone scan indicated if localized bone pain or elevated alkaline
T4, N0, M0 phosphatase
T4, N1, M0 · Abdominal ± pelvis CT or US or MRI if elevated alkaline
19/2/2551, 20:58
T4, N2, M0 phosphatase, abnormal liver function tests, abdominal symptoms,
abnormal physical
Stage lllC examination of the abdomen or pelvis
Any T, N3, M0 · Chest imaging (if pulmonary symptoms are present)
· FDG PET/CT scan (category 2B)

Stage IV
See Initial Workup for Stage IV Disease
17
Any T, any N, M1
01-53_pc22.pmd
18
18
PREOPERATIVE CHEMOTHERAPY LOCOREGIONAL TREATMENT ADJUVANT TREATMENT
FOR LOCALLY ADVANCED
INVASIVE BREAST CANCER
(NON-INFLAMMATORY)
Total mastectomy + level l/ll axillary · Complete planned chemotherapy
dissection + radiation therapy to chest regimen course if not completed
wall and infraclavicular and preoperatively plus endocrine
Response supraclavicular nodes (plus internal treatment if ER-positive and/or
mammary nodes if involved, consider PgR-positive (sequential chemotherapy
internal mammary nodes if not clinically followed by endocrine therapy).
involved [category 3]) ± delayed breast · Complete up to one year of
reconstruction trastuzumab therapy if HER2-
or positive (category 1). May be ´Ù
Preoperative Consider lumpectomy + level l/ll axillary administered concurrent with Follow-up/
chemotherapy dissection + radiation therapy to breast radiation therapy and with Surveillance
and infraclavicular and supraclavicular endocrine therapy if indicated. Ë¹Ò 19

nodes (plus internal mammary nodes if
19/2/2551, 20:58
involved)
Consider additional systemic Response - See above pathway

No response chemotherapy and/or preoperative
radiation No response Individualized
treatment
01-53_pc22.pmd
19
SURVEILLANCE/FOLLOW-UP RECURRENT WORKUP
or
INITIAL WORKUP FOR STAGE IV DISEASE
· Intervalhistory and physical exam every · History and physical exam

3-6 mo for 5 y, then every 12 mo · CBC, platelets Locoregional
· Annual mammography · Liver function tests disease
· Women on tamoxifen : annual gynecologic · Chest imaging
assessment every 12 mo if uterus present · Bone scan
· Women on an aromatase inhibitor or who · X-rays of symptomatic bones and long ´Ù Treatment
experience ovarian failure secondary to treat and weight-bearing bones abnormal on of Recurrence/
ment should have monitoring of bone health bone scan Stage IV Disease
with a bone mineral density determination · Consider abdominal CT or MRI Ë¹Ò 20
at baseline and periodically thereafter First recurrence of disease should be
· Assess and encourage adherence to biopsied
19/2/2551, 20:58
adjuvant endocrine therapy. · Consider determination of tumor ER/PgR
· Evidence suggests that active lifestyle, and HER2 status if unknown, originally
achieving and maintaining an ideal body negative or not over-expressedb Systemic
weight (20-25 BMI) may lead to optimal disease
breast cancer outcomes.
19
01-53_pc22.pmd
20
20
SYSTEMIC TREATMENT OF RECURRENT OR STAGE IV DISEASE
Initial treatment with lumpectomy Total mastectomy + axillary lymph node staging if
+ radiation therapy level l/ll axillary dissection not previously done
Local only Initial treatment with mastectomy + level l / ll Surgical resection if possible
recurrence axillary dissection and prior radiation therapy
Initial treatment with mastectomy Surgical resection if possible + radiation therapy to
no prior radiation therapy chest wall and supraclavicular and infraclavicular
nodes Consider
Surgical resection if possible + radiation therapy if systemic
Axillary recurrence possible to chest wall, supraclavicular and therapy
Regional infraclavicular nodes, and axilla
only
or Radiation therapy if possible to chest wall and
Local and Supraclavicular recurrence supraclavicular and infraclavicular nodes
regional
recurrence Radiation therapy if possible to chest wall,

Internal mammary node recurrence supraclavicular and infraclavicular nodes, and
19/2/2551, 20:58
internal mammary nodes
ER and/or PgR positive; HER2 negative
Bone disease present ER and/or PgR positive; HER2 positive
Systemic ER and PgR negative, or ER and/or PgR
disease positive and endocrine refractory; HER2
Bone disease not present negative
ER/PgR negative; HER2 positive
á¹Ç·Ò§¡ÒÃµÃÇ¨¤Ñ´¡ÃÍ§ÁÐàÃç§àµÒ¹Á·ÕèàËÁÒÐÊÁÊÓËÃÑº»ÃÐà·Èä·Â
¨Ò¡¡ÒÃÈÖ¡ÉÒ¢ÍÁÙÅ·Ñé§ã¹áÅÐµÒ§»ÃÐà·È¢Í§¤³Ð·Ó§Ò¹»ÃÐàÁÔ¹à·¤â¹âÅÂÕ¡ÒÃµÃÇ¨ÇÔ¹Ô¨©ÑÂ
ÁÐàÃç§àµÒ¹ÁÃÐÂÐáÃ¡¢Í§¡ÃÁ¡ÒÃá¾·Â¡ÃÐ·ÃÇ§ÊÒ¸ÒÃ³ÊØ¢ » ¾.È. 2546(1) «Öè§ä´ÁÕ¡ÒÃ»ÃÐªØÁÃÐ´Á
¤ÇÒÁ¤Ô´àËç¹¼ÙàªÕèÂÇªÒÃÇÁ·Ñé§¼Ù·Õèà¡ÕèÂÇ¢Í§·Ò§´Ò¹¹Õé ÊÃØ»ä´á¹Ç·Ò§ã¹¡ÒÃµÃÇ¨¤Ñ´¡ÃÍ§ÁÐàÃç§àµÒ¹Á·Õè
àËÁÒÐÊÁÊÓËÃÑº»ÃÐà·Èä·Â ´Ñ§¹Õé
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1. ¡ÒÃµÃÇ¨àµÒ¹Á´ÇÂµ¹àÍ§ (breast self examination: BSE)
2. ¡ÒÃµÃÇ¨àµÒ¹Áâ´Âá¾·ÂËÃ×ÍºØ¤ÅÒ¡Ã·Ò§¡ÒÃá¾·Â·äÕè ´ÃºÑ ¡ÒÃ½¡ÍºÃÁ (clinical breast exami-
nation: CBE)
3. ¡ÒÃµÃÇ¨´ÇÂà¤Ã×Íè §¶ÒÂÀÒ¾ÃÑ§ÊÕàµÒ¹Á (mammography: MM)
¢Íá¹Ð¹Ó (Recommendation)
1. Mass screening
¨Ò¡¢ÍÁÙÅËÅÑ¡°Ò¹·Ò§ÇÔªÒ¡ÒÃ·ÕÁè ÍÕ ÂãÙ ¹»¨¨Øº¹Ñ ÇÔ¸·Õ ´Õè ·Õ ÊÕè ´Ø áÅÐ¤ÁØ ¤Ò·ÕÊè ´Ø ã¹¡ÒÃµÃÇ¨¤Ñ´¡ÃÍ§ÁÐàÃç§
àµÒ¹Á·Õàè »¹áºº mass screening ÊÓËÃÑº»ÃÐà·Èä·Â ÊÃØ»ä´´§Ñ ¹Õé
· ¼ËÙ Ô§·ÕÁè ÍÕ ÒÂØµ§Ñé áµ 20 »¢¹Öé ä»
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¢Í¨Ó¡Ñ´ ¢Í§¡ÒÃµÃÇ¨àµÒ¹Á´ÇÂµ¹àÍ§ ÃÇÁ·Ñé§ä´ÃÑº¡ÒÃÊÍ¹¡ÒÃµÃÇ¨àµÒ¹Á´ÇÂµ¹àÍ§·Õè¶Ù¡ÇÔ¸Õ áÅÐËÒ¡
ÁÕÍÒ¡ÒÃ·ÕÊè §ÊÑÂ¤ÇÃÁÕ¡ÒÃµÃÇ¨â´Âá¾·ÂËÃ×ÍºØ¤ÅÒ¡Ã·Ò§¡ÒÃá¾·Â·äÕè ´ÃºÑ ¡ÒÃ½¡ÍºÃÁ
· ¼Ë Ù Ô§·ÕÁè ÍÕ ÒÂØ 40 - 69 » áÅÐäÁÁÍÕ Ò¡ÒÃ
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ÊÀÒÇÐÊØ¢ÀÒ¾ã¹¢³Ð¹Ñ¹é áÅÐ ¡ÒÃÁÕªÇÕ µÔ ÍÂµÙ Í ä» (life expectancy)
¶Ö§áÁÇÒ ¨ÐÁÕ¡ÒÃÈÖ¡ÉÒÇÒ ¡ÒÃµÃÇ¨àµÒ¹Á´ÇÂµ¹àÍ§äÁä´Á¼Õ ÅµÍ¡ÒÃÅ´ÍÑµÃÒµÒÂ áµ¡¶ç Í× ÇÒà»¹
ÇÔ¸¡Õ ÒÃµÃÇ¨¤Ñ´¡ÃÍ§ÁÐàÃç§àµÒ¹Á·Õ»è ÃÐËÂÑ´·Õàè ËÁÒÐÊÁÊÓËÃÑº»ÃÐà·Èä·Â áÅÐà»¹¡ÒÃÊÃÒ§¤ÇÒÁµÃÐË¹Ñ¡
ãË¡ºÑ ¼ËÙ Ô§ä·Â ãËÁ¤Õ ÇÒÁÊ¹ã¨¡ÑºÊØ¢ÀÒ¾¢Í§µ¹àÍ§
01-53_pc22.pmd 21 19/2/2551, 20:58

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2. Voluntary screening
2.1 ¼ËÙ Ô§·ÑÇè ä»
· ¼ËÙ Ô§·ÕÁè ÍÕ ÒÂØµ§Ñé áµ 20 »¢¹Öé ä»
¤ÇÃàÃÔèÁµÃÇ¨àµÒ¹Á´ÇÂµ¹àÍ§à´×Í¹ÅÐ¤ÃÑé§ áÅÐ¤ÇÃ¨ÐµÍ§ä´ÃÑº¡ÒÃºÍ¡¶Ö§»ÃÐâÂª¹áÅÐ
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¡ÒÃµÃÇ¨â´Âá¾·ÂËÃ×Í ºØ¤ÅÒ¡Ã·Ò§¡ÒÃá¾·Â·äÕè ´ÃºÑ ¡ÒÃ½¡ÍºÃÁ ÍÂÒ§¹ÍÂ·Ø¡ 3 »
· ¼Ë Ù Ô§·ÕÁè ÍÕ ÒÂØ 40 - 69 »¢¹Öé ä» áÅÐäÁÁÍÕ Ò¡ÒÃ
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¡ÒÃµÃÇ¨ ÍÑÅµÃÒ«ÒÇ´ÃÇ Á´ÇÂã¹¡ÅÁØ ·ÕÁè Õ Dense breast ¶ÒÊ¶Ò¹ºÃÔ¡ÒÃÁÕ¤ÇÒÁ¾ÃÍÁ·Õ¨è ÐµÃÇ¨ä´
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áÅÐà¹×èÍ§¨Ò¡à¹×éÍ àµÒ¹Á¢Í§ÊµÃÕä·ÂÁÕÅÑ¡É³Ðà»¹ Dense breast ÍÒ¨ãª¡ÒÃµÃÇ¨ ÍÑÅµÃÒ«ÒÇ´ ÃÇÁ´ÇÂ «Öè§
¨Ðãªã¹Ê¶ÒºÑ¹·ÕÁè ¤Õ ÇÒÁ¾ÃÍÁ¢Í§à¤Ã×Íè §Á×Í
2.2 ¡ÅØÁàÊÕèÂ§ (high risk)

¼ÙËÔ§¡ÅØÁ¹Õé¤ÇÃä´ÃÑº¡ÒÃµÃÇ¨¤Ñ´¡ÃÍ§ÁÐàÃç§àµÒ¹ÁàËÁ×Í¹¡Ñº¡ÅØÁ¼ÙËÔ§·ÑèÇä» áµ¤ÇÃ¨Ð
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¡ÅØÁàÊÕèÂ§ (high risk) ä´á¡
· ÁÕ»ÃÐÇÑµÔÒµÔÊÒÂµÃ§ ä´á¡ ÁÒÃ´Ò ¾ÕèÊÒÇ/¹Í§ÊÒÇ áÅÐºØµÃ à»¹ÁÐàÃç§àµÒ¹ÁËÃ×ÍÁÐàÃç§
·ÕÃè §Ñ ä¢
· ¼·Ù ÁÕè »Õ ÃÐÇÑµàÔ »¹ÁÐàÃç§àµÒ¹Á (invasive cancer or ductal carcinoma in situ)
· ¼· Ù äÕè ´ÃºÑ ¡ÒÃÃÑ¡ÉÒ´ÇÂ¡ÒÃ©ÒÂáÊ§ºÃÔàÇ³Ë¹ÒÍ¡ ä´á¡ ¼·Ù àÕè »¹âÃ¤à»¹ Hodgkin's disease
ËÃ×Í non- Hodgkin lymphoma à»¹µ¹
· ¼· Ù ÁÕè »Õ ÃÐÇÑµ·Ô Ó breast biopsy áÅÇÁÕ¼Åà»¹ atypical ductal hyperplasia, lobular neoplasia
· ¼· Ù äÕè ´ÃºÑ »ÃÐ·Ò¹ÎÍÃâÁ¹àÊÃÔÁ·´á·¹ÇÑÂËÁ´»ÃÐ¨Óà´×Í¹à»¹»ÃÐ¨Óà¡Ô¹¡ÇÒ 5 »
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01-53_pc22.pmd 22 19/2/2551, 20:58

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(Mammography)
á¹Ç·Ò§¹Õéä´»ÃÑº»ÃØ§ÁÒ¨Ò¡ "á¹Ç·Ò§¡ÒÃãªà¤Ã×èÍ§¶ÒÂÀÒ¾ÃÑ§ÊÕàµÒ¹Á (mammography) ã¹

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¤Ø³ÅÑ¡É³Ð¢Í§à¤Ã×èÍ§¶ÒÂÀÒ¾ÃÑ§ÊÕàµÒ¹Á
Mammographic Unit ·Õèä´ÁÒµÃ°Ò¹ÃÑºÃÍ§ãªä´·ÑèÇä»µÒÁÁÒµÃ°Ò¹ÊÒ¡Å àª¹ ÂØâÃ» ËÃ×Í ÊËÃÑ°
ÍàÁÃÔ¡Ò áÅÐÁÕà¤Ã×Íè §Á×Í·´ÊÍº¤Ø³ÀÒ¾»ÃÐ¨Óà¤Ã×Íè §
Í§¤»ÃÐ¡Íº¢Í§Ë¹ÇÂ¶ÒÂÀÒ¾ÃÑ§ÊÕàµÒ¹Á
· Ê¶Ò¹·Õè ãËàËÁÒÐÊÁ¡Ñºà¤Ã×Íè §Á×Í ¤ÇÃÁÔ´ªÔ´ áÅÐÁÕ¤ÇÒÁÊÐÍÒ´
· à¤Ã×Íè §Á×ÍÊ¹ÑºÊ¹Ø¹à¾ÔÁè àµÔÁ (·Õ¹è Ò ¨ÐÁÕÊÓËÃÑº¡ÒÃÇÔ¹¨Ô ©ÑÂ)
- à¤Ã×Íè §ÍÑÅµÃÒ«ÒÇ´·ÁÕè ËÕ ÇÑ µÃÇ¨ª¹Ô´ high resolution ÁÒ¡¡ÇÒ 10 MHz ¢Ö¹é ä»
· ºØ¤ÅÒ¡Ã
1. ÃÑ§ÊÕá¾·Â ·ÕÁè ¤Õ ³Ø ÊÁºÑµµÔ ÒÁ·Õ¡è ÓË¹´
2. ¹Ñ¡ÃÑ§ÊÕ¡ÒÃá¾·ÂËÃ×Íà¨ÒË¹Ò·ÕÃè §Ñ ÊÕ¡ÒÃá¾·Â ·ÕÁè ¤Õ ³ Ø ÊÁºÑµµÔ ÒÁ·Õ¡è ÓË¹´
3. à¨ÒË¹Ò·Õºè ¹Ñ ·Ö¡¢ÍÁÙÅáÅÐµÔ´µÍÊ×Íè ÊÒÃ¡Ñº¼»Ù Ç Â
4. à¨ÒË¹Ò·ÕÅè Ò §¿ÅÁ ¶ÒäÁä´ãª full-field digital mammography
á¹Ç·Ò§¡ÒÃ¤Çº¤ØÁ¤Ø³ÀÒ¾¢Í§¡ÒÃµÃÇ¨ÇÔ¹Ô¨©ÑÂàµÒ¹Áâ´Âà¤Ã×èÍ§¶ÒÂÀÒ¾
ÃÑ§ÊÕàµÒ¹Á (Guidelines for Mammography Quality Standard)
1. ºØ¤ÅÒ¡Ã (personal)
· ÃÑ§ÊÕá¾·Â (radiologist)
¤Ø³ÊÁºÑµ·Ô ÇÑè ä»: ¨ºá¾·ÂÈÒÊµÃº³ Ñ ±Ôµ áÅÐä´ÃºÑ ÇØ²ºÔ µÑ ÃÃÑ§ÊÕÇ·Ô ÂÒ ËÃ×ÍÇØ²ºÔ µÑ ÃÃÑ§ÊÕÇ¹Ô ¨Ô ©ÑÂ
¤Ø³ÊÁºÑµàÔ ©¾ÒÐ: 1. ä´ÃÑº¡ÒÃ½¡ÍºÃÁ ¡ÒÃÇÔ¹Ô¨©ÑÂ¡ÒÃµÃÇ¨àµÒ¹Áâ´Âà¤Ã×èÍ§¶ÒÂÀÒ¾ÃÑ§ÊÕ
àµÒ¹Á ã¹âÃ§àÃÕÂ¹á¾·ÂËÃ×ÍÊ¶ÒºÑ¹·Õèä´ÃÑº¡ÒÃÃÑºÃÍ§ÍÂÒ§¹ÍÂ 30
ªÑÇè âÁ§ ã¹¢³Ð·Õàè »¹á¾·Â»ÃÐ¨ÓºÒ¹
2. ¡Ã³ÕäÁä´ÃºÑ ¡ÒÃ½¡ÍºÃÁ¡ÒÃÇÔ¹¨Ô ©ÑÂ¡ÒÃµÃÇ¨àµÒ¹Á â´Âà¤Ã×Íè §¶ÒÂÀÒ¾
ÃÑ§ÊÕàµÒ¹Á ã¹¢³Ðà»¹á¾·Â»ÃÐ¨ÓºÒ¹ ËÃ×ÍäÁä´·Ó¡ÒÃÇÔ¹Ô¨©ÑÂ¡ÒÃ
01-53_pc22.pmd 23 19/2/2551, 20:58

µÃÇ¨ÀÒ¾ÃÑ§ÊÕàµÒ¹ÁËÅÑ§¨Ò¡¨º¡ÒÃÈÖ¡ÉÒà¡Ô¹ 3 » ¤ÇÃ¼Ò¹¡ÒÃÍºÃÁ
ËÅÑ¡ÊÙµÃ¡ÒÃÇÔ¹¨Ô ©ÑÂ¡ÒÃµÃÇ¨ÀÒ¾¶ÒÂÃÑ§ÊÕàµÒ¹Áã¹âÃ§àÃÕÂ¹á¾·ÂËÃ×Í
Ê¶ÒºÑ¹·Õäè ´ÃºÑ ¡ÒÃÃÑºÃÍ§ÍÂÒ§¹ÍÂ 120 ªÑÇè âÁ§ ËÃ×ÍÁÕ»ÃÐÊº¡ÒÃ³ã¹
¡ÒÃÍÒ¹á»Å¼Å ÀÒ¾¶ÒÂÃÑ§ÊÕàµÒ¹ÁÍÂÒ§¹ÍÂ 240 ÃÒÂ
· ¹Ñ¡ÃÑ§ÊÕ¡ÒÃá¾·Â ËÃ×Í à¨ÒË¹Ò·ÕÃè §Ñ ÊÕà·¤¹Ô¤ (radiologic technologist)
¤Ø³ÊÁºÑµ·Ô ÇÑè ä»: ä´ÃºÑ ãº»ÃÐ¡ÍºâÃ¤ÈÔÅ»¢Í§¹Ñ¡ÃÑ§ÊÕ¡ÒÃá¾·Â
¤Ø³ÊÁºÑµàÔ ©¾ÒÐ: ä´ÃºÑ ¡ÒÃ½¡ÍºÃÁ¡ÒÃµÃÇ¨àµÒ¹Áâ´Âà¤Ã×Íè §¶ÒÂÀÒ¾ÃÑ§ÊÕàµÒ¹Áã¹Ê¶ÒºÑ¹
·Õäè ´ÃºÑ ¡ÒÃÃÑºÃÍ§ÍÂÒ§¹ÍÂ 40 ªÑÇè âÁ§
2. à¤Ã×Íè §Á×Í (equipment)

· µÒÁ¤Ø³ÅÑ¡É³Ð¢Í§à¤Ã×Íè §¶ÒÂÀÒ¾ÃÑ§ÊÕàµÒ¹Áâ´Âà©¾ÒÐ
3. ¡ÒÃºÑ¹·Ö¡¢ÍÁÙÅáÅÐ¡ÒÃÃÒÂ§Ò¹¼Å (medical records and mammography

reports)
· ¡ÒÃÃÒÂ§Ò¹¼Å¢Í§¡ÒÃµÃÇ¨µÍá¾·Â¼ÊÙ § µÃÇ¨
¡ÒÃÃÒÂ§Ò¹¼Å mammography ãËÂÖ´ËÅÑ¡ Breast Imaging Reporting and Data System
(BIRADS)(4) «Ö§è á¹Ð¹ÓãË»ÃÐ¡Íº´ÇÂ
1. Indication for examination ä´á¡
- Screening exam with no presenting symptoms
- Recall of screening exam and/or clinical finding
- Follow-up of conservatively treated breast cancer
- Other, please specify
2. Succinct description of overall breast composition ä´á¡
- The breast is almost entirely fat (<25% glandular)
- There are scattered fibroglandular densities (approximately 25-50 %)
- The breast tissue is heterogeneously dense, which could obscure detection of small masses
(approximately 51-75 % glandular)
- The breast tissue is extremely dense. This may lower the sensitivity of mammography
(>75% glandular)
01-53_pc22.pmd 24 19/2/2551, 20:58

3. Clear description of any significant finding (s) ä´á¡

- Mass lesion
- Microcalcifications
- Architectural distortion
- Special cases:
- asymmetry: total/focal
- skin thickening / dimple
- dilated tubular structure, à»¹µ¹
4. Comparison to previous studies (if deemed necessary by radiologists)
5. Overall (summary) impression ã¹ÃÐºº BIRADS category
BI-RADS 0 Incomplete study Need additional imaging evaluation

BI-RADS 1 Negative (No detectable pathology) Normal screening interval
BI-RADS 2 Benign finding Normal screening interval
BI-RADS 3 Probably benign finding Short interval follow-up
BI-RADS 4 Suspicious abnormality Biopsy should be considered
BI-RADS 5 Highly suggestive of Malignancy Pathological study, appropriate action should be taken
BI-RADS 6 Known biopsy proven malignancy Appropriate action should be taken
ÃÒÂÅÐàÍÕÂ´¢Í§à·¤¹Ô¤¡ÒÃµÃÇ¨
1. ¤ÇÃ¶ÒÂ·ÒÁÒµÃ°Ò¹ 2 ·Ò ã¹áµÅÐ¢Ò§ ä´á¡ craniocaudal áÅÐ medeolateral oblique views
ÃÇÁ¶Ö§¡ÒÃ¶ÒÂÀÒ¾à¾ÔÁè àµÔÁ ·Òà©¾ÒÐµÒ§ æ ã¹¡Ã³Õ·¾Õè ºÃÍÂâÃ¤·ÕÊè §ÊÑÂËÃ×ÍäÁª´Ñ à¨¹
2. ã¹áµÅÐÀÒ¾¤ÇÃ¨ÐÁÕ¢Í ÁÙÅà¡ÕÂè Ç¡Ñº
- ª×Íè ¹ÒÁÊ¡ØÅ ÍÒÂØ áÅÐàÅ¢»ÃÐ¨ÓµÑÇ¼¶Ù ¡Ù µÃÇ¨
- ÇÑ¹·Õ·è äÕè ´ÃºÑ ¡ÒÃµÃÇ¨
- ·Ò·Õãè ªã¹¡ÒÃµÃÇ¨ áÅÐÍ§ÈÒ¢Í§¡ÒÃàÍÕÂ§ËÅÍ´¶ÒÂÀÒ¾
- kV & mAs
- à¤Ã×Íè §Á×Í·Õµè ÃÇ¨áÅÐcassette ·Õµè ÃÇ¨¤ÇÃÃÐºØªÍ×è ËÃ×ÍÃËÑÊ¢Í§¹Ñ¡ÃÑ§ÊÕà·¤¹Ô¤¼¶Ù Ò ÂÀÒ¾
· ¡ÒÃà¡çº¼Å¡ÒÃµÃÇ¨
¤ÇÃà¡çºÀÒ¾µ¹©ºÑºáÅÐ¼Å¡ÒÃµÃÇ¨ÍÂÒ§¹ÍÂ 5 » áÅÐµÍ§ãË¼ÅáÅÐÀÒ¾µ¹©ºÑºá¡¼»Ù Ç ÂËÒ¡
ÁÕ¡ÒÃÃÍ§¢Í (´Ñ´á»Å§¨Ò¡ ACR Practice guideline for the performance of screening mammography )(5)
01-53_pc22.pmd 25 19/2/2551, 20:58

4. ¡ÒÃàµÃÕÂÁµÑÇ¼»Ù Ç Â
· ¡ÒÃàµÃÕÂÁµÑÇ¼»Ù Ç Â
- ´Ò¹¨Ôµã¨
¤ÇÃÍ¸ÔºÒÂãË¼»Ù Ç Âà¢Òã¨¶Ö§¤ÇÒÁ¨Óà»¹ã¹¡ÒÃ´Ö§áÅÐ¡´·ÑºàµÒ¹Á¾ÃÍÁ·Ñ§é ¢Í¤ÇÒÁÃÇÁÁ×Í
´ÇÂ¤ÇÒÁ¹ÁØ ¹ÇÅÊØÀÒ¾
- ´Ò¹ÃÒ§¡ÒÂ
1. ËÒÁ·Òá»§áÅÐÂÒÃÐ§Ñº¡ÅÔ¹è µÑÇ à¹×Íè §¨Ò¡ÁÕÊÇ ¹¼ÊÁ¢Í§ÊÒÃ·Õ·è ÓãË¤ÅÒÂ¾ÂÒ¸ÔÊÀÒ¾ä´
2. ¤ÇÃµÃÇ¨ã¹ÇÑ¹·Õè 6 ¶Ö§ 7 ¹Ñº¨Ò¡ÇÑ¹áÃ¡¢Í§¡ÒÃÁÕ»ÃÐ¨Óà´×Í¹à¾×Íè ËÅÕ¡àÅÕÂè §âÍ¡ÒÊ·Õ¼è »Ù Ç Â
àÃÔÁè µÑ§é ¤ÃÃÀ áÅÐÅ´¤ÇÒÁá¹¹·Öº¢Í§àµÒ¹Á
3. ¤ÇÃºÑ¹·Ö¡ÇÑ¹·ÕèÁÕ»ÃÐ¨Óà´×Í¹¤ÃÑé§ÊØ´·ÒÂ áÅÐ¨Ó¹Ç¹ºØµÃ¢Í§¼ÙÁÒÃÑº¡ÒÃµÃÇ¨ »ÃÐÇÑµÔ
à¡ÕÂè Ç¡ÑºàµÒ¹Á àª¹ âÃ¤¢Í§àµÒ¹Á ¡ÒÃ¼ÒµÑ´âÃ¤ÁÐàÃç§àµÒ¹Áã¹¤ÃÍº¤ÃÑÇ à»¹µ¹
5. ¡ÒÃ¤Çº¤ØÁ¤Ø³ÀÒ¾ (quality assurance)

· ·ÑÇè ä»
¼ÁÙ ËÕ ¹Ò·ÕÃè ºÑ ¼Ô´ªÍº ¤ÇÃÁÕà¨ÒË¹Ò·ÕÃè §Ñ ÊÕËÃ×Í¹Ñ¡ÃÑ§ÊÕà·¤¹Ô¤ 1 ¤¹ »ÃÐ¨ÓËÍ§µÃÇ¨à»¹¼¤Ù Çº¤ØÁ
áÅÐà¡çººÑ¹·Ö¡¢ÍÁÙÅà¡ÕÂè Ç¡Ñºà¤Ã×Íè § ¡ÒÃ¤Çº¤ØÁ¤Ø³ÀÒ¾¢Í§à¤Ã×Íè § áÅÐ¡ÒÃ«ÍÁà¤Ã×Íè §·Ñ§é ËÁ´
· ¡ÒÃ¤Çº¤ØÁ¤Ø³ÀÒ¾¢Í§ÀÒ¾¶ÒÂÃÑ§ÊÕàµÒ¹Á
¤ÇÃÁÕÃÐºº¡ÒÃºÑ¹·Ö¡¡ÒÃ¤Çº¤ØÁ¤Ø³ÀÒ¾¢Í§ÀÒ¾¶ÒÂÃÑ§ÊÕàµÒ¹ÁáÅÐà¤Ã×èÍ§ÅÒ§¿ÅÁ·Õèà»¹
ÅÒÂÅÑ¡É³Í¡Ñ ÉÃ ÊÒÁÒÃ¶µÃÇ¨ÊÍºä´ â´Â»¯ÔºµÑ µÔ ÒÁµÒÃÒ§á¹º·ÒÂ
· »ÃÔÁÒ³ÃÑ§ÊÕ
Average glandular dose ã¹¡ÒÃ¶ÒÂ·Ò craniocaudal view ÊÓËÃÑºàµÒ¹Á·ÕÁè Õ ¤ÇÒÁË¹Ò 4.2 à«¹µÔàÁµÃ
»ÃÐ¡Íº´ÇÂà¹×Íé àµÒ¹Á 50% áÅÐä¢ÁÑ¹ 50% µÍ§äÁà¡Ô¹ 0.3 rad (3.0 milligray) â´Âãª¡ºÑ ·Ñ§é screen- film áÅÐ
full-field digital mammography
6. ¡Åä¡¡ÒÃ»ÃÐàÁÔ¹¼Å¤ÇÒÁ¾Íã¨¢Í§¼ÙÃÑº¡ÒÃµÃÇ¨áÅÐá¾·Â·ÕèÊ§µÃÇ¨
(Consumer complaint mechanism)
¤ÇÃÁÕÃÐºº¡ÒÃ»ÃÐàÁÔ¹¼Åà¡ÕèÂÇ¡Ñº¢Íº¡¾ÃÍ§¢Í§¡ÒÃµÃÇ¨·ÕèÁÕ¼Å¡ÃÐ·ºµÍ¼Å¡ÒÃµÃÇ¨ÍÂÒ§
ÃÒÂáÃ§ àª¹ ¤Ø³ÀÒ¾¢Í§ÀÒ¾äÁ´Õ ¡ÒÃÇÔ¹¨Ô ©ÑÂ¼Ô´¾ÅÒ´ ãªº¤Ø ÅÒ¡Ã·Õ¢è Ò´¤Ø³ÊÁºÑµÔ ¡ÒÃÃÒÂ§Ò¹¼ÅªÒ ¤ÇÒÁ
à¨çº»Ç´ÍÂÒ§ÃØ¹áÃ§ã¹¡ÒÃµÃÇ¨¢Í§¼ÃÙ ºÑ ¡ÒÃµÃÇ¨ à»¹µ¹ áÅÐ·Ó¡ÒÃÃÇºÃÇÁà¾×Íè ¹ÓÁÒ»ÃÐÁÇÅËÒË¹·Ò§
á¡ä¢µÍä»
01-53_pc22.pmd 26 19/2/2551, 20:58

Assessment Categories
a. ¡ÒÃ»ÃÐàÁÔ¹â´ÂãªáÁÁâÁá¡ÃÁÂÑ§äÁÊÁºÙÃ³
Category 0
- ¨Óà»¹µÍ§ÁÕ¡ÒÃ¶ÒÂàÍ¡«àÃÂà¾ÔÁè àµÔÁ áÅÐ/ËÃ×ÍáÁÁâÁá¡ÃÁ·Õàè ¤Â·Ó¡Í¹Ë¹Ò¹Õàé ¾×Íè ãªà»ÃÕÂº
à·ÕÂº
- ÁÕÊ§Ôè µÃÇ¨¾º·Õ¨è Óà»¹µÍ§ÁÕ¡ÒÃ¶ÒÂàÍ¡«àÃÂà¾ÔÁè àµÔÁ ËÑÇ¢Í¹Õ¨é Ðãª¡Ã³Õ·àÕè »¹¡ÒÃµÃÇ¨¤Ñ´¡ÃÍ§
à·Ò¹Ñ¹é (screening) ¡ÒÃ¶ÒÂàÍ¡«àÃÂà¾ÔÁè àµÔÁÍÒ¨ÃÇÁ¶Ö§ ¡ÒÃ¡´à¹×Íé àµÒ¹ÁáÅÇ¶ÒÂà©¾ÒÐ¨Ø´ (spot compression)
¡ÒÃ¶ÒÂÀÒ¾¢ÂÒÂ (magnification) ¡ÒÃ¶ÒÂÀÒ¾áÁÁâÁá¡ÃÁ¾ÔàÈÉÍ×¹è æ áÅÐ¡ÒÃãª¤Å×¹è àÊÕÂ§¤ÇÒÁ¶ÕÊè §Ù (ultra-
sound)
¶Ò¡ÒÃµÃÇ¨¾ºÊÔ§è ¼Ô´»¡µÔ·äÕè Áãª benign finding ÍÒ¨¨Óà»¹µÍ§ãª¡ÒÃà»ÃÕÂºà·ÕÂº¡ÑºáÁÁâÁá¡ÃÁ
·Õàè ¤Â·Ó¡Í¹Ë¹Ò¹Õé ÃÑ§ÊÕá¾·Â¨Ðà»¹¼»Ù ÃÐàÁÔ¹ÇÒÁÕ¤ÇÒÁ¨Óà»¹ã¹¡ÒÃµÔ´µÒÁáÁÁâÁá¡ÃÁà¡ÒÁÒà»ÃÕÂºà·ÕÂº
ÁÒ¡¹ÍÂà¾ÕÂ§ã´ Category 0 ¨Ðãªã¹¡Ã³ÕµÍ§¡ÒÃáÁÁâÁá¡ÃÁà¡ÒÁÒà»ÃÕÂºà·ÕÂºáµÂÑ§äÁÊÒÁÒÃ¶ËÒä´ã¹
¢³Ð¹Ñé¹
b. ¡ÒÃ»ÃÐàÁÔ¹â´ÂãªáÁÁâÁá¡ÃÁÊÁºÙÃ³¤Ãº¶Ç¹ - Final categories
Category 1
Negative
äÁ¾ºÊÔ§è ¼Ô´»¡µÔã´àÅÂ àµÒ¹ÁÊÁ´ØÅ¡Ñ¹·Ñ§é 2 ¢Ò§ äÁÁ¡Õ Í ¹à¹×Íé (mass), ¡ÒÃºÔ´àºÕÂé Ç¢Í§à¹×Íé àµÒ¹Á
(architectural distortion) ËÃ×ÍËÔ¹»Ù¹
Category 2
ÊÔ§è µÃÇ¨¾ºäÁãªÁÐàÃç§ (benign finding) àËÁ×Í¹ category 1 ÂÑ§¨Ñ´à»¹¡ÒÃ»ÃÐàÁÔ¹¡ÅÁØ "»¡µÔ"
áµ¼áÙ »Å¼ÅµÍ§¡ÒÃºÃÃÂÒÂÊÔ§è µÃÇ¨¾º·Õäè ÁãªÁÐàÃç§ ¡ÅÁØ µÍä»¹ÕÊé ÒÁÒÃ¶ºÍ¡ä´ÇÒ äÁãªÁÐàÃç§ÍÂÒ§á¹¹Í¹
ä´á¡ fibroadenoma ·Õè½ÍÁÕËÔ¹»Ù¹¨Ñº, ¡ÅØÁËÔ¹»Ù¹ã¹ secretory disease, ¡ÅØÁ¾ÂÒ¸ÔÊÀÒ¾·ÕèÁÕä¢ÁÑ¹à»¹
ÊÇ¹»ÃÐ¡Íº àª¹ oil cyst, lipoma, galactocele áÅÐ hamartoma ÃÇÁ¶Ö§ µÍÁ¹éÓàËÅ×Í§ã¹àµÒ¹Á (intramammary
lymph node),ËÔ¹»Ù¹¢Í§àÊ¹àÅ×Í´ã¹àµÒ¹Á, ÇÑÊ´ØàÊÃÔÁàµÒ¹Á ËÃ×Í¡ÒÃºÔ´àºÕÂé Ç¢Í§à¹×Íé àµÒ¹Á·Õàè ¡Ô´¨Ò¡¡ÒÃ¼ÒµÑ´
·Ñé§ Category 1 áÅÐ 2 º§ªÕéÇÒäÁÁÕÅÑ¡É³Ð¢Í§ÁÐàÃç§àµÒ¹Á»ÃÒ¡®ã¹áÁÁâÁá¡ÃÁ ¤ÇÒÁáµ¡
µÒ§¤×Íã¹ Category 2 ¨ÐÁÕ¡ÒÃºÃÃÂÒÂ¶Ö§ÊÔ§è ·Õµè ÃÇ¨¾º (benign finding) áµ Category 1 ¨ÐäÁÁ¡Õ ÒÃºÃÃÂÒÂ ´Ñ§¡ÅÒÇ
Category 3
ÍÒ¨¨Ðà»¹ benign finding
- ãËµ´Ô µÒÁ¼Å¡ÒÃµÃÇ¨ã¹ÃÐÂÐÊÑ¹é
ÊÔ§è ¼Ô´»¡µÔ·µÕè ÃÇ¨¾º¨ÐÁÕâÍ¡ÒÊà»¹ÁÐàÃç§àµÒ¹Á¹ÍÂ¡ÇÒ 2 % áÅÐ¤Ò´ÇÒ¨ÐäÁÁ¡Õ ÒÃà»ÅÕÂè ¹
á»Å§ã¹ªÇ§·Õµè ´Ô µÒÁ¼Å
01-53_pc22.pmd 27 19/2/2551, 20:58

ÁÕ¡ÒÃÈÖ¡ÉÒ·ÕèÂ×¹ÂÑ¹¤ÇÒÁ»ÅÍ´ÀÑÂáÅÐ»ÃÐÊÔ·¸Ô¼Å¢Í§¡ÒÃµÔ´µÒÁ¼Å¡ÒÃµÃÇ¨ã¹ÃÐÂÐÊÑé¹
(initial short- term follow-up) ã¹¼»Ù Ç Â¡ÅÁØ ¹Õé
ÊÇ¹ãË¼Ù»ÇÂã¹¡ÅØÁ¹Õé¨ÐµÔ´µÒÁ¼ÅÃÐÂÐÊÑé¹ 6 à´×Í¹ ã¹ 1 » áÅÐ·Ø¡ 1 » ¨¹¤Ãº 2 » à¾×èÍ
Â×¹ÂÑ¹ÇÒ¤ÇÒÁ¼Ô´»¡µÔ¹¹Ñé ¤§·Õè ¨Ö§à»ÅÕÂè ¹à»¹ Category 2
Category 4
¤ÇÒÁ¼Ô´»¡µÔ·¾Õè ºÊ§ÊÑÂÇÒÍÒ¨à»¹ÁÐàÃç§ (suspicious abnormality)
- ¤ÇÃä´ÃºÑ ¡ÒÃµÃÇ¨ªÔ¹é à¹×Íé
ËÑÇ¢Í¹Õ¨é ÐÃÇÁÊÔ§è ¼Ô´»¡µÔ·´Õè ¹Ù Ò ¡Ñ§ÇÅ¡ÇÒ Category 3 áµäÁàËÁ×Í¹ÅÑ¡É³Ðà©¾ÒÐ¢Í§ÁÐàÃç§
Category 5
Ê§ÊÑÂÍÂÒ§ÂÔ§è ÇÒ¨Ðà»¹ÁÐàÃç§ (highly suspicious)
- ¨Óà»¹µÍ§ä´ÃºÑ ¡ÒÃµÃÇ¨ªÔ¹é à¹×Íé ¤ÇÒÁ¼Ô´»¡µÔ·µÕè ÃÇ¨¾ºã¹¡ÅÁØ ¹ÕÁé âÕ Í¡ÒÊÊÙ§ÁÒ¡·Õ¨è Ðà»¹
ÁÐàÃç§ (> 95 %) ¤ÇÃÁÕ¡ÒÃ´Óà¹Ô¹¡ÒÃ·Õàè ËÁÒÐÊÁµÍä»
Category 6
·ÃÒº¼ÅªÔ¹é à¹×Íé áÅÇÇÒà»¹ÁÐàÃç§
- ¤ÇÃÁÕ¡ÒÃ´Óà¹Ô¹¡ÒÃ·Õàè ËÁÒÐÊÁµÍä»
ËÑÇ¢Í¹Õãé ªÊÓËÃÑº¤ÇÒÁ¼Ô´»¡µÔ·àÕè Ëç¹ã¹áÁÁâÁá¡ÃÁ â´ÂÁÕ¡ÒÃµÑ´ªÔ¹é à¹×Íé ¾ÔÊ¨Ù ¹¡Í ¹Ë¹Ò
¹Õáé ÅÇÇÒà»¹ÁÐàÃç§ áµÁÒµÃÇ¨áÁÁâÁá¡ÃÁà¾×Íè ´ÙÇÒ ÁÕÁÐàÃç§à¾ÕÂ§µÓáË¹§à´ÕÂÇ·Õäè ´ÃºÑ ¡ÒÃ¾ÔÊ¨Ù ¹ª¹Ôé à¹×Íé áÅÇ¨Ð
ä´ÇÒ§á¼¹¡ÒÃÃÑ¡ÉÒä´àËÁÒÐÊÁ ¶Ò¾º¤ÇÒÁ¼Ô´»¡µÔ·ÕèÍ×è¹µÍ§»ÃÐàÁÔ¹ä»µÒÁ¤ÇÒÁ¼Ô´»¡µÔ¹Ñé¹æ ÇÒÁÕ¤ÇÒÁ
Ê§ÊÑÂ¡ÒÃà»¹ÁÐàÃç§ÁÒ¡¹ÍÂà¾ÕÂ§ã´
¡ÒÃ¤Çº¤ØÁ¤Ø³ÀÒ¾¢Í§ÀÒ¾¶ÒÂÃÑ§ÊÕàµÒ¹Á
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- à¾×Íè ãËä´ÀÒ¾¶ÒÂÃÑ§ÊÕàµÒ¹Á·ÕÁè ¤Õ ³
Ø ÀÒ¾´Õ·ÊÕè ´Ø ´ÇÂ»ÃÔÁÒ³ÃÑ§ÊÕ·àÕè ËÁÒÐÊÁ·ÕÊè ´Ø
- à¾×Íè ãËä´ÀÒ¾¶ÒÂÃÑ§ÊÕàµÒ¹Á·ÕÊè ÒÁÒÃ¶µÃÇ¨ËÒÃÍÂâÃ¤¢Í§àµÒ¹Áä´ÅÐàÍÕÂ´¶Õ¶è Ç ¹·ÕÊè ´Ø
- à¾×Íè ËÅÕ¡àÅÕÂè §¤ÇÒÁ¼Ô´¾ÅÒ´ ÍÑ¹ÍÒ¨à¡Ô´¨Ò¡¡ÒÃÇÔ¹¨Ô ©ÑÂâÃ¤´ÇÂÀÒ¾¶ÒÂÃÑ§ÊÕàµÒ¹ÁãËä´ÁÒ¡·ÕÊè ´Ø
Ë¹Ò·Õáè ÅÐµÒÃÒ§àÇÅÒ
· ÊÓËÃÑºà¤Ã×Íè § Mammography áºº screen-film
¹Ñ¡ÃÑ§ÊÕà·¤¹Ô¤ÁÕË¹Ò·Õè 11 »ÃÐ¡ÒÃ µÒÁµÒÃÒ§àÇÅÒµÍä»¹Õé
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1. ·Ó¤ÇÒÁÊÐÍÒ´ËÍ§Á×´ ·Ø¡ÇÑ¹
2. ¤Çº¤ØÁ¤Ø³ÀÒ¾¡ÒÃÅÒ§¿ÅÁ ·Ø¡ÇÑ¹
3. ·Ó¤ÇÒÁÊÐÍÒ´¤ÒÊà«· - Ê¡ÃÕ¹ ÊÑ»´ÒËÅÐ¤ÃÑ§é
4. µÃÇ¨ÊÍºÊÀÒÇÐ¡ÒÃÍÒ¹¿ÅÁ ·Ó¤ÇÒÁÊÐÍÒ´µäÙ ¿ÊÍ§¿ÅÁ áÅÐáÇ¹¢ÂÒÂ ÊÑ»´ÒËÅÐ¤ÃÑ§é
·Õãè ªã¹¡ÒÃ´Ù¿Å Á
5. ¤Çº¤ØÁ¤Ø³ÀÒ¾â´ÂãªË¹Ø ¨ÓÅÍ§àµÒ¹Á à´×Í¹ÅÐ¤ÃÑ§é
6. µÃÇ¨ÊÍºÊÀÒ¾à¤Ã×Íè §´ÇÂµÒ à´×Í¹ÅÐ¤ÃÑ§é
7. ÇÔà¤ÃÒÐËÍµÑ ÃÒ¡ÒÃ¶ÒÂ¿ÅÁ «éÓ 3 à´×Í¹¤ÃÑ§é
8. µÃÇ¨ÊÍº»ÃÔÁÒ³µ¡¤Ò§¢Í§äÎâ»º¹¿ÅÁ 3 à´×Í¹¤ÃÑ§é
9. µÃÇ¨ÊÍºÃÐ´ÑºËÁÍ¡¤ÇÑ¹ (fog) ¢Í§ËÍ§Á×´ 6 à´×Í¹¤ÃÑ§é
10. µÃÇ¨ÊÍº¤ÇÒÁá¹ºªÔ´¢Í§Ê¡ÃÕ¹áÅÐ¿ÅÁ 6 à´×Í¹¤ÃÑ§é
11. µÃÇ¨ÊÍºáÃ§¡´¢Í§á¼¹¡´àµÒ¹Á 6 à´×Í¹¤ÃÑ§é
12. ã¹¡Ã³Õ·¨Õè ÐµÍ§ÁÕ¡ÒÃ·Ó breast intervention ¨ÐµÍ§µÃÇ¨ÊÍº¤ÇÒÁáÁ¹ÂÓ ·Ø¡¤ÃÑ§é ¡Í¹¡ÒÃ·Ó
¢Í§à¤Ã×Íè §¶ÒÂÃÑ§ÊÕÃÐºº stereotaxis
· ÊÓËÃÑºà¤Ã×Íè § Full-field digital mammography

»¯ÔºµÑ µÔ ÒÁÁÒµÃ°Ò¹¢Í§ºÃÔÉ·Ñ
References
1. ¡ÒÃ»ÃÐàÁÔ¹à·¤â¹âÅÂÕ¡ÒÃµÃÇ¨ÇÔ¹¨Ô ©ÑÂÁÐàÃç§àµÒ¹Áã¹ÃÐÂÐàÃÔÁè áÃ¡·Õàè ËÁÒÐÊÁÊÓËÃÑº»ÃÐà·Èä·Â. ¡ÃÁ¡ÒÃá¾·Â ¡ÃÐ·ÃÇ§ ÊÒ¸ÒÃ³ÊØ¢.
µØÅÒ¤Á 2546.
2. Lee CH, Dershaw D, Kopan D, Evan P, Monsees B, Monticciolo D, et al. Breast Cancer Screening with Imaging: Recommendations
from the Society of Breast Imaging and the ACR on the Use of Mammography, Breast MRI, Breast Ultrasound, and Other Technologies
for the Detection of Clinically Occult Breast Cancer. JACR 2010;7:18-27.
3. ÊÁã¨ ªÒÇÔàÈÉ, ÊØàÁ¸ ÃÔ¹ÊØÃ§¤Ç§È, ÊÁà¡ÕÂÃµÔ â¾¸ÔÊÑµÂ áÅÐ¤³Ð. á¹Ç·Ò§¡ÒÃãªà¤Ã×èÍ§¶ÒÂÀÒ¾ÃÑ§ÊÕàµÒ¹Á (Mammography)
ã¹¡ÒÃµÃÇ¨ÇÔ¹¨Ô ©ÑÂÁÐàÃç§àµÒ¹Á. ÇÒÃÊÒÃ¡ÃÁ¡ÒÃá¾·Â ¡ÃÐ·ÃÇ§ÊÒ¸ÒÃ³ÊØ¢. 2545; 27: 454-462.
4. American College of Radiology (ACR) Breast Imaging Reporting and Data System (BIRADSTM) Forth Edition. Reston (VA):
American College of Radiology, 2003.
5. ACR Practice Guideline for the Performance of Screening Mammography American College of Radiology. Revised 2008. Available
from: URL http://www.acr.org/departments/stand_accred/standards/pdf/screening_mammography. pdf. Accessed on February 22nd,
2011.
v v v
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á¹Ç·Ò§¡ÒÃµÃÇ¨ÇÔ¹Ô¨©ÑÂâÃ¤àµÒ¹Á·Õè¾ººÍÂ
· ÍÒ¡ÒÃ¤ÅÓä´¡Í ¹·Õàè µÒ¹Á (Breast mass)
· ÊÒÃ¤Ñ´ËÅÑè§ÍÍ¡·Ò§ËÑÇ¹Á (Nipple discharge)
· ÍÒ¡ÒÃà¨çººÃÔàÇ³àµÒ¹Á (Mastalgia)
á¹Ç·Ò§¡ÒÃÃÑ¡ÉÒÁÐàÃç§àµÒ¹Áâ´Â¡ÒÃ¼ÒµÑ´
· á¹Ç·Ò§¡ÒÃÃÑ¡ÉÒÁÐàÃç§àµÒ¹Áâ´Â¡ÒÃ¼ÒµÑ´
ËÁÒÂàËµØ: - á¹Ç·Ò§¡ÒÃµÃÇ¨ÇÔ¹Ô¨©ÑÂáÅÐÃÑ¡ÉÒâÃ¤ÁÐàÃç§àµÒ¹Á©ºÑº¹Õé ãªÊÓËÃÑºÊ¶Ò¹¾ÂÒºÒÅ·Õè

ºØ¤ÅÒ¡ÃáÅÐ·ÃÑ¾ÂÒ¡ÃÁÕ¢´Õ ¤ÇÒÁÊÒÁÒÃ¶¤Ãº¶Ç¹ áÅÐäÁÊÒÁÒÃ¶¹Óä»ãªÍÒ §ÍÔ§¡Ñº¡ÒÃ
ÃÑ¡ÉÒ¼»Ù Ç Â·Ø¡ÃÒÂâ´ÂÃÇÁä´
- ãËáµÅÐÊ¶Ò¹¾ÂÒºÒÅ¾Ô¨ÒÃ³Ò¨Ñ´·Óá¹Ç·Ò§¡ÒÃÃÑ¡ÉÒãËàËÁÒÐÊÁ¡Ñº¢Õ´¤ÇÒÁÊÒÁÒÃ¶
¢Í§Ê¶Ò¹¾ÂÒºÒÅ¹Ñ¹é æ
01-53_pc22.pmd 30 19/2/2551, 20:58

01-53_pc22.pmd
New dominant breast mass
Hx & CBE
Diagnostic Imaging evaluation
31
< 35 yr; ultrasound**
³ 35 yr, Mammogram + ultrasound
Cystic mass Solid mass***
Simple cyst Clinical concern Tissue diagnosis
Fine needle aspiration Core needle biopsy Excision and tissue

Needle aspiration orientation
All Malignant* All benign* Discordant* Malignant Cancer treatment
No residual Residual mass
mass or Bloody fluid
Cancer treatment mass ³ 2-3 cm. mass < 2 cm. Benign Follow up**
Repeat clinical Non-malignant but concern
examination 6-8 wks Follow up** Clinical concern - Atypical ductal hyperplasia
- Atypical lobular hyperplasia
19/2/2551, 20:58
- Lobular carcinoma in situ
- Lobular neoplasia
Recurrent - Radial scar
* Triple
- Phyllodes
Non recurrent - Mucocele lesion
** ¢Ö¹
é ¡Ñº´ØÅÂ¾Ô¹¨Ô ¢Í§á¾·Â·¼µÙ ÃÇ¨ÃÑ¡ÉÒ
*** ã¹¡Ã³Õ·¼Õè »Ù Ç ÂÍÒÂØ¹Í Â¡ÇÒ 25 »¡Í ¹¢¹Ò´àÅç¡ÁÕÅ¡Ñ É³Ð benign - Papillary lesion
ÍÒ¨ãË¡ÒÃ´ÙáÅâ´Â¡ÒÃµÔ´µÒÁµÒÁ¤ÇÒÁàËÁÒÐÊÁ ·Ø¡ 3-6 à´×Í¹
Routine screening Hx = history - Sclerosing adenosis
31
CBE = Clinical Breast Examination

Breast mass
á¹Ç·Ò§¡ÒÃ´ÙáÅ¼»Ù Ç Â·ÕÁè Ò´ÇÂÍÒ¡ÒÃ¤ÅÓä´¡Í ¹·Õàè µÒ¹Á ËÅÑ§¨Ò¡¡ÒÃ«Ñ¡»ÃÐÇÑµáÔ ÅÐµÃÇ¨ÃÒ§¡ÒÂ
Â×¹ÂÑ¹ÇÒÁÕ¡Í ¹·Õàè µÒ¹Á¨ÃÔ§ ÍÒ¨á¹Ð¹ÓãË·Ó ultrasound àµÒ¹Áã¹¼ËÙ Ô§ÍÒÂØ¹Í Â¡ÇÒ 35 » ÊÓËÃÑº¼ËÙ Ô§ÍÒÂØ
35 » ¢Ö¹é ä» ÍÒ¨á¹Ð¹ÓãË·Ó mammogram ÃÇÁ´ÇÂ â´ÂãËÍÂãÙ ¹´ØÅÂ¾Ô¹¨Ô ¢Í§á¾·Â¼ãÙ Ë¡ÒÃÃÑ¡ÉÒ à¹×Íè §¨Ò¡
¡ÒÃ·ÓáÁÁâÁá¡ÃÁ áÅÐËÃ×ÍÍÑÅµÃÒ«ÒÇ´ ÁÕâÍ¡ÒÊà¡Ô´¼ÅÅºÅÇ§ä´ (false negative ) 15 %(1)
Cystic mass
· ¡Ã³Õ simple cyst á¹Ð¹ÓÇÒÊÒÁÒÃ¶ãªÇÔ¸Õ¡ÒÃµÃÇ¨µÔ´µÒÁä´ ËÃ×Í·Ó needle aspiration ¶Ò¢Í§
àËÅÇ·Õäè ´äÁÁÅÕ ¡Ñ É³Ð bloody fluid áÅÐ¡Í¹ÂØºËÁ´ á¹Ð¹ÓãË·Ó¡ÒÃµÃÇ¨µÔ´µÒÁã¹ÍÕ¡ 6-8 ÊÑ»´ÒË ¶ÒäÁÁÕ
¡ÒÃ¡ÅÑºà»¹«éÓ ÊÒÁÒÃ¶·ÓµÒÁ screening program »¡µÔä´
· ¶ÒÁÕÅÑ¡É³Ð bloody fluid ËÃ×Í¡Í¹ÂØºäÁËÁ´ ËÃ×ÍÁÕ¡ÒÃ¡ÅÑºà»¹«éÓ¢Í§¡Í¹ã¹ 6-8 ÊÑ»´ÒË
á¹Ð¹ÓãË·Ó¡ÒÃÊ§µÃÇ¨µÍà¾×Íè ãËä´ tissue diagnosis
Solid mass
· àÁ×Íè µÃÇ¨àµÒ¹Á¾º solid mass á¹Ð¹ÓãËµÃÇ¨ªÔ¹é à¹×Íé ´ÇÂÇÔ¸Õ fine needle aspiration(2, 3) ËÃ×Í core
needle biopsy ËÃ×Í excision biopsy
· ¡Ã³Õ·Ó triple assessment ´ÇÂ clinical examination, imaging áÅÐ FNA ÁÕ¼Å¡ÒÃµÃÇ¨´Ñ§¹Õé
1. Benign ·Ñ§é ËÁ´ á¹Ð¹ÓÇÒÊÒÁÒÃ¶ÃÑ¡ÉÒ´ÇÂ¡ÒÃµÔ´µÒÁä´ ¶Ò¡Í¹ÁÕ¢¹Ò´àÅç¡¡ÇÒ 2 à«¹µÔàÁµÃ
¡ÒÃµÃÇ¨µÔ´µÒÁá¹Ð¹ÓãËµÃÇ¨àµÒ¹Á ·Ø¡ 6 à´×Í¹ à»¹àÇÅÒ 2 » ¶ÒÁÕ¢Í Ê§ÊÑÂ¨Ò¡ÍÒ¡ÒÃ·Ò§¤ÅÔ¹¡Ô á¹Ð¹Ó·Ó
core needle biopsy ËÃ×Í excision áÅÐ¶Ò¡Í¹ÁÕ¢¹Ò´ãË¡ÇÒ 2-3 «Á.á¹Ð¹Ó·Óexcision
2. Malignant ·Ñ§é ËÁ´ ÊÒÁÒÃ¶ãË¡ÒÃÇÔ¹¨Ô ©ÑÂáÅÐÃÑ¡ÉÒµÒÁá¹Ç·Ò§¡ÒÃÃÑ¡ÉÒÁÐàÃç§àµÒ¹Áä´
3. äÁÊÍ´¤ÅÍ§¡Ñ¹ á¹Ð¹ÓãËàÍÒªÔ¹é à¹×Íé µÃÇ¨à¾ÔÁè àµÔÁ à¾×Íè Â×¹ÂÑ¹¡ÒÃÇÔ¹¨Ô ©ÑÂ
· á¹Ð¹Ó·Ó excision ¡Í¹ ã¹¡Ã³Õ
1. ¼Å core biopsy à»¹(4-7)
- Atypical ductal hyperplasia
- Atypical lobular hyperplasia
- Lobular carcinoma in situ
- Lobular neoplasia
- Radial scar
- Phyllodes
- Mucocele lesion
- Papillary lesion
- Sclerosing adenosis
01-53_pc22.pmd 32 19/2/2551, 20:58

2. ¡Í¹ÁÕ¢¹Ò´ãË¡ÇÒ 2-3 à«¹µÔàÁµÃ ËÃ×Í¼»Ù Ç ÂµÍ§¡ÒÃàÍÒÍÍ¡

3. ¶ÒÁÕ¢Í Ê§ÊÑÂ¨Ò¡ÍÒ¡ÒÃ·Ò§¤ÅÔ¹¡Ô
References
1. Kerlikowske K, Smith-Bindman R, Ljung BM, Grady D. Evaluation of abnormal mammography results and palpable breast abnormalities.
Ann Intern Med. 2003 Aug 19;139(4):274-84.
2. Wanebo HJ, Feldman PS, Wilhelm MC, Covell JL, Binns RL. Fine needle aspiration cytology in lieu of open biopsy in management of
primary breast cancer. Ann Surg. 1984 May;199(5):569-79.
3. Rimsten A, Stenkvist B, Johanson H, Lindgren A. The diagnostic accuracy of palpation and fine-needle biopsy and an evaluation of their
combined use in the diagnosis of breast lesions: report on a prospective study in 1244 women with symptoms. Ann Surg. 1975 Jul;182(1):
1-8.
4. Chaney AW, Pollack A, McNeese MD, Zagars GK, Pisters PW, Pollock RE, et al. Primary treatment of cystosarcoma phyllodes of the
breast. Cancer. 2000 Oct 1;89(7):1502-11.
5. Foster MC, Helvie MA, Gregory NE, Rebner M, Nees AV, Paramagul C. Lobular carcinoma in situ or atypical lobular hyperplasia at
core-needle biopsy: is excisional biopsy necessary? Radiology. 2004 Jun;231(3):813-9.
6. Maganini RO, Klem DA, Huston BJ, Bruner ES, Jacobs HK. Upgrade rate of core biopsy-determined atypical ductal hyperplasia by open
excisional biopsy. Am J Surg. 2001 Oct;182(4):355-8.
7. Yeh IT, Dimitrov D, Otto P, Miller AR, Kahlenberg MS, Cruz A. Pathologic review of atypical hyperplasia identified by image-guided
breast needle core biopsy. Correlation with excision specimen. Arch Pathol Lab Med. 2003 Jan;127(1):49-54.
v v v
01-53_pc22.pmd 33 19/2/2551, 20:58

01-53_pc22.pmd
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¡ÒÃµÃÇ¨¤Ñ´¡ÃÍ§áÅÐÇÔ¹¨Ô ©ÑÂÁÐàÃç§àµÒ¹Á
34
¡ÒÃµÃÇ¨¤Ñ´¡ÃÍ§ ¡ÒÃµÃÇ¨¤Ñ´¡ÃÍ§¢Ñé¹µ¹
ËÃ×ÍáÊ´§ÍÒ¡ÒÃ
Consider endocrine
Bilateral Pregnancy Pregnancy Negative evaluation
Milky concern test
Positive Refer to obstetrician
Nipple Non- · Observation

discharge Spontaneous · Educate to stop compression of the breast
no palpable multiduct And report any spontaneous discharge
mass
BI-RADS
Final Mammography Ductography
Persistent áÅÐ/ËÃ×ÍU/S (optional) Duct excision
· Breast Assessment
Spontaneous, Imaging* Category 1-3**
19/2/2551, 20:58
unilateral · Guaiac or
single duct, cytology BI-RADS Benign/
or serous { optional
} Final Tissue indeterminate
sanguinous Assessment Diagnosis
Category 4-5** Malignant Cancer treatment
* ÍÒ¨·Ó Ductography ÃÇÁ´ÇÂ
** ´Ùá¹Ç·Ò§¡ÒÃ¶ÒÂÀÒ¾ÃÑ§ÊÕàµÒ¹Á (mammography)
Nipple discharge (ÊÒÃ¤Ñ´ËÅÑè§ÍÍ¡·Ò§ËÑÇ¹Á)

ã¹¼»Ù Ç Â·ÕÁè ÍÕ Ò¡ÒÃáÊ´§¢Í§ÊÒÃ¤Ñ´ËÅÑ§è ·ÕÍè Í¡ÁÒ·Ò§ËÑÇ¹Á áµäÁÊÒÁÒÃ¶µÃÇ¨¾ºÇÒÁÕ¡Í ¹¼Ô´»¡µÔ
·Õàè µÒ¹Á¹Ñ¹é ¤ÇÃ¨ÐµÍ§ä´ÃºÑ ¡ÒÃµÃÇ¨ã¹¢Ñ¹é µÍ¹áÃ¡´ÇÂ¡ÒÃ»ÃÐàÁÔ¹ÅÑ¡É³Ð¢Í§ÊÒÃ¤Ñ´ËÅÑ§è ·ÕÍè Í¡ÁÒ¨Ò¡·Ò§
ËÑÇ¹Á ¶ÒÅÑ¡É³Ð¢Í§ÊÒÃ¤Ñ´ËÅÑè§ÍÍ¡ÁÒ¨Ò¡ËÑÇ¹Á·Ñé§ 2 ¢Ò§ áÅÐÁÕÅÑ¡É³Ð¤ÅÒÂ¹éÓ¹Á¹Ñé¹ ¤ÇÃ¨ÐµÍ§ä´ÃÑº
¡ÒÃµÃÇ¨ÀÒÇÐ¡ÒÃµÑ§é ¤ÃÃÀ ËÃ×ÍÍÒ¨¨ÐµÍ§ä´ÃºÑ ¡ÒÃµÃÇ¨ã¹àÃ×Íè §ÀÒÇÐ·Õ¼è ´Ô »¡µÔ¢Í§ÃÐººÎÍÃâÁ¹ã¹ÃÒ§¡ÒÂ
·ÕÍè Ò¨¼Ô´»¡µÔ
ÊÒÃ¤Ñ´ËÅÑ§è ·ÕÁè ÅÕ ¡Ñ É³Ð¤ÅÒÂ¹éÓ¹Á (milky secretion) ÁÕÊÒàËµØÊÇ ¹ãË¨Ò¡¡ÒÃÃÑº»ÃÐ·Ò¹ÂÒºÒ§¡ÅÁØ
àª¹ psychoactive drugs, antihypertensive medications, opiates, oral contraceptives áÅÐ estrogen
ã¹¡Ã³Õ·ÁÕè ÊÕ ÒÃ¤Ñ´ËÅÑ§è äÁä´ÍÍ¡ÁÒàÍ§ (non-spontaneous) ËÃ×Íà¡Ô´¨Ò¡¡ÒÃºÕºà¤¹àµÒ¹ÁËÒ¡¼»Ù Ç Â
ÁÕÍÒÂØµèÓ¡ÇÒ 40 » áÅÐÍÍ¡ÁÒ¨Ò¡·Í¹éÓ¹ÁËÅÒÂæ ·Í¹Ñ¹é ¤ÇÃ¨ÐÁÕ¡ÒÃà½ÒµÔ´µÒÁÊÑ§à¡µÍÒ¡ÒÃ¢Í§¼»Ù Ç Âã¹¡ÅÁØ ¹Õé
ÃÇÁ·Ñ§é ¨ÐµÍ§ãË¤ÇÒÁÃáÙ ÅÐ¤ÇÒÁÊ¹ã¨á¡¼»Ù Ç ÂäÁá¹Ð¹ÓãËä»ºÕºËÃ×Í¡´à¹×Íé àµÒ¹ÁÍÕ¡µÍä» ÊÓËÃÑº¼»Ù Ç Â
·ÕÁè ÍÕ ÒÂØÁÒ¡¡ÇÒ 40 » á¹Ð¹ÓãË·Ó screening mammogram áÅÐ/ËÃ×Í ultrasound ÃÇÁ´ÇÂ áÅÐãË·Ó¡ÒÃÃÑ¡ÉÒ
µÒÁ¼Å¡ÒÃµÃÇ¨·Õäè ´ÃºÑ ÃÇÁ·Ñ§é µÍ§ãË¤ÇÒÁÃ¤Ù ÇÒÁà¢Òã¨àËÁ×Í¹ã¹¡ÅÁØ ¼»Ù Ç Â·ÕÍè ÒÂØ¹Í Â¡ÇÒ 40 »
ÅÑ¡É³Ð¢Í§ÊÒÃ¤Ñ´ËÅÑè§·ÕèµÍ§ãË¤ÇÒÁÊ¹ã¨à»¹¾ÔàÈÉ ¤×Í pathological discharge «Öè§ÁÕÅÑ¡É³Ð
¢Í§ÊÒÃ¤Ñ´ËÅÑ§è ·ÕÍè Í¡ÁÒ¤§·Õè â´ÂäÁä´à¡Ô´¨Ò¡¡ÒÃä»ºÕºà¤¹, ÍÍ¡ÁÒ¢Ò§ã´¢Ò§Ë¹Ö§è áÅÐÅÑ¡É³Ð·Õàè »¹ serous
sanguinous ËÃ×Í serosanguinous ÍÒ¨µÃÇ¨ guaiac test áÅÐ cytology à¾ÔÁè àµÔÁ¶ÒÍÂãÙ ¹Ê¶Ò¹·ÕÊè ÒÁÒÃ¶Ê§µÃÇ¨ä´
¶Ö§áÁ¼Å¡ÒÃµÃÇ¨ test ´Ñ§¡ÅÒÇ¶Òä´¼ÅÅº (negative result) ¡ç¨ÐµÍ§·Ó¡ÒÃµÃÇ¨ÃÑ¡ÉÒã¹ÅÓ´ÑºµÍä» à¹×Íè §¨Ò¡
äÁÊÒÁÒÃ¶ÇÔ¹¨Ô ©ÑÂáÂ¡¨Ò¡âÃ¤ÁÐàÃç§ÍÍ¡ä´ á¹Ð¹ÓãË·Ó duct excision ã¹¼»Ù Ç Â·ÕÁè ÍÕ Ò¡ÒÃ´Ñ§¡ÅÒÇ·Ø¡ÃÒÂ
ÍÒ¨·Ó ductography ¡Í¹¼ÒµÑ´à¾×èÍ»ÃÐâÂª¹ÊÓËÃÑº´ÙÅÑ¡É³Ð¤ÇÒÁ¼Ô´»¡µÔ·Õèà¡Ô´¢Öé¹ª¹Ô´¼Ô´»¡µÔ
ËÅÒÂµÓáË¹§ (multiple lesions)
ã¹¼»Ù Ç Â·ÕÁè Õ BI-RADS 4 ËÃ×Í 5 ¹Ñ¹é ¡ç¤ÇÃ¨ÐÁÕ¡ÒÃÊ§µÃÇ¨ÇÔ¹¨Ô ©ÑÂµÍ«Ö§è ¶Ò¼Å¢Í§¡ÒÃµÃÇ¨à»¹áºº
benign ËÃ×Í intermediate ¡ÒÃÊ§µÃÇ¨ ductography ¡çá¹Ð¹ÓãË·Ó¶ÒÍÂÙã¹Ê¶Ò¹·ÕèÊÒÁÒÃ¶Ê§µÃÇ¨ä´áÅÐ
¶Ò¨Ð¹Ó¼»Ù Ç Âä»¼ÒµÑ´·Ó duct excision áµ¶Ò ¼Å¡ÒÃµÃÇ¨¾ºÇÒà»¹ÁÐàÃç§ ¼»Ù Ç Â¡ç¤ÇÃ¨Ðä´ÃºÑ ¡ÒÃÃÑ¡ÉÒµÒÁ
á¹Ç·Ò§µÍä»
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Mastalgia
Abnormal ´ÙµÒÁá¹Ç·Ò§¡ÒÃ´ÙáÅ
àÃ×èÍ§ Abnormal Imaging
·ÓImaging µÒÁ¢Íº§ªÕé
Normal Reassure ± Medication
äÁÁÕÊÔè§¼Ô´»¡µÔ ¾Ô¨ÒÃ³Ò Imaging*
äÁä´·Ó Imaging Reassure ± Medication
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* ·Ó Imaging µÒÁ¢Íº§ªÕé
Mastalgia
ÍÒ¡ÒÃà¨çººÃÔàÇ³àµÒ¹Áà»¹ÍÒ¡ÒÃ·Õ¾è ººÍÂã¹¼ËÙ Ô§áÅÐÁÕ¤ÇÒÁÃØ¹áÃ§·Õáè µ¡µÒ§¡Ñ¹ä» áº§ÍÍ¡
à»¹ÍÒ¡ÒÃà¨çº·Õàè µÒ¹Á áÅÐà¨çººÃÔàÇ³ chest wall* «Ö§è ÍÒ¨¨ÐÃØ¹áÃ§ÁÒ¡¨¹ÁÕ¼ÅµÍ¤Ø³ÀÒ¾ªÕÇµÔ ä´ áÅÐÍÒ¨¨Ð
à»¹àÃ×Íé ÃÑ§ä´ºÍ Â æ
ÍÒ¡ÒÃà¨çºàµÒ¹ÁÍÒ¨µÃÇ¨¾ºÊÔ§è ¼Ô´»¡µÔÍ¹×è æ ÃÇÁ´ÇÂä´ àª¹ ¡Í¹ ¼»Ù Ç Â·ÕÁè ÍÕ Ò¡ÒÃà¨çºàµÒ¹Áà¾ÕÂ§
ÍÂÒ§à´ÕÂÇáÅÐäÁÁ¤Õ ÇÒÁ¼Ô´»¡µÔÍ¹×è ÊÇ¹ãËäÁä´ÁÊÕ ÒàËµØ¨Ò¡ÁÐàÃç§
á¹Ç·Ò§¡ÒÃ´ÙáÅÍÒ¡ÒÃà¨çºàµÒ¹Á¹Ñ¹é µÍ§µÃÇ¨»ÃÐàÁÔ¹ÇÒÁÕÊ§Ôè ¼Ô´»¡µÔÍ¹×è ÃÇÁ´ÇÂËÃ×ÍäÁ «Ö§è µÍ§
´ÙáÅä»µÒÁÊÔ§è ¼Ô´»¡µÔ¹¹Ñé àª¹ àÃ×Íè §¡Í¹, nipple discharge áµ¶Ò äÁÁÊÕ §Ôè ¼Ô´»¡µÔÍ¹×è ÃÇÁ´ÇÂ ãË¾¨Ô ÒÃ³Ò·Ó breast
imaging µÒÁ¢Íº§ªÕé (´Ùá¹Ç·Ò§¡ÒÃµÃÇ¨¤Ñ´¡ÃÍ§ÁÐàÃç§àµÒ¹Á)
ã¹¡Ã³Õ·Õè·Ó imaging ¶Ò¾ºÊÔè§¼Ô´»¡µÔ ãË´ÙáÅµÒÁá¹Ç·Ò§¡ÒÃÇÔ¹Ô¨©ÑÂ¹Ñé¹ áµ¶ÒäÁ¾ºÊÔè§¼Ô´»¡µÔ
¡çãË¤Óá¹Ð¹Ó¼»Ù Ç ÂáÅÐ¡ÒÃÃÑ¡ÉÒµÒÁ¤ÇÒÁ¨Óà»¹
ã¹¡Ã³Õ·ÕèäÁä´·Ó imaging áÅÐäÁ¾ºÊÔè§¼Ô´»¡µÔã´æ ãË¤Óá¹Ð¹Óà¡ÕèÂÇ¡ÑºÍÒ¡ÒÃà¨çºàµÒ¹ÁáÅÐ
¾Ô¨ÒÃ³ÒãË¡ÒÃÃÑ¡ÉÒµÒÁ¤ÇÒÁ¨Óà»¹
v v v
* Chest wall pain ËÁÒÂ¶Ö§ No pattern; any age; almost always unilateral; consider costochondritis (Tietze's syndrome), musculo-skeletal
origin, surgical trauma, referred pain.
01-53_pc22.pmd 37 19/2/2551, 20:58

á¹Ç·Ò§¡ÒÃÃÑ¡ÉÒÁÐàÃç§àµÒ¹Áâ´Â¡ÒÃ¼ÒµÑ´
á¹Ç·Ò§¡ÒÃÃÑ¡ÉÒÁÐàÃç§àµÒ¹Áâ´Â¡ÒÃ¼ÒµÑ´ áº§¡ÒÃÃÑ¡ÉÒµÒÁÃÐÂÐ¢Í§âÃ¤ (staging) ä´´§Ñ ¹Õé
Stage 0 (Pure Noninvasive Carcinomas)
1. Lobular Carcinoma In Situ (LCIS)
á¹Ð¹Ó¡ÒÃÃÑ¡ÉÒ LCIS ´ÇÂ¡ÒÃà½ÒÃÐÇÑ§ (surveillance)(1)
à¹×èÍ§¨Ò¡ LCIS ÁÕâÍ¡ÒÊà¡Ô´ invasive carcinoma µèÓ (»ÃÐÁÒ³ 21% over 15 years) ÍÂÒ§äÃ
¡çµÒÁ¼»Ù Ç Â¡ÅÁØ ¹Õµé Í §¹Ñ´ÁÒµÔ´µÒÁ¡ÒÃÃÑ¡ÉÒâ´Â¡ÒÃµÃÇ¨ÃÒ§¡ÒÂ·Ø¡ 6-12 à´×Í¹ áÅÐ ·Ó mammogram »ÅÐ¤ÃÑ§é
¹Í¡¨Ò¡¹ÕÍé Ò¨¾Ô¨ÒÃ³Ò risk reduction «Ö§è ã¹»¨¨Øº¹Ñ ÁÕ¢Í á¹Ð¹Ó 2 ÇÔ¸Õ
1. â´Â¡ÒÃãªÂÒ à¾×Íè Å´âÍ¡ÒÊà¡Ô´ invasive carcinoma «Ö§è á¹Ð¹ÓãËÂÒ´Ñ§¹Õé
- tamoxifen(2) à»¹àÇÅÒ 5 »
- ÊÇ¹ÂÒµÑÇÍ×¹è àª¹ ¡ÅÁØ aromatase inhibitors ã¹¢³Ð¹ÕÂé §Ñ ÁÕ¢Í ÁÙÅäÁà¾ÕÂ§¾Í(1, 3)
2. â´Â¡ÒÃ¼ÒµÑ´ ¡ÒÃ·Ó bilateral prophylactic mastectomies ± reconstruction ¨Ðãªà»¹
ºÒ§¡Ã³Õà·Ò¹Ñé¹ àª¹ã¹¼Ù»ÇÂ high risk, äÁÂÍÁÃÑºÍÑµÃÒàÊÕèÂ§·Õèà¾ÔèÁ¢Öé¹¢Í§¡ÒÃà»¹ÁÐàÃç§àµÒ¹Á·Ñé§ÊÍ§¢Ò§
ã¹Í¹Ò¤µ áÅÐ¤ÇÃµÑ´àµÒ¹ÁÍÍ¡·Ñ§é 2 ¢Ò§ à¾ÃÒÐÇÒâÍ¡ÒÊà¡Ô´ invasive carcinoma ã¹¼»Ù Ç Â LCIS ¨Ðà·Ò¡Ñ¹·Ñ§é
2 ¢Ò§ (8-11 à·Ò¢Í§»ÃÐªÒ¡Ã·ÑÇè ä» ËÃ×Í»ÃÐÁÒ³ 1% µÍ», subsequent carcinoma à»¹ invasive ductal ÁÒ¡¡ÇÒ
lobular carcinoma)(4)
Í¹Öè§¡ÒÃ·Ó mastectomy ± contralateral breast biopsy ã¹»¨¨ØºÑ¹äÁ¹ÔÂÁáÅÇ à¹×èÍ§¨Ò¡¼Ù»ÇÂ
ÊÇ¹ãË·àÕè »¹ LCIS ÁÕâÍ¡ÒÊà¡Ô´ invasive carcinoma µèÓ ¡ÒÃ·Ó mastectomy ÁÕ¢Í àÊÕÂÁÒ¡¡ÇÒáÅÐà»Å×Í§¤Òãª¨Ò Â
ÊÇ¹¡ÒÃµÑ´ªÔ¹é à¹×Íé ¨Ò¡àµÒ¹ÁÍÕ¡¢Ò§¡çÍÒ¨¨ÐäÁä´µÓáË¹§·Õàè »¹ÁÐàÃç§ âÍ¡ÒÊ¢Í§¡ÒÃà¡Ô´ÁÐàÃç§ÂÑ§¤§à·Òà´ÔÁ(5)
2. Ductal Carcinoma In Situ (DCIS)
¡ÒÃÃÑ¡ÉÒÁÕ·Ò§àÅ×Í¡´Ñ§¹Õé
1. Total mastectomy ± reconstruction
2. Wide local excision + radiotherapy
3. Wide local excision alone
¡ÒÃÃÑ¡ÉÒâ´Â total mastectomy à»¹·ÕèÂÍÁÃÑºÇÒä´¼Å´Õ (survival 98-99%) ÁÕâÍ¡ÒÊà¡Ô´ local
recurrence (0-2%) ä´¹Í Â¡ÇÒÇÔ¸ÍÕ ¹×è æ ´Ñ§¹Ñ¹é DCIS ·Ø¡¢¹Ò´ËÃ×ÍËÅÒÂµÓáË¹§ÊÒÁÒÃ¶àÅ×Í¡ãªÇ¸Ô ¹Õ Õé
¡ÒÃÃÑ¡ÉÒâ´Â wide local excision + radiotherapy ÁÕâÍ¡ÒÊà¡Ô´ local recurrence ¹ÍÂ¡ÇÒ¡ÒÃ·Ó
wide local excision à¾ÕÂ§ÍÂÒ§à´ÕÂÇ ¤×Í ¨Ò¡ 10.4% à»¹ 7.5% ·Õè 5 »(6, 7) ¨Ö§à»¹·ÕÂè ÍÁÃÑºä´ áÅÐ overall survival
¡çà·Ò¡Ñº¡ÒÃÃÑ¡ÉÒâ´Â total mastectomy ¡ÒÃ·Ó¼ÒµÑ´¤ÇÃä´ free margin áÅÐµÒÁ´ÇÂ¡ÒÃ©ÒÂáÊ§(7) «Öè§
ÇÔ¸¹Õ äÕé ÁàËÁÒÐ¶ÒÁÕ DCIS ËÅÒÂµÓáË¹§ ËÃ×Í¡Í¹âµÁÒ¡áÅÐ¼»Ù Ç ÂµÍ§äÁÁ¢Õ Í ËÒÁã¹¡ÒÃ©ÒÂáÊ§
¡ÒÃÃÑ¡ÉÒâ´Â wide local excision alone ãªã¹¤¹ä¢·ÁÕè ¡Õ Í ¹àÅç¡¡ÇÒ 0.5 à«¹µÔàÁµÃ, low grade,
noncomedonecrosis ¹Í¡¨Ò¡¹ÕÂé §Ñ µÍ§¤Ó¹Ö§¶Ö§ ÍÒÂØ¢Í§¼»Ù Ç Â áÅÐ margin ¢Í§¡ÒÃ¼ÒµÑ´´ÇÂ(8)
01-53_pc22.pmd 38 19/2/2551, 20:58

äÁá¹Ð¹ÓãË·Ó axillary dissection ã¹¼Ù»ÇÂ DCIS à¾ÃÒÐâÍ¡ÒÊ·Õè¨Ð¾ºÁÕ¡ÒÃ¡ÃÐ¨ÒÂä»µÍÁ

¹éÓàËÅ×Í§ÁÕ¹Í Â (1.7%)(9) à¹×Íè §¨Ò¡¡ÒÃ·Ó sentinel node biopsy ·Óä´§Ò ÂáÅÐ¼Åá·Ã¡«Í¹µèÓ ¶Ò¼»Ù Ç ÂàÅ×Í¡ÇÔ¸Õ
mastectomy ÍÒ¨¾Ô¨ÒÃ³Ò·Ó sentinel lymph node biopsy(10-12) ¼Ù»ÇÂ DCIS ·ÕèÁÕ microinvasion á¹Ð¹ÓãË·Ó
sentinel lymph node biopsy ÃÇÁ´ÇÂ ¶Ò·Ó sentinel lymph node biopsy äÁä´ ¤ÇÃ·Ó axillary lymph node
dissection
¼Ù»ÇÂ DCIS µÍ§¹Ñ´ÁÒµÔ´µÒÁ¡ÒÃÃÑ¡ÉÒâ´Â¡ÒÃµÃÇ¨ÃÒ§¡ÒÂ·Ø¡ 6 à´×Í¹ áÅÐ·Ó mammogram
»ÅÐ¤ÃÑ§é ¹Í¡¨Ò¡¹ÕÍé Ò¨¾Ô¨ÒÃ³ÒãË tamoxifen à»¹àÇÅÒ 5 » à¾×Íè Å´âÍ¡ÒÊà¡Ô´ invasive carcinoma (Å´¨Ò¡ 13%
à»¹ 8.8% ·ÕèÃÐÂÐàÇÅÒ 5 »)(13, 14)
Stage I, IIA, IIB Invasive Breast Cancer

¡ÒÃÃÑ¡ÉÒÁÕ·Ò§àÅ×Í¡´Ñ§¹Õé
1. Total mastectomy + axillary management* ± reconstruction àª¹ Total mastectomy + sentinel
lymph node biopsy, Modified radical mastectomy (MRM)
2. Breast conserving therapy (BCT) ËÁÒÂ¶Ö§¡ÒÃ·Ó breast conserving surgery ÃÇÁ¡Ñº axillary
management* áÅÐ radiotherapy) ¶ÒäÁÁ¢Õ Í ËÒÁ (´ÙË¹Ò 41)
¡ÒÃ¼ÒµÑ´·Ñ§é ÊÍ§ÇÔ¸ÁÕ Õ overall survival à·Ò¡Ñ¹(15-22) ¨ÐàÅ×Í¡ãªÇ¸Ô ãÕ ´¢Ö¹é ÍÂ¡Ù ºÑ ¡ÒÃµÑ´ÊÔ¹ã¨¢Í§¼»Ù Ç Â
áÅÐ·ÕÁá¾·Â¼·Ù Ó¡ÒÃÃÑ¡ÉÒ
Í¹Öè§ã¹¡Ã³Õ·Õè¼Ù»ÇÂ stage IIA (T2 N0 M0) áÅÐ stage IIB (T2 N1 M0, T3 N0 M0) ¶ÒÁÕ¤ÇÒÁ
»ÃÐÊ§¤¨Ðà¡çºàµÒ¹ÁáÅÐäÁÁÕ¢ÍËÒÁ¢Í§¡ÒÃ·Ó breast conserving therapy (BCT) ÍÒ¨¾Ô¨ÒÃ³Ò¡ÒÃãË
preoperative systemic therapy à¾×Íè ·ÓãË¡Í ¹ÁÐàÃç§ÁÕ¢¹Ò´àÅç¡Å§ à»¹ÍÕ¡·Ò§àÅ×Í¡Ë¹Ö§è (23, 24)
Stage III Invasive Breast Cancer

· Operable Locally Advanced Breast Cancer
¡ÒÃ¼ÒµÑ´ÃÑ¡ÉÒÁÕ·Ò§àÅ×Í¡´Ñ§¹Õé
1. Modified radical mastectomy ? reconstruction
2. Preoperative systemic therapy + BCT or MRM ¶ÒäÁÊÒÁÒÃ¶·Ó BCT ä´ ¨ÐàÅ×Í¡ãªÇÔ¸Õã´
¢Ö¹é ÍÂ¡Ù ºÑ ¡ÒÃµÑ´ÊÔ¹ã¨¢Í§¼»Ù Ç ÂÃÇÁ¡Ñº·ÕÁá¾·Â¼·Ù Ó¡ÒÃÃÑ¡ÉÒ
· Inoperable Locally Advanced Breast Cancer
¼Ù»ÇÂ¡ÅØÁ¹Õé¤ÇÃä´ÃÑº¡ÒÃÃÑ¡ÉÒâ´Â preoperative systemic therapy áÅÇµÒÁ´ÇÂ¡ÒÃ¼ÒµÑ´«Öè§ÁÕ
·Ò§àÅ×Í¡´Ñ§¹Õé
1. Modified radical mastectomy ± reconstruction
* ¡ÒÃ·Ó axillary management ãË´ÃÙ ÒÂÅÐàÍÕÂ´ã¹Ë¹Ò 40
01-53_pc22.pmd 39 19/2/2551, 20:58

2. Breast conserving therapy

¨ÐàÅ×Í¡ãªÇ¸Ô ãÕ ´¢Ö¹é ÍÂ¡Ù ºÑ ¡ÒÃµÑ´ÊÔ¹ã¨¢Í§¼»Ù Ç ÂÃÇÁ¡Ñº·ÕÁá¾·Â¼·Ù Ó¡ÒÃÃÑ¡ÉÒ
Stage IV Metastatic Breast Cancer

¡ÒÃÃÑ¡ÉÒ stage IV breast cancer à»¹¡ÒÃÃÑ¡ÉÒ´ÇÂ systemic â´Â¡ÒÃãª chemotherapy áÅÐ/ËÃ×Í
hormonal therapy à»¹ËÅÑ¡ ãË´ÃÙ ÒÂÅÐàÍÕÂ´ã¹á¹Ç·Ò§¡ÒÃÃÑ¡ÉÒ¢Í§¡ÒÃãªÂÒ
º·ºÒ·¢Í§ÈÑÅÂ¡ÃÃÁÁÕà¾ÕÂ§à¾×èÍãËä´¡ÒÃÇÔ¹Ô¨©ÑÂ·Õèá¹¹Í¹ ËÃ×Íà»¹ local control áÅÐÃÑ¡ÉÒµÒÁ
ÍÒ¡ÒÃàª¹ ã¹ÃÒÂ·ÕÁè ÁÕ ÐàÃç§¡ÃÐ¨ÒÂä»·Õ¡è ÃÐ´Ù¡ÍÒ¨¨Óà»¹µÍ§¼ÒµÑ´´ÒÁ¡ÃÐ´Ù¡ÃÇÁ¡ÑºÃÑ§ÊÕÃ¡Ñ ÉÒ ã¹ÃÒÂ·ÕÁè ÁÕ ÐàÃç§
¡ÃÐ¨ÒÂä»·ÕÊè ÁÍ§ÍÒ¨¾Ô¨ÒÃ³ÒãË¡ÒÃÃÑ¡ÉÒâ´Â¡ÒÃ¼ÒµÑ´¶Òà»¹¡Í¹à´ÕÂÇáÅÐäÁÁ¡Õ ÒÃ¡ÃÐ¨ÒÂä»ÂÑ§ÍÇÑÂÇÐÊÓ¤Ñ
Í×¹è æ ã¹ÃÒÂ·ÕÁè Õ massive pleural effusion ÃÑ¡ÉÒâ´Â pleural tapping and pleurodesis à»¹µ¹
Local recurrent Breast Cancer

¼Ù»ÇÂ·Õèä´ÃÑº¡ÒÃ¼ÒµÑ´áºº mastectomy àÁ×èÍÁÕ local recurrence â´Â·ÕèäÁÁÕ¡ÒÃ¡ÃÐ¨ÒÂä»·ÕèÍ×è¹
¶ÒÊÒÁÒÃ¶¼ÒµÑ´ä´¤ÇÃä´ÃÑº¡ÒÃÃÑ¡ÉÒâ´Â¡ÒÃ¼ÒµÑ´àÍÒ local recurrence ÍÍ¡â´ÂãËä´ free margin áÅÇ
µÒÁ´ÇÂ¡ÒÃ©ÒÂÃÑ§ÊÕ ã¹¡Ã³Õ·ÕèäÁä´ÃÑº¡ÒÃ©ÒÂÃÑ§ÊÕÁÒ¡Í¹ËÃ×ÍÃÑ§ÊÕá¾·Â¾Ô¨ÒÃ³ÒãË©ÒÂÃÑ§ÊÕ (´Ù·ÕèË¹Ò 48)
ËÅÑ§¨Ò¡¹Ñ¹é ¤ÇÃ¾Ô¨ÒÃ³ÒãË systemic treatment ËÃ×Í¡ÒÃÃÑ¡ÉÒ´ÇÂÇÔ¸ÍÕ ¹×è æ µÒÁ¤ÇÒÁàËÁÒÐÊÁµÍä»
¼Ù»ÇÂ·Õèä´ÃÑº¡ÒÃ¼ÒµÑ´áºº BCT àÁ×èÍÁÕ local recurrence â´Â·ÕèäÁÁÕ¡ÒÃ¡ÃÐ¨ÒÂä»·ÕèÍ×è¹ ¤ÇÃä´ÃÑº
¡ÒÃÃÑ¡ÉÒâ´Â¡ÒÃ·Ó total mastectomy ËÃ×ÍÍÒ¨·Ó lumpectomy ÍÕ¡¤ÃÑ§é Ë¹Ö§è ä´ áÅÇµÒÁ´ÇÂ¡ÒÃÃÑ¡ÉÒÇÔ¸ÍÕ ¹×è æ
µÒÁ¤ÇÒÁàËÁÒÐÊÁ
¢ÍËÒÁ¢Í§¡ÒÃ·Ó BCT (contraindications for BCT)

1. Prior radiotherapy to the breast or chest wall
2. RT during pregnancy
3. Diffuse suspicious or malignant appearing microcalcifications
4. Widespread disease that cannot be incorporated by local excision through a single incision that
achieves negative margins with a satisfactory cosmetic result
5. Positive pathologic margin
Axillary management ÁÕ 2 ·Ò§àÅ×Í¡ ¤×Í

1. ¡ÒÃ·Ó axillary lymph node dissection (ALND) ãË·Óã¹ÃÐ´Ñº level I áÅÐ level II ¨Ð·Ó¶Ö§ level
III àÁ×Íè ¤ÅÓµÍÁ¹éÓàËÅ×Í§ä´áÅÐÊ§ÊÑÂÇÒÁÕ¡ÒÃá¾Ã¡ÃÐ¨ÒÂä»¶Ö§ level II ¢³Ð·Ó¡ÒÃ¼ÒµÑ´ áÅÐ¡ÒÃ·Ó ALND
¤ÇÃä´µÍ Á¹éÓàËÅ×Í§äÁ¹Í Â¡ÇÒ 10 µÍÁ
01-53_pc22.pmd 40 19/2/2551, 20:58

2. ¡ÒÃ·Ó sentinel lymph node biopsy (SLNB) à» ¹ ÍÕ ¡ ·Ò§àÅ× Í ¡á·¹ ALND ã¹¡Ã³Õ ·Õè
¤Ò´ÇÒäÁÁ¡Õ ÒÃ¡ÃÐ¨ÒÂ¢Í§ÁÐàÃç§ä»ÂÑ§µÍÁ¹éÓàËÅ×Í§·ÕÃè ¡Ñ áÃ
á¹Ç·Ò§¡ÒÃ»¯ÔºµÑ àÔ Á×Íè ·ÃÒº¼Å¡ÒÃµÃÇ¨ sentinel node

1. ¶Ò sentinel node negative (äÁÁÕ metastasis) äÁá¹Ð¹ÓãË·Ó axillary lymph node dissection
2. ¶Ò sentinel node ¾ºÁÕ isolated tumor cell (< 0.2 mm.) äÁá¹Ð¹ÓãË·Ó axillary lymph node
dissection
3. ¶Ò sentinel node ¾ºÁÕ micrometastasis (> 0.2 mm áµ < 2 mm) ÍÒ¨¾Ô¨ÒÃ³Ò·Ó axillary lymph
node dissection
4. ¶Ò sentinel node positive (ÁÕ metastasis > 2 mm.) á¹Ð¹ÓãË·Ó axillary lymph node dissection
level I/II ÍÂÒ§äÃ¡çµÒÁàÃÔÁè ÁÕ¢Í ÁÙÅÇÒÍÒ¨¨ÐäÁ¨Óà»¹µÍ§·Ó axillary lymph node dissection
5. ¶ÒËÒ sentinel node äÁ¾ºá¹Ð¹ÓãË·Ó axillary lymph node dissection level I/II
Oncoplastic Breast Surgery(25)

ã¹¡ÒÃÃÑ¡ÉÒ¼»Ù Ç ÂÁÐàÃç§àµÒ¹Á´ÇÂÇÔ¸¡Õ ÒÃ¼ÒµÑ´ ÍÒ¨¹Óà·¤¹Ô¤ Oncoplastic surgery ã¹ÃÙ»áººµÒ§ æ
ÁÒ¾Ô¨ÒÃ³ÒµÒÁ¤ÇÒÁàËÁÒÐÊÁáÅÐ¤ÇÒÁµÍ§¡ÒÃ¢Í§¼»Ù Ç ÂáµÅÐºØ¤¤Å à¾×Íè »ÃÐâÂª¹ã¹¡ÒÃà¾ÔÁè ¤Ø³ÀÒ¾ªÕÇµÔ
â´ÂãË¤Ó¹Ö§¶Ö§»¨¨ÑÂ´Ñ§µÍä»¹Õé
- µÍ§äÁÁ¼Õ ÅàÊÕÂµÍÍÑµÃÒ¡ÒÃ¡ÅÑº«éÓ¢Í§âÃ¤ áÅÐÍÑµÃÒ¡ÒÃÃÍ´ªÕÇµÔ ÃÇÁ¶Ö§¡ÒÃµÃÇ¨µÔ´µÒÁ¡ÒÃ
ÃÑ¡ÉÒ
- äÁ¤ÇÃ·ÓãËà¡Ô´¤ÇÒÁÅÒªÒã¹¡ÒÃãË¡ÒÃÃÑ¡ÉÒàÊÃÔÁ â´ÂÊÒÁÒÃ¶·Óã¹¼Ù»ÇÂ·Õè·Ó Breast
conserving surgery ËÃ×Í Total mastectomy «Öè§ÊÒÁÒÃ¶·Óä´·Ñ¹·Õã¹¡ÒÃ¼ÒµÑ´¤ÃÑé§à´ÕÂÇ¡Ñ¹ËÃ×Í¾Ô¨ÒÃ³Ò·Ó·Õ
ËÅÑ§¡ÒÃÃÑ¡ÉÒàÊÃÔÁä´
Oncoplastic in Breast conserving surgery

ã¹¼Ù»ÇÂ·ÕèµÍ§¡ÒÃà¡çºàµÒ¹Áà´ÔÁäÇ ÍÒ¨¾Ô¨ÒÃ³Ò¹Óà·¤¹Ô¤ oncoplastic ÁÒªÇÂÅ´¡ÒÃà¡Ô´ Breast
deformity à¾ÔÁè ¤ÇÒÁÊÁ´ØÅ¢Í§àµÒ¹Á·Ñ§é ÊÍ§¢Ò§ ªÇÂà¾ÔÁè margin ËÃ×ÍªÇÂãË¡ÒÃ©ÒÂáÊ§§ÒÂ¢Ö¹é â´ÂÍÒ¨¾Ô¨ÒÃ³Ò
ã¹ÃÒÂ·ÕÁè ÅÕ ¡Ñ É³Ð´Ñ§¹Õé
- resection of more than 20% of the breast volume;
- central, medial and lower pole resections;
- axillary dissection through lumpectomy incision;
- periareolar incisions in inferior quadrants;
- incomplete mobilization of breast parenchyma to allow reshaping of the breast.
01-53_pc22.pmd 41 19/2/2551, 20:58

Breast reconstruction
¡ÒÃ·Ó Breast reconstruction ÊÒÁÒÃ¶·Óä´·§Ñé Immediate ËÃ×Í Delayed reconstruction ã¹¡ÒÃ·Ó Im-
mediate breast reconstruction ¡ÒÃ·Ó Skin sparing mastectomy ¾ºÇÒ¼Åã¹¡ÒÃ¨Ñ´¡ÒÃ Primary tumor
ãË¼Åà·ÕÂºà·Ò¡ÒÃ·Ó Standard mastectomy á¹Ð¹ÓÇÒäÁ¤ÇÃ·Ó immediate breast reconstruction ã¹¼»Ù Ç ÂµÍä»¹Õé
- Non-resectable local chest wall disease
- Rapidly progressive systemic disease
- Patients who have serious co-morbidity
- Patients who are psychologically unsuitable
References
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Apr;225(4):370-6.
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carcinoma in situ?: analysis of 587 cases. Breast Cancer Res Treat. 2006 Aug;98(3):311-4.
11. Veronesi P, Intra M, Vento AR, Naninato P, Caldarella P, Paganelli G, et al. Sentinel lymph node biopsy for localised ductal carcinoma
in situ? Breast. 2005 Dec;14(6):520-2.
12. Zavagno G, Carcoforo P, Marconato R, Franchini Z, Scalco G, Burelli P, et al. Role of axillary sentinel lymph node biopsy in patients
with pure ductal carcinoma in situ of the breast. BMC Cancer. 2005 Mar 11;5:28.
13. Fisher B, Dignam J, Wolmark N, Wickerham DL, Fisher ER, Mamounas E, et al. Tamoxifen in treatment of intraductal breast cancer:
National Surgical Adjuvant Breast and Bowel Project B-24 randomised controlled trial. Lancet. 1999 Jun 12;353(9169):1993-2000.
14. Fisher B, Land S, Mamounas E, Dignam J, Fisher ER, Wolmark N. Prevention of invasive breast cancer in women with ductal carcinoma
in situ: an update of the national surgical adjuvant breast and bowel project experience. Semin Oncol. 2001 Aug;28(4):400-18.
15. Fisher B et al: Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation
for the treatment of invasive breast cancer, N Engl J Med 2002; 347:1233.
01-53_pc22.pmd 42 19/2/2551, 20:58

16. Veronesi U et al: Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early
breast cancer, N Engl J Med 2002; 347:1227.
17. Jacobson JA et al: Ten-year results of a comparison of conservation with mastectomy in the treatment of stage I and II breast cancer, N
Engl J Med 1995; 332:951.
18. Van Dongen JA et al: Factors influencing local relapse and survival and results of salvage treatment after breast conserving therapy in
operable breast cancer: EORTC trial 1081, breast conservation compared with mastectomy in TNM stage I and II breast cancer, Eur J
Cancer 1992; 28:801.
19. Van Dongen JA et al: Randomized clinical trial to assess the value of breast-conserving therapy in stage I and II breast cancer: EORCT
1080 trial, J Natl Cancer Inst 1992; 11: 15.
20. Bilchert-Toft M et al: Danish randomized trial comparing breast conservation therapy with mastectomy: six years of life-table analysis,
J Natl Cancer Inst Monogr 1992; 11:19.
21. Arriagada R et al, for the Institute Gustave Roussy Breast Cancer Group: Conservative treatment versus mastectomy in early breast
cancer: patterns of failure with 15 years of follow-up data, J Clin Oncol 1996; 14:1558.
22. Early Breast Cancer Trialists' Collaborative Group: Effects of radiotherapy and surgery in early breast cancer: an overview of the
randomized trials, N Engl J Med 1995; 333:1444.
23. Van der Hage JA et al: Preoperative chemotherapy in primary operable breast cancer: results from the European Organization for
Research and Treatment of Cancer trial 10902, J Clin Oncol 2001; 19: 4224.
24. Fisher B et al: Effect of preoperative chemotherapy on local-regional disease in women with operable breast cancer: findings from
National Surgical Adjuvant Breast and Bowel Project B-18, J Clin Oncol 1997; 15: 2483.
25. Oncoplastic breast surgery e A guide to good practice, Association of Breast Surgery at BASO, BAPRAS and the Training Interface
Group in Breast Surgery / EJSO 33 (2007) S1eS23
v v v
01-53_pc22.pmd 43 19/2/2551, 20:58

á¹Ç·Ò§ÃÑ§ÊÕÃÑ¡ÉÒã¹¼Ù»ÇÂÁÐàÃç§àµÒ¹Á
(Radiation Therapy for Breast Cancer)
¡ÒÃÃÑ¡ÉÒÁÐàÃç§àµÒ¹ÁãËä´¼Å´Õ à»¹·Õ·è ÃÒº¡Ñ¹´ÕÇÒ µÍ§ãª¡ÒÃÃÑ¡ÉÒ´ÇÂ¡ÒÃ¼ÒµÑ´

¡ÒÃ©ÒÂÃÑ§ÊÕ à¤ÁÕºÓºÑ´ áÅÐ/ËÃ×Í ÎÍÃâÁ¹ºÓºÑ´
º·ºÒ·¡ÒÃãªÃ§Ñ ÊÕÃ¡Ñ ÉÒã¹¼»Ù Ç ÂÁÐàÃç§àµÒ¹Á áº§ÍÍ¡à»¹¡ÅÁØ ´Ñ§¹Õ¤é Í×
1. Postmastectomy Radiotherapy (PMRT)
2. Breast Conserving Therapy (BCT)
2.1 Invasive Breast Cancer
2.2 Ductal Carcinoma In Situ
3. Locally Advanced Breast Cancer
4. Palliative Radiation Therapy
5. Locoregional Recurrence Breast Cancer
6. Ovarian Castration
1. Postmastectomy Radiotherapy
à»¹·ÕÂè ÍÁÃÑº¡Ñ¹áÅÇÇÒ¡ÒÃ¼ÒµÑ´ modified radical mastectomy à»¹¡ÒÃÃÑ¡ÉÒËÅÑ¡·Õ¶è Í× à»¹¡ÒÃÃÑ¡ÉÒ
áººÁÒµÃ°Ò¹ÊÓËÃÑº¼Ù»ÇÂÁÐàÃç§àµÒ¹Á·Õèà»¹ operable breast cancer(1) ÍÂÒ§äÃ¡çµÒÁÁÕ¼Ù»ÇÂ¨Ó¹Ç¹Ë¹Öè§
ÂÑ§¤§ÁÕ¡ÒÃ¡ÅÑºà»¹«éÓ¢Í§âÃ¤à¡Ô´¢Ö¹é ·Õºè ÃÔàÇ³á¼Å¼ÒµÑ´º¹Ë¹ÒÍ¡áÅÐµÍÁ¹éÓàËÅ×Í§¢Ò§à¤ÕÂ§(2)
¨Ò¡¡ÒÃÈÖ¡ÉÒÃÒÂ§Ò¹ÍØºµÑ ¡Ô ÒÃ³¡ÒÃ¡ÅÑºà»¹«éÓ¢Í§âÃ¤à©¾ÒÐ·Õè (locoregional recurrence) ËÅÑ§¨Ò¡
¡ÒÃ·Ó modified radical mastectomy ¾ºÇÒ¢Ö¹é ¡Ñº T áÅÐ N stage(2-5)
ÊÇ¹ãË¨Ðà¡Ô´¡ÒÃ¡ÅÑºà»¹«éÓ·ÕèºÃÔàÇ³ chest wall áÅÐ supraclavicular nodes ÊÇ¹µÓáË¹§Í×è¹æ
¾ºä´¹Í Â ¹Í¡¨Ò¡¹ÕÊé §Ôè ÊÓ¤Ñ¤×Í àÁ×Íè ÁÕ¡ÒÃ¡ÅÑºà»¹«éÓ¢Í§âÃ¤à©¾ÒÐ·Õáè ÅÇ ¨Ð¡ÍãËà¡Ô´ÍÒ¡ÒÃÍÑ¹äÁ¾§Ö »ÃÐÊ§¤
ËÃ×Í¤ÇÒÁ·Ø¡¢·ÃÁÒ¹µÍ¼Ù»ÇÂ àª¹ ÁÕ ulceration, bleeding, pain, arm edema ËÃ×ÍÍÒ¨ÁÕ brachial plexus
compression áÅÐÁÑ¡¨ÐäÁÊÒÁÒÃ¶¤Çº¤ØÁâÃ¤ä´
ÃÒÂ§Ò¹¡ÒÃÈÖ¡ÉÒ¡ÒÃãªÃÑ§ÊÕÃÑ¡ÉÒËÅÑ§¡ÒÃ·Ó¼ÒµÑ´ mastectomy ¾ºÇÒÊÒÁÒÃ¶Å´ÍØºÑµÔ¡ÒÃ³¡ÅÑº
à»¹«éÓ¢Í§âÃ¤à©¾ÒÐ·ÕèÅ§ä´ÍÂÒ§ÁÕ¹ÑÂÊÓ¤Ñ·Ò§Ê¶ÔµÔ â´Â¨ÐÅ´ÍØºÑµÔ¡ÒÃ³¡ÅÑºà»¹«éÓ¢Í§âÃ¤ä´ÍÂÒ§¹ÍÂ
¤ÃÖ§è Ë¹Ö§è ¶Ö§ÊÍ§ã¹ÊÒÁ¢Í§¼»Ù Ç Â·Õàè »¹¡ÅÁØ high risk(6-9)
»¨¨Øº¹
Ñ ¢Íº§ªÕ¢é Í§¡ÒÃãË postmastectomy radiotherapy ÁÕ´§Ñ ¹Õ¤é Í×
1. Four or more positive axillary lymph nodes
01-53_pc22.pmd 44 19/2/2551, 20:58

2. ³ T3 tumor
3. Positive or close (< 1-2 mm) surgical margins (µÒÁ´ØÅÂ¾Ô¹¨Ô ¢Í§á¾·Â¼ÃÙ ¡Ñ ÉÒ)
4. Pectoral fascia involvement
5. Grossly extracapsular invasion (fixed or matted nodes)
ËÁÒÂàËµØ: ÊÒÁÒÃ¶ãË postmastectomy radiotherapy µÒÁ´ØÅÂ¾Ô¹¨Ô ¢Í§á¾·Â¼ÃÙ ¡Ñ ÉÒã¹¡Ã³Õ
1. 1-3 positive axillary nodes â´Â´ÙµÒÁ»¨¨ÑÂàÊÕÂè § ä´á¡ inadequate axillary lymph node
dissection, T size, grade, margin, ÍÒÂØ ÏÅÏ
2. T2 tumor àÁ×Íè à·ÕÂº¡Ñº¢¹Ò´àµÒ¹Á¢Í§¼»Ù Ç ÂáÅÇÁÕ¢¹Ò´ãË ËÃ×ÍÁÕÀÒÇÐ extensive
lymphovascular invasion
á¹Ð¹ÓãËàÃÔèÁÃÑ§ÊÕÃÑ¡ÉÒ ÀÒÂã¹ 4-8 ÊÑ»´ÒË ËÅÑ§¼ÒµÑ´ áµËÒ¡ÁÕ¤ÇÒÁ¨Óà»¹µÍ§ãËà¤ÁÕºÓºÑ´´ÇÂ
ÊÒÁÒÃ¶àÃÔÁè ÃÑ§ÊÕÃ¡Ñ ÉÒËÅÑ§ãËÂÒà¤ÁÕºÓºÑ´¤ÃºáÅÇ áµäÁ¤ÇÃà¡Ô¹ 6 à´×Í¹ËÅÑ§¼ÒµÑ´
Locoregional Treatment after Mastectomy

Radiation to chest wall
and supraclavicular/
infraclavicular area*
(Category 1)
Strongly consider radiation to
1-3 positive nodes chest wall and supraclavicular/
infraclavicular area *
Total mastectomy Negative nodes and Radiation to chest wall

with surgical Tumor > 5 cm Margins Consider radiation to
axillary staging positive supraclavicular/infravicular area
(Category 3)
Negative nodes and

tumor £ 5 cm and Consider radiation to chest wall
margins close (<1-2 mm)
Negative nodes and

tumor £ 5 cm and No postoperative radiation
margins > 1-2 mm
* Internal mammary node radiation for clinical or pathological internal mammary node positive, otherwise the treatment to the internal
mammary field is at the discretion of radiation oncologist. (Category 2B)
01-53_pc22.pmd 45 19/2/2551, 20:58

Radiation in Breast Reconstruction

Cosmetic result ¨Ð´Õ¡ÇÒ áÅÐ complication ¹ÍÂ¡ÇÒ ¶ÒãªÇÔ¸Õ autologous tissue reconstruction
àÁ×Íè à·ÕÂº¡ÑºÇÔ¸Õ prosthesis
2. Breast Conserving Therapy

µÑ§é áµ» ¤.È. 1980 ÁÕ¡ÒÃÈÖ¡ÉÒ¾ºÇÒ Breast conserving surgery (BCS) ÃÇÁ¡Ñº¡ÒÃ©ÒÂÃÑ§ÊÕ·àÕè µÒ¹Á
ä´¼Å¡ÒÃÃÑ¡ÉÒà·Ò¡Ñº¡ÒÃ·Ó mastectomy(10-16) áµËÒ¡·Ó¼ÒµÑ´ BCS ÍÂÒ§à´ÕÂÇâ´ÂäÁÁÕ¡ÒÃ©ÒÂÃÑ§ÊÕ·ÕèàµÒ¹Á
ÃÇÁ´ÇÂ ¨ÐÁÕ¡ÒÃ¡ÅÑºà»¹«éÓ¢Í§âÃ¤·Õàè µÒ¹ÁÊÙ§ 30-40%
á¹Ð¹ÓãËàÃÔèÁÃÑ§ÊÕÃÑ¡ÉÒ ÀÒÂã¹ 4-8 ÊÑ»´ÒËËÅÑ§¼ÒµÑ´ áµËÒ¡ÁÕ¤ÇÒÁ¨Óà»¹µÍ§ãËà¤ÁÕºÓºÑ´´ÇÂ
ÊÒÁÒÃ¶àÃÔÁè ÃÑ§ÊÕÃ¡Ñ ÉÒËÅÑ§ãËÂÒà¤ÁÕºÓºÑ´¤ÃºáÅÇ áµäÁ¤ÇÃà¡Ô¹ 6 à´×Í¹ËÅÑ§¼ÒµÑ´
2.1 Invasive Breast Cancer
Radiation to whole breast and

³ 4 positive nodes supraclavicular/infra clavicular area*
(Category 1) ± boost to tumor bed
Lumpectomy and Radiation to whole breast ± boost

surgical axillary 1-3 positive nodes to tumor bed (Category 1) Consider
staging radiation to supraclavicular/
infraclavicular area* (Category 2B)
Radiation to whole breast ± boost

Negative nodes to tumor bed (Category 1) or Partial
Breast Irradiation (PBI) in selected
patients
* Internal mammary node radiation for clinical or pathological internal mammary node positive, otherwise the treatment to the internal
mammary field is at the discretion of radiation oncologist. (Category 2B)
ËÁÒÂàËµØ: á¹Ð¹ÓãË Boost tumor bed ã¹¼Ù»ÇÂ·ÕèÁÕ»¨¨ÑÂàÊÕèÂ§µÍ¡ÒÃà¡Ô´ Local failure ´Ñ§¹Õé ÍÒÂØ
¹ÍÂ¡ÇÒ 50 » positive axillary nodes, lymphovascular invasion, close margins
01-53_pc22.pmd 46 19/2/2551, 20:58

2.2 Ductal Carcinoma in Situ (DCIS)(17-19)
Wide excision Radiation to whole breast*

(Category 1) ± boost to tumor bed
DCIS Wide excision Without radiation to whole breast (Category 2B)
Total mastectomy no radiation
* Radiation to the whole breast reduces recurrence rates about 50%. Factors determine risk of local recurrence include tumor size, grade,
margin, and age.
3. Locally Advanced Breast Cancer(20-22)

Locally advanced breast cancer ä´á¡ T3-4 Tumor, N2-3 Tumor ·ÕèäÁÁÕ distant metastasis
¼Ù»ÇÂ¡ÅØÁ¹Õé¶ÒãË¡ÒÃÃÑ¡ÉÒà©¾ÒÐ·Õèà¾ÕÂ§ÍÂÒ§à´ÕÂÇ¾ºÇÒ 80% ¢Í§¼Ù»ÇÂ¨Ðà¡Ô´¡ÒÃá¾Ã¡ÃÐ¨ÒÂ¢Í§âÃ¤
¡ÒÃÃÑ¡ÉÒ¨Ö§ãªà»¹ combined modality therapy â´ÂãË Neoadjuvant Systemic Therapy µÒÁ´ÇÂ¡ÒÃ¼ÒµÑ´
áÅÐ©ÒÂÃÑ§ÊÕºÃÔàÇ³ chest wall ËÃ×Í breast áÅÐ supraclavicular area
ËÒ¡ËÅÑ§¨Ò¡¡ÒÃãË Neoadjuvant Systemic Therapy áÅÇÂÑ§äÁÊÒÁÒÃ¶¼ÒµÑ´ä´ ¾Ô¨ÒÃ³ÒãËÃÑ§ÊÕ·Õè
breast áÅÐ supraclavicular area(23) áÅÇ¾Ô¨ÒÃ³Ò¼ÒµÑ´¶Ò·Óä´
4. Palliative Radiation Therapy

¼Ù»ÇÂÁÐàÃç§àµÒ¹Á·ÕèÁÕ¡ÒÃá¾Ã¡ÃÐ¨ÒÂ¢Í§âÃ¤ ¡ÍãËà¡Ô´ÍÒ¡ÒÃÍÑ¹äÁ¾Ö§»ÃÐÊ§¤ ·ÓãË¼Ù»ÇÂÁÕ
¤Ø³ÀÒ¾ªÕÇµÔ ·Õáè ÂÅ§ ÃÑ§ÊÕÃ¡Ñ ÉÒÁÕº·ºÒ·ÊÓ¤Ñ¤×Í ÁÕ»ÃÐÊÔ·¸ÔÀÒ¾·Õ´è ãÕ ¹¡ÒÃÅ´ÍÒ¡ÒÃ·Ø¡¢·ÃÁÒ¹¢Í§¼»Ù Ç Â àª¹
ÀÒÇÐµÍä»¹Õé
1. ¡ÒÃá¾Ã¡ÃÐ¨ÒÂ¢Í§ÁÐàÃç§àµÒ¹Áä»·Õ¡è ÃÐ´Ù¡áÅÐ¡ÍãËà¡Ô´ÍÒ¡ÒÃ»Ç´ à»¹ÀÒÇÐ·Õ¾è ººÍÂ·ÕÊè ´Ø
¡ÒÃ©ÒÂÃÑ§ÊÕà¾×èÍºÃÃà·ÒÍÒ¡ÒÃ»Ç´ »Í§¡Ñ¹¡ÃÐ´Ù¡ËÑ¡ËÃ×Í¡ÒÃÂØºµÑÇ¢Í§¡ÃÐ´Ù¡äÁãËä»¡´ä¢ÊÑ¹ËÅÑ§ à»¹
ÇÔ¸¡Õ ÒÃÃÑ¡ÉÒ·Õäè ´¼Å´Õ·ÊÕè ´Ø ÇÔ¸ËÕ ¹Ö§è ¹Í¡¨Ò¡¹ÕÂé §Ñ à»¹ÇÔ¸¡Õ ÒÃ·Õ§è Ò Â ÊÐ´Ç¡ »ÃÐËÂÑ´ ãªàÇÅÒ¡ÒÃÃÑ¡ÉÒÊÑ¹é ÊÇ¹ÁÒ¡
¨Ðãª»ÃÔÁÒ³ÃÑ§ÊÕ 20 Gy / 5F / wk ËÃ×Í 30 Gy / 10 F / 2 wks(24-25) ËÃ×ÍÍÒ¨ãªà»¹ single fraction 8-10 Gy
ÊÓËÃÑº¼Ù»ÇÂ·ÕèÁÕ life span ÊÑé¹ à´Ô¹·Ò§ÅÓºÒ¡ ËÃ×Íã¹ºÃÔàÇ³·Õè©ÒÂÃÑ§ÊÕÁÕ¢¹Ò´àÅç¡áÅÐäÁÁÕÍÇÑÂÇÐÊÓ¤Ñ·ÕèäÇ
µÍÃÑ§ÊÕ
2. ¡ÒÃá¾Ã¡ÃÐ¨ÒÂ¢Í§ÁÐàÃç§àµÒ¹ÁÊÙÊÁÍ§ ¶Òà»¹ solitary lesion ÍÂÙã¹µÓáË¹§·ÕèÊÒÁÒÃ¶·Ó
¼ÒµÑ´ä´â´Â§ÒÂ ÍÒ¨¾Ô¨ÒÃ³Ò·Ó¼ÒµÑ´¡Í¹ÍÍ¡áÅÇµÒÁ´ÇÂ¡ÒÃ©ÒÂÃÑ§ÊÕ áµ¶Òà»¹ multiple brain metastasis
01-53_pc22.pmd 47 19/2/2551, 20:58

¹ÔÂÁãª palliative whole brain radiation â´Âãª»ÃÔÁÒ³ÃÑ§ÊÕ 30 Gy / 10F / 2 wks. áÅÐÍÒ¨¾Ô¨ÒÃ³Ò local tumor
boost ´ÇÂ stereotactic radiotherapy (SRT) ËÃ×Í stereotactic radiosurgery (SRS) ã¹¡Ã³Õ·ÕèÁÕ brain metastasis
äÁà¡Ô¹ 3 lesions(26-29)
3. ¡ÒÃá¾Ã¡ÃÐ¨ÒÂ¢Í§ÁÐàÃç§àµÒ¹ÁÊÙµÍÁ¹éÓàËÅ×Í§ã¹ªÍ§·ÃÇ§Í¡ ÍÒ¨¡ÍãËà¡Ô´ÍÒ¡ÒÃ superior
vena cava obstruction (SVCO) ÃÑ§ÊÕÃÑ¡ÉÒ¡çà»¹¡ÒÃÃÑ¡ÉÒÇÔ¸ÕË¹Öè§·ÕèÁÕ»ÃÐÊÔ·¸ÔÀÒ¾áÅÐä´¼ÅàÃçÇ ÊÇ¹ãËãª
»ÃÔÁÒ³ÃÑ§ÊÕ 30 Gy / 10F / 2 wks.
5. Locoregional Recurrence
¼Ù»ÇÂÁÐàÃç§àµÒ¹Á·ÕèÁÕâÃ¤¡ÅÑºà»¹«éÓà©¾ÒÐ·Õèà¾ÕÂ§ÍÂÒ§à´ÕÂÇ áº§ÍÍ¡à»¹ 2 ¡ÅØÁ¤×Í ¡ÅØÁ·Õèä´ÃÑº
¡ÒÃÃÑ¡ÉÒáºº mastectomy ¡Ñº¡ÅÁØ ·Õäè ´ÃºÑ ¡ÒÃÃÑ¡ÉÒáºº BCT ÁÒ¡Í¹
¼»Ù Ç Â·ÕÃè ºÑ ¡ÒÃÃÑ¡ÉÒáºº mastectomy
- ¶Ò·Ó¼ÒµÑ´ä´ ¤ÇÃ¾Ô¨ÒÃ³Ò¼ÒµÑ´¡Í¹ÁÐàÃç§ÍÍ¡áÅÇµÒÁ´ÇÂ¡ÒÃ©ÒÂÃÑ§ÊÕ ¶ÒäÁà¤Â©ÒÂÃÑ§ÊÕ
ÁÒ¡Í¹
- ã¹¡Ã³Õ·Õèà¤Â©ÒÂÃÑ§ÊÕÁÒ¡Í¹ ËÒ¡¾Ô¨ÒÃ³ÒáÅÇÇÒ¡ÒÃ©ÒÂÃÑ§ÊÕ«éÓ¹Ñé¹»ÅÍ´ÀÑÂáÅÐà¡Ô´
»ÃÐâÂª¹µÍ ¼»Ù Ç ÂÊÒÁÒÃ¶©ÒÂÃÑ§ÊÕ«éÓä´
- ¶Ò·Ó¼ÒµÑ´äÁä´ãËãªÃ§Ñ ÊÕÃ¡Ñ ÉÒ(30-31)
- ÊÓËÃÑº Systemic treatmentãË¾¨Ô ÒÃ³Òà»¹ÃÒÂæ ä»(32-34)
¼»Ù Ç Â·ÕÃè ºÑ ¡ÒÃÃÑ¡ÉÒáºº BCT
- ¤ÇÃ·Ó¡ÒÃ¼ÒµÑ´µÒÁ´ØÅÂ¾Ô¹Ô¨¢Í§ÈÑÅÂá¾·Â ÊÇ¹¡ÒÃ©ÒÂÃÑ§ÊÕáÅÐ Systemic treatment ãË
¾Ô¨ÒÃ³Òà»¹ÃÒÂæ ä»(32-34)
6. Ovarian Castration
ÊÒÁÒÃ¶ãªã¹¼Ù»ÇÂ Premenopause ·ÕèÁÕ¡ÒÃá¾Ã¡ÃÐ¨ÒÂ¢Í§âÃ¤áÅÐ Hormone Receptor Positive
â´Â©ÒÂÃÑ§ÊÕ¤ÃÍº¤ÅØÁ true pelvis dose 14 - 20 Gy ã¹ 4-5 ¤ÃÑ§é ¢Ö¹é ÍÂ¡Ù ºÑ ÊÀÒ¾ áÅÐÀÒÇÐ»ÃÐ¨Óà´×Í¹¢Í§ ¼»Ù Ç Â(35)
à·¤¹Ô¤¡ÒÃ©ÒÂÃÑ§ÊÕ(36, 37)
1. ¡ÒÃ©ÒÂÃÑ§ÊÕºÃÔàÇ³ chest wall ËÃ×Í intact breast (ÃÙ»·Õè 1)
â´Âãª medial áÅÐ lateral tangential portals ¤ÃÍº¤ÅØÁ chest wall ËÃ×Í whole breast áÅÐ¾ÂÒÂÒÁãË
ÃÑ§ÊÕ¶¡Ù à¹×Íé »Í´áÅÐËÑÇã¨ãË¹Í Â·ÕÊè ´Ø ÁÕ¢Íºà¢µ¢Í§ field ´Ñ§¹Õé
- Upper margin : ¢ÍºÅÒ§¢Í§ clavicular head
- Medial margin : midline ËÃ×Í¢ÒÁ midline ä»´Ò¹µÃ§¢ÒÁ»ÃÐÁÒ³ 1 à«¹µÔàÁµÃ
- Lateral margin : mid axillary line ËÃ×Í»ÃÐÁÒ³ 2 à«¹µÔàÁµÃ ¨Ò¡¢Íº¢Ò§¢Í§ breast tissue
01-53_pc22.pmd 48 19/2/2551, 20:58

- Inferior margin : 1-2 à«¹µÔàÁµÃ ãµµÍ inframammary fold

- »ÃÔÁÒ³ÃÑ§ÊÕ 45-50 Gy / 25 F / 5 wks ËÃ×Í 42.5 Gy / 16 F(38)
- ¶Òà»¹ BCT ¾Ô¨ÒÃ³Ò boost tumor bed 10-20 Gy / 5-10 F
ÃÙ»·Õè 1 ÀÒ¾áÊ´§à·¤¹Ô¤¡ÒÃ©ÒÂÃÑ§ÊÕ·àÕè µÒ¹ÁËÃ×ÍË¹ÒÍ¡ áÅÐ Supraclavicular area
2. Supraclavicular area (ÃÙ»·Õè 2)

à»¹¡ÒÃ©ÒÂÃÑ§ÊÕà¾×Íè ¤Çº¤ØÁâÃ¤ºÃÔàÇ³µÍÁ¹éÓàËÅ×Í§·ÕÍè ÂàÙ Ë¹×ÍáÅÐãµ µÍ¡ÃÐ´Ù¡äË»ÅÒÃÒáÅÐ
ºÒ§ÊÇ¹¢Í§µÍÁ¹éÓàËÅ×Í§ºÃÔàÇ³ÃÑ¡áÃ
- Inferior border: 1st ËÃ×Í 2nd intercostal space ¢¹Ò¹¡Ñº upper margin ¢Í§ chest wall field
- Medial border: 1 à«¹µÔàÁµÃ ¨Ò¡ midline ¢¹Ò¹¢Ö¹é ä»µÒÁ¢Íºã¹¢Í§ sternocleidomastoid
muscle ¶Ö§ÃÐ´Ñº thyrocricoid groove
- Superior border: ÃÐ´Ñº¢Í§ thyroid groove
- Lateral border: vertical line ·ÕÃè Ð´Ñº lateral edge ¢Í§ coracoid process
- »ÃÔÁÒ³ÃÑ§ÊÕ·Õèãª 45-50 Gy / 25 F / 5 wks ËÃ×Í 42.5 Gy / 16 F
01-53_pc22.pmd 49 19/2/2551, 20:58

ÃÙ»·Õè 2 ÀÒ¾àÍ¡«àÃÂ¢Íºà¢µ¢Í§¡ÒÃ©ÒÂ Supraclavicular area
A. B.
ÃÙ»·Õè 3 ¡ÒÃ¨Ñ´·Ò¼»Ù Ç Â¢³Ð©ÒÂÃÑ§ÊÕ·àÕè µÒ¹Á
3. Internal mammary node field

- Medial border : midline ËÃ×Í 1 à«¹µÔàÁµÃ ¢ÒÁ midline ä»´Ò¹µÃ§¢ÒÁ
- Lateral border : 5-6 à«¹µÔàÁµÃ Lateral µÍ midline
- Inferior border : ÃÐ´Ñº xiphoid ËÃ×Í 3 upper intercostal spaces
- Superior border : ¢¹Ò¹¡Ñº inferior border ¢Í§ supraclavicular field
- »ÃÔÁÒ³ÃÑ§ÊÕ·ãÕè ª 45-50 Gy / 25F / 5 wks ¤Ô´·Õ¤è ÇÒÁÅÖ¡ 3-4 à«¹µÔàÁµÃ ¨Ò¡¼ÔÇË¹Ñ§
01-53_pc22.pmd 50 19/2/2551, 20:58

ÊÓËÃÑº axillary recurrence ¾ºä´»ÃÐÁÒ³ 0.5-3% à·Ò¹Ñ¹é ËÅÑ§¨Ò¡¡ÒÃ·Ó axillary dissection of level
I áÅÐ II ËÃ×Í¾º axillary recurrence à¾ÕÂ§ 1% ã¹¼Ù»ÇÂ·ÕèÁÕ axillary positive 1-3 nodes ·Õè¼ÒµÑ´µÍÁ
¹éÓàËÅ×Í§·ÕÃè ¡Ñ áÃÍÍ¡ÁÒ 10 nodes áÅÐ¾ºÇÒÁÕ axillary recurrence ä´ 6% ã¹¼»Ù Ç Â·ÕÁè Õ axillary positive 1-3 nodes
·Õè¼ÒµÑ´µÍÁ¹éÓàËÅ×Í§·ÕèÃÑ¡áÃÍÍ¡ÁÒ 4 nodes(39-42) ´Ñ§¹Ñé¹¨Ö§äÁÁÕ¤ÇÒÁ¨Óà»¹µÍ§©ÒÂÃÑ§ÊÕºÃÔàÇ³ÃÑ¡áÃ Â¡àÇ¹
áµäÁÊÒÁÒÃ¶¼ÒµÑ´µÍÁ¹éÓàËÅ×Í§ÍÍ¡ä´ËÁ´ ,ã¹¡Ã³Õ·ÁÕè Õ clinical matted axillary nodes , extracapsular invasion
ÍÒ¨¾Ô¨ÒÃ³Ò©ÒÂÃÑ§ÊÕ·Õè axilla ´ÇÂ
¾Ô¨ÒÃ³Òãª¡ÒÃ©ÒÂÃÑ§ÊÕÊÒÁÁÔµÔ ¶Ò¡ÒÃ©ÒÂÃÑ§ÊÕÊÍ§ÁÔµÔ·ÓãË»Í´áÅÐËÑÇã¨ä´ÃÑº»ÃÔÁÒ³ÃÑ§ÊÕÊÙ§
·Ñ§é ¹Õ¢é ¹Öé ÍÂ¡Ù ºÑ ´ØÅÂ¾Ô¹¨Ô ¢Í§á¾·Â¼ÃÙ ¡Ñ ÉÒ(43)
Sequencing of Systemic Therapy and Radiotherapy

¡Ã³Õ·ÕèµÍ§ãË¡ÒÃÃÑ¡ÉÒàÊÃÔÁ·Ñé§ÂÒà¤ÁÕºÓºÑ´áÅÐÃÑ§ÊÕÃÑ¡ÉÒËÅÑ§¼ÒµÑ´ »¨¨ØºÑ¹ÁÕ¢ÍÁÙÅ¡ÒÃÈÖ¡ÉÒ
·ÕÃè ÒÂ§Ò¹ÇÒÊÒÁÒÃ¶ãËÃ§Ñ ÊÕÃ¡Ñ ÉÒËÅÑ§¨Ò¡ãËÂÒà¤ÁÕºÓºÑ´¨¹¤ÃºáÅÇ ¤×Í»ÃÐÁÒ³ 6 à´×Í¹ËÅÑ§¼ÒµÑ´ â´ÂäÁ¾º
ÁÕ¤ÇÒÁáµ¡µÒ§ã¹ÍØºµÑ ¡Ô ÒÃ³¡ÅÑºà»¹«éÓ¢Í§âÃ¤à©¾ÒÐ·Õáè µÍÂÒ§ã´ àÁ×Íè à·ÕÂº¡Ñº¡ÅÁØ ·Õãè ËÃ§Ñ ÊÕÃ¡Ñ ÉÒËÅÑ§¼ÒµÑ´
·Ñ¹·Õ (ÊÇ¹ãËàÃÔÁè ÀÒÂã¹ 4-8 ÊÑ»´ÒËËÅÑ§¼ÒµÑ´) áµ¼»Ù Ç Â¡ÅÁØ ¹Õµé Í §à»¹ negative resected margins(44-47)
ã¹¡Ã³Õ·Õè positive resected margins ¢Ñ¹é µÍ¹¡ÒÃÃÑ¡ÉÒàÊÃÔÁãËÍÂãÙ ¹´ØÅÂ¾Ô¹¨Ô ¢Í§·ÕÁá¾·Â¼ÃÙ ¡Ñ ÉÒ
¶Ò¡ÒÃÃÑ¡ÉÒàÊÃÔÁà»¹ÎÍÃâÁ¹ºÓºÑ´ÊÒÁÒÃ¶àÃÔÁè ¡ÒÃ©ÒÂÃÑ§ÊÕä»¾ÃÍÁ¡ÑºÎÍÃâÁ¹ºÓºÑ´ä´·¹Ñ ·Õ(48-49)
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Cancer J Sci Am 1999; 5: 147-149.
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v v v
01-53_pc22.pmd 53 19/2/2551, 20:58

á¹Ç·Ò§¡ÒÃÃÑ¡ÉÒàÊÃÔÁËÅÑ§¼ÒµÑ´ã¹¼Ù»ÇÂÁÐàÃç§àµÒ¹ÁÃÐÂÐáÃ¡
(Guideline for Adjuvant Systemic Therapy in Early Breast Cancer)
¤ÓÊÓ¤Ñ
1. ÁÐàÃç§àµÒ¹ÁÃÐÂÐáÃ¡ (early stage breast cancer) ¼Ù»ÇÂ·ÕèÁÕÃÍÂâÃ¤ÍÂÙà©¾ÒÐ·ÕèàµÒ¹ÁáÅÐ/
ËÃ×ÍµÍÁ¹éÓàËÅ×Í§·ÕÃè ¡Ñ áÃ ÂÑ§äÁÁ¡Õ ÒÃá¾Ã¡ÃÐ¨ÒÂÅØ¡ÅÒÁÁÒÂÑ§¼ÔÇË¹Ñ§ ËÃ×ÍµÍÁ¹éÓàËÅ×Í§·Õºè ÃÔàÇ³Í×¹è ËÃ×Í·Õè
ÍÇÑÂÇÐ·ÕËè Ò §ä¡ÅÍÍ¡ä»
2. ¡ÒÃÃÑ¡ÉÒàÊÃÔÁËÅÑ§¼ÒµÑ´´ÇÂÇÔ¸·Õ Ò§ÂÒ (systemic adjuvant therapy) à»¹¡ÒÃÃÑ¡ÉÒ´ÇÂà¤ÁÕºÓºÑ´
ÂÒµÒ¹ÎÍÃâÁ¹ËÃ×ÍÂÒ Targeted therapy â´ÂãËËÅÑ§¨Ò¡¼»Ù Ç Âä´ÃºÑ ¡ÒÃÃÑ¡ÉÒà©¾ÒÐ·Õ¤è Í× ¡ÒÃ¼ÒµÑ´ÁÐàÃç§ÍÍ¡
ä»·Ñ§é ËÁ´áÅÇ áÅÐ¼»Ù Ç ÂµÍ§äÁÁÃÕ ÍÂâÃ¤·Õàè ËÅ×ÍÍÂËÙ ÅÑ§¼ÒµÑ´
¨Ø´»ÃÐÊ§¤¢Í§¡ÒÃÃÑ¡ÉÒ
à¾×èÍà¾ÔèÁÃÐÂÐàÇÅÒÃÍ´ªÕÇÔµâ´Â»ÅÍ´âÃ¤ (Disease free survival) áÅÐà¾ÔèÁÃÐÂÐàÇÅÒ¡ÒÃÃÍ´ªÕÇÔµ
(overall survival)
ª¹Ô´¢Í§¡ÒÃÃÑ¡ÉÒã¹ adjuvant systemic therapy

1. Adjuvant hormonal therapy à»¹¡ÒÃÃÑ¡ÉÒâ´ÂãªÂÒµÒ¹ÎÍÃâÁ¹ ÁÕ»ÃÐâÂª¹áÅÐÁÕ¢Í º§ªÕÊé ÓËÃÑº
ÁÐàÃç§àµÒ¹Á·Õµè ´Ô µÑÇÃÑº·Ò§ÎÍÃâÁ¹à·Ò¹Ñ¹é (hormone responsive breast cancer)
2. Adjuvant anti-HER2 therapy à»¹¡ÒÃÃÑ¡ÉÒâ´ÂãªÂÒµÒ¹ÂÕ¹¡ÍÁÐàÃç§·ÕèÊÓ¤Ñ¤×Í HER2 ÂÕ¹
¡ÒÃÃÑ¡ÉÒâ´ÂÇÔ¸¹Õ ÁÕé ¢Õ Í º§ªÕàé ©¾ÒÐÁÐàÃç§àµÒ¹Á·ÕÁè ¡Õ ÒÃáÊ´§ÍÍ¡¼Ô´»¡µÔ¢Í§ÂÕ¹ HER2 à·Ò¹Ñ¹é (HER2 positive
breast cancer)
3. Adjuvant chemotherapy à»¹¡ÒÃÃÑ¡ÉÒâ´ÂãªÂÒà¤ÁÕºÓºÑ´ ¾Ô¨ÒÃ³ÒãËÊÓËÃÑº¼»Ù Ç Â·ÕÁè ¤Õ ÇÒÁàÊÕÂè §
ã¹¡ÒÃ¡ÅÑºà»¹«éÓÊÙ§ ·Ñ§é ¹Õ¢é ¹Öé ÍÂ¡Ù ºÑ ¡ÒÃ¾Ô¨ÒÃ³Ò¤ÇÒÁàÊÕÂè §ã¹¼»Ù Ç Âã¹áµÅÐÃÒÂ
»¨¨ÑÂ·Õèá¾·ÂµÍ§»ÃÐàÁÔ¹áÅÐ·ÃÒº¡Í¹¡ÒÃµÑ´ÊÔ¹ã¨ãË¡ÒÃÃÑ¡ÉÒ adjuvant
systemic therapy
1. Host factors ä´á¡ ÍÒÂØ, ÊÀÒÇÐ»ÃÐ¨Óà´×Í¹ (menopausal status), co-morbid diseases áÅÐ
performance status
2. Tumor factors ä´á¡ tumor size, tumor grading, lymphovascular invasion, surgical margins, lymph
node status áÅÐ¡ÒÃÂÍÁ¾ÔàÈÉ·ÕÊè Ó¤Ñ¢Í§ÁÐàÃç§àµÒ¹Á·Õ¤è ÇÃµÍ§·ÃÒº¡Í¹¡ÒÃÃÑ¡ÉÒ¤×Í HR (hormone receptor
status«Ö§è ä´á¡ ER, PgR status) , HER2 áÅÐ Ki-67
54-117_pc22.pmd 54 19/2/2551, 20:59

Adjuvant Systemic Therapy in Early Breast Cancer Algorithm(1)

¢Ñ¹
é µÍ¹áÃ¡
- ¨Óá¹¡¼»Ù Ç Âà»¹ 3 ¡ÅÁØ â´Âãª»¨ ¨ÑÂ·Ó¹ÒÂ¼Å¡ÒÃÃÑ¡ÉÒ (predictive markers) ¤×Í HR (hormone
receptor status) áÅÐ HER2 status
- ¨Ò¡¢Ñ¹é µÍ¹¹ÕÊé ÒÁÒÃ¶áº§¼»Ù Ç ÂÍÍ¡ä´à»¹ 3 ¡ÅÁØ ¤×Í HR positive disease, HER2 positive disease
áÅÐ triple negative disease
¢Ñ¹
é µÍ¹·ÕÊè Í§
- ¾Ô¨ÒÃ³Òá¹Ç·Ò§¡ÒÃÃÑ¡ÉÒËÅÑ¡µÒÁµÒÃÒ§·Õè 1
µÒÃÒ§·Õè 1 áÊ´§¡ÒÃ¨Óá¹¡¼Ù»ÇÂÁÐàÃç§àµÒ¹ÁÃÐÂÐáÃ¡ ¤Ó¨Ó¡Ñ´¤ÇÒÁÊÓËÃÑº¼Ù»ÇÂáµÅÐ¡ÅØÁ

áÅÐá¹Ç·Ò§¡ÒÃÃÑ¡ÉÒËÅÑ¡ÊÓËÃÑº¼»Ù Ç Â
¡ÅÁØ ¼»Ù Ç Â ¤Ó¨Ó¡Ñ´¤ÇÒÁ (definition) á¹Ç·Ò§ËÅÑ¡ã¹¡ÒÃÃÑ¡ÉÒ

Hormone receptor positive Any ER stainingA Endocrine therapy
breast cancer
HER 2 positive breast cancer HER 2 positiveB Anti-HER2 therapy
Triple negative breast cancer ER and PgR and HER2 negative Chemotherapy
A
Endocrine responsive breast cancer ã¹»¨¨Øº¹Ñ ËÁÒÂ¶Ö§ ER áÅÐ/ËÃ×Í PgR positive äÁÇÒ ¨ÐµÔ´ã¹»ÃÔÁÒ³à·Òã´¡çµÒÁ
B
Standard definition of HER2 positive µÒÁ ASCO CAP guideline ¤×Í IHC 3+ (> 30% of tumor cells with intense and complete membrane
staining) ËÃ×Í FISH positive > /= 2.2 ËÃ×Í CISH >/= 6
- à¹×Íè §¨Ò¡â´ÂÁÒ¡áÅÇ¼»Ù Ç ÂáµÅÐÃÒÂÍÒ¨µÍ§¡ÒÃÇÔ¸¡Õ ÒÃÃÑ¡ÉÒÁÒ¡¡ÇÒË¹Ö§è ÇÔ¸´Õ §Ñ á¹Ç·Ò§ã¹¡ÒÃ

¾Ô¨ÒÃ³Ò¡ÒÃÃÑ¡ÉÒÂÍÂµÒÁµÒÃÒ§·Õè 2
µÒÃÒ§·Õè 2 á¹Ç·Ò§¡ÒÃÃÑ¡ÉÒÊÓËÃÑº¼»Ù Ç ÂáµÅÐ¡ÅÁØ
ÇÔ¸Õ¡ÒÃÃÑ¡ÉÒËÅÑ¡ ¡ÅÁØ ¼»Ù Ç Â·Õàè ËÁÒÐÊÁÊÓËÃÑº¡ÒÃÃÑ¡ÉÒ ¤ÓÍ¸ÔºÒÂà¾ÔÁè àµÔÁ

¡ÒÃÃÑ¡ÉÒ´ÇÂÂÒµÒ¹ÎÍÃâÁ¹ ÁÕ¢Í º§ªÕãé ¹¼»Ù Ç Â·Õàè ¹×Íé §Í¡µÔ´µÑÇÃÑº·Ò§
(endocrine therapy) ÎÍÃâÁ¹äÁÇÒ ¨ÐµÔ´ã¹»ÃÔÁÒ³à·Òã´¡çµÒÁ
¡ÒÃÃÑ¡ÉÒ´ÇÂÂÒµÒ¹ HER2 ÁÕ¢Í º§ªÕãé ¹¼»Ù Ç Â·ÕÁè ¡Õ ÒÃáÊ´§ÍÍ¡
(Anti-HER2 therapy) ¢Í§ÂÕ¹¡ÍÁÐàÃç§ HER2 â´Âà©¾ÒÐÊÓËÃÑº ÂÒµÒ¹HER2 ÁÕ¤ÇÒÁ¨Óà»¹
¼»Ù Ç Â·ÕÁè ¤Õ ÇÒÁàÊÕÂè §ã¹¡ÒÃ¡ÅÑºà»¹«éÓÊÙ§C µÍ§ãËÃÇ Á¡Ñºà¤ÁÕºÓºÑ´D
54-117_pc22.pmd 55 19/2/2551, 20:59

µÒÃÒ§·Õè 2 á¹Ç·Ò§¡ÒÃÃÑ¡ÉÒÊÓËÃÑº¼»Ù Ç ÂáµÅÐ¡ÅÁØ (µÍË¹Ò 55)

ÇÔ¸Õ¡ÒÃÃÑ¡ÉÒËÅÑ¡ ¡ÅÁØ ¼»Ù Ç Â·Õàè ËÁÒÐÊÁÊÓËÃÑº¡ÒÃÃÑ¡ÉÒ ¤ÓÍ¸ÔºÒÂà¾ÔÁè àµÔÁ
¡ÒÃÃÑ¡ÉÒ´ÇÂÂÒà¤ÁÕºÓºÑ´ ÁÕ¢Í º§ªÕÊé ÓËÃÑº¼»Ù Ç Â·ÕÁè ÅÕ ¡Ñ É³ÐµÍä»¹Õé ÊÓËÃÑº¼»Ù Ç Â·Õµè ´Ô µÑÇÃÑº·Ò§
(Chemotherapy) 1. ¼»Ù Ç ÂÊÇ¹ãË·äÕè Áµ´Ô µÑÇÃÑºã´æã¹¼ÔÇ ÎÍÃâÁ¹¹Ñ¹é à¤ÁÕºÓºÑ´äÁÁÕ
à«ÅÅ (Triple negative breast cancer) ¤ÇÒÁ¨Óà»¹ÊÓËÃÑº·Ø¡ÃÒÂ
2. ¼»Ù Ç Â·ÕÁè ¡Õ ÒÃáÊ´§ÍÍ¡¢Í§ÂÕ¹ HER2 â´Âà©¾ÒÐÍÂÒ§ÂÔ§è ã¹¼»Ù Ç Â
â´ÂãËÃÇ Á¡ÑºÂÒµÒ¹ HER2 ·ÕÁè ¤Õ ÇÒÁàÊÕÂè §ã¹¡ÒÃ¡ÅÑº
3. ÊÓËÃÑº¼»Ù Ç ÂºÒ§ÃÒÂ·Õµè ´Ô µÑÇÃÑº·Ò§ à»¹«éÓ¹ÍÂËÃ×Í»Ò¹¡ÅÒ§
ÎÍÃâÁ¹·ÕÁè ¤Õ ÇÒÁàÊÕÂè §ã¹¡ÒÃ¡ÅÑºà»¹«éÓ
ÊÙ§ (HR positive breast cancer with high
risk of recurrence)E
C
äÁÁ¢Õ Í ÁÙÅ·Õªè ´Ñ à¨¹ÊÓËÃÑº¡ÒÃãªÂÒµÒ¹ HER2 ã¹¼»Ù Ç Â·Õäè ÁÁ¡Õ ÒÃ¡ÃÐ¨ÒÂä»ÂÑ§µÍÁ¹éÓàËÅ×Í§áÅÐÁÕ¢¹Ò´¹ÍÂ¡ÇÒ 1 à«¹µÔàÁµÃ
D
äÁÁ¢Õ Í ÁÙÅÊÓËÃÑº¡ÒÃãªà¾ÕÂ§ÂÒµÒ¹ HER2 ¤¡Ù ºÑ à©¾ÒÐÂÒµÒ¹ÎÍÃâÁ¹ã¹¡ÒÃÃÑ¡ÉÒàÊÃÔÁËÅÑ§¼ÒµÑ´
E
á¹Ç·Ò§¡ÒÃ¾Ô¨ÒÃ³Ò¤ÇÒÁàÊÕÂè §ã¹¡ÒÃ¡ÅÑºà»¹«éÓÊÓËÃÑº¼»Ù Ç Â HR positive ãË´µÙ ÒÁµÒÃÒ§·Õè 3
µÒÃÒ§·Õè 3 á¹Ç·Ò§¡ÒÃ¾Ô¨ÒÃ³Ò¤ÇÒÁàÊÕÂè §ÊÓËÃÑº¼»Ù Ç Â hormonal receptor positive à¾×Íè µÑ´ÊÔ¹ã¨

¡ÒÃãËÂÒà¤ÁÕºÓºÑ´àÊÃÔÁËÅÑ§¼ÒµÑ´
»¨¨ÑÂà¡ÕÂè Ç¡Ñº¼»Ù Ç Â »¨¨ÑÂº§ªÕÇé Ò ¼»Ù Ç ÂÁÕ »¨¨ÑÂ·Õäè ÁªÇ Âã¹ »¨¨ÑÂ·Õºè § ªÕÇé Ò ¼»Ù Ç ÂÁÕ
áÅÐÅÑ¡É³Ð·Ò§ ¤ÇÒÁàÊÕÂè §ÊÙ§ ¤ÇÃä´ÃºÑ ¡ÒÃµÑ´ÊÔ¹ã¨ÇÒ¨ÐãË ¤ÇÒÁàÊÕèÂ§µèÓáÅÐäÁ
ªÔ¹é à¹×Íé ¢Í§ÁÐàÃç§ ÂÒà¤ÁÕºÓºÑ´àÊÃÔÁ¡Ñº à¤ÁÕºÓºÑ´àÊÃÔÁÃÇÁ ¨Óà»¹µÍ§ä´ÃºÑ à¤ÁÕ
(Clinicopathological ÂÒµÒ¹ÎÍÃâÁ¹ ¡ÑºÂÒµÒ¹ÎÍÃâÁ¹ ºÓºÑ´àÊÃÔÁÃÇÁ¡Ñº
features) (Relative indications (Factors not useful ÂÒµÒ¹ÎÍÃâÁ¹
for chemoendocrine for decision) (Relative indications for
therapy) endocrine therapy alone)
ER and PgR Lower ER and PgR level Higher ER and PgR level
Histological grade Grade 3 (poorly differentiated) Grade 2 (moderately) Grade 1 (well differentiated)
Proliferation index High Intermediate Low
Nodes Positive (>/= 4 nodes) Positive 1 - 3 nodes Negative
PVI Presence of extensive LVI Absence of extensive LVI
pT size >/= 5 cms 2.1 - 5 cms </= 2 cms
Patient preference Use all available treatment Avoid chemotherapy related
side effects
54-117_pc22.pmd 56 19/2/2551, 20:59

ÊÃØ»¤Óá¹Ð¹Óã¹¡ÒÃÃÑ¡ÉÒàÊÃÔÁËÅÑ§¼ÒµÑ´ã¹ÁÐàÃç§àµÒ¹ÁÃÐÂÐáÃ¡
1. ¼»Ù Ç Â·Õäè Á¨Óà»¹µÍ§ä´ÃºÑ ¡ÒÃÃÑ¡ÉÒàÊÃÔÁã´æËÅÑ§¼ÒµÑ´
¢Íº§ªÕé ¼»Ù Ç Â·ÕÁè ¢Õ ¹Ò´¢Í§¡Í¹à¹×Íé §Í¡ </= 5 ÁÔÅÅÔàÁµÃ äÁÇÒ ¨ÐÁÕ»¨ ¨ÑÂº§ªÕ¡é ÒÃ¾ÂÒ¡Ã³âÃ¤·Õè
äÁ´ÍÕ ¹×è ã´ËÃ×ÍäÁ
ÃÐ´Ñº¤Óá¹Ð¹Ó 2A
2. ¡ÒÃÃÑ¡ÉÒàÊÃÔÁ´ÇÂÂÒµÒ¹ÎÍÃâÁ¹ (Adjuvant Endocrine Therapy) (ÃÒÂ

ÅÐàÍÕÂ´ã¹ appendix 2)
¢Íº§ªÕé á¹Ð¹ÓãËãªÊÓËÃÑº·Ø¡ÃÒÂ·Õàè ¹×Íé §Í¡µÔ´µÑÇÃÑºÎÍÃâÁ¹ (hormone responsive breast
cancer) «Ö§è ÍÒ¨ÊÒÁÒÃ¶Â¡àÇ¹ä´ã¹¼»Ù Ç Â·ÕÁè ¤Õ ÇÒÁàÊÕÂè §¹ÍÂÁÒ¡ã¹¡ÒÃ¡ÅÑºà»¹«éÓ
àª¹¼»Ù Ç Â T1a
ÃÐ´Ñº¤Óá¹Ð¹Ó 1
ÇÔ¸Õ¡ÒÃÃÑ¡ÉÒ´ÇÂÂÒµÒ¹ÎÍÃâÁ¹
¢Ö¹é ¡ÑºÀÒÇÐ»ÃÐ¨Óà´×Í¹¢Í§¼»Ù Ç Ââ´Âáº§¼»Ù Ç Âà»¹ premenopausal áÅÐ postmenopausal women
µÒÁ¤Ó¨Ó¡Ñ´¤ÇÒÁ¢Í§ postmenopausal women (ÃÒÂÅÐàÍÕÂ´ã¹ appendix 1 Ë¹Ò·Õè 62)
¡ÒÃ¾Ô¨ÒÃ³Ò¤ÇÒÁàÊÕÂè §ã¹¡ÒÃ¡ÅÑºà»¹«éÓã¹¼»Ù Ç ÂÁÐàÃç§àµÒ¹Á·Õµè ´Ô µÑÇÃÑº·Ò§

ÎÍÃâÁ¹
ãª¤Óá¹Ð¹ÓµÒÁµÒÃÒ§·Õè 3
ÊÃØ»¤Óá¹Ð¹Óã¹¡ÒÃàÅ×Í¡¡ÒÃÃÑ¡ÉÒàÊÃÔÁ·Ò§ÎÍÃâÁ¹ËÅÑ§¼ÒµÑ´
1. ¼Ù Ë Ô § ·Õè ÂÑ § äÁ Ë Á´»ÃÐ¨Óà´× Í ¹ (Premenopausal women and/or
perimenopausal women) ¤Óá¹Ð¹Óã¹¡ÒÃãË¡ÒÃÃÑ¡ÉÒàÊÃÔÁ´ÇÂÂÒµÒ¹ÎÍÃâÁ¹ã¹¼»Ù Ç Â
·ÕÂè §Ñ äÁËÁ´»ÃÐ¨Óà´×Í¹ (pre and perimenopausal women)
· ÂÒµÒ¹ÎÍÃâÁ¹·Õáè ¹Ð¹Óà»¹¡ÒÃÃÑ¡ÉÒÁÒµÃ°Ò¹ã¹¼»Ù Ç Â·Ø¡¤ÇÒÁàÊÕÂè §¤×Í tamoxifen
· ÊÓËÃÑº¼»Ù Ç Â·ÕÁè ¢Õ Í ËÒÁã¹¡ÒÃãª tamoxifen ËÃ×ÍäÁÊÒÁÒÃ¶·¹¼Å¢Ò§à¤ÕÂ§¢Í§ tamoxifen
ä´ÍÒ¨ãªÇ¸Ô ¡Õ ÒÃ·Ó OFS (Ovarian function suppression) ·´á·¹
· ÊÓËÃÑº¼Ù»ÇÂ·ÕèÁÕ¤ÇÒÁàÊÕèÂ§ã¹¡ÒÃ¡ÅÑºà»¹«éÓÊÙ§ á¾·ÂÍÒ¨¾Ô¨ÒÃ³ÒãË¡ÒÃÃÑ¡ÉÒ´ÇÂ OFS
ÃÇÁ¡Ñº tamoxifen ÊÓËÃÑºÃÐÂÐàÇÅÒ¢Í§¡ÒÃ·Ó OFS äÁÁÃÕ ÐÂÐàÇÅÒÁÒµÃ°Ò¹·Õáè ¹¹Í¹â´Â
·ÑÇè ä»ãª»ÃÐÁÒ³ 2-3 »
ÃÐ´Ñº¤Óá¹Ð¹Ó 2B
54-117_pc22.pmd 57 19/2/2551, 20:59

· äÁá¹Ð¹Ó¡ÒÃãªÂÒ¡ÅØÁ aromatase inhibitors (AIs)à¾ÕÂ§ª¹Ô´à´ÕÂÇã¹¼Ù»ÇÂ premenopausal

äÁÇÒ ¨ÐÍÂãÙ ¹Ê¶Ò¹¡ÒÃ³ã´¡çµÒÁ
· ¢¹Ò´¢Í§ÂÒ tamoxifen ¤×Í 20 mg µÍÇÑ¹ áÅÐÃÐÂÐàÇÅÒÁÒµÃ°Ò¹¢Í§¡ÒÃÃÑ¡ÉÒàÊÃÔÁ¤×Í 5 »
2. ¼ËÙ Ô§ÇÑÂËÁ´»ÃÐ¨Óà´×Í¹ (Postmenopausal women)

ÁÕÂÒµÒ¹ÎÍÃâÁ¹ÊÍ§ª¹Ô´·ÕÁè »Õ ÃÐÊÔ·¸ÔÀÒ¾ã¹¡ÒÃÅ´¡ÒÃ¡ÅÑºà»¹«éÓ¤×Í tamoxifen áÅÐÂÒ¡ÅÁØ AIs
áÅÐÁÕÇ¸Ô ¡Õ ÒÃãËÂÒµÒ¹ÎÍÃâÁ¹´Ñ§µÍä»¹Õé
· ãªÂÒµÑÇã´µÑÇË¹Ö§è µÑ§é áµµ¹ áÅÐãªµÅÍ´ÃÐÂÐàÇÅÒ¡ÒÃÃÑ¡ÉÒ 5 » (upfront and continue)
· ãªÂÒÊÍ§ª¹Ô´ÃÇÁ¡Ñ¹ â´ÂÁÕÇ¸Ô ãÕ ª·àÕè »¹ÁÒµÃ°Ò¹´Ñ§µÍä»¹Õé
- Sequential treatment begin with tamoxifen ÇÔ¸¹Õ àÕé ÃÔÁè ¡ÒÃÃÑ¡ÉÒ´ÇÂÂÒ tamoxifen ¡Í¹à»¹àÇÅÒ
2-3 » ¨Ò¡¹Ñ¹é à»ÅÕÂè ¹à»¹ÂÒ¡ÅÁØ AIs ¨¹¤Ãº 5 »
- Sequential treatment begin with AIs ÇÔ¸¹Õ àÕé ÃÔÁè ¡ÒÃÃÑ¡ÉÒ´ÇÂÒ AIs ¡Í¹à»¹àÇÅÒ 2 » ¨Ò¡¹Ñ¹é
à»ÅÕÂè ¹à»¹ tamoxifen ¨¹¤Ãº 5 »
- Extended treatment ÇÔ¸¹Õ àÕé ÃÔÁè µ¹´ÇÂ tamoxifen 5 » ¨Ò¡¹Ñ¹é µÍ´ÇÂÂÒ¡ÅÁØ AIs ÍÕ¡ 5 »¨¹¤Ãº
10 »
¤Óá¹Ð¹Óã¹¡ÒÃãË¡ÒÃÃÑ¡ÉÒàÊÃÔÁ´ÇÂÂÒµÒ¹ÎÍÃâÁ¹ã¹¼»Ù Ç Â·ÕËè Á´»ÃÐ¨Óà´×Í¹ (Postmenopausal
women)
· ÊÓËÃÑº¼» Ù Ç Â·ÕÁè ¤Õ ÇÒÁàÊÕÂè §ã¹¡ÒÃ¡ÅÑºà»¹«éÓ¹ÍÂËÃ×Íà»¹¼»Ù Ç Â·ÕÁè ¢Õ Í ËÒÁã¹¡ÒÃãªÂÒ¡ÅÁØ AIs
á¹Ð¹ÓãËãªÂÒ tamoxifen à¾ÕÂ§µÑÇà´ÕÂÇã¹¢¹Ò´áÅÐÃÐÂÐàÇÅÒÁÒµÃ°Ò¹àª¹à´ÕÂÇ¡Ñº¼Ù»ÇÂ
ÇÑÂ¡Í¹ËÁ´»ÃÐ¨Óà´×Í¹
· ÊÓËÃÑº¼» Ù Ç Â·ÕÁè ¤Õ ÇÒÁàÊÕÂè §ã¹¡ÒÃ¡ÅÑºà»¹«éÓ»Ò¹¡ÅÒ§ ¡ÅÁØ ¹Õ¤é ÇÃÁÕÂÒ AIs ÁÒÃÇÁà»¹ÂÒµÑÇË¹Ö§è
ã¹¡ÒÃÃÑ¡ÉÒàÊÃÔÁ
· ÊÇ¹ÇÔ¸ãÕ ¹¡ÒÃãªÂÒÊÍ§ª¹Ô´ÃÇÁ¡Ñ¹ÃÐËÇÒ§ tamoxifen áÅÐ AIs ¹Ñ¹ é á¹Ð¹Ó¡ÒÃãªÂÒÊÍ§ª¹Ô´
ÃÇÁ¡Ñ¹ã¹ áºº sequential â´ÂÍÒ¨àÃÔÁè ´ÇÂ tamoxifen ¡Í¹ËÃ×Í AIs ¡Í¹
· ÊÓËÃÑº¼» Ù Ç Â·ÕÁè ¤Õ ÇÒÁàÊÕÂè §ã¹¡ÒÃ¡ÅÑºà»¹«éÓÊÙ§ ÊÒÁÒÃ¶àÅ×Í¡ÇÔ¸ãÕ ´ÇÔ¸ËÕ ¹Ö§è µÍä»¹Õé
- á¹Ð¹Ó¡ÒÃãªÂÒÊÍ§ª¹Ô´ÃÇÁ¡Ñ¹ã¹áºº sequential
54-117_pc22.pmd 58 19/2/2551, 20:59

- á¹Ð¹Ó¡ÒÃãªÂÒ¡ÅÁØ AIs µÑ§é áµàÃÔÁè µ¹áÅÐãË¨¹¤Ãº 5 »

ÃÐ´Ñº¤Óá¹Ð¹Ó 2B
· ÊÓËÃÑº¼Ù»ÇÂ·ÕèÁÕ¡ÒÃ¡ÃÐ¨ÒÂä»ÂÑ§µÍÁ¹éÓàËÅ×Í§áÅÐà»¹¼Ù»ÇÂ·ÕèÍÂÙã¹ÀÒÇÐ postmenopausal
ËÅÑ§¨Ò¡ÃÑº tamoxifen ¤Ãº 5 »
- á¹Ð¹Ó¡ÒÃãªÂÒ AIs µÍÍÕ¡ 5 » (extended adjuvant treatment)
· ÃÐÂÐàÇÅÒÁÒµÃ°Ò¹ã¹¡ÒÃÃÑ¡ÉÒàÊÃÔÁâ´ÂÇÔ¸Õ·Ò§ÎÍÃâÁ¹¤×Í 5 » â´Â¶Òà»¹¡ÒÃãªÃÙ»áºº
sequential ãËàÃÔÁè ´ÇÂÂÒµÑÇáÃ¡ã¹ÃÐÂÐàÇÅÒ 2 »¨Ò¡¹Ñ¹é µÍ´ÇÂÂÒµÑÇ·ÕÊè Í§ã¹ÃÐÂÐàÇÅÒ 3 »¨¹¤Ãº
5 »
- ÃÐÂÐàÇÅÒ¡ÒÃãªÂÒ AIs ã¹ÃÙ»áºº sequential äÁ¤ÇÃãªà¡Ô¹ 2 »
- ÃÐÂÐàÇÅÒ¡ÒÃãªÂÒ AIs ã¹ÃÙ»áºº extended ¤ÇÃãª 3-5 »
3. ¡ÒÃÃÑ¡ÉÒàÊÃÔÁ´ÇÂÂÒà¤ÁÕºÓºÑ´ (Adjuvant Chemotherapy) (ÃÒÂÅÐàÍÕÂ´ã¹

appendix 3)
· ¢Íº§ªÕÁé ÒµÃ°Ò¹ÊÓËÃÑº¡ÒÃãËÂÒà¤ÁÕºÓºÑ´àÊÃÔÁÁÕ´§Ñ µÍä»¹Õé
- ÊÓËÃÑº¼»Ù Ç ÂÁÐàÃç§àµÒ¹Á·Õäè Áµ´Ô µÑÇÃÑº·Ò§ÎÍÃâÁ¹áÅÐäÁµ´Ô µÑÇÃÑº HER2 (triple negative)
·ÕÁè ¢Õ ¹Ò´¢Í§¡Í¹à¹×Íé §Í¡ÁÒ¡¡ÇÒ 0.5 à«¹µÔàÁµÃ¢Ö¹é ä»
- ÊÓËÃÑº¼»Ù Ç ÂÁÐàÃç§àµÒ¹Á·Õµè ´Ô µÑÇÃÑº HER2 (HER2 positive) ·ÕÁè ¤Õ ÇÒÁàÊÕÂè §ÊÙ§ã¹¡ÒÃ¡ÅÑºà»¹«éÓ
- ÊÓËÃÑº¼»Ù Ç ÂÁÐàÃç§àµÒ¹Á·Õµè ´Ô µÑÇÃÑº·Ò§ÎÍÃâÁ¹ (HR positive) ·ÕÁè ¤Õ ÇÒÁàÊÕÂè §ÊÙ§ã¹¡ÒÃ¡ÅÑº
à»¹«éÓ â´Â¾Ô¨ÒÃ³ÒµÒÁ»¨¨ÑÂàÊÕÂè §ã¹µÒÃÒ§·Õè 3 ã¹ËÑÇ¢Í·Õàè »¹¢Íº§ªÕãé ¹¡ÒÃãËÂÒà¤ÁÕºÓºÑ´
ÃÇÁ¡ÑºÂÒµÒ¹ÎÍÃâÁ¹
- ÊÓËÃÑº¼»Ù Ç ÂÁÐàÃç§àµÒ¹Á·Õµè ´Ô µÑÇÃÑº·Ò§ÎÍÃâÁ¹ (HR positive) ºÒ§ÃÒÂ·ÕÁè ¤Õ ÇÒÁàÊÕÂè §»Ò¹
¡ÅÒ§ã¹¡ÒÃ¡ÅÑºà»¹«éÓ â´Â¾Ô¨ÒÃ³ÒµÒÁ»¨¨ÑÂàÊÕÂè §ã¹µÒÃÒ§·Õè 3
- äÁá¹Ð¹ÓãËãªã¹¼»Ù Ç ÂÁÐàÃç§àµÒ¹Á·Õµè ´Ô µÑÇÃÑº·Ò§ÎÍÃâÁ¹·ÕÁè ¤Õ ÇÒÁàÊÕÂè §¹ÍÂã¹¡ÒÃ¡ÅÑº
à»¹«éÓ â´Â¾Ô¨ÒÃ³ÒµÒÁ»¨¨ÑÂàÊÕÂè §ã¹µÒÃÒ§·Õè 3
54-117_pc22.pmd 59 19/2/2551, 20:59

· ÊÙµÃÂÒà¤ÁÕºÓºÑ´ã¹¡ÒÃÃÑ¡ÉÒàÊÃÔÁËÅÑ§¼ÒµÑ´
- á¹Ð¹ÓãËãªÊµÙ Ã classical CMF x 6 ËÃ×Í AC x 4 ËÃ×Í FAC x 6 ËÃ×Í FEC x 6 ËÃ×Í CEF x 6 ÃÍº
ÊÓËÃÑº¼»Ù Ç Â¤ÇÒÁàÊÕÂè §ã¹¡ÒÃ¡ÅÑºà»¹«éÓ»Ò¹¡ÅÒ§
- á¹Ð¹ÓãËãªÊµÙ Ã taxane- based chemotherapy ÃÇÁ¡Ñº anthracycline- based chemotherapy
à©¾ÒÐã¹¼»Ù Ç Â·ÕÁè ¤Õ ÇÒÁàÊÕÂè §ã¹¡ÒÃ¡ÅÑºà»¹«éÓÊÙ§à·Ò¹Ñ¹é ä´á¡¼»Ù Ç Â·ÕÁè ¡Õ ÒÃ¡ÃÐ¨ÒÂä»ÂÑ§µÍÁ
¹éÓàËÅ×Í§ÃÇÁ¡Ñºà¹×Íé §Í¡äÁµ´Ô µÑÇÃÑº·Ò§ÎÍÃâÁ¹ËÃ×ÍÁÕ¡ÒÃáÊ´§ÍÍ¡¢Í§ÂÕ¹ HER2
- á¹Ð¹ÓãËãªÊÙµÃ non-anthracycline, taxane-based ã¹¼Ù»ÇÂ·ÕèÁÕ¤ÇÒÁàÊÕèÂ§ã¹¡ÒÃ¡ÅÑºà»¹
«éÓ»Ò¹ ¡ÅÒ§¶Ö§ÊÙ§áÅÐÁÕ¢Í ËÒÁã¹¡ÒÃãªÂÒ¡ÅÁØ anthracyclines
- á¹Ð¹ÓãËãªÊµÙ Ã anthracycline-based chemotherapy , taxane-based chemotherapy ÃÇÁ¡Ñº
¡ÒÃãª trastuzumab ÊÓËÃÑº¼»Ù Ç Â HER2 positive ·Õäè ´ÃºÑ ¡ÒÃÃÑ¡ÉÒàÊÃÔÁ´ÇÂÂÒµÒ¹ HER2
- ÃÐÂÐàÇÅÒ¢Í§ adjuvant chemotherapy á¹Ð¹ÓãËãªà»¹ÃÐÂÐàÇÅÒ 6 ÃÍº - 8 ÃÍº¡ÒÃÃÑ¡ÉÒ
(¢Ö¹é ÍÂ¡Ù ºÑ ÊÙµÃ)
- Sequence ÃÐËÇÒ§¡ÒÃÃÑ¡ÉÒ´ÇÂ chemotherapy ¡Ñº¡ÒÃÃÑ¡ÉÒàÊÃÔÁª¹Ô´Í×è¹ á¹Ð¹ÓãËÃÑ¡ÉÒ
´ÇÂ adjuvant chemotherapy ¡Í¹¨¹¤ÃºµÒÁ¨Ó¹Ç¹ÃÍº¡ÒÃÃÑ¡ÉÒ·Õ¡è ÓË¹´áÅÇ¨Ö§µÒÁ´ÇÂ
adjuvant endocrine therapy
4. ¡ÒÃÃÑ¡ÉÒàÊÃÔÁ´ÇÂÂÒµÒ¹ HER2 ã¹ÁÐàÃç§àµÒ¹Á·Õµè ´Ô HER2 (Adjuvant

Trastuzumab in HER2 positive early breast cancer)
· ¡ÒÃÇÔ¹Ô¨©ÑÂÀÒÇÐ HER2 à»¹¼ÅºÇ¡
- ãË¶Í× ÇÒ HER2 à»¹¼ÅºÇ¡ àÁ×Íè ¡ÒÃÂÍÁ IHC à»¹ 3+ ¢Ö¹é ä» áÅÐ/ËÃ×Í ¡ÒÃµÃÇ¨ FISH ratio
>/= 2.2 ËÃ×Í CISH >/= 6
- ã¹¡Ã³Õ·Õè IHC 2+ á¹Ð¹ÓãËµÃÇ¨´ÇÂ FISH à¾×Íè Â×¹ÂÑ¹ áÅÐ¶×ÍÇÒà»¹¼ÅºÇ¡àÁ×Íè FISH ratio
>/= 2.2 ËÃ×Í CISH > 6
54-117_pc22.pmd 60 19/2/2551, 20:59

· ¡ÒÃãª Trastuzumab ã¹¡ÒÃÃÑ¡ÉÒàÊÃÔÁÊÓËÃÑºÁÐàÃç§àµÒ¹ÁÃÐÂÐáÃ¡ ·ÕÁè Õ HER2 à»¹¼ÅºÇ¡

- á¹Ð¹ÓãËãª Trastuzumab ÃÇÁ¡Ñº¡ÒÃÃÑ¡ÉÒàÊÃÔÁ´ÇÂÂÒà¤ÁÕºÓºÑ´à·Ò¹Ñ¹é
- á¹Ð¹ÓãËãª Trastuzumab ã¹¡Ã³Õ·ÕèÁÐàÃç§¡ÃÐ¨ÒÂä»ÂÑ§µÍÁ¹éÓàËÅ×Í§·ÕèÃÑ¡áÃ (Node
positive early breast cancer)
- ÇÔ¸¡Õ ÒÃãËÂÒ trastuzumab ÊÒÁÒÃ¶àÃÔÁè trastuzumab ÃÐËÇÒ§à¤ÁÕºÓºÑ´â´ÂãË¾ÃÍÁ¡Ñº taxanes
áµäÁ¤ÇÃãË¾ÃÍÁ anthracycline (concurrent approach) ËÃ×ÍãËµÒÁËÅÑ§¨Ò¡ãËà¤ÁÕºÓºÑ´àÊÃç¨
ÊÔ¹é áÅÇ¡çä´ (sequential approach)
- á¹Ð¹ÓãËãª trastuzumab ã¹¡ÒÃÃÑ¡ÉÒàÊÃÔÁà»¹ÃÐÂÐàÇÅÒ 1 »
- ÊÙµÃà¤ÁÕºÓºÑ´·Õáè ¹Ð¹ÓãËãªã¹¡Ã³Õ·¾Õè ¨Ô ÒÃ³ÒãË adjuvant trastuzumab ÃÇÁ´ÇÂ
- Anthracycline- based regimens µÒÁ´ÇÂ trastuzumab 1 »
- AC ¨Ó¹Ç¹ 4 ÃÍºµÒÁ´ÇÂ paclitaxel weekly ¨Ó¹Ç¹12 ÃÍº ËÃ×Í paclitaxel áººãË·¡Ø 3
ÊÑ»´ÒË¨Ó¹Ç¹ 4 ËÃ×Í docetaxel áººãË·¡Ø 3 ÊÑ»´ÒË¨Ó¹Ç¹ 4 ÃÍº â´ÂàÃÔÁè ãË trastuzumab
ªÇ§·Õãè Ë taxanes áÅÐµÍ´ÇÂ trastuzumab à¾ÕÂ§µÑÇà´ÕÂÇ¨¹¤Ãº 1 »
- Docetaxel ÃÇÁ¡Ñº carboplatin ·Ø¡ 3 ÊÑ»´ÒË¨Ó¹Ç¹ 6 ÃÍº¡ÒÃÃÑ¡ÉÒ â´ÂãË trastuzumab
µÑ§é áµáÃ¡áÅÐµÍ´ÇÂ trastuzumab ¨¹¤Ãº 1 »
· ¤Óá¹Ð¹Óã¹¡ÒÃ¤Ñ´àÅ×Í¡¼Ù»ÇÂ¡Í¹ÃÑºÂÒ trastuzumab áÅÐ¡ÒÃà½ÒÃÐÇÑ§¼Å¢Ò§à¤ÕÂ§àÃ×èÍ§
¡ÒÃ·Ó§Ò¹¢Í§ËÑÇã¨
- ¼Ù»ÇÂ·Ø¡ÃÒÂ¡Í¹àÃÔèÁÂÒ trastuzumab µÍ§ä´ÃÑº¡ÒÃ»ÃÐàÁÔ¹¡ÒÃ·Ó§Ò¹¢Í§ËÑÇã¨â´ÂÇÔ¸Õ
echocardiogram ËÃ×Í MUGA scan áÅÐµÍ§ÁÕ¡ÒÃºÕºµÑÇ¢Í§ËÑÇã¨ (EF, ejection fraction)
ÁÒ¡¡ÇÒÃÍÂÅÐ 50 ¡Í¹àÃÔÁè ÂÒ
- ¼Ù»ÇÂ¤ÇÃä´ÃÑº¡ÒÃ»ÃÐàÁÔ¹»ËÒ´Ò¹ËÑÇã¨áÅÐÊ§¾ºá¾·Â¼ÙàªÕèÂÇªÒ àÁ×èÍ¾º¼Ù»ÇÂ·ÕèÁÕ
»ËÒàª¹¼Ù»ÇÂ·ÕèÁÕ»ËÒ¨Ñ§ËÇÐ¡ÒÃàµ¹¢Í§ËÑÇã¨ÁÕ»ËÒàÃ×èÍ§ÅÔé¹ËÑÇã¨ËÃ×ÍÁÕ»ÃÐÇÑµÔ
ËÅÍ´àÅ×Í´ËÑÇã¨¡Í¹¡ÒÃãËÂÒ trastuzumab
- ã¹ÃÐËÇÒ§¡ÒÃÃÑ¡ÉÒ¤ÇÃÁÕ¡ÒÃµÃÇ¨¡ÒÃ·Ó§Ò¹¢Í§ËÑÇã¨´ÇÂechocardiogram, MUGA scan
·Ø¡ 3 à´×Í¹
54-117_pc22.pmd 61 19/2/2551, 20:59

Appendix 1 ¤Ó¨Ó¡Ñ´¤ÇÒÁ¢Í§¼Ù»ÇÂÇÑÂËÁ´»ÃÐ¨Óà´×Í¹ (postmenopausal

women)
1. ¼»Ù Ç Âä´ÃºÑ ¡ÒÃµÑ´ÃÑ§ä¢·§Ñé ÊÍ§¢Ò§ (prior bilateral oophorectomy)
2. ÍÒÂØÁÒ¡¡ÇÒËÃ×Íà·Ò¡Ñº 60 »
3. ÍÒÂØ¹ÍÂ¡ÇÒ 60 »áÅÐäÁÁÕ»ÃÐ¨Óà´×Í¹ÁÒàÅÂà»¹àÇÅÒÍÂÒ§¹ÍÂ 12 à´×Í¹â´Âà»¹¡ÒÃËÁ´
»ÃÐ¨Óà´×Í¹µÒÁ¸ÃÃÁªÒµÔ äÁÁÕ»ÃÐÇÑµÔä´ÃÑºÂÒà¤ÁÕºÓºÑ´ tamoxifen, toremifene ËÃ×Íä´ÃÑº¡ÒÃ·Ó ovarian
function suppression áÅÐ¤Ò FSH, estradiol ÍÂãÙ ¹à¡³±ÇÂÑ ËÁ´»ÃÐ¨Óà´×Í¹
4. ¶Òä´ÃÑºÂÒ tamoxifen, toremifene áÅÐÁÕÍÒÂØ¹ÍÂ¡ÇÒ 60 » ¡ÅØÁ¹ÕéµÍ§ÁÕ¤Ò FSH, estradiol
ÍÂãÙ ¹à¡³±ÇÂÑ ËÁ´»ÃÐ¨Óà´×Í¹
Appendix 2 ÃÒÂÅÐàÍÕÂ´¢Í§ adjuvant endocrine therapy in early breast

cancer
1. Tamoxifen
à»¹ÂÒµÒ¹ÎÍÃâÁ¹·ÕèÁÕ»ÃÐÊÔ·¸ÔÀÒ¾áÅÐÊÒÁÒÃ¶Å´¡ÒÃ¡ÅÑºà»¹«éÓä´ã¹ HR positive tumors
äÁÇÒ ¨Ðà»¹ premenopausal women ËÃ×Í postmenopausal women ¢ÍÁÙÅÅÒÊØ´¨Ò¡ metaanalysis â´Â EBCCTG
2005(2) ¾ºÇÒ¡ÒÃãª tamoxifen à»¹àÇÅÒ 5 »ÊÒÁÒÃ¶Å´¤ÇÒÁàÊÕèÂ§ã¹¡ÒÃ¡ÅÑºà»¹«éÓä´ÃÍÂÅÐ 41 áÅÐÅ´
¤ÇÒÁàÊÕèÂ§ã¹¡ÒÃàÊÕÂªÕÇÔµä´ÃÍÂÅÐ 34 äÁÇÒ¨ÐÍÒÂØÁÒ¡¡ÇÒËÃ×Í¹ÍÂ¡ÇÒ 50 » â´Â tamoxifen Å´¡ÒÃ
¡ÅÑºà»¹«éÓä´ÃÍÂÅÐ 11.8 áÅÐÅ´ÍÑµÃÒµÒÂä´ÃÍÂÅÐ 9.2 ¹Í¡¨Ò¡¹Ñé¹ÂÑ§ÁÕ carry over effect ¤×Í¼Åã¹
¡ÒÃÅ´¡ÒÃ¡ÅÑºà»¹«éÓÂÑ§¤§ÍÂÙáÅÐà¾ÔèÁ¢Öé¹ËÅÑ§¨Ò¡ËÂØ´ÂÒä»áÅÇ ´Ñ§¹Ñé¹ tamoxifen 5 »¨Ö§¶×ÍÇÒà»¹
¡ÒÃÃÑ¡ÉÒÁÒµÃ°Ò¹·ÕÊè ÒÁÒÃ¶¾Ô¨ÒÃ³ÒãËä´ã¹¼»Ù Ç Â·Ø¡¡ÅÁØ ÍÒÂØ ¹Í¡¨Ò¡Å´ÍÑµÃÒ¡ÒÃ¡ÅÑºà»¹«éÓáÅÐàÊÕÂªÕÇµÔ
¨Ò¡ÁÐàÃç§àµÒ¹ÁáÅÇ tamoxifen ÂÑ§Å´ÍØºµÑ ¡Ô ÒÃ³¢Í§¡ÒÃà¡Ô´ÁÐàÃç§àµÒ¹ÁÍÕ¡¢Ò§ (contralateral breast cancer)
ä´ÍÂÒ§ÁÕ¹ÂÑ ÊÓ¤ÑÍÕ¡´ÇÂ(3)
ÊÓËÃÑº¼Å¢Ò§à¤ÕÂ§·Õàè ¾ÔÁè ¢Ö¹é ¨Ò¡¡ÒÃãª tamoxifen 5 »¤Í× à¾ÔÁè ÍØºµÑ ¡Ô ÒÃ³¢Í§¡ÒÃà¡Ô´ thromboemlolic
events áÅÐà¾ÔèÁÍØºÑµÔ¡ÒÃ³¢Í§ÁÐàÃç§Á´ÅÙ¡ ·ÓãË¼Ù»ÇÂºÒ§ÃÒÂÍÒ¨äÁàËÁÒÐÊÁ·Õè¨ÐãªÂÒµÑÇ¹Õé â´Âà©¾ÒÐã¹
¼»Ù Ç Â·ÕÁè »Õ ÃÐÇÑµ¡Ô ÒÃà¡Ô´ÅÔÁè àÅ×Í´ÍØ´µÑ¹ËÃ×ÍÁÕ»ÃÐÇÑµàÔ ÊÕÂè §µÍ¡ÒÃà»¹ÁÐàÃç§Á´ÅÙ¡à»¹µ¹
2. OFS (Ovarian Function Suppression)

¢ÍÁÙÅ¨Ò¡ EBCTCG ¾ºÇÒ¡ÒÃ·Ó OFS äÁÇÒ¨Ðà»¹ surgery, radiotherapy ËÃ×ÍãªÂÒ¡ÅØÁ LHRH
inhibitors ã¹¼Ù»ÇÂ·Õèà»¹ hormonal responsive breast cancer ÊÒÁÒÃ¶Å´¡ÒÃ¡ÅÑºà»¹«éÓáÅÐ¡ÒÃàÊÕÂªÕÇÔµ·Õè
15 »ä´ÍÂÒ§ÁÕ¹ÑÂÊÓ¤Ñà·ÕÂº¡Ñº¡ÅØÁ·ÕèäÁä´·Ó â´ÂÅ´¡ÒÃ¡ÅÑºà»¹«éÓä´ÃÍÂÅÐ 4.2 áÅÐÅ´¡ÒÃàÊÕÂªÕÇÔµä´
ÃÍÂÅÐ 2.7
54-117_pc22.pmd 62 19/2/2551, 20:59

3. GnRH analog ÃÇÁ¡Ñº tamoxifen

äÁÁÕ¢ÍÁÙÅ¨Ò¡¡ÒÃÈÖ¡ÉÒÃÐÂÐ·Õè 3 ·ÕèáÊ´§ãËàËç¹ÇÒ¡ÒÃà¾ÔèÁ GnRH analog à¢Òä»¡Ñº tamoxifen
¨ÐãË»ÃÐÊÔ·¸ÔÀÒ¾´Õ¡ÇÒ¡ÒÃãªà¾ÕÂ§ tamoxifen à¾ÕÂ§ÍÂÒ§à´ÕÂÇ
4. GnRH analog ÃÇÁ¡Ñº AIs(4)

äÁá¹Ð¹ÓãËãªÊÓËÃÑº¼Ù»ÇÂÇÑÂ¡Í¹ËÁ´»ÃÐ¨Óà´×Í¹à¹×èÍ§¨Ò¡¡ÒÃÈÖ¡ÉÒ ABCSG-12 ¾ºÇÒ¡ÅØÁ
¼»Ù Ç Â·Õãè ª GnRH analog ÃÇÁ¡Ñº AIs äÁä´ãË¼Å·Õ´è ¡Õ ÇÒ¡ÒÃãªà¾ÕÂ§ GnRH analog ¡Ñº tamoxifen
5. AIs
ÁÕ¢Í º§ªÕàé ©¾ÒÐ¼»Ù Ç Â postmenopausal women à·Ò¹Ñ¹é ÁÕ 3 ÇÔ¸ãÕ ¹¡ÒÃãª adjuvant AIs ´Ñ§µÍä»¹Õé
· AIs 5 » (·´á·¹ tamoxifen) ÁÕ¡ÒÃÈÖ¡ÉÒ 2 ¡ÒÃÈÖ¡ÉÒ¤×Í ATAC study(5) à»ÃÕÂºà·ÕÂº¡ÒÃãª
anastrozole 5 »¡ºÑ ¡ÅÁØ ·Õãè ª tamoxifen 5 » àÁ×Íè µÔ´µÒÁ¼Å¡ÒÃÈÖ¡ÉÒ¨¹¶Ö§·Õè 100 à´×Í¹ ¾ºÇÒ¡ÅÁØ ·Õãè ª anastrozole
5 »ÁÕ DFS ´Õ¡ÇÒ¡ÅØÁ·Õèãª tamoxifen 5 »ÃÍÂÅÐ 4.8 áÅÐÁÕ HR = 0.76 «Öè§´Õ¡ÇÒÍÂÒ§ÁÕ¹ÑÂÊÓ¤Ñ·Ò§Ê¶ÔµÔ
áÅÐ¹Í¡¨Ò¡¹Ñ¹é ¡ÅÁØ ·Õäè ´ anastrozole 5 »Â§Ñ Å´ÍÑµÃÒ¡ÒÃà¡Ô´ contralateral breast cancer ä´ÍÂÒ§ÁÕ¹ÂÑ ÊÓ¤Ñâ´ÂÁÕ
HR = 0.68 áµäÁÁ¤Õ ÇÒÁáµ¡µÒ§ã¹á§¢Í§ overall survival ¡ÒÃÈÖ¡ÉÒ·ÕÊè Í§¤×Í BIG 1-98(6) ã¹¡ÒÃÈÖ¡ÉÒ ¹ÕÁé ¡Õ ÅÁØ ·Õãè ª
tamoxifen 5 »à»¹¡ÅÁØ ¤Çº¤ØÁáÅÐÁÕ¡ÅÁØ ·Õãè ª letrozole 5 » ¾ºÇÒàÁ×Íè µÔ´µÒÁ¡ÒÃÈÖ¡ÉÒ·Õè 76 à´×Í¹ ¡ÅÁØ ·Õäè ´ÃºÑ
letrozole 5 »ÁÕ DFS ´Õ¡ÇÒÍÂÒ§ÁÕ¹ÂÑ ÊÓ¤Ñ·Ò§Ê¶ÔµàÔ ª¹à´ÕÂÇ¡Ñ¹ â´ÂÁÕ HR = 0.88 áµäÁÁ¤Õ ÇÒÁáµ¡µÒ§ã¹á§¢Í§
overall survival àª¹à´ÕÂÇ¡Ñ¹
· Sequential treatment ÇÔ¸Õ¹Õé¤×ÍãËÂÒµÑÇã´µÑÇË¹Öè§¡Í¹ã¹ªÇ§ 2-3 »áÃ¡áÅÇÊÅÑºÁÒà»¹ÂÒÍÕ¡
ª¹Ô´Ë¹Ö§è ¨¹¤Ãº 5 » ÁÕÊÍ§ÇÔ¸ÂÕ Í Â¤×Í
- Tamoxifen 2-3 » ¨Ò¡¹Ñ¹é ÊÅÑºÁÒà»¹ AIs ÍÕ¡ 2-3 »¨¹¤Ãº 5 »
¡ÒÃÈÖ¡ÉÒÊÓ¤Ñ·Õàè »ÃÕÂºà·ÕÂº¡ÒÃãªÅ¡Ñ É³Ð¹Õàé ·ÕÂº¡Ñº¡ÒÃãª AIs µÅÍ´ 5 »·àÕè ÃÔÁè ÊÁØ ¼»Ù Ç Â
µÑ§é áµµÍ¹àÃÔÁè µ¹¤×Í BIG 1-98 study â´Â¡ÒÃÇÔà¤ÃÒÐË¢Í ÁÙÅ¢Í§ STA (sequential treatment
analysis) ·ÕèÁÕ¡ÒÃµÔ´µÒÁ¼Ù»ÇÂ 71 à´×Í¹ ¾ºÇÒäÁÁÕ¤ÇÒÁáµ¡µÒ§¡Ñ¹ÍÂÒ§ÁÕ¹ÑÂÊÓ¤Ñ·Ò§
Ê¶ÔµÔà·ÕÂº¡Ñº¡ÒÃãª letrozole 5 » â´ÂÁÕ HR for DFS, OS and TTDR ·Õè 1.05, 1.13 áÅÐ 1.22
ÍÂÒ§äÃ¡çµÒÁàÁ×Íè ÇÔà¤ÃÒÐË¨Óá¹¡¼»Ù Ç Âà»¹¡ÅÁØ ·ÕÁè ËÕ Ã×ÍäÁÁ¡Õ ÒÃ¡ÃÐ¨ÒÂä»ÂÑ§µÍÁ¹éÓàËÅ×Í§
¾ºÇÒ¶Òà»¹¼Ù»ÇÂ·ÕèäÁÁÕ¡ÒÃ¡ÃÐ¨ÒÂä»ÂÑ§µÍÁ¹éÓàËÅ×Í§ÍÑµÃÒ¡ÒÃ¡ÅÑºà»¹«éÓäÁÁÕ¤ÇÒÁ
áµ¡µÒ§¡Ñ¹ÁÒ¡¹Ñ¡ áµ¶Òà»¹¡ÅØÁ·ÕèÁÕ¡ÒÃ¡ÃÐ¨ÒÂä»ÂÑ§µÍÁ¹éÓàËÅ×Í§ ÍÑµÃÒ¡ÒÃ¡ÅÑºà»¹«éÓ
·Õè 2 »áÃ¡ 4.7% à·ÕÂº¡Ñº 7.9% áÅÐ·Õè 5 »ÍÂÙ·Õè 12.4% áÅÐ 14.7% «Öè§ÊÙ§¡ÇÒã¹¡ÅØÁ·Õèä´ÃÑº
tamoxifen ¡Í¹à·ÕÂº¡Ñº¡ÒÃä´ÃÑº letrozole ·Ñé§ 5 » ÍÂÒ§äÃ¡çµÒÁÁÕÍÕ¡Ë¹Öè§¡ÒÃÈÖ¡ÉÒ·Õè
à»ÃÕÂºà·ÕÂºã¹ÅÑ¡É³Ð¹Õ¤é Í× TEAM study(7) «Ö§è à»ÃÕÂºà·ÕÂº¼»Ù Ç Â·Õäè ´ÃºÑ exemestane «Ö§è à»¹
54-117_pc22.pmd 63 19/2/2551, 20:59

steroidal AI µÅÍ´ 5 »¡ºÑ ÍÕ¡¡ÅÁØ ·Õäè ´ÃºÑ tamoxifen ¡Í¹ ¼Å¡ÒÃÈÖ¡ÉÒ·Õè 5 »¾ºÇÒäÁÁ¤Õ ÇÒÁ
áµ¡µÒ§¡Ñ¹ã¹á§¢Í§ DFS â´ÂÁÕ HR = 0.97 áÅÐ overall survival â´ÂÁÕ HR = 1.0
- AIs ¡Í¹ 2-3 »¨Ò¡¹Ñ¹é ¡ÅÑºÁÒà»¹ tamoxifen ¨¹¤Ãº 5 »
ÁÕà¾ÕÂ§¡ÒÃÈÖ¡ÉÒà´ÕÂÇ·ÕÈè ¡Ö ÉÒ¶Ö§ÇÔ¸¹Õ ¤Õé Í× BIG 1-98 study ¾ºÇÒàÁ×Íè à·ÕÂº¡Ñº¡ÒÃãË letrozol
µÅÍ´ 5 » ¡ÒÃãª letrozole ¡Í¹ 2 »áÅÇ¡ÅÑºÁÒà»¹ tamoxifen ¨¹¤Ãº 5 »äÁÁÕ¤ÇÒÁ
áµ¡µÒ§¡Ñ¹ã¹á§¢Í§ DFS, OS áÅÐ TTDR áÅÐàÁ×èÍ´ÙÍÑµÃÒ¡ÒÃ¡ÅÑºà»¹«éÓ·Ñé§·Õè 2 áÅÐ 5
»·Ñé§ã¹¼Ù»ÇÂ¡ÅØÁ·ÕèÁÕËÃ×ÍäÁÁÕ¡ÒÃá¾Ã¡ÃÐ¨ÒÂÁÒÂÑ§µÍÁ¹éÓàËÅ×Í§¡çäÁ¾º¤ÇÒÁáµ¡µÒ§
àª¹à´ÕÂÇ¡Ñ¹ áµÍÂÒ§äÃ¡çµÒÁà»¹à¾ÕÂ§¡ÒÃÈÖ¡ÉÒà´ÕÂÇà·Ò¹Ñ¹é ·Õµè Íº¤Ó¶ÒÁ¹Õé
· Extended AIs ¤×ÍãËÂÒ tamoxifen 5 »áÅÐ¶Ò¼Ù»ÇÂÂÑ§äÁÁÕ¡ÒÃ¡ÅÑºà»¹«éÓáÅÐÍÂÙã¹ÇÑÂËÁ´
»ÃÐ¨Óà´×Í¹¡çãËÂÒ AIs µÍÍÕ¡ 5 » ÃÇÁÃÐÂÐàÇÅÒ¡ÒÃãËÂÒ·Ñ§é ËÁ´ 10 »
¡ÒÃÈÖ¡ÉÒÊÓ¤Ñ¤×Í MA 17(8) à»ÃÕÂºà·ÕÂºÃÐËÇÒ§¡ÅØÁ·Õèä´ÃÑº tamoxifen 5 »«Öè§¶×ÍÇÒà»¹¡ÅØÁ
¤Çº¤ØÁ¡Ñº¡ÅÁØ ÈÖ¡ÉÒ¤×Íä´ÃºÑ ÂÒ tamoxifen 5 »áÅÇµÒÁ´ÇÂ letrozole ÍÕ¡ 5 » ¼Å¡ÒÃÈÖ¡ÉÒ¾ºÇÒ¡ÅÁØ ·Õäè ´ÃºÑ letrozole
µÍÁÕ DFS ·Õè´Õ¡ÇÒÍÂÒ§ÁÕ¹ÑÂÊÓ¤Ñ HR = 0.58 áÅÐã¹¼Ù»ÇÂ·ÕèÁÕ¡ÒÃ¡ÃÐ¨ÒÂä»ÂÑ§µÍÁ¹éÓàËÅ×Í§ÁÕ OS ´Õ¡ÇÒ
ÍÂÒ§ÁÕ¹ÂÑ ÊÓ¤Ñ·Ò§Ê¶ÔµàÔ ª¹à´ÕÂÇ¡Ñ¹â´ÂÁÕ HR = 0.61
Appendix 3 ÃÒÂÅÐàÍÕÂ´¢Í§ adjuvant chemotherapy

Adjuvant chemotherapy ÊÒÁÒÃ¶Å´¡ÒÃ¡ÅÑºà»¹«éÓáÅÐ¡ÒÃàÊÕÂªÕÇÔµä´ÍÂÒ§ÁÕ¹ÑÂÊÓ¤Ñà·ÕÂº¡Ñº
¡ÒÃäÁãËµÒÁ¢ÍÁÙÅ¢Í§ EBCTCG(9) â´ÂÁÕ»ÃÐâÂª¹ÁÒ¡ã¹¼»Ù Ç ÂÍÒÂØ¹Í Â¡ÇÒ 50 »à·ÕÂº¡Ñº¡ÅÁØ ·ÕÍè ÒÂØ 50-69 »
áÅÐÁÕ¢Í ÁÙÅ¹ÍÂà¡ÕÂè Ç¡Ñº¡ÒÃãËà¤ÁÕºÓºÑ´ã¹¼»Ù Ç ÂÊÙ§ÍÒÂØ â´Âã¹¡ÅÁØ ÍÒÂØ¹Í Â¡ÇÒ 50 »¡ÒÃãËà¤ÁÕºÓºÑ´·Õàè »¹
polychemotherapy ÊÒÁÒÃ¶Å´¡ÒÃ¡ÅÑºà»¹«éÓáÅÐÅ´¡ÒÃàÊÕÂªÕÇÔµä´ÃÍÂÅÐ 12.3 áÅÐ 10 ·Õè 15 »ã¹¢³Ð·Õè
Å´¡ÒÃ¡ÅÑºà»¹«éÓáÅÐàÊÕÂªÕÇµÔ ä´ÃÍ ÂÅÐ 4.1 áÅÐ 3 ã¹¼»Ù Ç ÂÍÒÂØ 50-69 » áµ»ÃÐâÂª¹¹¨Õé Ðä´ÁÒ¡¢Ö¹é ã¹¡Ã³Õ
·Õàè »¹¼»Ù Ç Â·Õäè Áµ´Ô ËÃ×ÍµÔ´µÑÇÃÑº·Ò§ÎÍÃâÁ¹¹ÍÂ (ER poor disease) «Ö§è ¡ÒÃãªà¤ÁÕºÓºÑ´Å´ÍÑµÃÒ¡ÒÃ¡ÅÑºà»¹
«éÓáÅÐàÊÕÂªÕÇµÔ ä´à¾ÔÁè ¢Ö¹é à»¹ÃÍÂÅÐ 9.6 áÅÐ 4.9 µÒÁÅÓ´Ñºã¹¼»Ù Ç ÂÍÒÂØ 50-69 »
ÅÒÊØ´ÁÕ¢Í ÁÙÅ meta-analysis ¢Í§¡ÒÃãª adjuvant polychemotherapy ã¹¼»Ù Ç Â ER poor breast cancer
¾ºÇÒ¡ÒÃãªÂÒà¤ÁÕ«Öè§à»¹ non-taxane chemotherapy 6 ÃÍº¡ÒÃÃÑ¡ÉÒÊÒÁÒÃ¶Å´¡ÒÃ¡ÅÑºà»¹«éÓ Å´ÍÑµÃÒ
µÒÂ¨Ò¡·Ñé§ÁÐàÃç§àµÒ¹ÁáÅÐÍÑµÃÒµÒÂ¨Ò¡ÊÒàËµØÍ×è¹ä´ÍÂÒ§ÁÕ¹ÑÂÊÓ¤Ñà·ÕÂº¡Ñº¡ÒÃäÁä´ãË â´Â»ÃÐâÂª¹·Õè
ä´¹¹Ñé ä´·§Ñé ¡ÅÁØ ¼»Ù Ç Â·ÕÍè ÒÂ¹ÍÂ¡ÇÒ 50 »áÅÐ¡ÅÁØ ¼»Ù Ç Â·ÕÍè ÒÂØ 50-69 » áµÁ¢Õ Í ÁÙÅ¹ÍÂÊÓËÃÑº¼»Ù Ç Â·ÕÍè ÒÂØÁÒ¡¡ÇÒ
70 » â´Âã¹¡ÅØÁ¼Ù»ÇÂÍÒÂØ¹ÍÂ¡ÇÒ 50 » adjuvant polychemotherapy Å´¡ÒÃ¡ÅÑºà»¹«éÓ·Õè 10 »ä´ÃÍÂÅÐ 12
áÅÐÅ´¡ÒÃàÊÕÂªÕÇÔµä´ÃÍÂÅÐ 8 ÊÇ¹ã¹¡ÅØÁ¼Ù»ÇÂÍÒÂØ 50-69 » adjuvant polychemotherapy Å´¡ÒÃ¡ÅÑºà»¹
«éÓáÅÐàÊÕÂªÕÇµÔ ä´ÃÍ ÂÅÐ 10 áÅÐ 6 µÒÁÅÓ´Ñº
ÂÒ CMF x 6 ÃÍº¹Ñé¹ÁÕ¢ÍÁÙÅªÑ´à¨¹ÇÒÅ´¡ÒÃ¡ÅÑºà»¹«éÓä´´Õ¡ÇÒ¡ÒÃäÁãËà¤ÁÕËÅÑ§¼ÒµÑ´ÍÂÒ§
ÁÕ¹ÂÑ ÊÓ¤Ñ(10) ÊÇ¹ÊÙµÃÂÒà¤ÁÕºÓºÑ´·ÕÁè Õ anthracyclines à»¹ÊÇ¹»ÃÐ¡Íº ¶Òãª doxorubicin ¤×Í¡ÒÃãªÊµÙ Ã CEF
54-117_pc22.pmd 64 19/2/2551, 20:59

x 6 ÃÍº¹Ñé¹´Õ¡ÇÒ CMF x 6 ÃÍº(11) ÊÓËÃÑºÊÙµÃÂÒ·Õè¹ÔÂÁãªà¹×èÍ§¨Ò¡ÁÕ anthracyclines à»¹ÊÇ¹»ÃÐ¡Íº

áÅãË§Ò Â¡ÇÒ CEF ¹Ñ¹é ¤×Í FAC áµÍÂÒ§äÃ¡çµÒÁäÁÁ¢Õ Í ÁÙÅà»ÃÕÂºà·ÕÂºâ´ÂµÃ§ÇÒ»ÃÐÊÔ·¸ÔÀÒ¾à·Ò¡Ñ¹ËÃ×ÍäÁ
¢ÍÁÙÅ¢Í§ÂÒ¡ÅØÁãËÁ·ÕèÁÕ taxanes à»¹ÊÇ¹»ÃÐ¡Íº ÊÇ¹ãË¢Í§¡ÒÃÈÖ¡ÉÒ·Óã¹¼Ù»ÇÂ·ÕèÁÕÃÐÂÐ
¢Í§âÃ¤ÅØ¡ÅÒÁ¤×Í¡ÅÁØ ¼»Ù Ç Â·ÕÁè ¡Õ ÒÃ¡ÃÐ¨ÒÂä»ÂÑ§µÍÁ¹éÓàËÅ×Í§ ¹Í¡¨Ò¡¹Ñ¹é ¢ÍÁÙÅ¢Í§¡ÒÃãª paclitaxel à»¹
ÊÇ¹Ë¹Öè§ã¹¡ÒÃÃÑ¡ÉÒ¾ºÇÒàÁ×èÍÁÕ¡ÒÃÃÇºÃÇÁ¢ÍÁÙÅ¨Ò¡ 2 ¡ÒÃÈÖ¡ÉÒ¾ºÇÒ¡ÅØÁ¼Ù»ÇÂ·Õèà¹×éÍ§Í¡µÔ´µÑÇÃÑº·Ò§
ÎÍÃâÁ¹ (ER positive) áÅÐäÁµÔ´µÑÇÃÑº HER 2 (HER2 negative) äÁä´»ÃÐâÂª¹¨Ò¡¡ÒÃà¾ÔèÁÂÒ paclitaxel
à¢Òä»(12,13) ÁÕ¢Í ÁÙÅÅÒÊØ´·Õàè »¹ meta-analysis ¢Í§¡ÒÃãª docetaxel à»¹ÊÇ¹»ÃÐ¡Íºà·ÕÂº¡Ñºà¤ÁÕºÓºÑ´ÊÙµÃ
·ÕèäÁÁÕ docetaxel à»¹ÊÇ¹»ÃÐ¡Íº ÁÕ¡ÒÃÈÖ¡ÉÒ·Ñé§ËÁ´ 12 ¡ÒÃÈÖ¡ÉÒ(14) ¼Ù»ÇÂ 20468 ÃÒÂ ÁÕ·Ñé§¡ÒÃÈÖ¡ÉÒ·Õè
·Óà©¾ÒÐã¹¼Ù»ÇÂ·ÕèÁÕ¡ÒÃ¡ÃÐ¨ÒÂä»ÂÑ§µÍÁ¹éÓàËÅ×Í§áÅÐ¡ÒÃÈÖ¡ÉÒ·ÕèÁÕ·Ñé§¼Ù»ÇÂ·ÕèÁÕáÅÐäÁÁÕ¡ÒÃ¡ÃÐ¨ÒÂ
ä»ÂÑ§µÍÁ¹éÓàËÅ×Í§ ¾ºÇÒà¤ÁÕºÓºÑ´·ÕÁè Õ docetaxel à»¹ÊÇ¹»ÃÐ¡Íº¹Ñ¹é à¾ÔÁè DFS áÅÐ OS ä´ÍÂÒ§ÁÕ¹ÂÑ ÊÓ¤Ñ
HR ·Õè 0.82 áÅÐ 0.82 µÒÁÅÓ´Ñº ã¹á§¢Í§ subgroup analysis ¾ºÇÒ¼»Ù Ç ÂäÁÇÒ ¨Ðà»¹ÍÒÂØÁÒ¡¡ÇÒËÃ×Í¹ÍÂ¡ÇÒ
50 » µÔ´ËÃ×ÍäÁµ´Ô µÑÇÃÑº·Ò§ÎÍÃâÁ¹ à»¹¡ÅÁØ triple negative ËÃ×ÍäÁãª triple negative µÔ´ HER2 ËÃ×ÍäÁµ´Ô
HER2 ¹Ñé¹ä´»ÃÐâÂª¹·Ñé§ DFS áÅÐ OS ÍÂÒ§ÁÕ¹ÑÂÊÓ¤ÑäÁáµ¡µÒ§¡Ñ¹ áµã¹á§¢Í§¡ÒÃÁÕËÃ×ÍäÁÁÕµÍÁ
¹éÓàËÅ×Í§¾ºÇÒ»ÃÐâÂª¹·äÕè ´ã¹á§¢Í§ OS ¹Ñ¹é ÁÕ¤ÇÒÁáµ¡µÒ§ÍÂÒ§ÁÕ¹ÂÑ ÊÓ¤Ñà©¾ÒÐã¹¼»Ù Ç Â·ÕÁè ¡Õ ÒÃ¡ÃÐ¨ÒÂ
ä»ÂÑ§µÍÁ¹éÓàËÅ×Í§·ÕÃè ¡Ñ áÃà·Ò¹Ñ¹é
Appendix 4 ÊÙµÃÂÒà¤ÁÕºÓºÑ´ÁÒµÃ°Ò¹·Õáè ¹Ð¹ÓãËãª

1. classical CMF x 6 cycles(15)
oral cyclophosphamide 100 mg/m2 D1-D14
Methotrexate 40 mg/m2 D1, D8
5-FU 600 mg/m2 D1,D8 ·Ø¡ 28 ÇÑ¹ 6 ÃÍº
2. AC x 4 (16)
Doxorubicin 60 mg/m2 D1
Cyclophosphamide 600 mg/m2 D1 ·Ø¡ 21 ÇÑ¹ 4 ÃÍº
3. FAC x 6
5-FU 500 mg/m2 D1
Doxorubicin 50 mg/m2 D1
4. FE(100)C x 6(17)
5-FU 500 mg/m2 D1
Epirubicin 100 mg/m2 D1
54-117_pc22.pmd 65 19/2/2551, 20:59

5. AC x 4 then weekly T x 12(18)

AC x 4 µÒÁ¢¹Ò´áÅÐÃÐÂÐàÇÅÒ·Õäè ´¡ÅÒÇã¹¢Í 2 ¨Ò¡¹Ñ¹é µÒÁ´ÇÂ
Paclitaxel 80 mg/m2 D1 ·Ø¡ÊÑ»´ÒË 12 ÃÍº
6. AC x 4 then D x 4(18)
AC x 4 µÒÁ¢¹Ò´áÅÐÃÐÂÐàÇÅÒ·Õäè ´¡ÅÒÇ¶Ö§ã¹¢Í 2 ¨Ò¡¹Ñ¹é µÒÁ´ÇÂ
Docetaxel 100 mg/m2 D1 ·Ø¡ 21 ÇÑ¹ 4 ÃÍº
7. FEC x 3 then D x 3(19)
FEC »ÃÐ¡Íº´ÇÂ
5-FU 500 mg/m2 D1
Epirubicin 100 mg/m2 D1
D »ÃÐ¡Íº´ÇÂ
Docetaxel 100 mg/m2 D1 ·Ø¡ 21 ÇÑ¹ 3 ÃÍº
8. TC x 4(20)
Docetaxel 5 mg/m2 D1
Appendix 5 ÃÒÂÅÐàÍÕÂ´¢Í§ Adjuvant Trastuzumab

ã¹»¨¨Øº¹Ñ ÁÕ¡ÒÃÈÖ¡ÉÒãË 5 ¡ÒÃÈÖ¡ÉÒà»ÃÕÂºà·ÕÂº¡ÒÃãª trastuzumab à»¹¡ÒÃÃÑ¡ÉÒàÊÃÔÁã¹¼»Ù Ç Â
ÁÐàÃç§ÃÐÂÐàÃÔèÁµ¹·ÕèÁÕ HER2 à»¹¼ÅºÇ¡ áÅÐ·Ø¡¡ÒÃÈÖ¡ÉÒÁÕÃÒÂ§Ò¹àº×éÍ§µ¹áÅÇÇÒ¡ÒÃãª trastuzumab ¹Ñé¹
ÁÕ»ÃÐâÂª¹¨ÃÔ§ã¹´Ò¹Å´¡ÒÃà»¹«éÓ áÅÐ¡ÒÃÅ´ÍÑµÃÒ¡ÒÃàÊÕÂªÕÇµÔ ÃÒÂÅÐàÍÕÂ´ÁÕ´§Ñ µÍä»¹Õé
1. ¡ÒÃÃÇÁ¢ÍÁÙÅ¢Í§ 2 ¡ÒÃÈÖ¡ÉÒà¢Ò´ÇÂ¡Ñ¹ ä´á¡ NSABP B-31 áÅÐ NCCTG N981(21)
¨Ò¡¡ÒÃµÔ´µÒÁ¼Å¡ÒÃÃÑ¡ÉÒâ´Âà©ÅÕèÂ 2.9 » ¾ºÇÒ¡ÅØÁ·Õèä´à¤ÁÕºÓºÑ´áÅÐ trastuzumab à»¹àÇÅÒ 1 » ÁÕ 4-year
disease-free survival ´Õ¡ÇÒ¡ÅÁØ ·Õäè ´à¤ÁÕºÓºÑ´ÍÂÒ§à´ÕÂÇÍÂÒ§ÁÕ¹ÂÑ ÊÓ¤Ñ·Ò§Ê¶ÔµÔ (85.9% ¡Ñº 73.1% µÒÁÅÓ´Ñº)
áÅÐä´»ÃÐâÂª¹ã¹á§Å´ÍÑµÃÒ¡ÒÃàÊÕÂªÕÇÔµÍÂÒ§ÁÕ¹ÑÂÊÓ¤Ñ·Ò§Ê¶ÔµÔàª¹à´ÕÂÇ¡Ñ¹ (92.6% ¡Ñº 89.4%) áÅÐ
»ÃÐâÂª¹·Õèä´äÁ¢Öé¹¡ÑºÍÒÂØ ¡ÒÃáÊ´§ÍÍ¡¢Í§ hormonal receptor áÅÐ¡ÒÃ¡ÃÐ¨ÒÂËÃ×ÍäÁ¡ÃÐ¨ÒÂä»ÂÑ§
µÍÁ¹éÓàËÅ×Í§
2. ¡ÒÃÈÖ¡ÉÒ¢Í§ HERA(22) ÃÒÂ§Ò¹ÅÒÊØ´¨Ò¡¡ÒÃµÔ´µÒÁ¼Å¡ÒÃÃÑ¡ÉÒâ´Âà©ÅÕèÂ 2 » ¾ºÇÒ¡ÅØÁ·Õè
ä´à¤ÁÕºÓºÑ´áÅÇµÒÁ´ÇÂ trastuzumab à»¹àÇÅÒ 1 » ÁÕ 3-year disease-free survival ´Õ¡ÇÒ¡ÅØÁ·Õèä´à¤ÁÕºÓºÑ´
à¾ÕÂ§ÍÂÒ§à´ÕÂÇ ÍÂÒ§ÁÕ¹ÑÂÊÓ¤Ñ·Ò§Ê¶ÔµÔ (80.6% ¡Ñº 74.3% µÒÁÅÓ´Ñº) áÅÐÁÕ 3-year overall survival
´Õ¡ÇÒ¡ÅÁØ ·Õäè ´ÃºÑ à¤ÁÕºÓºÑ´à¾ÕÂ§ÍÂÒ§à´ÕÂÇÍÂÒ§ÁÕ¹ÂÑ ÊÓ¤Ñ·Ò§Ê¶ÔµÔ (92.4% ¡Ñº 89.7% µÒÁÅÓ´Ñº)
54-117_pc22.pmd 66 19/2/2551, 20:59

3. ¡ÒÃÈÖ¡ÉÒ BCIRG 006(23) ¾ºÇÒ¡ÅÁØ ·Õäè ´ trastuzumab à»¹¡ÒÃÃÑ¡ÉÒàÊÃÔÁ äÁÇÒ ¨ÐãªÃÇ Á¡ÑºÊÙµÃÂÒ
·ÕèÁÕËÃ×ÍäÁÁÕ anthracyclines à»¹ÊÇ¹»ÃÐ¡Íº ÃÒÂ§Ò¹ËÅÑ§µÔ´µÒÁ¼Å¡ÒÃÃÑ¡ÉÒ 36 à´×Í¹ ¾ºÇÒ¡ÅØÁ·Õèä´
trastuzumab ÁÕ DFSáÅÐ OS ·Õ´è ¡Õ ÇÒ¡ÅÁØ ·Õäè Áä´ÃºÑ ÂÒÍÂÒ§ÁÕ¹ÂÑ ÊÓ¤Ñ·Ò§Ê¶ÔµÔ (absolute benefit 5-6%)
4. FinHer trial ä´È¡Ö ÉÒ¡ÒÃãª Trastuzumab à»¹àÇÅÒ 9 ÊÑ»´ÒË ÃÇÁ¡Ñº docetaxel ËÃ×Í vinorelbine
µÔ´µÒÁ´ÇÂ FEC ¨Ó¹Ç¹ 3 ÃÍº â´ÂäÁÁÕ Trastuzumab ã¹¼»Ù Ç ÂÁÐàÃç§àµÒ¹ÁÃÐÂÐáÃ¡·ÕÁè Õ HER-2 à»¹¼ÅºÇ¡
·Ñé§ÁÕáÅÐäÁÁÕ¡ÒÃ¡ÃÐ¨ÒÂä»ÂÑ§µÍÁ¹éÓàËÅ×Í§¨Ò¡¡ÒÃµÔ´µÒÁà»¹àÇÅÒ 36 à´×Í¹ ¾ºÇÒ¼Ù»ÇÂã¹¡ÅØÁ·Õèä´ÃÑº
Trastuzumab ÁÕÍÑµÃÒ¡ÒÃÍÂÙÃÍ´â´Â»ÃÒÈ¨Ò¡âÃ¤ (RFS) ´Õ¢Öé¹¡ÇÒ¡ÅØÁ·ÕèäÁä´ÃÑºÍÂÒ§ÁÕ¹ÑÂÊÓ¤Ñ (89 % áÅÐ
78 % µÒÁÅÓ´Ñº) áµäÁÁ¤Õ ÇÒÁáµ¡µÒ§¢Í§ÃÐÂÐàÇÅÒ¡ÒÃÍÂÃÙ Í´ (OS)
à¹×Íè §¨Ò¡¡ÒÃãª Trastuzumab ÁÕ¼Å¢Ò§à¤ÕÂ§·ÕÊè Ó¤Ñ ¤×Í ÀÒÇÐËÑÇã¨ÅÁàËÅÇ ¨Ö§µÍ§ÁÕ¡ÒÃà½ÒµÔ´µÒÁ
¡ÒÃ·Ó§Ò¹¢Í§ËÑÇã¨à»¹ÃÐÂÐã¹ÃÐËÇÒ§¡ÒÃÃÑ¡ÉÒ ¨Ò¡¡ÒÃÇÔà¤ÃÒÐË¼ÅÃÇÁ¢Í§¡ÒÃÈÖ¡ÉÒ NSABP B31 áÅÐ
NCCTG 9831 ¾ºÇÒ ã¹¡ÅÁØ ·Õäè ´ Trastuzumab ¾ÃÍÁ¡Ñº paclitaxel ÁÕÀÒÇÐËÑÇã¨ÅÁàËÅÇ 51 ÃÒÂ ã¹¢³Ð·ÕÁè àÕ ¾ÕÂ§
5 ÃÒÂã¹¡ÅØÁ¤Çº¤ØÁ ã¹¡ÒÃÈÖ¡ÉÒ HERA ¾ºÀÒÇÐËÑÇã¨ÅÁàËÅÇ 9 ÃÒÂ ¨Ò¡ 1,677 ÃÒÂ ·Õèä´ Trastuzumab
µÒÁËÅÑ§à¤ÁÕºÓºÑ´ áÅÐäÁ¾ºÀÒÇÐ¹Õéã¹¡ÅØÁ¤Çº¤ØÁ ÍØºÑµÔ¡ÒÃ³¢Í§ÀÒÇÐËÑÇã¨ÅÁàËÅÇã¹ HERA ¹ÍÂ¡ÇÒ
NSABP B31 áÅÐ NCCTG 9831 ÍÒ¨à»¹à¾ÃÒÐ¡ÒÃãË Trastuzumab µÒÁËÅÑ§à¤ÁÕºÓºÑ´ ÁÔä´ãË¾ÃÍÁ¡Ñ¹
áÅÐ¼»Ù Ç Â ·Õàè ¢ÒÃÇÁµÍ§ÁÕ LVEF ÁÒ¡¡ÇÒ 55 % á·¹·Õ¨è Ðà»¹ 50 % ã¹¡ÒÃÈÖ¡ÉÒÍ×¹è
â´ÂÊÃØ»¡ÒÃãª trastuzumab à»¹¡ÒÃÃÑ¡ÉÒàÊÃÔÁã¹¼»Ù Ç ÂÁÐàÃç§àµÒ¹ÁÃÐÂÐáÃ¡·ÕÁè Õ HER2 positive
¾ºÇÒÂÑ§¤§ãËÃÐÂÐàÇÅÒÃÍ´ªÕÇÔµâ´Â»ÃÒÈ¨Ò¡âÃ¤áÅÐÃÐÂÐàÇÅÒÃÍ´ªÕÇµÔ´Õ¢Öé¹ÍÂÒ§ÁÕ¹ÑÂÊÓ¤Ñ·Ò§Ê¶ÔµÔ
áµÍÂÒ§äÃ¡çµÒÁÂÑ§ÁÕºÒ§¨Ø´·ÕÂè §Ñ äÁÁ¤Õ ÓµÍº·Õªè ´Ñ à¨¹ àª¹ÃÐÂÐàÇÅÒ·Õàè ËÁÒÐÊÁã¹¡ÒÃãË trastuzumab ÃÐËÇÒ§
1 ËÃ×Í 2 » ËÃ×ÍÃÐÂÐÊÑ¹é ¡ÇÒ¹Õé ¡ÒÃãËÂÒ trastuzumab ÃÇÁ¡ÑºÂÒ¡ÅÁØ taxanes ËÃ×ÍãªËÅÑ§¨Ò¡ÃÑ¡ÉÒ´ÇÂà¤ÁÕºÓºÑ´
¨ºÊÔ¹é áÅÇ ¹Í¡¨Ò¡¹Ñ¹é ¡ÒÃÃÑ¡ÉÒ´ÇÂ trastuzumab ÁÕ¼Å¢Ò§à¤ÕÂ§µÍËÑÇã¨à¾ÔÁè ÁÒ¡¢Ö¹é
Appendix 6 ÊÙµÃÂÒà¤ÁÕºÓºÑ´ÃÇÁ¡Ñº trastuzumab ·Õáè ¹Ð¹ÓãËãª

1. Sequential approach
àÃÔÁè µ¹´ÇÂ¡ÒÃÃÑ¡ÉÒàÊÃÔÁ´ÇÂÂÒà¤ÁÕºÓºÑ´ÊÙµÃã´¡çä´¨¹¨º ¨Ò¡¹Ñ¹é µÒÁ´ÇÂ trastuzumab µÑÇà´ÕÂÇ¨¹
¤Ãº 1 » Trastuzumab ÊÑ»´ÒËáÃ¡ 8 mg/kg ¨Ò¡¹Ñ¹é ãË 6 mg/kg ·Ø¡ 3 ÊÑ»´ÒË ¨¹¤Ãº 1 »
2. Concurrent approach
· AC x 4 cycles (µÒÁ¢Í 2 ã¹ appendix 4) ¨Ò¡¹Ñ¹é µÒÁ´ÇÂ taxane ÃÇÁ¡Ñº trastuzumab â´ÂÁÕÇ¸Ô ãÕ Ë
2 ÇÔ¸´Õ §Ñ ¹Õé
- paclitaxel ÊÒÁÒÃ¶ãËä´·§Ñé ÃÙ»áºº weekly ·Ø¡ÊÑ»´ÒË¨Ó¹Ç¹ 12 ÃÍºËÃ×Í·Ø¡ 3 ÊÑ»´ÒË
¨Ó¹Ç¹ 4ÃÍº (´Ñ§ÃÒÂÅÐàÍÕÂ´¢Í 3 ã¹ appendix 4) â´ÂãË trastuzumab áºº·Ø¡
ÊÑ»´ÒËã¹ªÇ§·Õãè Ë taxanes ¤×Í 4 mg/kg ÊÑ»´ÒËáÃ¡ µÒÁ´ÇÂ 2 mg/kg ·Ø¡ÊÑ»´ÒË¨Ó¹Ç¹
11 ¤ÃÑ§é ¨Ò¡¹Ñ¹é ãË trastuzumab 6 mg/kg ·Ø¡ 3 ÊÑ»´ÒË¨¹¤Ãº 1 »
54-117_pc22.pmd 67 19/2/2551, 20:59

- docetaxel â´ÂãËáºº·Ø¡ 3 ÊÑ»´ÒË (´Ñ§ÃÒÂÅÐàÍÕÂ´¢Í 4 ã¹ appendix 4) áÅÐãË

trastuzumab àª¹à´ÕÂÇ¡ÑºÇÔ¸¡Õ ÒÃãËÃÇ Á¡Ñº paclitaxel ¢Ò§µ¹
· Docetaxel plus carboplatin plus trastuzumab
- Docetaxel 75 mg/m2 ·Ø¡ 3 ÊÑ»´ÒË ¨Ó¹Ç¹ 6 ÃÍº¡ÒÃÃÑ¡ÉÒ
- Carboplatin AUC 6
- Trastuzumab 4 mg/kg ÊÑ»´ÒËáÃ¡ ¨Ò¡¹Ñ¹é 2 mg/kg ·Ø¡ÊÑ»´ÒËÍ¡Õ 11 ÊÑ»´ÒË (ªÇ§
·Õãè Ë¾ÃÍÁ¡Ñºà¤ÁÕºÓºÑ´) ¨Ò¡¹Ñ¹é 6 mg/kg ·Ø¡ÊÒÁÊÑ»´ÒË¨¹¤Ãº 1 »
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v v v
54-117_pc22.pmd 69 19/2/2551, 20:59

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3. äÁá¹Ð¹ÓãËãªÎÍÃâÁ¹¾ÃÍÁ¡Ñºà¤ÁÕºÓºÑ´ã¹¡ÒÃÃÑ¡ÉÒÁÐàÃç§àµÒ¹ÁÃÐÂÐ
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¨Ò¡¢ÍÁÙÅ¡ÒÃÈÖ¡ÉÒáºº Randomized trials áÅÐ overview analysis ¾ºÇÒ¡ÒÃãªÎÍÃâÁ¹¾ÃÍÁ¡Ñº
à¤ÁÕºÓºÑ´ ÍÒ¨ÁÕ¡ÒÃµÍºÊ¹Í§·Õèà¾ÔèÁ¢Öé¹ áµäÁ·ÓãË¼Ù»ÇÂÁÕªÕÇÔµÂ×¹ÂÒÇ¢Öé¹àÁ×èÍà·ÕÂº¡Ñº¡ÒÃãªÎÍÃâÁ¹à¾ÕÂ§
ÍÂÒ§à´ÕÂÇ(3,4,11-16)
4. ã¹¡ÒÃãªÎÍÃâÁ¹áµÅÐª¹Ô´¨Ðà»ÅÕÂè ¹á»Å§ª¹Ô´ãËÁµÍ àÁ×Íè âÃ¤ÅØ¡ÅÒÁ¢Ö¹ é

à·Ò¹Ñ¹é ã¹¡Ã³Õ·âÕè Ã¤ÂÑ§¤§¢¹Ò´à´ÔÁ (stable disease) ÊÒÁÒÃ¶ãªÎÍÃâÁ¹µÑÇà´ÔÁµÍä»ä´
ÁÕ¡ÒÃÈÖ¡ÉÒ¾ºÇÒªÇ§ªÕÇÔµ¢Í§¼Ù»ÇÂ·ÕèÃÑ¡ÉÒ´ÇÂÎÍÃâÁ¹áµâÃ¤ÂÑ§¤§à´ÔÁ¨Ðà·Ò¡Ñº¢Í§¼Ù»ÇÂ·ÕèÁÕ
¡ÒÃµÍºÊ¹Í§ºÒ§ÊÇ¹ ËÃ×ÍÊÁºÙÃ³ ( partial ËÃ×Í complete response )( 17,18)
5. ª¹Ô´¢Í§ÎÍÃâÁ¹·Õãè ª : ¢Ö¹
é ÍÂ¡Ù ºÑ ÇÒ¼»Ù Ç Âà»¹ÇÑÂ¡Í¹ËÁ´»ÃÐ¨Óà´×Í¹ ËÃ×Í
ÇÑÂËÅÑ§ËÁ´»ÃÐ¨Óà´×Í¹
5.1 ¼»Ù Ç ÂÇÑÂ¡Í¹ËÁ´»ÃÐ¨Óà´×Í¹ (µÒÁ¤Ó¨Ó¡Ñ´¤ÇÒÁ¢Í§¡ÒÃËÁ´»ÃÐ¨Óà´×Í¹ã¹á¹Ç·Ò§¢Í§
¼»Ù Ç ÂÃÐÂÐáÃ¡)
· ÎÍÃâÁ¹µÑÇáÃ¡·Õ¤ è ÇÃãª Tamoxifen ËÃ×Í ovarian ablation
ã¹Í´Õµá¹Ð¹ÓãË·Ó ovarian ablation (bilateral oophorectomy) à»¹¡ÒÃÃÑ¡ÉÒËÅÑ¡ ¾ºÇÒÁÕ¡ÒÃ
µÍºÊ¹Í§ÍÂãÙ ¹ªÇ§ÃÍÂÅÐ15-56 áÅÐÁÕ¡ÒÃµÍºÊ¹Í§â´Âà©ÅÕÂè 9-15 à´×Í¹(19) ¡ÒÃ·Ó bilateral oophorectomy
ÍÒ¨ãªÇÔ¸Õ¼ÒµÑ´ ©ÒÂáÊ§ ËÃ×ÍãËÂÒ¡ÅØÁ LHRH agonist àª¹ leuprolide ËÃ×Í goserelin(20) ã¹ÃÐÂÐËÅÑ§¹ÔÂÁ
ãË Tamoxifen à»¹¡ÒÃÃÑ¡ÉÒËÅÑ¡ÁÒ¡¢Öé¹ à¹×èÍ§¨Ò¡ÁÕÃÒÂ§Ò¹ÇÒÁÕ»ÃÐÊÔ·¸ÔÀÒ¾à·Ò¡Ñº¡ÒÃ·Ó bilateral oopho-
rectomy(21,22)
¨Ð¾Ô¨ÒÃ³Òãª tamoxifen ã¹¡Ã³Õ·¼Õè »Ù Ç ÂäÁà¤Âä´ tamoxifen ÁÒ¡Í¹ËÃ×Íà¤Âä´ tamoxifen
à»¹¡ÒÃÃÑ¡ÉÒàÊÃÔÁÀÒÂËÅÑ§¼ÒµÑ´áÅÇËÂØ´ä»áÅÇ¹Ò¹à¡Ô¹ 1 »¢¹Öé ä»
· ÎÍÃâÁ¹µÑÇ·ÕÊ è Í§·Õ¤è ÇÃãª ¡Ã³Õ·âÕè Ã¤ÅØ¡ÅÒÁÁÒ¡¢Ö¹é ËÅÑ§¨Ò¡·ÕÁè ¡Õ ÒÃµÍºÊ¹Í§µÍÎÍÃâÁ¹
µÑÇáÃ¡ÃÐÂÐË¹Ö§è ¤×Í ovarian ablation ËÃ×Í tamoxifen ËÃ×Í progestin
¡Ã³Õ·¼Õè »Ù Ç Âà¤Âãª tamoxifen à»¹µÑÇáÃ¡ ÍÒ¨¾Ô¨ÒÃ³Òãª ovarian ablation ËÃ×Í¶Ò¼»Ù Ç Âà¤Âãª
ovarian ablation à»¹µÑÇáÃ¡¡ç¾¨Ô ÒÃ³Ò ãË tamoxifen à»¹µÑÇ·ÕÊè Í(23,24) ã¹¡Ã³Õ·¼Õè »Ù Ç Â»®ÔàÊ¸ ovarian ablation
ÍÒ¨¾Ô¨ÒÃ³ÒãË progestin ( megestrol acetate ËÃ×Í medroxyprogesterone acetate )
54-117_pc22.pmd 71 19/2/2551, 20:59

· ÎÍÃâÁ¹µÑÇ·ÕÊè ÒÁ·Õ¤è ÇÃãª¡Ã³Õ·âÕè Ã¤ÅØ¡ÅÒÁÁÒ¡¢Ö¹é ËÅÑ§¨Ò¡·ÕÁè ¡Õ ÒÃµÍºÊ¹Í§µÍÎÍÃâÁ¹µÑÇ

·ÕÊè Í§ÃÐÂÐË¹Ö§è ¤×Í progestin (megestrol acetate ËÃ×Í medroxyprogesterone acetate) ËÃ×Í aromatase inhibitors
(AI)
ã¹¡Ã³Õ·´Õè Í×é µÍÎÍÃâÁ¹µÑÇ·ÕÊè Í§ËÅÑ§¨Ò¡µÍºÊ¹Í§ÃÐÂÐË¹Ö§è ÍÒ¨¾Ô¨ÒÃ³ÒãË progestin ËÃ×Í
ÍÒ¨¾Ô¨ÒÃ³ÒãË AI ä´ã¹ÃÒÂ·Õ·è Ó Oophorectomy áÅÇ (25)
5.2 ¼»Ù Ç ÂÇÑÂËÁ´»ÃÐ¨Óà´×Í¹ ä´á¡¢Íã´¢ÍË¹Öè§µÍä»¹Õé 1. ¼Ù»ÇÂÍÒÂØ > 60» ËÃ×Í 2. ¼Ù»ÇÂÍÒÂØ

< 60 » áÅÐ»ÃÐ¨Óà´×Í¹ËÁ´ä»µÒÁ¸ÃÃÁªÒµÔÁÒ¡¡ÇÒ 1 » â´Â¼»Ù Ç ÂµÍ§äÁä´ÃºÑ à¤ÁÕºÓºÑ´ GnRH analogue ËÃ×Í
tamoxifen áÅÐÃÐ´Ñº¢Í§ FSH áÅÐ estradiol ÍÂÙã¹à¡³±ÇÑÂËÁ´»ÃÐ¨Óà´×Í¹ ËÃ×Í 3. à¤Â¼ÒµÑ´ÃÑ§ä¢ÍÍ¡
·Ñ§é ÊÍ§¢Ò§
· ÎÍÃâÁ¹µÑÇáÃ¡·Õ¤ è ÇÃãª¤Í× tamoxifen ËÃ×Í aromatase inhibitor
Tamoxifen ä´ÃÑº¡ÒÃÂÍÁÃÑºÇÒ ¤ÇÃãªà»¹ÎÍÃâÁ¹µÑÇáÃ¡ã¹¼Ù»ÇÂÁÐàÃç§àµÒ¹ÁÃÐÂÐ
á¾Ã¡ÃÐ¨ÒÂ ã¹¼»Ù Ç ÂÇÑÂËÁ´»ÃÐ¨Óà´×Í¹ (26-28) «Ö§è ÁÕ¡ÒÃµÍºÊ¹Í§ 50% áÅÐÁÕÃÐÂÐàÇÅÒ¢Í§¡ÒÃµÍºÊ¹Í§ 12-
15 à´×Í¹
ÁÕÃÒÂ§Ò¹¡ÒÃÈÖ¡ÉÒ¢Í§ AI ( àª¹ anastrozole, letrozole ËÃ×Í exemestane ) à»ÃÕÂºà·ÕÂº¡Ñº
tamoxifen â´Âãªà»¹ÎÍÃâÁ¹µÑÇáÃ¡ã¹¡ÒÃÃÑ¡ÉÒÁÐàÃç§àµÒ¹ÁÃÐÂÐá¾Ã¡ÃÐ¨ÒÂ ¾ºÇÒ AI ÁÕ»ÃÐÊÔ·¸ÔÀÒ¾
à·Ò¡ÑºËÃ×Í´Õ¡ÇÒ Tamoxifen àª¹ã¹á§ response rate áÅÐ time to progression áµäÁÁ¤Õ ÇÒÁáµ¡µÒ§¡Ñ¹ã¹á§¢Í§
overall survival(29-31)
ÊÇ¹ÂÒ fulvestrant «Ö§è ¨Ñ´à»¹ÂÒãËÁã¹¡ÅÁØ ÎÍÃâÁ¹¹Ñ¹é ÁÕÃÒÂ§Ò¹¡ÒÃÈÖ¡ÉÒà»ÃÕÂºà·ÕÂºÂÒ¹Õ¡é ºÑ
tamoxifen à»¹ÎÍÃâÁ¹µÑÇáÃ¡ã¹¡ÒÃÃÑ¡ÉÒÁÐàÃç§àµÒ¹ÁÃÐÂÐá¾Ã¡ÃÐ¨ÒÂ ¾ºÇÒÁÕ»ÃÐÊÔ·¸ÔÀÒ¾ à·Ò¡Ñº
tamoxifen ·Ñé§ã¹á§¢Í§¡ÒÃ¤Çº¤ØÁâÃ¤ÃÇÁ¶Ö§ÍÑµÃÒ¡ÒÃÃÍ´ªÕ¾(32) áµÁÕÃÒ¤ÒÊÙ§¡ÇÒ tamoxifen ÁÒ¡ ÃÇÁ·Ñé§
à»¹ÂÒ·Õµè Í §©Õ´à¢Ò¡ÅÒÁà¹×Íé «Ö§è ÍÒ¨¡ÍãËà¡Ô´¤ÇÒÁäÁÊÐ´Ç¡µÍ¼»Ù Ç Â ¨Ö§äÁá¹Ð¹ÓãËãªÂÒ¹Õàé »¹ÂÒ¢¹Ò¹áÃ¡
´Ñ§¹Ñé¹ ¨Ö§á¹Ð¹ÓãËãª tamoxifen à»¹ÎÍÃâÁ¹µÑÇáÃ¡ áÅÐÍÒ¨¾Ô¨ÒÃ³Òãª AI ã¹¡Ã³Õ·Õè¼Ù»ÇÂÁÕ
¢ÍËÒÁã¹¡ÒÃãª tamoxifen àª¹ ÁÕ» ËÒ thromboembolism (deep vein thrombosis) à»¹µ¹
· ÎÍÃâÁ¹µÑÇ·ÕÊ è Í§·Õ¤è ÇÃãª ¡Ã³Õ·âÕè Ã¤ÅØ¡ÅÒÁÁÒ¡¢Ö¹é ËÅÑ§¨Ò¡·ÕÁè ¡Õ ÒÃµÍºÊ¹Í§µÍÎÍÃâÁ¹
µÑÇáÃ¡ (tamoxifen) ÃÐÂÐË¹Öè§ ¤×Í aromatase inhibitor ËÃ×Í progestin ( megestrol acetate ËÃ×Í medroxypro-
gesterone acetate ) ËÒ¡ãª AIs à»¹ÂÒµÑÇáÃ¡ãËãª tamoxifen à»¹ÂÒ¢¹Ò¹·ÕÊè Í§
ã¹¡Ã³Õ·ãÕè ª tamoxifen à»¹ÎÍÃâÁ¹µÑÇáÃ¡ á¹Ð¹ÓãËãª AI à»¹ÎÍÃâÁ¹µÑÇ·ÕÊè Í§ËÅÑ§¨Ò¡·Õè
âÃ¤ÅØ¡ÅÒÁ áµÍÒ¨¾Ô¨ÒÃ³Òãª progestin ä´ã¹¡Ã³Õ·¼Õè »Ù Ç Â¼ÍÁËÃ×ÍÁÕÍÒ¡ÒÃàº×Íè ÍÒËÒÃÃÇÁ´ÇÂà¾ÃÒÐ progestin
54-117_pc22.pmd 72 19/2/2551, 20:59

·ÓãË¼»Ù Ç ÂÍÂÒ¡ÍÒËÒÃáÅÐ¹éÓË¹Ñ¡à¾ÔÁè ¢Ö¹é ¡ÒÃÈÖ¡ÉÒà»ÃÕÂºà·ÕÂºÃÐËÇÒ§ aromatase inhibitor (àª¹ anastrozole,

letrozole ËÃ×Í exemestane ) ¡Ñº progestin ã¹¼Ù»ÇÂ·ÕèâÃ¤ÅØ¡ÅÒÁËÅÑ§ãË tamoxifen ¾ºÇÒ AI ÁÕ»ÃÐÊÔ·¸ÔÀÒ¾
ã¹á§¡ÒÃµÍºÊ¹Í§ËÃ×Í¼ÅµÍªÇ§ªÕÇÔµ´Õ¡ÇÒËÃ×Íà·Ò¡Ñº progestin áµÁÕ¼Å¢Ò§à¤ÕÂ§¹ÍÂ¡ÇÒâ´Âà©¾ÒÐàÃ×èÍ§
¹éÓË¹Ñ¡µÑÇ·Õèà¾ÔèÁ¢Öé¹(33-35) ÊÇ¹ã¹¡Ã³Õ·Õèãª AI à»¹ÎÍÃâÁ¹µÑÇáÃ¡ ÍÒ¨¾Ô¨ÒÃ³Òãª tamoxifen à»¹ÎÍÃâÁ¹
µÑÇ·ÕÊè Í§ ÊÓËÃÑº fulvestrant ¹Ñ¹é ÁÕ¡ÒÃÈÖ¡ÉÒà»ÃÕÂºà·ÕÂº¡Ñº anastrozole ã¹¼»Ù Ç Â·Õâè Ã¤ÅØ¡ÅÒÁËÅÑ§ tamoxifen
áÅÐ¾ºÇÒÂÒ fulvestrant ãË¼Åà·ÕÂºà·Ò anastrozole ·Ñ§é ã¹á§¢Í§¡ÒÃ¤Çº¤ØÁâÃ¤ÃÇÁ¶Ö§ÍÑµÃÒ¡ÒÃÃÍ´ªÕ¾(36,37)
áµÁÃÕ Ò¤ÒÊÙ§¡ÇÒ tamoxifen ÁÒ¡ ÃÇÁ·Ñ§é à»¹ÂÒ·Õµè Í §©Õ´à¢Ò¡ÅÒÁà¹×Íé «Ö§è ÍÒ¨¡ÍãËà¡Ô´¤ÇÒÁäÁÊÐ´Ç¡µÍ¼»Ù Ç Â
¨Ö§äÁá¹Ð¹ÓãËãªÂÒ¹Õãé ¹¼»Ù Ç Â·Õâè Ã¤ÅØ¡ÅÒÁËÅÑ§ tamoxifen
· ÎÍÃâÁ¹µÑÇ·ÕÊ è ÒÁ·Õ¤è ÇÃãª¡Ã³Õ·âÕè Ã¤ÅØ¡ÅÒÁÁÒ¡¢Ö¹é ËÅÑ§¨Ò¡·ÕÁè ¡Õ ÒÃµÍºÊ¹Í§µÍÎÍÃâÁ¹
µÑÇ·ÕÊè Í§ÃÐÂÐË¹Ö§è ¤×Í steroidal aromatase inhibitor (exemestane) ËÒ¡ÂÑ§äÁà¤Âä´ÂÒ¹Õé ËÒ¡à¤Âä´ÂÒ¹ÕÁé ÒáÅÇ
¾Ô¨ÒÃ³ÒãË fulvestrant ËÃ×Í progestin
ÂÒã¹¡ÅÁØ AI ÁÕ·§Ñé ª¹Ô´·Õàè »¹ steroidal AI ä´á¡ exemestane áÅÐª¹Ô´·Õàè »¹ non-steroidal AI
ä´á¡ anastrozole áÅÐ letrozole «Ö§è ¾ºÇÒäÁä´ÁÕ cross resistance ÍÂÒ§ÊÁºÙÃ³ ÁÕÃÒÂ§Ò¹¡ÒÃãª exemestane
ã¹¼Ù»ÇÂ·ÕèâÃ¤ÅØ¡ÅÒÁËÅÑ§ãË non-steroidal AI áÅÇ¾ºÇÒÁÕ¡ÒÃµÍºÊ¹Í§(38) ´Ñ§¹Ñé¹ ã¹¡Ã³Õ·Õèà¤Âä´ non-
steroidal AI à»¹ÎÍÃâÁ¹µÑÇ·ÕÊè Í§áÅÇâÃ¤ÅØ¡ÅÒÁ á¹Ð¹ÓãËãª exemestane
ÊÓËÃÑº fulvestrant ¹Ñ¹é ÁÕ¡ÒÃÈÖ¡ÉÒà»ÃÕÂºà·ÕÂº¡Ñº exemestane ã¹¼»Ù Ç Â·Õâè Ã¤ÅØ¡ÅÒÁËÅÑ§ non-
steroidal AI ¾ºÇÒÂÒ fulvestrant ãË¼Åà·ÕÂºà·Ò exemestane(39) á¹Ð¹ÓãËãª fulvestrant à©¾ÒÐã¹¡Ã³Õ·àÕè ¤Âä´
exemestane ÁÒ¡Í¹ ÂÒ·Õèà»¹·Ò§àÅ×Í¡ÍÕ¡µÑÇã¹¡Ã³Õ¹Õé¤×Í progestin ¶Ö§áÁ¨ÐÁÕ¢ÍÁÙÅÊ¹ÑºÊ¹Ø¹äÁªÑ´à¨¹
áµà»¹ÂÒ·ÕÁè ¡Õ ÒÃãªá¾ÃËÅÒÂÁÒ¹Ò¹ã¹ÃÒÂ·Õ´è Í×é µÍÂÒÎÍÃâÁ¹ã¹Í´Õµ
6. ¢¹Ò´¢Í§ÎÍÃâÁ¹áµÅÐª¹Ô´·Õáè ¹Ð¹ÓãËãª
Antiestrogen
Tamoxifen 20 mg/day per oral
Fulvestrant 250 mg intramuscular q 4 weeks
LHRH agonist
Leuprolide 3.75 mg subcutaneous q 4 weeks
Goserelin 3.6 mg subcutaneous q 4 wks
Aromatase inhibitors
Anastrozole 1 mg/day per oral
Letrozole 2.5 mg/day per oral
Exemestane 25 mg/day per oral
54-117_pc22.pmd 73 19/2/2551, 20:59

Progestin
Megestrol acetate 160 mg/day per oral
Medroxyprogesterone acetate 1000 mg/day per oral
¡ÒÃãªÂÒà¤ÁÕºÓºÑ´ã¹ÁÐàÃç§àµÒ¹ÁÃÐÂÐá¾Ã¡ÃÐ¨ÒÂ
¢Íº§ªÕé
1. ¼»Ù Ç Â·ÕÁè ¼Õ Å ER áÅÐ PgR à»¹¼ÅÅº
2. ¼»Ù Ç Â·Õâè Ã¤ÅØ¡ÅÒÁÃÐËÇÒ§¡ÒÃÃÑ¡ÉÒ´ÇÂÂÒÎÍÃâÁ¹ËÃ×Í´×Íé µÍÎÍÃâÁ¹
3. ¼»Ù Ç Â·Õâè Ã¤á¾Ã¡ÃÐ¨ÒÂÍÂÒ§ÃÇ´àÃçÇ á¾Ã¡ÃÐ¨ÒÂä»ÂÑ§ÍÇÑÂÇÐÊÓ¤ÑáÅÐÍÒ¨ÁÕÍ¹Ñ µÃÒÂ¶Ö§ªÕÇµÔ
àª¹µÑº »Í´ ÊÁÍ§à»¹µ¹
ÂÑ§äÁÁ¡Õ ÒÃÈÖ¡ÉÒáººÊÁØ à»ÃÕÂºà·ÕÂº ¡ÅÁØ ·Õãè Ëà¤ÁÕºÓºÑ´¡Ñº¡ÅÁØ ·ÕÃè ¡Ñ ÉÒµÒÁÍÒ¡ÒÃ áµÁ¡Õ ÒÃÈÖ¡ÉÒ
áºº metaanalysis áÅÐ population-based cohort ·Õºè § ÇÒà¤ÁÕºÓºÑ´ªÇÂãËªÇ §ªÕÇµÔ à¾ÔÁè ¢Ö¹é »ÃÐÁÒ³ 6-9 à´×Í¹(42,43)
äÁá¹Ð¹ÓãËãªÂÒà¤ÁÕºÓºÑ´ÃÇÁ¡ÑºÎÍÃâÁ¹ áµãËãªµÍ ¨Ò¡¡Ñ¹

¡ÒÃãªà¤ÁÕºÓºÑ´¾ÃÍÁ¡ÑºÎÍÃâÁ¹äÁä´·ÓãËªÇ §ªÕÇµÔ à¾ÔÁè ¢Ö¹é àÁ×Íè à·ÕÂº¡Ñºà¤ÁÕºÓºÑ´à¾ÕÂ§ÍÂÒ§
à´ÕÂÇ (3,4,44-53)
ÇÔ¸¡Õ ÒÃãËÂÒà¤ÁÕºÓºÑ´ã¹¼»Ù Ç ÂÁÐàÃç§àµÒ¹ÁÃÐÂÐá¾Ã¡ÃÐ¨ÒÂ

1. ¡ÒÃàÅ×Í¡ãªà¤ÁÕºÓºÑ´ÍÒ¨à»¹ÂÒáµÅÐµÑÇµÍ¡Ñ¹ (sequential single agent) ËÃ×ÍãËÂÒËÅÒÂµÑÇ
¾ÃÍÁ¡Ñ¹ (combination chemotherapy) ¢Öé¹ÍÂÙ¡Ñº¤ÇÒÁÃØ¹áÃ§¢Í§âÃ¤áÅÐÊÀÒ¾¢Í§¼Ù»ÇÂ ¡ÒÃãªà¤ÁÕºÓºÑ´
·Ñ§é 2 ÇÔ¸ÁÕ ¡Õ ÒÃÃÍ´ªÕÇµÔ à·Ò¡Ñ¹
2. â´Â·ÑèÇä»á¹Ð¹ÓãËà¤ÁÕºÓºÑ´äÁà¡Ô¹ 3 ÊÙµÃ Â¡àÇ¹¼Ù»ÇÂºÒ§ÃÒÂ·ÕèÁÕÊÀÒ¾ÃÒ§¡ÒÂ·Õè´ÕáÅÐ
µÍºÊ¹Í§´ÕµÍ à¤ÁÕºÓºÑ´ ÍÒ¨ãËà¡Ô¹ 3 ÊÙµÃä´
ª¹Ô´¢Í§à¤ÁÕºÓºÑ´
1. ¡Ã³Õ¢Í§ÂÒÊÙµÃáÃ¡ á¹Ð¹ÓãËãª classical CMF ËÃ×Í anthracycline-containing regimen àª¹
FAC, AC, EC, ËÃ×Í FEC à»¹µ¹ â´ÂÁÕËÅÑ¡¡ÒÃàÅ×Í¡ÊÙµÃÂÒ´Ñ§¹Õé
· ¡Ã³Õ·¼Õè »
Ù Ç ÂäÁà¤Âä´ÃºÑ ¡ÒÃÃÑ¡ÉÒàÊÃÔÁËÅÑ§¼ÒµÑ´´ÇÂÂÒà¤ÁÕºÓºÑ´ÁÒ¡Í¹ á¹Ð¹ÓãËãª classical
CMF ËÃ×Í anthracycline-containing regimen àª¹ FAC, AC, EC, ËÃ×Í FEC à»¹µ¹
54-117_pc22.pmd 74 19/2/2551, 20:59

· ¡Ã³Õ ·Õè ¼Ù » Ç Âà¤Âä´ ÃÑ º ¡ÒÃÃÑ ¡ ÉÒàÊÃÔ Á ËÅÑ § ¼ Ò µÑ ´ ´ Ç ÂÂÒà¤ÁÕ ºÓºÑ ´ ÁÒ¡ Í ¹¹Ò¹à¡Ô ¹ 1»
á¹Ð¹ÓãËãªÂÒà¤ÁÕºÓºÑ´ªØ´à´ÔÁä´â´Âà©¾ÒÐ classical CMF ã¹¡Ã³Õ¢Í§ anthracycline-containing regimen
á¹Ð¹ÓãËãªÂÒà¤ÁÕºÓºÑ´ªØ´ãËÁá·¹
· ¡Ã³Õ·Õè¼Ù»ÇÂà¤Âä´ÃÑº¡ÒÃÃÑ¡ÉÒàÊÃÔÁËÅÑ§¼ÒµÑ´´ÇÂÂÒà¤ÁÕºÓºÑ´ÁÒ¡Í¹¹Ò¹¹ÍÂ¡ÇÒ 1 »
á¹Ð¹ÓãËãªÂÒà¤ÁÕºÓºÑ´ªØ´ãËÁá·¹
ÁÕ¡ÒÃÈÖ¡ÉÒáºº metaanalysis ¾ºÇÒ¡ÒÃãªÂÒà¤ÁÕºÓºÑ´ËÅÒÂµÑÇ¾ÃÍÁ¡Ñ¹¨Ðä´»ÃÐÊÔ·¸ÔÀÒ¾´Õ¡ÇÒ
¡ÒÃãªÂÒà¤ÁÕºÓºÑ´à¾ÕÂ§µÑÇà´ÕÂÇâ´ÂÁÕ relative hazard ratio (HR) ¢Í§ªÇ§ªÕÇÔµà»¹ 0.70 (95% confidence
intervals (CIs) 0.59-0.84)(4) ã¹¡Ã³Õ¢Í§ CMF¡ÒÃãª classical CMF (ãª cyclophosphamide áºº¡Ô¹)
àÁ×Íè à·ÕÂº¡Ñº¡ÒÃãª modified CMF ( intravenous 3-week CMF) ¾ºÇÒ¡ÒÃãª classical CMF ÁÕ¡ÒÃµÍºÊ¹Í§·Õ´è ¡Õ ÇÒ
(48% ¡Ñº 29%; p = 0.003) áÅÐÁÕªÇ §ªÕÇµÔ ·Õ´è ¡Õ ÇÒ (17 ¡Ñº 12 à´×Í¹; p = 0.016) ¡ÒÃãª modified CMF (55)
anthracycline-containing regimen ÁÕ¡ÒÃµÍºÊ¹Í§·Õ´è ¡Õ ÇÒáÅÐÁÕªÇ §ªÕÇµÔ ·Õ´è ¡Õ ÇÒ CMF àÅç¡¹ÍÂâ´ÂÁÕ
relative HR 0.89 (95% CIs 0.82-0.97) (4) áµÁ¼Õ Å¢Ò§à¤ÕÂ§ÁÒ¡¡ÇÒ CMF ´ÇÂ ÍÂÒ§äÃ¡çµÒÁ¢ÍÁÙÅ¢Í§¡ÒÃÈÖ¡ÉÒ
ä´ÃÇÁ·Ñ§é classical CMF áÅÐ modified CMF
ã¹»¨¨Øº¹Ñ ÁÕ¢Í ÁÙÅ¾ºÇÒ¡ÒÃãª taxanes (docetaxel ËÃ×Í paclitaxel) ÃÇÁ¡Ñº anthracycline (doxorubi-
cin ËÃ×Í epirubicin) ÁÕ¡ÒÃµÍºÊ¹Í§·Õè´Õ¡ÇÒ¡ÒÃãª Anthracycline ÃÇÁ¡Ñº cyclophosphamide áµÂÑ§äÁÁÕ
¢ÍÁÙÅªÑ´à¨¹ÇÒ ·ÓãËªÇ §ªÕÇµÔ Â×¹ÂÒÇ¢Ö¹é (56-62) ¨Ö§ÂÑ§äÁá¹Ð¹ÓãËãªà»¹ÂÒªØ´áÃ¡ã¹¢³Ð¹Õé
· ¡Ã³Õ¢Í§ÂÒÊÙµÃ·ÕÊ è Í§àÁ×Íè âÃ¤ÅØ¡ÅÒÁËÅÑ§ãËÂÒªØ´áÃ¡
1. ¡Ã³Õ·àÕè ¤Âä´ anthracycline-containing regimen à»¹ÂÒÊÙµÃáÃ¡
á¹Ð¹ÓãËãª taxanes (docetaxel ËÃ×Í paclitaxel)
2. ¡ÒÃãªÂÒµÑÇÍ×¹è ·Õäè Áãª taxane àª¹ vinorelbine, capecitabine, gemcitabine ËÃ×Í CMF
· ¡Ã³Õ·ãÕè ª CMF à»¹ÂÒÊÙµÃáÃ¡
á¹Ð¹ÓãËãª anthracycline-containing regimen à»¹ÂÒÊÙµÃ·ÕèÊÍ§ áÅÇ¤ÍÂ¾Ô¨ÒÃ³Òãª
ÂÒµÑÇÍ×¹è ´Ñ§·Õ¡è ÅÒÇäÇã¹ 2 µÍä»
äÁÁ¢Õ Í ÁÙÅà»ÃÕÂºà·ÕÂºÃÐËÇÒ§¡ÅÁØ ·Õãè ËÂÒà¤ÁÕºÓºÑ´¡Ñº¡ÅÁØ ·ÕÃè ¡Ñ ÉÒµÒÁÍÒ¡ÒÃ áµÁ¢Õ Í ÁÙÅà»ÃÕÂºà·ÕÂº
ÃÐËÇÒ§ ÂÒãËÁã¹¡ÅÁØ taxane áÅÐ vinorelbine à·ÕÂº¡ÑºÂÒà¡Ò·Õàè ¤Âãªã¹Í´Õµ¾ºÇÒÊÒÁÒÃ¶·ÓãËÁªÕ ÇÕ µÔ Â×¹ÂÒÇ
¢Öé¹(50,63-66) ÁÕÃÒÂ§Ò¹à»ÃÕÂºà·ÕÂºÃÐËÇÒ§¡ÒÃãª docetaxel ÃÇÁ¡Ñº capecitabine ¡Ñº docetaxel à¾ÕÂ§µÑÇà´ÕÂÇ
ã¹¼»Ù Ç Â·Õàè ¤Âä´ÃºÑ anthracycline ÁÒ¡Í¹ ¾ºÇÒ¡ÒÃãª docetaxel ÃÇÁ¡Ñº capecitabine ·ÓãËÁªÕ Ç §ªÕÇµÔ à¾ÔÁè ÁÒ¡¢Ö¹é
(14.5 à´×Í¹ ¡Ñº 11.5 à´×Í¹; p=0.0126) àÁ×Íè à·ÕÂº¡Ñº docetaxel à¾ÕÂ§µÑÇà´ÕÂÇ(54) ÁÕÃÒÂ§Ò¹à»ÃÕÂºà·ÕÂºÃÐËÇÒ§¡ÒÃãª
54-117_pc22.pmd 75 19/2/2551, 20:59

paclitaxel ÃÇÁ¡Ñº gemcitabine ¡Ñº pacllitaxel à¾ÕÂ§µÑÇà´ÕÂÇ ã¹¼»Ù Ç Â·Õàè ¤Âä´ÃºÑ anthracycline ÁÒ¡Í¹ ¾ºÇÒ¡ÒÃãª
paclitaxel ÃÇÁ¡Ñº gemcitabine ·ÓãËÁÕ progression-free survival áÅÐ overall survival à¾ÔÁè ÁÒ¡¢Ö¹é àÁ×Íè à·ÕÂº¡Ñº
paclitaxel à¾ÕÂ§µÑÇà´ÕÂÇ(79,82) ÁÕÃÒÂ§Ò¹¡ÒÃãª capecitabine, gemcitabine áÅÐ Vinorelbine ã¹¼Ù»ÇÂ·Õèà¤Âä´
anthracycline ÁÒ¡Í¹ áÅÇ¾ºÇÒÁÕ¡ÒÃµÍºÊ¹Í§(80)
· ¡Ã³Õ¢Í§ÂÒÊÙµÃ·ÕÊ è ÒÁàÁ×Íè âÃ¤ÅØ¡ÅÒÁËÅÑ§ãËÂÒÊÙµÃ·ÕÊè Í§
á¹Ð¹ÓãËãª capecitabine ËÃ×Í vinorelbine ËÃ×Í gemcitabine ã¹¡Ã³Õ·Õèà¤Âä´ taxane
à»¹ÂÒÊÙµÃ·ÕÊè Í§ ËÃ×Í¾Ô¨ÒÃ³Òà¢Òâ¤Ã§¡ÒÃÈÖ¡ÉÒ (clinical trial) ËÃ×ÍÃÑ¡ÉÒµÒÁÍÒ¡ÒÃáÅÇáµ¡Ã³Õ
ÁÕ¡ÒÃÈÖ¡ÉÒáºº Phase II ¢Í§ capecitabine ã¹¼Ù»ÇÂ·Õè´×éÍµÍ anthracycline áÅÐ taxane ¾ºÇÒ
ÁÕ¡ÒÃµÍºÊ¹Í§ 20%(67) ¹Í¡¨Ò¡¹ÕÁé ¡Õ ÒÃÈÖ¡ÉÒáºº Phase II ¢Í§ vinorelbine áÅÐ gemcitabine ã¹¼»Ù Ç Â·Õ´è Í×é µÍ
taxane áÅÇ¾ºÇÒÁÕ¡ÒÃµÍºÊ¹Í§àª¹¡Ñ¹(68,69) ÁÕ¡ÒÃÈÖ¡ÉÒáºº randomized phase III ¢Í§¡ÒÃãË ixabepilone
ÃÇÁ¡Ñº capecitabine ¡Ñº capecitabine ã¹¼»Ù Ç Â·Õàè ¤Âä´ taxane áÅÐ anthracycline ÁÒ¡Í¹¾ºÇÒ ixabepilone ÃÇÁ¡Ñº
capecitabine ÁÕ¡ÒÃµÍºÊ¹Í§ (43% ¡Ñº 29%; p<0.0001) áÅÐ progression-free survival (6.2 à´×Í¹¡Ñº 4.2 à´×Í¹;
p=0.0005) ·Õ´è ¡Õ ÇÒ capecitabineáµ¡ÒÃÃÍ´ªÕÇµÔ äÁáµ¡µÒ§¡Ñ¹ (16.4 à´×Í¹ ¡Ñº 15.6 à´×Í¹; p=0.1162)
ÃÐÂÐàÇÅÒ¢Í§¡ÒÃãËÂÒà¤ÁÕºÓºÑ´
ã¹¡Ã³Õ·ÁÕè ¡Õ ÒÃµÍºÊ¹Í§µÍÂÒà¤ÁÕºÓºÑ´ ÍÒ¨¾Ô¨ÒÃ³ÒãËÂÒà¤ÁÕºÓºÑ´ä»ÃÐÂÐË¹Ö§è (6-8 ªØ´) áÅÇËÂØ´
ËÃ×ÍãËä»àÃ×Íè Âæ ¨¹¡ÇÒâÃ¤¨ÐÅØ¡ÅÒÁµÍä»
ÁÕ¡ÒÃÈÖ¡ÉÒà»ÃÕÂºà·ÕÂºÃÐËÇÒ§¡ÒÃãËà¤ÁÕºÓºÑ´áºº intermittent ¡Ñº continuous ¾ºÇÒ¼Å¡ÒÃÈÖ¡ÉÒ
ÂÑ§äÁÊÒÁÒÃ¶Â×¹ÂÑ¹ä´ªÑ´à¨¹ÇÒÇÔ¸ÕäË¹´Õ¡ÇÒ¡Ñ¹à¾ÃÒÐÁÕ·Ñé§¢ÍÁÙÅ·ÕèÇÒ ¡ÒÃãËáºº continuous äÁä´·ÓãË
ªÇ§ªÕÇµÔ Â×¹ÂÒÇ¢Ö¹é àÁ×Íè à·ÕÂº¡Ñº intermittent(70-74) áµÍÒ¨ÁÕ progression-free survival à¾ÔÁè ÁÒ¡¢Ö¹é (70,72,73) ºÒ§ÃÒÂ§Ò¹
¾ºÇÒ¡ÒÃãËáºº continuous ÁÕ·Ñé§ progression-free survival áÅÐ overall survival à¾ÔèÁ¢Öé¹ àÁ×èÍà·ÕÂº¡Ñºáºº
intermittent(75,76) ÍÂÒ§äÃ¡çµÒÁ¡ÒÃãËáºº continuous ÁÕ¼Å¢Ò§à¤ÕÂ§ÁÒ¡ÇÒáººintermittent
º·ºÒ·¢Í§ high-dose chemotherapy áÅÐ bone marrow transplanta-

tion ËÃ×Í stem cell support
äÁá¹Ð¹ÓãËãªÇ¸Ô ¡Õ ÒÃÃÑ¡ÉÒ´Ñ§¡ÅÒÇã¹ÁÐàÃç§àµÒ¹ÁÃÐÂÐá¾Ã¡ÃÐ¨ÒÂã¹¢³Ð¹Õé
ÁÕ¢ÍÁÙÅã¹»¨¨ØºÑ¹¾ºÇÒ¡ÒÃãª high-dose chemotherapy äÁ·ÓãËªÕÇÔµÂ×¹ÂÒÇ¢Öé¹ áµÁÕ¼Å¢Ò§à¤ÕÂ§
à¾ÔÁè ¢Ö¹é (77,78)
54-117_pc22.pmd 76 19/2/2551, 20:59

¢¹Ò´áÅÐÊÙµÃ¢Í§à¤ÁÕºÓºÑ´·Õèá¹Ð¹ÓãËãª:
CMF regimen cyclophosphamide 100 mg/m2/day po d1-14
(q 4 weeks) Methotrexate 40 mg/m2 IV d1,8
5-FU 600 mg/m2 IV d1,8
FAC regimen 5-FU 500 mg/m2 IV
(q 3 weeks) Doxorubicin 50 mg/m2 IV
Cyclophosphamdie 500 mg/m2 IV
AC regimen Doxorubicin 60 mg/m2 IV
(q 3 weeks) Cyclophosphamide 600 mg/m2 IV
FEC regimen 5-FU 500 mg/m2 IV
Epirubicin 50-90 mg/m2 IV q 3 weeks
Cyclophosphamide 500 mg/m2 IV
EC regimen Epirubicin 60-90 mg/m2 IV q 3 weeks
Cyclophosphamide 600 mg/m2 IV
Paclitaxel 175 mg/m2 IV q 3 weeks
Docetaxel 70-100 mg/m2 IV q 3 weeks
Gemcitabine 800-1250 mg/m2 IV d1,8,15 q 4 weeks (single)
1000 mg/m2 IV d1,8 q 3 weeks (combined)
Vinorelbine 25-30 mg/m2 IV d1,8 q 3 weeks
Capecitabine 1250 mg/m2 PO bid pc d1-14 q 3 weeks
(single drug)
1000 mg/m2 PO bid pc d1-14 q 3 weeks
(combined drug)
Ixabepilone 40 mg/m2 IV q 3 week
¡ÒÃãª novel molecular-targeted therapy ã¹¡ÒÃÃÑ¡ÉÒÁÐàÃç§àµÒ¹ÁÃÐÂÐ

á¾Ã¡ÃÐ¨ÒÂ
1. ¤Óá¹Ð¹ÓÊÓËÃÑº¼»Ù Ç ÂÁÐàÃç§àµÒ¹ÁÃÐÂÐá¾Ã¡ÃÐ¨ÒÂ·ÕÁè Õ HER2/neu à»¹¼ÅºÇ¡
· á¹Ð¹ÓãËãª trastuzumab ã¹¡ÒÃÃÑ¡ÉÒÁÐàÃç§àµÒ¹ÁÃÐÂÐá¾Ã¡ÃÐ¨ÒÂ·ÕèÁÕ HER2/neu
à»¹¼ÅºÇ¡ (µÒÁ¹ÔÂÒÁàª¹à´ÕÂÇ¡Ñº¼»Ù Ç ÂÁÐàÃç§àµÒ¹ÁÃÐÂÐáÃ¡) â´Âãªà»¹ÂÒªØ´áÃ¡ÃÇÁ¡Ñº¡ÒÃãªÂÒà¤ÁÕºÓºÑ´
ã¹¡ÅÁØ taxanes (paclitaxel ËÃ×Í docetaxel) ã¹¼»Ù Ç Â·Õàè ¤Âä´ÃºÑ adjuvant chemotherapy ´ÇÂÂÒ¡ÅÁØ anthracycline
ËÃ×Íãªà»¹ÂÒªØ´·ÕÊè Í§ÃÇÁ¡Ñº¡ÒÃãª taxanes ã¹¼»Ù Ç Â·Õäè Áà¤Âä´ÃºÑ ÂÒ¡ÅÁØ anthracycline ÁÒ¡Í¹
54-117_pc22.pmd 77 19/2/2551, 20:59

ÁÕ¡ÒÃÈÖ¡ÉÒáºº randomized controlled trial â´Â Slamon DJ et al. ã¹¼»Ù Ç Â·Õàè »¹ÁÐàÃç§àµÒ¹ÁÃÐÂÐ
á¾Ã¡ÃÐ¨ÒÂ·ÕèÁÕ HER2 à»¹¼ÅºÇ¡·ÕèäÁà¤Âä´ÃÑº¡ÒÃÃÑ¡ÉÒ´ÇÂÂÒà¤ÁÕºÓºÑ´ÁÒ¡Í¹ â´Âà»ÃÕÂºà·ÕÂºÃÐËÇÒ§
¡ÒÃãËÂÒà¤ÁÕºÓºÑ´ÍÂÒ§à´ÕÂÇ (doxorubicin ËÃ×Í epirubicin / cyclophosphamide ËÃ×Í paclitaxel) ¡Ñº¡ÒÃãË
ÂÒà¤ÁÕºÓºÑ´ÃÇÁ¡Ñº trastuzumab ¾ºÇÒ ¼»Ù Ç Â¡ÅÁØ ·Õäè ´ÃºÑ ÂÒà¤ÁÕºÓºÑ´ÃÇÁ¡Ñº trastuzumab ÁÕÍµÑ ÃÒ¡ÒÃµÍºÊ¹Í§
¢Í§âÃ¤·Õ´è ¡Õ ÇÒ (50% vs 32%, p < 0.001) median time to disease progression ·ÕÂè ÒÇ¡ÇÒ (7.4 à´×Í¹ vs 4.6 à´×Í¹,
p < 0.001) áÅÐÁÕÍµÑ ÃÒ¡ÒÃÃÍ´ªÕÇµÔ ·ÕÁè Ò¡¡ÇÒ â´ÂÁÕ median survival 25.1 à´×Í¹ à·ÕÂº¡Ñº 20.3 à´×Í¹ (p = 0.046)
â´ÂÁÕ¼Å¢Ò§à¤ÕÂ§·ÕèÊÓ¤Ñ ¤×Í ¡ÒÃ·Ó§Ò¹¢Í§¡ÅÒÁà¹×éÍËÑÇã¨Å´Å§ «Öè§¾ºä´ÊÙ§¶Ö§ 27% ã¹¡ÅØÁ¼Ù»ÇÂ·Õèä´ÃÑº
anthracycline / cyclophosphamide ÃÇÁ¡Ñº trastuzumab áÅÐ¾ºä´ 13% ã¹¡ÅØÁ·Õèä´ÃÑº paclitaxel ÃÇÁ¡Ñº
trastuzumab ¨Ö§äÁá¹Ð¹ÓãËãª trastuzumab ÃÇÁ¡ÑºÂÒã¹¡ÅÁØ anthracycline
· ¼»Ù Ç Â·Õ¨è Ðä´ÃºÑ trastuzumab µÍ§ä´ÃºÑ ¡ÒÃµÃÇ¨¡ÒÃ·Ó§Ò¹¢Í§ËÑÇã¨¡Í¹ä´ÃºÑ ÂÒ áÅÐãªÂÒ
ä´ã¹¡Ã³Õ·ÁÕè Õ left ventricular ejection fraction ³ 50% ¼»Ù Ç Â¤ÇÃä´ÃºÑ ¡ÒÃµÃÇ¨»ÃÐàÁÔ¹¡ÒÃ·Ó§Ò¹¢Í§ËÑÇã¨·Ø¡
3 à´×Í¹ ã¹ÃÐËÇÒ§·Õäè ´ÃºÑ trastuzumab ÍÂÙ
ã¹¡Ã³Õ·Õè¼Ù»ÇÂÁÕ¡ÒÃµÍºÊ¹Í§¢Í§âÃ¤µÍ¡ÒÃÃÑ¡ÉÒ´ÇÂ taxanes / trastuzumab áÅÐàÃÔèÁÁÕ¼Å
¢Ò§à¤ÕÂ§¨Ò¡ taxanes ÁÒ¡¢Öé¹ ÍÒ¨¾Ô¨ÒÃ³ÒãË trastuzumab µÍà»¹ monotherapy áÅÐ¤ÇÃ¾Ô¨ÒÃ³ÒËÂØ´ÂÒ
trastuzumab ËÅÑ§ä´ÂÒ¤Ãº 1 »
· äÁá¹Ð¹ÓãËãª trastuzumab ÃÇÁ¡ÑºÂÒà¤ÁÕºÓºÑ´ª¹Ô´Í×è¹ ã¹¡Ã³Õ·ÕèâÃ¤ÅØ¡ÅÒÁÁÒ¡¢Öé¹ã¹
¢³Ð·Õäè ´ÃºÑ trastuzumab
· á¹Ð¹ÓãËãª trastuzumab ã¹¡ÒÃÃÑ¡ÉÒÁÐàÃç§àµÒ¹ÁÃÐÂÐá¾Ã¡ÃÐ¨ÒÂ·ÕèÁÕ HER2/neu à»¹
¼ÅºÇ¡â´Âãªà»¹ÂÒªØ´áÃ¡ÃÇÁ¡ÑºÂÒà¤ÁÕºÓºÑ´ª¹Ô´Í×¹è ä´á¡ vinorelbine ã¹¡Ã³Õ·¼Õè »Ù Ç Âà¤Âä´ÃºÑ adjuvant
chemotherapy ´ÇÂÂÒ¡ÅÁØ taxanes áÅÐâÃ¤ÅØ¡ÅÒÁã¹ÃÐÂÐàÇÅÒ¹ÍÂ¡ÇÒ 1 »ËÅÑ§ËÂØ´ taxanes
ÁÕ¡ÒÃÈÖ¡ÉÒà»ÃÕÂºà·ÕÂº¡ÒÃãªÂÒ trastuzumab ÃÇÁ¡ÑºÂÒã¹¡ÅØÁ taxanes ¡Ñº trastuzumab ÃÇÁ¡Ñº
vinorelbine à»¹ÂÒªØ´áÃ¡ã¹¼»Ù Ç ÂÁÐàÃç§àµÒ¹ÁÃÐÂÐá¾Ã¡ÃÐ¨ÒÂ·ÕÁè Õ HER2 à»¹¼ÅºÇ¡ äÁ¾ºÇÒÁÕ¤ÇÒÁáµ¡µÒ§
¡Ñ¹ã¹´Ò¹ÍÑµÃÒ¡ÒÃµÍºÊ¹Í§ áÅÐ time to disease progression
· ã¹¡Ã³Õ·¼ Õè »Ù Ç Âà¤Âä´ÃºÑ trastuzumab à»¹ adjuvant treatment áÅÐÁÕ¡ÒÃ¡ÅÑºà»¹«éÓ¢Í§âÃ¤ã¹
ÃÐÂÐàÇÅÒà¡Ô¹ 1 » ÊÒÁÒÃ¶¹Ó trastuzumab ¡ÅÑºÁÒãªãËÁä´
· á¹Ð¹ÓãËãª lapatinib ã¹¡ÒÃÃÑ¡ÉÒ¼Ù»ÇÂÁÐàÃç§àµÒ¹ÁÃÐÂÐá¾Ã¡ÃÐ¨ÒÂ·ÕèÁÕ HER2/neu
à»¹¼ÅºÇ¡·ÕèÁÕâÃ¤ÅØ¡ÅÒÁã¹¢³Ð·Õèä´ÃÑºËÃ×ÍËÅÑ§¨Ò¡ä´ÃÑº¡ÒÃÃÑ¡ÉÒ´ÇÂ trastuzumab â´ÂãËãªÃÇÁ¡ÑºÂÒ
capecitabine
54-117_pc22.pmd 78 19/2/2551, 20:59

ÁÕ¡ÒÃÈÖ¡ÉÒáºº randomized controlled trial ã¹¼Ù»ÇÂÁÐàÃç§àµÒ¹ÁÃÐÂÐá¾Ã¡ÃÐ¨ÒÂ·ÕèÁÕ HER2

à»¹¼ÅºÇ¡ ·Õàè ¤Âä´ÃºÑ anthracycline, taxane áÅÐ trastuzumab â´Âà»ÃÕÂºà·ÕÂºÃÐËÇÒ§¡ÒÃãË lapatinib ÃÇÁ¡Ñº
capecitabine ¡Ñº¡ÒÃãË capecitabine ÍÂÒ§à´ÕÂÇ ¾ºÇÒ ã¹¡ÅÁØ ·Õäè ´ÃºÑ lapatinib / capecitabine ÁÕ ÍÑµÃÒ¡ÒÃµÍºÊ¹Í§,
time to disease progression áÅÐ progression-free survival ÁÒ¡¡ÇÒ¡ÅØÁ·Õèä´ÃÑº capecitabine â´Â median
progression-free survival ã¹¡ÅÁØ ·Õäè ´ÃºÑ lapatinib / capecitabine = 27.1 ÊÑ»´ÒË à·ÕÂº¡Ñº 17.6 ÊÑ»´ÒËã¹¡ÅÁØ ·Õäè ´
ÃÑº capecitabine, hazaad ratio (HR) 0.55 (0.41, 0.74) (p = 0.000033) äÁ¾ºÇÒÁÕ¤ÇÒÁáµ¡µÒ§¡Ñ¹ã¹´Ò¹ overall
survival (67.7 vs 66.6 weeks, HR 0.78, p = 0.177)
2. ¼Ù»ÇÂÁÐàÃç§àµÒ¹Á·ÕèÁÕ HER2/neu à»¹¼ÅÅº
· äÁá¹Ð¹ÓãËãª bevacizumab ÃÇÁ¡ÑºÂÒà¤ÁÕºÓºÑ´ã¹¡ÒÃÃÑ¡ÉÒ¼Ù»ÇÂÁÐàÃç§àµÒ¹ÁÃÐÂÐ
á¾Ã¡ÃÐ¨ÒÂ
ÁÕ¡ÒÃÈÖ¡ÉÒáºº randomized controlled trial (E2100 trial) ã¹¼»Ù Ç ÂÁÐàÃç§àµÒ¹ÁÃÐÂÐá¾Ã¡ÃÐ¨ÒÂ
·Õäè ÁÁÕ HER2 ·Õäè Áà¤Âä´ÃºÑ ¡ÒÃÃÑ¡ÉÒÁÒ¡Í¹ â´Âà»ÃÕÂºà·ÕÂº¡ÒÃÃÑ¡ÉÒÃÐËÇÒ§¡ÒÃãË weekly paclitaxel ¡Ñº¡ÒÃãË
weekly paclitaxel ÃÇÁ¡Ñº bevacizumab 10 mg/kg ·Ø¡ 2 ÊÑ»´ÒË ¾ºÇÒ ¼»Ù Ç Â¡ÅÁØ ·Õäè ´ paclitaxel / bevacizumab
ÁÕÍµÑ ÃÒ¡ÒÃµÍºÊ¹Í§¢Í§âÃ¤ (36.9% vs 21.2% p < 0.001) áÅÐ progression-free survival ÁÒ¡¡ÇÒ¡ÅÁØ ·Õäè ´ÃºÑ
paclitaxel (11.8 à´×Í¹ vs 5.9 à´×Í¹, HR = 0.60 p < 0.001) áµäÁÁÕ¤ÇÒÁáµ¡µÒ§¡Ñ¹ã¹´Ò¹ overall survival
â´Â¡ÅÁØ ·Õäè ´ bevacizumab ¨Ð¾º¼Å¢Ò§à¤ÕÂ§ ä´á¡ ¤ÇÒÁ´Ñ¹âÅËÔµÊÙ§, »Ç´ÈÕÃÉÐ, proteinuria áÅÐ cerebrovas-
cular ischemia ·ÕÁè Ò¡¡ÇÒÍÂÒ§ÁÕ¹ÂÑ ÊÓ¤í·Ò§Ê¶ÔµÔ ¡ÒÃÈÖ¡ÉÒâ´Âãª bevacizumab ÃÇÁ¡ÑºÂÒà¤ÁÕºÓºÑ´ª¹Ô´Í×¹è àª¹
docetaxel, capecitabine ·Õàè »ÃÕÂºà·ÕÂº¡Ñº¡ÒÃãËÂÒà¤ÁÕºÓºÑ´ÍÂÒ§à´ÕÂÇ ¾ºÇÒ ÁÕÍµÑ ÃÒ¡ÒÃµÍºÊ¹Í§·Õ´è ¢Õ ¹Öé áÅÐÁÕ
progression-free survival à¾ÔÁè ¢Ö¹é áµäÁÁ»Õ ÃÐâÂª¹ã¹´Ò¹ overall survival ÃÇÁ¡ÑºÁÕ¼Å¢Ò§à¤ÕÂ§·Õàè ¾ÔÁè ¢Ö¹é àª¹¡Ñ¹
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v v v
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ªÔ¹é à¹×Íé ¢¹Ò´äÁãË ÊÒÁÒÃ¶áªã¹ 10% neutral buffered formalin ä´àÅÂ â´ÂãË»ÃÔÁÒµÃ¢Í§
¹éÓÂÒÁÒ¡¡ÇÒ 10 à·Ò¢Í§ªÔ¹é à¹×Íé
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· ¡ÒÃàµÃÕÂÁªÔ¹é à¹×Íé ·ÕÁè ¢Õ ¹Ò´à¡Ô¹ 5 à«¹µÔàÁµÃ

ªÔ¹é à¹×Íé ¢¹Ò´ãË àª¹ mastectomy ËÃ×Í ¡Í¹à¹×Íé ·ÕÁè ¢Õ ¹Ò´à¡Ô¹ 5 à«¹µÔàÁµÃ ¡Ã³Õ·µÕè Í §Ê§à¹×Íé
µÃÇ¨¹Í¡Ê¶ÒºÑ¹ ËÃ×ÍµÍ§à¡çºäÇ¹Ò¹ÁÒ¡¡ÇÒ 6 ªÑÇè âÁ§·Õ¨è Ðä´µÃÇ¨ªÔ¹é à¹×Íé ¤ÇÃµÍ§¼Òáº§¤ÃÖ§è ªÔ¹é à¹×Íé ¡Í¹áªã¹
10% neutral buffered formalin ·Ñ§é ¹Õé à¾×Íè ãË¡ÒÃ fix ¢Í§à¹×Íé à¡Ô´ä´ÍÂÒ§ÊÁºÙÃ³
ÃÙ»·Õè 1 Total mastectomy with surgical axillary
ãº¢ÍµÃÇ¨
µÍ§ÁÕÃÒÂÅÐàÍÕÂ´´Ñ§¹Õé
1. ª×Íè -¹ÒÁÊ¡ØÅ, HN (ID, ËÃ×Í ËÁÒÂàÅ¢»ÃÐ¨ÓµÑÇ·ÕÍè Ò §ÍÔ§ä´), à¾È, ÍÒÂØ ¢Í§¼»Ù Ç Â
2. ÅÑ¡É³ÐÃÍÂâÃ¤, µÓáË¹§, ¢Ò§¢Í§¹Á, ¨Ó¹Ç¹ÃÍÂâÃ¤áÅÐ¢¹Ò´·Õµè ÃÇ¨¾º·Ò§¤ÅÔ¹¡Ô
3. ª¹Ô´ËÃ×ÍÇÔ¸¡Õ ÒÃ¼ÒµÑ´ ÃÒÂÅÐàÍÕÂ´¢Í§¢ÍºµÒ§æ¢Í§ªÔ¹é à¹×Íé
4. ÃÐºØÃÒÂ¡ÒÃ·Õ¢è ÍµÃÇ¨
5. ÇÑ¹·Õ·è ¼Õè Ò µÑ´, ª×Íè á¾·ÂáÅÐËÁÒÂàÅ¢â·ÃÈÑ¾·µ´Ô µÍ
¡ÒÃÊ§µÑÇÍÂÒ§
¤ÇÃÊ§µÑÇÍÂÒ§à«ÅÅÇ·Ô ÂÒáÅÐËÃ×ÍªÔ¹é à¹×Íé ÁÒ·ÕËè Í §»¯ÔºµÑ ¡Ô ÒÃ·Õàè ´ÕÂÇ·Ñ§é ËÁ´ äÁ¤ÇÃáº§Ê§µÑÇÍÂÒ§
(¡Ã³Õ·ÕèµÍ§¡ÒÃ¢Í second opinion ÀÒÂËÅÑ§ ÊÒÁÒÃ¶¡ÃÐ·Óä´ â´Â¢Í ÊàÁÕÂÃ áÅÐËÃ×Í ÊäÅ´/ ºÅçÍ¡ªÔé¹à¹×éÍ
ä»µÃÇ¨ÂÑ§ËÍ§»¯ÔºµÑ ¡Ô ÒÃáË§·ÕÊè Í§)
54-117_pc22.pmd 89 19/2/2551, 20:59

1. ¡ÒÃÊ§ÀÒÂã¹Ê¶ÒºÑ¹à´ÕÂÇ¡Ñ¹
Ê§µÑÇÍÂÒ§áÅÐãº¢ÍµÃÇ¨ÁÒ·ÕËè Í §»¯ÔºµÑ ¡Ô ÒÃã¹ÇÑ¹¹Ñ¹é ËÃ×ÍµÒÁ¢Íµ¡Å§ÀÒÂã¹Ê¶ÒºÑ¹ (ÃÐÇÑ§
ÁÔãË formalin Ë¡ãÊãº¢ÍµÃÇ¨ )
2. ¡ÒÃÊ§µÃÇ¨¹Í¡Ê¶ÒºÑ¹
¤ÇÃáÂ¡¾ÑÊ´ØµÇÑ ÍÂÒ§à«ÅÅÇ·Ô ÂÒÍÍ¡¨Ò¡¾ÑÊ´Øª¹Ôé à¹×Íé ¡ÒÃºÃÃ¨ØµÇÑ ÍÂÒ§¤ÇÃãª¾ÊÑ ´Ø·áÕè ¹¹Ë¹Ò¾ÃÍÁ
¡ÑºÁÕãº¢ÍµÃÇ¨·Õãè ÊäÇã¹¶Ø§¾ÅÒÊµÔ¡«Ô»ÅçÍ¤ à¾×Íè »Í§¡Ñ¹¡Ã³Õ·ÁÕè ¢Õ Í§àËÅÇËÃ×Í formalin ÍÒ¨ÃÑÇè ËÃ×Íáµ¡ä´
v v v
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á¹Ç·Ò§¡ÒÃÍÒ¹à«ÅÅÇÔ·ÂÒáÅÐÃÒÂ§Ò¹¼ÅÊÔè§à¨ÒÐ´Ù´¨Ò¡àµÒ¹ÁÍÂÒ§à»¹
ÃÐºº
º·¹Ó
¡ÒÃÇÔ¹¨Ô ©ÑÂµÑÇÍÂÒ§·Ò§à«ÅÅÇ·Ô ÂÒà»¹Ë¹Ö§è ã¹ triple test «Ö§è ãªã¹¡ÒÃ¾Ô¨ÒÃ³Òá¹Ç·Ò§¡ÒÃ´ÙáÅÃÑ¡ÉÒ
ÃÍÂâÃ¤¢Í§àµÒ¹Á â´ÂÃÇÁ¡Ñº¡ÒÃÇÔ¹Ô¨©ÑÂ·Ò§ÃÑ§ÊÕÇÔ·ÂÒáÅÐ¢ÍÁÙÅ·Ò§¤ÅÔ¹Ô¡ ã¹¡ÒÃÇÔ¹Ô¨©ÑÂ·Ò§à«ÅÅÇÔ·ÂÒ
ÁÕÁµÔ ·Ô áÕè Â¡ä´à»¹ 3 ÊÇ¹ ¤×Í ¡ÒÃÍÒ¹ÊàÁÕÂÃâ´Â¹Ñ¡à«ÅÅÇ·Ô ÂÒ ¡ÒÃá»Å¼Å áÅÐ¡ÒÃÃÒÂ§Ò¹¼Åâ´Â¾ÂÒ¸Ôá¾·Â
áµÅÐÊÇ¹ÁÕ¤ÇÒÁÊÓ¤ÑáÅÐÃÒÂÅÐàÍÕÂ´ã¹¡ÒÃÊ×Íè ÊÒÃà¾×Íè ãËà¢Òã¨µÃ§¡Ñ¹ ¹Í¡¨Ò¡¹Õ¤é ÇÃÁÕÃÐºº¡ÒÃµÃÇ¨ÊÍº
¤Ø³ÀÒ¾à¾×Íè ãË¼Å¡ÒÃÇÔ¹¨Ô ©ÑÂÁÕ¤ÇÒÁ¶Ù¡µÍ§ÁÒ¡·ÕÊè ´Ø
¡ÒÃÍÒ¹ÊàÁÕÂÃ
· ¤ÇÒÁÊÓ¤Ñ ¡ÒÃÍÒ¹ÊàÁÕÂÃà»¹ÊÇ¹áÃ¡ ÊÒÁÒÃ¶ãË¹¡Ñ à«ÅÅÇ·Ô ÂÒ·Óá·¹¾ÂÒ¸Ôá¾·Âä´ ·Ñ§é ¹Õé
à¾×Íè ãËà»¹á¹Ç·Ò§à´ÕÂÇ¡Ñ¹ áÅÐäÁãËà¡Ô´¤ÇÒÁÊÑºÊ¹ ¨Ö§àÊ¹ÍËÅÑ¡à¡³±ã¹¡ÒÃÍÒ¹áÅÐ¡ÒÃºÑ¹·Ö¡¼Å¡ÒÃÍÒ¹
à«ÅÅÇ·Ô ÂÒ¢Í§àµÒ¹ÁÍÂÒ§à»¹ÃÐºº¢Ö¹é
· ÃÐºº¢Í§¡ÒÃÍÒ¹
ÍÒ¹ áÅÐºÑ¹·Ö¡¼Å µÒÁÅÓ´Ñº ´Ñ§¹Õé
1. ¤Ø³ÅÑ¡É³ÐáÅÐ»ÃÔÁÒ³¢Í§ÊÔ§è à¨ÒÐ´Ù´·Õàè Ëç¹´ÇÂµÒ
2. ¡ÒÃ»ÃÐàÁÔ¹»ÃÔÁÒ³à«ÅÅ ·Õàè Ëç¹¨Ò¡¡ÓÅÑ§¢ÂÒÂµèÓ
3. ¡ÒÃµÃÇ¨à«ÅÅ·ÍÕè ÂàÙ »¹à«ÅÅà´ÕÂè Ç
4. ¡ÒÃµÃÇ¨à«ÅÅ·ÍÕè ÂàÙ »¹¡ÅÁØ
5. ¡ÒÃµÃÇ¨¾×¹é ËÅÑ§ÊàÁÕÂÃ
· ÃÒÂÅÐàÍÕÂ´
1. ¤Ø³ÅÑ¡É³ÐáÅÐ»ÃÔÁÒ³¢Í§ÊÔ§è à¨ÒÐ´Ù´·Õàè Ëç¹´ÇÂµÒ
1.1 ºÑ¹·Ö¡ÇÒÊÔ§è à¨ÒÐ´Ù´·Õäè ´ÃºÑ à»¹¹éÓ ¹éÓ»¹àÅ×Í´ ËÃ×Í à»¹ÊàÁÕÂÃ
1.2 ¡Ã³Õà»¹¹éÓ ËÃ×Í¹éÓ»¹àÅ×Í´ ãËºÑ¹·Ö¡»ÃÔÁÒµÃà»¹ÁÔÅÅÔÅÔµÃ áÅÐ¹Óä»»¹à¾×èÍ·Óà»¹
ÊàÁÕÂÃµÍ ä»
1.3 ¡ÒÃ»ÃÐàÁÔ¹»ÃÔÁÒ³¢Í§ÊàÁÕÂÃ ãËãªÇ´Ñ µÒÁÂÒÇ â´Âà¡³± ´Ñ§¹Õé
ÊàÁÕÂÃÁ¤Õ ÇÒÁÂÒÇ ¹ÍÂ¡ÇÒ 1 à«¹µÔàÁµÃ = »ÃÔÁÒ³¹ÍÂ (small volume smear)
ÊàÁÕÂÃÁ¤Õ ÇÒÁÂÒÇ ÃÐËÇÒ§ 1-2 à«¹µÔàÁµÃ = »ÃÔÁÒ³»Ò¹¡ÅÒ§ (medium volume smear)
ÊàÁÕÂÃÁ¤Õ ÇÒÁÂÒÇ ÁÒ¡¡ÇÒ 2 à«¹µÔàÁµÃ = »ÃÔÁÒ³ÁÒ¡ (large volume smear)
2. ¡ÒÃ»ÃÐàÁÔ¹»ÃÔÁÒ³à«ÅÅáÅÐ¾×¹é ËÅÑ§ÊàÁÕÂÃ ·Õàè Ëç¹¨Ò¡¡ÓÅÑ§¢ÂÒÂµèÓ
2.1 ËÅÑ¡à¡³±ã¹¡ÒÃ»ÃÐàÁÔ¹»ÃÔÁÒ³à«ÅÅ ÁÕ´§Ñ ¹Õé
¨Ó¹Ç¹à«ÅÅ¹Í Â¡ÇÒ 10 µÑÇ = »ÃÔÁÒ³à«ÅÅ¹Í Â (low cellularity)
54-117_pc22.pmd 91 19/2/2551, 20:59

¨Ó¹Ç¹à«ÅÅÃÐËÇÒ§ 10 - 100 µÑÇ = »ÃÔÁÒ³à«ÅÅ»Ò¹¡ÅÒ§ (moderate cellularity)

¨Ó¹Ç¹à«ÅÅÁÒ¡¡ÇÒ 100 µÑÇ = »ÃÔÁÒ³à«ÅÅÁÒ¡ (high cellularity)
(ËÁÒÂàËµØ à«ÅÅàÁç´àÅ×Í´á´§ àÁç´àÅ×Í´¢ÒÇ ä¢ÁÑ¹ áÅÐä¿ºÃÑÊ à»¹à«ÅÅ¾¹×é ËÅÑ§)
2.2 ºÑ¹·Ö¡¼Å¡ÒÃ»ÃÐàÁÔ¹â´ÂáÂ¡à»¹ »ÃÔÁÒ³à«ÅÅ·ÍÕè ÂàÙ ´ÕÂè Çæ áÅÐ»ÃÔÁÒ³à«ÅÅ·ÍÕè ÂàÙ »¹¡ÅÁØ
3. ¡ÒÃµÃÇ¨à«ÅÅ·ÍÕè ÂàÙ »¹à«ÅÅà´ÕÂè Ç
3.1 à»¹ bipolar naked nuclei ËÃ×ÍäÁ
3.2 à»¹ histiocytes/ macrophages ËÃ×ÍäÁ
3.3 à»¹à«ÅÅ¡ÓÅÑ§àÊ×Íè ÁËÃ×ÍµÒÂËÃ×ÍäÁ
3.4 à»¹à«ÅÅ¼´Ô »¡µÔËÃ×ÍÁÐàÃç§·ÕËè ÅØ´ÅÍ¡¨Ò¡¡ÅÁØ ËÃ×ÍäÁ â´ÂÁÕà¡³±¾¨Ô ÒÃ³Ò¤×Í
ÅÑ¡É³Ð¢Í§à«ÅÅ¼´Ô »¡µÔáÅÐà«ÅÅÁÐàÃç§
- Nuclear enlargement
- Irregular nuclear contour
- Macronucleoli
- Coarsely clumped chromatin
- Hyperchromasia
- Pleomorphism
4. ¡ÒÃµÃÇ¨à«ÅÅ·ÍÕè ÂàÙ »¹¡ÅÁØ
4.1 ÁÕà«ÅÅ¡ÅÁØ ãËÁÒ¡ËÃ×ÍäÁ (ÁÕà«ÅÅÁÒ¡¡ÇÒÃÍÂµÑÇã¹¡ÅÁØ ) ¶ÒÁÕ ÁÕÃ»Ù áºº¢Í§¡ÒÃ¨Ñ´àÃÕÂ§
µÑÇ¾ÔàÈÉËÃ×ÍäÁ
ÃÙ»áºº¢Í§¡ÒÃ¨Ñ´àÃÕÂ§µÑÇ¾ÔàÈÉ¢Í§à«ÅÅ¡ÅÁØ ãË
- Discohesive, with cells dropping off the edges
- Crowded with overlapping of the nuclei in clusters
- Flat honeycomb sheets, with or without folding
- Branched, drum stick shaped and 3D (antler horn)
- Papillary with or without fibrovascular cores and palisaded arrays ("picket fence")
- Complex with punched out oval or round holes
- Small slit-like irregular spaces with streaming or irregular nuclear orientation
4.2 à«ÅÅ¡ÅÁØ àÅç¡áÅÐ¡ÅÒ§¨Ó¹Ç¹ÁÒ¡äËÁ ÁÕÃ»Ù áºº¡ÒÃ¨Ñ´àÃÕÂ§µÑÇ¾ÔàÈÉËÃ×ÍäÁ
- ¶ÒÁÕÁÒ¡¡ÇÒ 10 ¡ÅÁØ ¶×ÍÇÒ ÁÒ¡
- ÃÙ»áºº¡ÒÃ¨Ñ´àÃÕÂ§µÑÇ¾ÔàÈÉÁÕ ´Ñ§¹Õé
(1) Open, angulated tubule
(2) Linear cord
54-117_pc22.pmd 92 19/2/2551, 20:59

(3) Monolayered sheet

(4) 3-D aggregate
(5) Papillary-frond like
4.3 ÁÕà«ÅÅÅ¡Ñ É³Ð¼Ô´»¡µÔáÅÐÁÐàÃç§ËÃ×ÍäÁ
ÅÑ¡É³Ð¢Í§à«ÅÅ¼´Ô »¡µÔáÅÐà«ÅÅÁÐàÃç§
- Nuclear enlargement
- Irregular nuclear contour
- Macronucleoli
- Coarsely clumped chromatin
- Hyperchromasia
- Pleomorphism
5. ¡ÒÃµÃÇ¨¾×¹é ËÅÑ§ÊàÁÕÂÃ
¾×¹é ËÅÑ§ÊàÁÕÂÃÁÅÕ ¡Ñ É³Ð¨Óà¾ÒÐËÃ×ÍäÁ
ÅÑ¡É³Ð¨Óà¾ÒÐ¢Í§¾×¹é ËÅÑ§ÊàÁÕÂÃ
- cystic
- inflamed
- hemorrhage
- mucin (µÍ§ÁÕÅ¡Ñ É³Ðà»¹ÅÒÂàÊ¹ ËÃ×Í fibrillary ¨Ö§à»¹ mucin)
- necrotic
- adipose-rich
- cellular fibro-stromal fragment rich
¡ÒÃá»Å¼Å
· ¤ÇÒÁÊÓ¤Ñ à»¹ÊÇ¹·ÕÊè Í§ ËÅÑ§¨Ò¡¡ÒÃÍÒ¹ÊàÁÕÂÃ ¹Ó¼Å¡ÒÃÍÒ¹ÁÒá»Å¼Å â´ÂÁÕÇ¸Ô ¡Õ ÒÃá»Å¼Å
áÂ¡à»¹ÊÍ§ÃÐºº ¤×Í ¡ÒÃá»Å¼Å¨Ò¡ÅÑ¡É³ÐÊàÁÕÂÃ (cytomorphologic base) áÅÐ¡ÒÃá»Å¼ÅµÒÁâÃ¤ áÅÐ
¡ÒÃà»ÅÕÂè ¹á»Å§¢Í§àµÒ¹Á (clinicopathological entity base) ¡ÒÃá»Å¼ÅÇÔ¸ËÕ ÅÑ§µÍ§ãª¾ÂÒ¸Ôá¾·ÂËÃ×Íá¾·Â·ÁÕè Õ
¤ÇÒÁªÓ¹Ò
1. ¡ÒÃá»Å¼Å¨Ò¡ÅÑ¡É³ÐÊàÁÕÂÃ (cytomorphologic base)
- Presence of malignant cells in clusters
- Presence of malignant cells in dispersal
- Large epithelial fragments with atypia
54-117_pc22.pmd 93 19/2/2551, 20:59

- Large epithelial fragments without atypia

- Fibroadenoma feature
- Mucinous feature
- Cyst feature, benign
- Cyst feature with atypical cells
- Low/ scant cellularity
2. ¡ÒÃá»Å¼ÅµÒÁâÃ¤áÅÐ¡ÒÃà»ÅÕÂè ¹á»Å§¢Í§àµÒ¹Á (clinicopathological entities base)
- Cyst and/ or apocrine metaplasia
- Duct ectasia
- Proliferative changes (Ductal hyperplasia, Adenosis, Complex sclerosing lesion or radial
scar)
- Papilloma
- Atypical hyperplasia / carcinoma in situ
- Fibroadenoma
- Cellular fibroadenoma or Phyllodes
- Phyllodes, no atypia or with atypia
- Ductal carcinoma, low grade or high grade
- Lobular carcinoma
- Mucinous carcinoma
- Lymphoma
- Sarcoma
- Suppurative inflammation (Mastitis, abscess)
- Granulomatous mastitis
- Fat necrosis
¡ÒÃÃÒÂ§Ò¹¼Å
· ¤ÇÒÁÊÓ¤Ñ à»¹ÊÇ¹·ÕèÊÒÁ ãªÊÓËÃÑºÊ×èÍÊÒÃ¶Ö§¼Å¡ÒÃÇÔ¹Ô¨©ÑÂ«Öè§ÁÕ¤ÇÒÁËÁÒÂÃÇÁ¶Ö§¤ÇÒÁ
ÁÑ¹è ã¨ã¹ ¼ÅÍÂ´Ù Ç Âà¾×Íè á¾·Â·ÃÕè ºÑ ¼Å¨Ðãªã¹¡ÒÃµÑ´ÊÔ¹ã¨ã¹¡ÒÃ´ÙáÅÃÑ¡ÉÒµÍä» ÃÐºº¢Í§¡ÒÃÃÒÂ§Ò¹¼ÅÁÕ
áººãªµÑÇàÅ¢à»¹ÃËÑÊáÅÐÃÐºº¢Í§¡ÒÃÃÒÂ§Ò¹¼Å·ÕèãªÇÅÕËÃ×Í¢Í¤ÇÒÁ ÊÓËÃÑº»ÃÐà·Èä·Â ¹ÔÂÁãªµÒÁ
ÃÐººËÅÑ§ ÃÐºº¡ÒÃÃÒÂ§Ò¹·Õ¹è ÓàÊ¹Í à»¹ÃÐºº¡ÒÃÃÒÂ§Ò¹·Õ¼è ÊÁ¡ÒÃá»Å¼ÅµÒÁÅÑ¡É³ÐÊàÁÕÂÃáÅÐµÒÁ¡ÒÃ
¨Óá¹¡âÃ¤¢Í§àµÒ¹Áâ´Â¾ÂÒ¸Ôá¾·Â
54-117_pc22.pmd 94 19/2/2551, 20:59

ÃÐºº¢Í§¡ÒÃÃÒÂ§Ò¹¼Å
- Cyst with or without apocrine cells
- Scant cells, Benign change
- Inflammation
- Fibroadenomatoid feature
- Fibroadenoma
- Benign Phyllodes or cellular fibroadenoma
- Large fragment/Epithelial hyperplasia
- Atypical or suspicious cells
- Mammary carcinoma, grade specified
- Mucinous carcinoma
- Carcinoma, subtype suggested
- Lymphoma
- Spindle cell tumor/ Melanoma
ÃÐºº¡ÒÃµÃÇ¨ÊÍº¤Ø³ÀÒ¾
· ¤ÇÒÁÊÓ¤Ñ ¡ÒÃµÃÇ¨ÊÍº¤Ø³ÀÒ¾à»¹ÊÇ¹ÊÓ¤Ñã¹¡ÒÃ»¯ÔºÑµÔà¾×èÍÃÐÇÑ§¢Í¼Ô´¾ÅÒ´áÅÐ
ªÇÂ¾Ñ²¹Ò »ÃÐÊÔ·¸ÔÀÒ¾¢Í§¡ÒÃÇÔ¹¨Ô ©ÑÂ·Ò§à«ÅÅÇ·Ô ÂÒãËä´¼Å·Õàè ËÁÒÐÊÁ ¶Ù¡µÍ§ áÅÐ¹Òàª×Íè ¶×Í
¡ÒÃµÃÇ¨ÊÍº¤Ø³ÀÒ¾»ÃÐ¡Íº´ÇÂ
1. ÃÐÇÑ§ artifact
â´Âà©¾ÒÐÍÂÒ§ÂÔ§è forcefully smeared discohesion áÅÐ degenerating apocrine cells in cyst
2. ´Ù¡ÓÅÑ§¢ÂÒÂµèÓ´ÇÂàÊÁÍ
ã¹¡ÒÃ»¯ÔºµÑ §Ô Ò¹ ¤ÇÃÁÕÅÓ´Ñº¡ÒÃ·Ó§Ò¹´Ñ§¹Õé
- ´Ù»ÃÔÁÒ³´ÇÂµÒà»ÅÒà¾×Íè áÂ¡ large volume, high cellularity smear ÍÍ¡¨Ò¡ small volume,
high cellularity áÅÐáÂ¡ cyst ÍÍ¡¨Ò¡ non-cyst à»¹µ¹
- ´Ù¡ÓÅÑ§¢ÂÒÂµèÓ à¾×Íè áÂ¡à«ÅÅà´ÕÂè Ç à«ÅÅ¡ÅÁØ áÅÐ¾×¹é ËÅÑ§ áÅÐ»ÃÐàÁÔ¹àªÔ§»ÃÔÁÒ³
- ´Ù¡ÓÅÑ§¢ÂÒÂÊÙ§ à¾×Íè ´ÙÃÒÂÅÐàÍÕÂ´à«ÅÅà´ÕÂÇ à«ÅÅ¡ÅÁØ áÅÐ¾×¹é ËÅÑ§
- ´Ù¡ÓÅÑ§¢ÂÒÂµèÓ à¾×Íè àª×Íè ÁâÂ§¡Í¹ÇÔ¹¨Ô ©ÑÂ
54-117_pc22.pmd 95 19/2/2551, 20:59

3. µÃÇ¨ÊÍº¡ÒÃÍÒ¹¡Ñº·Ò§¤ÅÔ¹¡Ô áÅÐÃÑ§ÊÕÇ·Ô ÂÒ
¤ÇÃÁÕ¡ÒÃ»ÃÐªØÁÃÇÁ·Ò§¤ÅÔ¹¡Ô ÃÑ§ÊÕÇ·Ô ÂÒ áÅÐ¾ÂÒ¸ÔÇ·Ô ÂÒà»¹»ÃÐ¨Óà¾×Íè àª×Íè ÁâÂ§à«ÅÅÇ·Ô ÂÒ
¡ÑºÅÑ¡É³Ð·Ò§¤ÅÔ¹¡Ô ¡ÑºÃÑ§ÊÕÇ·Ô ÂÒ ¶ÒÁÕ¤ÇÒÁ¢Ñ´áÂ§ ¤ÇÃ¾Ô¨ÒÃ³Ò·Ó¡ÒÃµÑ´ªÔ¹é à¹×Íé ËÃ×ÍµÃÇ¨à¾ÔÁè àµÔÁ¡ÒÃµÃÇ¨ÊÍº
ÍÂàÙ ÊÁÍ·ÓãËà¡Ô´¤ÇÒÁÁÑ¹è ã¨áÅÐÅ´¢Í¼Ô´¾ÅÒ´
¡ÒÃÍÒ¹ÁÐàÃç§·Õèà»¹à«ÅÅ¢¹Ò´àÅç¡ áÅÐà«ÅÅ·ÕèÁÕ differentiation ´Õ µÍ§ÍÒÈÑÂ»ÃÐÊº¡ÒÃ³
áÅÐ¤ÇÒÁªÓ¹Ò¢Í§¾ÂÒ¸Ôá¾·Â
References
1. The uniform approach to breast fine needle aspiration biopsy. A synopsis. Developed and approved at an NCI-sponsored conference,
Bethesda, MD, Sept. 9-10, 1996. Acta Cytol 1996; 40:1120-1126.
2. Guidelines for non-operative diagnostic procedures and reporting in breast cancer screening NHSBSP publication No.50; June 2001.
3. European guidelines for quality assurance in mammography screening, 3rd ed. 2001, p1145-1147.
4. Maygarden SJ, Novotny DB, Johnson DE, Frable WJ. Subclassification of benign breast disease by fine needle aspiration cytology. Acta
Cyto 1994;38:115-129.
v v v
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á¹Ç·Ò§¡ÒÃµÑ´ªÔé¹à¹×éÍ wide excision

º·¹Ó
¡ÒÃµÃÇ¨ªÔ¹é à¹×Íé wide excision áÅÐ needle-guided excision à»¹¢Ñ¹é µÍ¹·ÕÁè ¤Õ ÇÒÁÊÓ¤ÑÁÒ¡ ÈÑÅÂá¾·Â
áÅÐÃÑ§ÊÕá¾·Â·Õèà¡ÕèÂÇ¢Í§µÍ§ãËÃÒÂÅÐàÍÕÂ´·Õè¤Ãº¶Ç¹à¾×èÍãË¾ÂÒ¸Ôá¾·ÂÊÒÁÒÃ¶à¢Òã¨¡ÒÃÇÒ§·ÔÈ·Ò§áÅÐ
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54-117_pc22.pmd 97 19/2/2551, 20:59

á¹Ç·Ò§¡ÒÃµÃÇ¨à¹×éÍ¼ÒµÑ´·Ñé§àµÒ¹Á (Practical Pathological Guideline

for Whole Breast Specimen)
A. Macroscopic examination:
1. Identify and orient the specimen
2. Measure and record
· Either the whole breast with axillary content, together; or whole breast and axillary content,
separately (measure three dimensions)
· Skin ellipse (measure two substantial dimensions)
3. Describe the covering skin and nipple (if applicable)
· Describe and locate position of visible/palpable mass (es) and other abnormalities such as scar,
ulcer or surgical wound
· Describe the nipple and state the abnormality
4. Ink the deep margin and other margin(s) related to tumor
5. Cut whole breast specimen and record
· Serially section along sagittal axis at approximately 1 cm intervals (maintaining the orientation)
· Locate and record location of lesion(s) eg. mass, cavity, cyst, calcification, etc. For location, use
quadrant if applicable
· Measure distance of mass(es)/hemorrhagic or biopsy cavity from deep and other related
margins
· Record size of the lesion(s) (three dimensions if applicable)
- Size of hemorrhagic or biopsy cavity
- Size of mass(es)
- Size of residual tumor(s)
· Describe tumor mass(es)
- Color
- Consistency (eg. soft, hard, firm, rubbery, gritty sensation, etc.)
- Border
- Hemorrhage/Necrosis (if applicable)
- In case of multifocality/multicentricity, describe all other mass(es) as aforementioned and
state the distance(s) from the main mass
- Describe the remaining breast tissue and state the abnormality (if applicable).
Note : For definition of multifocality or multicentricity (see appendix -1)
54-117_pc22.pmd 98 19/2/2551, 20:59

B. Sections submitted
· Tumor mass(es) /Residual tumor mass(es)
- Representative sections from tumor and adjacent normal breast tissue are submitted. Addi
tional sections for ancillary study are suggested.
· Previous biopsy cavity (if present)
- Representative sections around the biopsy cavity are submitted. More sampling is indicated
in case of DCIS alone (to exclude areas of invasion).
· Deep margin and other margin(s) related to tumor
- At least one perpendicular section of the nearest deep margin and other margin(s) related to
tumor is submitted.
· Skin
- In case of suspected epidermal involvement or inflammatory breast carcinoma, represen-
tative sections from related skin are submitted.
· Nipple
- At least one section is submitted. (Cutting detail, see appendix-2)
Note: Four quadrant samplings may be helpful to detect microscopic multifocal or multicen-
tric tumor(s).
C. Microscopic examination/Diagnosis
1. Tumor mass (es)/Residual tumor(s):
· Histologic subtype: According to WHO classification or other internationally accepted classi
fication
· Grade:
· Invasive ductal carcinoma: Employ international accepted grading system (Prefer the
Modified Bloom-Richardson grade). If other grading system is used, specify the system used.
(see appendix-3 for Modified Bloom-Richardson grading system)
· Ductal carcinoma in situ: Employ the international grading system, specify the system used.
· Estimated size: Macroscopic or microscopic measurement (see appendix-4)
2. Lymphatic/vessel invasion: Blood/lymphatic vessel around tumor needs evaluation for me-
tastasis and reported if positive (see appendix-5)
3. Margin: Status of deep margin and other margin(s) related to tumor (assess the distance from
tumor to the nearest resected margin, if applicable)
54-117_pc22.pmd 99 19/2/2551, 20:59

4. Nipple and related skin: Status of nipple, epidermis and positive dermal blood/lymphatic vessel
invasion.
Note: 1. Histologic subtype and grading can be omitted if amount of tumor is insufficient for
evaluation.
2. There is no international recommendation for grading system of special subtype
(eg. lobular carcinoma, medullary carcinoma, mucinous carcinoma, papillary carcinoma,
etc.)
3. Tumor size around or less than 2.0 cm needed special attention. (see appendix-4)
4. In case of multifocal/multicentric tumors, all foci needed evaluation and reported.
5. Breast lesion(s) other than carcinoma should be reported.
Appendix
1. Definition of multifocal and multicentric tumor
2. Nipple cutting
3. Modified Scarff-Bloom-Richardson Grading
4. Macroscopic and microscopic measurement of mass (es)
5. Rosen criteria of lymphatic/vessel invasion
Appendix 1. Definition of multifocal and multicentric tumor
Multifocality: presence of more than a single focus of intraductal carcinoma, lobular neoplasia, or
invasive carcinoma within a slide or a biopsy specimen not larger than 5 cm in its
maximum dimension
Multicentricity: presence of independent foci of lesion (lobular neoplasia, in situ, or invasive carci-
noma) at 5 cm or more distant from one another
Appendix 2. Nipple cutting
Either approach of the following is accepted.
· Perpendicular bisection/serial section
· En face section plus perpendicular section
Appendix 3. Modified Scarff Bloom-Richardson Grading of breast carcinoma
· Tubule formation (Clear lumina must be present)
Majority of tumor (>75%) 1 point
Moderate degree (10-75%) 2 points
Little or none (<10%) 3 points
54-117_pc22.pmd 100 19/2/2551, 20:59

· Nuclear pleomorphism
- Uniform or regular, small nuclei and 1 point
minimal variation
- Moderate degree of variation in nuclear 2 points
size and shape, and occasional nucleoli
- Marked variation in nuclear size and bizarre 3 points
nuclei, often one or more prominent nucleoli
· Mitotic count: - Count at periphery or the most mitotically active part of the tumor, at least
10 HPF
0-5/10 HPF 1 point
6-10/10 HPF 2 points
>10/10 HPF 3 points
Note: Based on a microscopic field with a diameter of 0.44 mm and an area of 0.152 mm2
(Nikon Labophot microscope with a x40 objective lens)
Tumor grade (Tubule formation + nuclear pleomorphism + mitotic count)
3 to 5 points = Grade I, well differentiated
6 to 7 points = Grade II, moderately differentiated
8 to 9 points = Grade III, poorly differentiated
Appendix 4. Macroscopic and microscopic measurement of the mass
In case of tumor size around 2.0 cm, more accurate microscopic measurement is preferred.
Rationale :
· TNM clinical classification
T- Primary tumor
T1 = Tumor 2 cm or less in greatest dimension
T1mic = Microinvasion 0.1 cm or less in greatest dimension
T1a = More than 0.1 cm but not more than 0.5 cm in greatest dimension
T1b = More than 0.5 cm but not more than 1.0 cm in greatest dimension
T1c = More than 1.0 cm but not more than 2.0 cm in greatest dimension
T2 = Tumor more than 2 cm but not more than 5 cm in greatest dimension
T3 = Tumor more than 5 cm in greatest dimension
T4 = Tumor of any size with direct extension to chest wall or skin
54-117_pc22.pmd 101 19/2/2551, 20:59

· pTNM pathological classificaiton

pT- Primary tumor
The pathologic classification requires the examination of the primary carcinoma with no gross
tumor at the margins of resection. A case can be classified pT if there is only microscopic tumor in a margin.
The pT categories correspond to the T categories.
Note: When classifying pT, the tumor size is a measurement of the invasive component.
If there is a large in situ component (eg.4 cm.) and a small invasive component (eg.0.5 cm.), the
tumor is coded pT1a.
Appendix 5. Rosen criteria of lymphovascular invasion
· Lymphovascular invasion (LVI) must be diagnosed outside the border of the invasive carcinoma.
The most common area for LVI to occur is within 0.1cm from the edge of the carcinoma.
· The tumor emboli usually do not conform exactly to the contours of the space in which they are
found. In contrast, invasive carcinoma with retraction artifacts mimicking LVI has exactly the
same shape.
· Endothelial cell nuclei should be seen in the cells lining the space.
· Lymphatics are often found adjacent to blood vessels and often partially encircle a blood vessel.
References
1. Tavassoli F. General Consideration. In: Pathology of the breast. 2nded. New York: McGraw-Hill,1999: 27-74.
2. Lester SC. Breast. In. Lester SC. Manual of Surgical Pathology. 1st ed. New York: Churchill Livingstone, 2001: 129-146.
v v v
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á¹Ç·Ò§¡ÒÃµÃÇ¨à¹×éÍ¼ÒµÑ´µÍÁ¹éÓàËÅ×Í§·ÕèÃÑ¡áÃ (Practical Pathological

Guideline for axillary dissection)
I. Axillary lymph nodes dissection
1. Measure three dimensions of the axillary content
2. Dissect all lymph nodes
a. Record the total number of possible lymph nodes
b. Record the size of the largest single lymph node
c. If present, record the number and size of matted lymph nodes
1. One representative section from each possible lymph node is submitted.
2. For matted lymph nodes, one representative section from each node is submitted.
Note: For optimal quality of sections, each block should contain no more than 4 presumed
lymph nodes.
1. Specify the number of positive lymph nodes and total microscopically verified lymph nodes.
2. Specify extracapsular invasion, if present.
II. Sentinel lymph nodes

Dissect all lymph nodes
a. Record the total number and size of well-defined lymph nodes
b. Slice each lymph node with 0.2 cm intervals
1. Upon frozen sections, the parallel side of every slice of every lymph node is examined.
2 All slices of each lymph node are submitted.
3. If positive grossly, only one section from positive lesion could be submitted.
1. Specify the number of positive lymph nodes and total microscopically verified lymph
nodes.
54-117_pc22.pmd 103 19/2/2551, 20:59

2. Specify size of the largest metastatic deposit (macrometastases are defined as being >
0.2 cm in size, micrometastases are 0.02-0.2 cm and isolated tumor cells are less than
0.02 cm).
References
1. Tavassoli F. General Consideration. In: Pathology of the breast. 2nded. New York: McGraw-Hill,1999: 27-74.
2. Lester SC. Breast. In. Lester SC. Manual of Surgical Pathology. 1sted. New York: Churchill Livingstone, 2001: 129-146.
v v v
54-117_pc22.pmd 104 19/2/2551, 20:59

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´Ñ§¹Õé
¼ÅºÇ¡ (Positive test) = ÁÕµ§Ñé áµ 10% ¢Í§à«ÅÅÁÐàÃç§¢Ö¹é ä»·Õãè Ë¼ÅºÇ¡
¼ÅºÇ¡¹ÍÂ (Low positive test) = ÁÕ¹Í Â¡ÇÒ 10% ¢Í§à«ÅÅÁÐàÃç§·Õãè Ë¼ÅºÇ¡
¼ÅÅº (Negative test) = äÁÁàÕ «ÅÅÁÐàÃç§·Õãè Ë¼ÅºÇ¡
ËÁÒÂàËµØ ¡ÒÃÂÍÁÊÕ·àÕè ËÁÒÐÊÁ à«ÅÅ»¡µÔ¢Í§àµÒ¹ÁµÍ§ÁÕ¡ÒÃµÔ´ÊÕ·Õè nucleus ºÒ§
· ¡ÒÃÃÒÂ§Ò¹¼Å ER áÅÐ PgR
ãËÃÒÂ§Ò¹¼ÅÇÒ positive ËÃ×Í negative ¾ÃÍÁÃÐºØ¤Ò»ÃÐàÁÔ¹ÃÍÂÅÐ¢Í§à«ÅÅÁÐàÃç§·ÕèãË
¼ÅºÇ¡
References
1. Harris L, Fritsche H, Mennel R, et al: American Society of Clinical Oncology 2007 Update of Recommendations for the Use of Tumor
Markers in Breast Cancer. J Clin Oncol 2007; 25:1-26.
2. Allred DC, Brown P, Medina D. The origins of estrogen receptor alpha-positive and estrogen receptor slpha-negative human breast
cancer. Breast Cancer Res 2004; 6: 240-245.
3. Dabbs DJ. Breast Pathology. Philadelphia: Elsevier Saunders; 2012.
54-117_pc22.pmd 106 19/2/2551, 20:59

4. Sampatanukul P, Chaiwun B, Wongwaisayawan S, Suwanagool P, Vinyuvat S, Karalak A, Praditphol N, Paueksakon P, Ruangvejvorachai
P, Field AS, Wannakrairot P. A two-phase study model for the standardization of HER2 immunohistochemical assay on invasive ductal
carcinoma of the breast. J Med Assoc Thai 2005; 88:1680-1688.
5. Hammond MEH, Hayes DF, Dowsett M, et al: American Society of Clinical Oncology/College of American Pathologists guideline
recommendations for immunohistochemical testing of estrogen and progesterone receptors in breast cancer. J Clin Oncol.2010; doi:
10.1200/JCO.2009.25.6529.
v v v
54-117_pc22.pmd 107 19/2/2551, 20:59

ËÅÑ¡à¡³±¡ÒÃá»Å¼ÅáÅÐÃÒÂ§Ò¹¼Å HER2 ¢Í§ÁÐàÃç§àµÒ¹Á

1. ¡ÒÃµÃÇ¨ HER2 ´ÇÂÇÔ¸Õ immunohistochemistry
¡ÒÃµÃÇ¨ HER 2 receptor ´ÇÂÇÔ¸Õ immunohistochemistry ÁÕ¢Í á¹Ð¹ÓáÅÐ¢Í¤ÇÃÃÐÇÑ§àª¹à´ÕÂÇ¡Ñº
¡ÒÃµÃÇ¨ immunohistochemistry ¢Í§ ER áÅÐ PgR ¡ÒÃÂÍÁÍÒ¨ãªÇ¸Ô Õ Standardized Automated Immunostainer
ËÃ×Íãª water-bath «Ö§è ¤Çº¤ØÁÍØ³ËÀÙÁµÔ ÒÁ protocol ÊÓËÃÑº¡ÒÃÂÍÁ immunohistochemistry ¢Í§ HER2 receptor
ÊÓËÃÑº¡ÒÃÂÍÁ immunocytochemistry º¹ÊàÁÕÂÃ¹¹Ñé ÊÒÁÒÃ¶ÂÍÁä´àª¹à´ÕÂÇ¡ÑºªÔ¹é à¹×Íé áµ»ÃÔÁÒ³à«ÅÅÁÐàÃç§
¤ÇÃµÍ§ÁÕÁÒ¡¾Í
¡ÒÃÃÒÂ§Ò¹¼Å HER2 receptor ´ÇÂÇÔ¸Õ immunohistochemistry
¼ÅºÇ¡ (Positive HER2 status) = ¤Ðá¹¹ 3+
¼Å¡éÓ¡Ö§è (Equivocal HER2 status) = ¤Ðá¹¹ 2+
¼ÅÅº (Negative HER2 status) = ¤Ðá¹¹ 1+ ËÃ×Í 0
â´ÂãªÃÐºº¡ÒÃãË¤Ðá¹¹ ´Ñ§¹Õé
¤Ðá¹¹ 0 = äÁÁÕ¡ÒÃµÔ´ÊÕ cytoplasmic membrane ËÃ×Í¡ÒÃµÔ´ÊÕÁÕ¹ÍÂ¡ÇÒ 10% ¢Í§
à«ÅÅ·àÕè »¹ invasive carcinoma ·Ñ§é ËÁ´·Õ»è ÃÒ¡¯ã¹ section
¤Ðá¹¹ 1+ = µÔ´ÊÕ membrane áµäÁ¤ÃºÇ§¢Í§à«ÅÅ (>10%¢Í§à«ÅÅ·Õèà»¹ invasive
carcinoma ·Ñ§é ËÁ´·Õè »ÃÒ¡¯ã¹ section)
¤Ðá¹¹ 2+ = µÔ´ÊÕ membrane ¤ÃºÇ§¢Í§à«ÅÅ áµäÁà¢Á (>10%¢Í§à«ÅÅ·Õèà»¹ invasive
carcinoma ·Ñ§é ËÁ´·Õ»è ÃÒ¡¯ã¹ section) ËÃ×ÍµÔ´ÊÕ membrane ¤ÃºÇ§à«ÅÅáÅÐ
à¢Á £ 30%
¤Ðá¹¹ 3+ = µÔ´ÊÕ membrane ¤ÃºÇ§¢Í§à«ÅÅ áÅÐà¢Á (>30%¢Í§à«ÅÅ·Õèà»¹ invasive
carcinoma ·Ñ§é ËÁ´·Õ»è ÃÒ¡¯ã¹ section)
(Positive HER2 result requires homogeneous, dark circumferential (chicken wire) pattern in
>30% of invasive carcinoma)(1)
ã¹¡Ã³Õ¡ÒÃµÔ´ÊÕäÁÊÁèÓàÊÁÍ ãËãª¤Ðá¹¹·Õäè ´Ê§Ù ÊØ´µÒÁà¡³±¢Ò §µ¹
ËÁÒÂàËµØ ¡ÒÃÂÍÁÊÕ·àÕè ËÁÒÐÊÁ à«ÅÅ»¡µÔ¢Í§àµÒ¹ÁäÁ¤ÇÃÁÕ¡ÒÃµÔ´ÊÕ membrane ·Õ¤è ÃºÇ§
ËÒ¡»ÃÒ¡¯Ç Ò à«ÅÅ Á ÐàÃç § áÅÐà«ÅÅ » ¡µÔ ÁÕ ¡ ÒÃµÔ ´ ÊÕ membrane ·Õè ¤ ÃºÇ§
¤ÇÃá»Å¼Åà»¹ equivocal à¾×èÍ¨Ðä´ÁÕ¡ÒÃÂÍÁãËÁËÃ×ÍµÃÇ¨´ÇÂÇÔ¸Õ¡ÒÃµÃÇ¨
ÃÐ´ÑºÂÕ¹â´Â FISH (Fluorescent in situ hybridization) ËÃ×Í CISH (Chromogenic
in situ hybridization) ËÃ×Í DISH (Dual-color silver-enhanced in situ
hybridization)
¡ÒÃÃÒÂ§Ò¹¼Å HER2
ãËÃÒÂ§Ò¹¼ÅÇÒ "positive", "equivocal" ËÃ×Í "negative" HER2 status
54-117_pc22.pmd 108 19/2/2551, 20:59

2. ¡ÒÃµÃÇ¨ HER2 ´ÇÂÇÔ¸Õ in situ hybridization

ÂÕ¹ HER2 à»¹ oncogene ·ÕèÍÂÙº¹â¤ÃâÁâ«Áá·§·Õè 17 à·¤¹Ô¤·Ò§ËÍ§»¯ÔºÑµÔ¡ÒÃ·Õèãª»ÃÐàÁÔ¹
ÃÐ´Ñº¡ÒÃà¾ÔèÁ»ÃÔÁÒ³¢Í§ÂÕ¹ HER2 (HER2 amplification level) ã¹¡ÒÃ¤Ñ´¡ÃÍ§ÃÐ´Ñº¢Í§â»ÃµÕ¹ HER2
¢Í§¼Ù»ÇÂÁÐàÃç§àµÒ¹Áãªà·¤¹Ô¤ IHC «Öè§à»¹¡ÒÃÂÍÁâ»ÃµÕ¹ HER2 ·ÕèºÃÔàÇ³àÂ×èÍËØÁà«ÅÅ ã¹¡Ã³Õ·Õè¼Å¢Í§
¡ÒÃµÃÇ¨ HER2 â´Âà·¤¹Ô¤ IHCãË¼Åà»¹ IHC 2+ «Öè§à»¹¼Å·Õè¡éÓ¡Öè§ÃÐËÇÒ§¼ÅºÇ¡áÅÐ¼ÅÅº ·ÓãËá¾·Â
äÁÊÒÁÒÃ¶á»Å¼Åä´ ´Ñ§¹Ñ¹é ¨Ö§¨Óà»¹µÍ§ÁÕÇ¸Ô ¡Õ ÒÃ·´ÊÍºâ´Âãªà·¤¹Ô¤ in situ hybridization (ISH) à¾ÔÁè àµÔÁà¾×Íè
Â×¹ÂÑ¹¼Å àª¹ FISH (Fluorescence in situ hybridization) ËÃ×Í CISH (Chromogenic in situ hybridization) ËÃ×Í
DISH (Dual-color silver-enhanced in situ hybridization) â´Âà·¤¹Ô¤ ISH à»¹¡ÒÃÈÖ¡ÉÒÇÔà¤ÃÒÐËËÒ»ÃÔÁÒ³
¢Í§ÂÕ¹ã¹ÅÑ¡É³Ð¢Í§ÍÑµÃÒÊÇ¹ÃÐËÇÒ§ÂÕ¹à»ÒËÁÒÂ (ÂÕ¹ HER2) áÅÐ¨Ó¹Ç¹¢Í§ centromere ¢Í§â¤ÃâÁâ«Á
á·§·Õè 17 â´Â»ÃÐàÁÔ¹¤Ø³ÀÒ¾¢Í§¢Í§ÊÑÒ³ÊÕ áÅÐ¹Ñº¨Ó¹Ç¹ÊÑÒ³ÊÕ¢Í§ ÂÕ¹ HER2 µÍ¨Ó¹Ç¹ÊÑÒ³
ÊÕ¢Í§¨Ó¹Ç¹ centromere ¢Í§â¤ÃâÁâ«Áá·§·Õè 17
¡ÒÃá»Å¼Å HER2 â´Âà·¤¹Ô¤ FISH (HER2 FISH)(2,3)
ÇÔ¸Õ¡ÒÃá»Å¼ÅãªËÅÑ¡¡ÒÃËÒÍÑµÃÒÊÇ¹ÃÐËÇÒ§ÂÕ¹ HER2 áÅÐ¨Ó¹Ç¹ centromere ¢Í§
â¤ÃâÁâ«Áá·§·Õè 17 ã¹ Ë¹Öè§à«ÅÅ â´Â´Ù¨Ò¡ ÂÕ¹ HER2 «Öè§ãËÊÑÒ³áÊ§ÊÕá´§áÅÐ centromere ¢Í§
â¤ÃâÁâ«Áá·§·Õè 17 ãËÊ Ñ Ò³áÊ§ÊÕà¢ÕÂÇ ¨Ó¹Ç¹ 20 à«ÅÅ ÁÕà¡³±¡ÒÃá»Å¼Å´Ñ§¹Õé
¼ÅºÇ¡ (Positive HER2 status) ËÁÒÂ¶Ö§ ÁÕÍµÑ ÃÒÊÇ¹ÁÒ¡¡ÇÒ 2.2 (> 2.2)
¼Å¡éÓ¡Ö§è (Equivocal HER2 status) ËÁÒÂ¶Ö§ ÁÕÍµÑ ÃÒÊÇ¹ÍÂÃÙ ÐËÇÒ§ËÃ×Íà·Ò¡Ñº
1.8 ¶Ö§ 2.2 (1.8 £ ÍÑµÃÒÊÇ¹ £ 2.2)
¼ÅÅº (Negative HER2 status) ËÁÒÂ¶Ö§ ÁÕÍµÑ ÃÒÊÇ¹¹ÍÂ¡ÇÒ 1.8 (< 1.8)
¼ÅÅº ( Polysomy 17) ËÁÒÂ¶Ö§ ÁÕ¨Ó¹Ç¹à©ÅÕèÂ¢Í§â¤ÃâÁâ«Áá·§ 17 à·Ò¡Ñº
ËÃ×ÍÃÐËÇÒ§ 4-6 signals/cell
¡ÒÃÍÒ¹¼Å FISH
ã¹¡Ã³Õ¼Å¡ÒÃµÃÇ¨ÇÔà¤ÃÒÐËà»¹¼Å¡éÓ¡Ö§è (Equivocal HER2 status) ·ÕÁè ¤Õ Ò ÃÐËÇÒ§ 1.8 £ ÍÑµÃÒÊÇ¹
£ 2.2 ãË¼Ç Ù àÔ ¤ÃÒÐËÍÒ ¹à¾ÔÁè ÍÕ¡ 20 à«ÅÅ áÅÐÃÒÂ§Ò¹¼Å¨Ò¡¡ÒÃ¹Ñº 40 à«ÅÅ
ã¹¡Ã³Õ·¼Õè ÅÂÑ§à»¹ Equivocal ÍÂÙ ãË¹ºÑ ãËÁ·§Ñé ËÁ´ÍÕ¡¤ÃÑ§é ÍÂÒ§¹ÍÂ 20 à«ÅÅ áÅÐÃÒÂ§Ò¹¼Å¨Ò¡
¡ÒÃ¹Ñº¤ÃÑ§é ãËÁ¹Õé
· ¡ÒÃá»Å¼Å HER2 â´Âà·¤¹Ô¤ CISH (HER2 CISH)(4,5)
ÇÔ¸¡Õ ÒÃá»Å¼ÅãªËÅÑ¡¡ÒÃ¹Ñº¨Ó¹Ç¹ dot (signal) ¢Í§ HER2 «Ö§è µÔ´ÊÕ¹éÓµÒÅ (¢Ö¹é ¡Ñº chromogen
·Õãè ª) ã¹ nucleus ¢Í§ tumor cell (invasive part) äÁ¹Í Â¡ÇÒ 50% ¢Í§ cancer cell áÅÇÃÒÂ§Ò¹¼Å´Ñ§¹Õé : Positive/
Negative HER2 status, using HER2 CISH method
54-117_pc22.pmd 109 19/2/2551, 20:59

¼ÅºÇ¡ (Positive HER2 status) àÁ×Íè ¹Ñº¨Ó¹Ç¹ dot ä´¤Ò > 5 dots / nucleus «Ö§è áº§à»¹
- Low amplification: àÁ×èÍ¹Ñº¨Ó¹Ç¹ dot ä´¤ÒÃÐËÇÒ§ 6-10 dots µÍ nucleus ËÃ×Í¾º small
clusters ËÃ×Íà»¹ mixture of multiple dots áÅÐ small clusters of the HER2 gene present per
nucleus in > 50% of cancer cell
- High amplification: àÁ×èÍ¹Ñº¨Ó¹Ç¹ dot ä´ÁÒ¡¡ÇÒ 10 dots (>10) µÍ nucleus ËÃ×Í¾º large
clusters ËÃ×Íà»¹ mixture of multiple dots áÅÐ large clusters of the HER2 gene present per
nucleus in > 50% of cancer cell
¼ÅÅº (Negative HER2 status) àÁ×Íè ¹Ñº¨Ó¹Ç¹ dot ä´µ§Ñé áµ 5 Å§ÁÒ (£ 5)
Diploid: àÁ×Íè ¹Ñº¨Ó¹Ç¹ dot ä´1-2 dots of the HER2 gene µÍ nucleus in > 50% of cancer
cell
Polysomy: àÁ×Íè ¹Ñº¨Ó¹Ç¹ dots ä´ 3-5 dots of the HER2 gene µÍ nucleus in > 50% of cancer
cell
¡ÒÃ¹Ñº signal - a single dot (signal) ÁÕÅÑ¡É³Ðà»¹¨Ø´¡ÅÁ¢ÍºàÃÕÂº¾ºä´ã¹ nucleus ¢Í§
normal cell ã¹ slide à´ÕÂÇ¡Ñ¹ (use as reference)
- a small cluster ÁÕÅ¡Ñ É³Ðà»¹¡ÅÁØ ¢Í§ dot ·Õ¢è ÍºäÁàÃÕÂº ¢¹Ò´ 3-5 à·Ò¢Í§ single
dot
- a large cluster ÁÕÅ¡Ñ É³Ðà»¹¡ÅÁØ ¢Í§ dot ·Õ¢è ÍºäÁàÃÕÂº ¢¹Ò´ãË¡ÇÒ 5 à·Ò¢Í§
single dot
· ¡ÒÃá»Å¼Å HER2 â´Âà·¤¹Ô¤ Dual-color silver-enhanced in situ hybridization (HER2
DISH)(3, 6, 7)
ÇÔ¸¡Õ ÒÃá»Å¼ÅãªÇ¸Ô ¡Õ ÒÃ¹Ñº¨Ó¹Ç¹ dot (signal) ¢Í§ HER2 «Ö§è µÔ´ÊÕ´Ó¢Í§ silver áÅÐ Chromo-
some 17 (Chr 17) «Öè§µÔ´ÊÕá´§ã¹ nucleus ¢Í§ tumor cell ã¹ºÃÔàÇ³ invasive breast cancer ·Õèáµ¡µÒ§¡Ñ¹ 2
µÓáË¹§ ¹ÑºáË§ÅÐ 20 nuclei áÅÐ¤Ó¹Ç³ËÒÍÑµÃÒÊÇ¹ÃÐËÇÒ§ total number of HER2 signals in 40 nuclei µÍ
total number of Chr17 signals in 40 nuclei, (HER2/Chr17 ratio) áÅÇÃÒÂ§Ò¹¼Å´Ñ§¹Õé
¼ÅºÇ¡: Amplification of HER2 gene using HER2 DISH method.
(HER2/Chr 17 ratio is 2)
¼ÅÅº: No amplification of HER2 gene using HER2 DISH method.
(HER2/Chr17 ratio is 2)
¡ÒÃ¹Ñº signal - ÁÕ·§Ñé single dot (copy, or signal), multiple dots, small cluster áÅÐ large cluster
- ¢¹Ò´¢Í§áµÅÐ dot ÍÒ¨ vary ä´ã¹áµÅÐ case ãËãª¢¹Ò´¢Í§ dot ã¹ HER2
ËÃ×Í Chr 17 ã¹ nucleus ·Õèà»¹ non-neoplastic cells àª¹ stromal fibroblasts,
endothelial cells, lymphocytes áÅÐ benign breast epithelial cells à»¹ internal
54-117_pc22.pmd 110 19/2/2551, 20:59

positive control ¢Í§ slide ¹Ñ¹é æ (ãªà»¹ reference) ã¹¡ÅÁØ ¹Õ¨é Ð¾º normal HER2
or Chr17 signals ·ÕÁè Õ 1-2 copies µÍ nucleus
- a small cluster ÁÕ¢¹Ò´à·Ò¡Ñº 6 dots
- a large cluster ÁÕ¢¹Ò´à·Ò¡Ñº 12 dots
References
1. Sampatanukul P, Chaiwun B, Wongwaisayawan S, Suwanagool P, Vinyuvat S, Karalak A, Praditphol N, Paueksakon P, Ruangvejvorachai
P, Field AS, Wannakrairot P. A two-phase study model for the standardization of HER2 immunohistochemical assay on invasive ductal
carcinoma of the breast. J Med Assoc Thai 2005; 88:1680-1688.
2 Wang S, Saboorian M, Frenkel EP, Haley BB, Siddiqui MT, Gakaslan S, et al. Aneusomy 17 in breast cancer: its role in HER-2/neu
protein expression and implication for clinical assessment of HER-2/neu status. Mod Pathol 2002; 15:137-145.
3 Wolff AC, Hammond MEH, Schwartz, Hagerty KL, Allred DC, Cote RJ, et al. American Society of Clinical Oncology/College of
American Pathologists Guideline Recommendations for human epidermal growth factor receptor 2 testing in breast cancer. J Clin Oncol
2007; 25:118-145.
4. Tanner M, Gancberg D, Leo AD, Larsimont D, Rouas G, Piccart MJ, et al. Chromogenic in situ hybridization (CISH): a pratical
alternative for FISH to detect HER-2/NEU oncogene amplification in archival breast cancer samples. Am J Pathol 2000; 157:1467-72.
5. Di Palma S, Collins N, Bilous M, Sapino A, Mottolese M, Kapranos N, et al. A quality assurance exercise to evaluate the accuracy
and reproducibility of chromogenic in situ hybridization for HER2 analysis in breast cancer. J Clin Pathol 2008; 61:757-60.
6. Dietel M, Ellis IO, H?fler H, Kreipe H, Moch H, Dankof A, et al. Comparison of automated silver enhanced in situ hybridization (SISH)
and fluorescence ISH (FISH) for the validation of HER2 gene status in breast carcinoma according to the guidelines of the American
Society of Clinical Oncology and the College of American Pathologists. Virchows Arch 2007; 451:19-25.
7. Kang J, Kwon GY, Lee YH, Gong G. Comparison of silver-enhanced in situ hybridization and fluorescence in situ hybridization for
HER2 gene status in breast carcinomas. J Breast Cancer 2009; 12:235-40.
v v v
54-117_pc22.pmd 111 19/2/2551, 20:59

ËÅÑ¡à¡³±¡ÒÃá»Å¼ÅáÅÐÃÒÂ§Ò¹¼Å Ki-67 ¢Í§ÁÐàÃç§àµÒ¹Á

º·¹Ó
ã¹¡ÒÃÇÒ§á¼¹ÃÑ¡ÉÒÁÐàÃç§àµÒ¹Á ¹Í¡¨Ò¡¡ÒÃµÃÇ¨ËÒ ER, PgR áÅÐ HER2 à¾×èÍãªà»¹á¹Ç·Ò§
ã¹¡ÒÃàÅ×Í¡ÇÔ¸Õ¡ÒÃÃÑ¡ÉÒáÅÇ ÂÑ§ÁÕ¡ÒÃÈÖ¡ÉÒ biomarker Í×è¹æ·ÕèàËÁÒÐÊÁà¾ÔèÁàµÔÁ àª¹ Ki-67, p53, cyclin D, Ca
15-3 , p21, p27 à»¹µ¹ áµ biomarker µÒ§æàËÅÒ¹ÕÂé §Ñ äÁÁ¢Õ Í ÊÃØ»ÇÒ¨Óà»¹µÍ§µÃÇ¨ã¹¼»Ù Ç ÂÁÐàÃç§àµÒ¹Á·Ø¡ÃÒÂ(1)
ÍÂÒ§äÃ¡çµÒÁ¡ÒÃµÃÇ¨ËÒ Ki-67 «Ö§è à»¹µÑÇªÕÇé ´Ñ ¡ÒÃáº§µÑÇ¢Í§à«ÅÅ ÊÒÁÒÃ¶ãªªÇ ÂÇÒ§á¼¹¡ÒÃÃÑ¡ÉÒ
ä´ã¹ËÅÒÂ¡Ã³Õ àª¹ãªªÇÂáÂ¡ subtype ÃÐËÇÒ§ luminal A áÅÐ luminal B (HER2 negative)(2,3) ãªªÇÂã¹
¡ÒÃµÑ´ÊÔ¹ã¨äÁãË¡ÒÃÃÑ¡ÉÒ´ÇÂÇÔ¸Õ cytotoxic neoadjuvant therapy ã¹¼Ù»ÇÂÁÐàÃç§àµÒ¹Á·ÕèÁÕ¡ÒÃáº§µÑÇ¢Í§
à«ÅÅÁÐàÃç§µèÓ ËÃ×Íãªà»¹µÑÇªÕÇé ´Ñ à¾×Íè ÂØµËÔ Ã×Íà»ÅÕÂè ¹á»Å§¡ÒÃÃÑ¡ÉÒâ´ÂÇÔ¸Õ systemic therapy à»¹µ¹(2,4)
¹Í¡¨Ò¡¹Õé Ki-67 ÂÑ§ÁÕ¤ÇÒÁÊÑÁ¾Ñ¹¸¡ºÑ disease-free survival ÁÕÃÒÂ§Ò¹¡ÒÃÈÖ¡ÉÒËÅÒÂ©ºÑº·Õºè § ªÕÇé Ò
Ki-67 à»¹ independent prognostic factor áµäÁÊÒÁÒÃ¶ãª·Ó¹ÒÂ¡ÒÃµÍºÊ¹Í§µÍ¡ÒÃÃÑ¡ÉÒ (4,5)
·Ñé§¹Õé ¤ÇÒÁáÁ¹ÂÓ¢Í§¡ÒÃµÃÇ¨ Ki-67 ¨Ö§ÁÕ¤ÇÒÁÊÓ¤ÑÍÂÒ§ÂÔè§ â´Â¤ÇÒÁ¶Ù¡µÍ§áÁ¹ÂÓ¢Í§¤Ò
Ki-67 ¨Ðà¡Ô´¢Ö¹é ä´ µÍ§ÍÒÈÑÂ»¨¨ÑÂËÅÒÂÍÂÒ§ àËÁ×Í¹ ER áÅÐ PgR µÑ§é áµ¡ÒÃ¤§ÊÀÒ¾ªÔ¹é à¹×Íé ÍÂÒ§´Õ ¡ÒÃÂÍÁ
immunohistochemistry ÍÂÒ§¶Ù¡ÇÔ¸Õ ÃÇÁ¶Ö§¡ÒÃ»ÃÐàÁÔ¹à«ÅÅÁÐàÃç§áÅÐá»Å¼Å¶Ù¡µÍ§µÒÁà¡³±¡ÒÃ»ÃÐàÁÔ¹(4)
¡ÒÃá»Å¼Å Ki-67
¡ÒÃá»Å¼Åãªà¡³±´§Ñ ¹Õé
¼ÅºÇ¡ (Positive test) ¤×Íà«ÅÅÁÐàÃç§ã¹ÊÇ¹¢Í§ invasive carcinoma ÁÕ¡ÒÃµÔ´ÊÕ·Õè nucleus
¼ÅÅº (Negative test) ¤×ÍäÁ¾º nucleus ¢Í§à«ÅÅÁÐàÃç§µÔ´ÊÕ
ËÁÒÂàËµØ
1. ¡ÒÃÂÍÁÊÕ·àÕè ËÁÒÐÊÁà«ÅÅ»¡µÔàª¹ à«ÅÅ·ÁÕè ¡Õ ÒÃáº§µÑÇ¤ÇÃÁÕ¡ÒÃµÔ´ÊÕ·Õè nucleus
2. ¶ÒªÔé¹à¹×éÍÁÕ¡ÒÃµÔ´ÊÕ·ÕèÊÁèÓàÊÁÍ á¹Ð¹ÓãË¹ÑºÍÂÒ§¹ÍÂ 3 ºÃÔàÇ³´ÇÂ high power (x40
objective) à¾×Íè ãËä´à«ÅÅÁÐàÃç§ÍÂÒ§¹ÍÂ 500-1000 à«ÅÅ(4)
3. ¶ÒªÔ¹é à¹×Íé ÁÕ¡ÒÃµÔ´ÊÕäÁÊÁèÓàÊÁÍ ÂÑ§äÁÁ¢Õ Í ÊÃØ»·Õªè ´Ñ à¨¹ÇÒ¨Ð¹Ñº¨Ò¡ºÃÔàÇ³ã´(4)
¡ÒÃÃÒÂ§Ò¹¼Å Ki-67
ãËÃÒÂ§Ò¹¼ÅÇÒ positive ËÃ×Í negative ¾ÃÍÁÃÐºØ¤Ò »ÃÐàÁÔ¹ÃÍÂÅÐ¢Í§à«ÅÅÁÐàÃç§·Õãè Ë¼ÅºÇ¡
References
1. Harris L, Fritsche H, Mennel R, et al. American Society of Clinical Oncology 2007 update of recommendations for the use of tumor
markers in breast cancer. J Clin Oncol 2007;25(33)5287-5312.
2. Goldhirsch A, Wood WC, Coates AS et al. Strategies for subtypes-dealing with the diversity of breast cancer: highlights of the St Gallen
International Expert Consensus on the Primary Therapy of Early Breast Cancer 2011. Ann Oncol 2011;22(8)1736-1747.
54-117_pc22.pmd 112 19/2/2551, 20:59

3. Cheang MCU, Chia SK, Voduc D et al. Ki67 index, HER2 status, and prognosis of patients with luminal B breast cancer. J Natl Cancer
Inst 2009;101:736-750.
4. Dowsett M, Nielsen TO, A'Hern R et al. Assessment of Ki67 in breast cancer : recommendations from the International Ki67 in Breast
Cancer Working Group. J Natl Cancer Inst 2011;103(22)1656-1664.
5. Luporsi E, Andr? F, Spyratos F et al. Ki-67: level of evidence and methodological considerations for its role in the clinical management
of breast cancer: analytical and critical review. Breast Cancer Res Treat DOI 10.1007/s10549-011-1837-z.
v v v
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3. ¤³Ð¼·Ù Ã§¤Ø³ÇØ²´Ô Ò ¹ÈÑÅÂÈÒÊµÃ (Surgery)
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5. ¤³Ð¼·Ù Ã§¤Ø³ÇØ²´Ô Ò ¹ÃÑ§ÊÕÃ¡Ñ ÉÒ (Radiotherapy)
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7. ¤³Ð¼·Ù Ã§¤Ø³ÇØ²´Ô Ò ¹¾ÂÒ¸ÔÇ·Ô ÂÒ (Pathology)
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11. ¼ÙÍÓ¹ÇÂ¡ÒÃâÃ§¾ÂÒºÒÅÁÐàÃç§ªÅºØÃÕ âÃ§¾ÂÒºÒÅÁÐàÃç§ªÅºØÃÕ ¤³Ð·Ó§Ò¹
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12. ¼ÙÍÓ¹ÇÂ¡ÒÃâÃ§¾ÂÒºÒÅÁÐàÃç§Å¾ºØÃÕ âÃ§¾ÂÒºÒÅÁÐàÃç§Å¾ºØÃÕ ¤³Ð·Ó§Ò¹

13. ¼ÙÍÓ¹ÇÂ¡ÒÃâÃ§¾ÂÒºÒÅÁÐàÃç§ÅÓ»Ò§ âÃ§¾ÂÒºÒÅÁÐàÃç§ÅÓ»Ò§ ¤³Ð·Ó§Ò¹
14. ¼ÙÍÓ¹ÇÂ¡ÒÃâÃ§¾ÂÒºÒÅÁÐàÃç§ÍØºÅÃÒª¸Ò¹Õ âÃ§¾ÂÒºÒÅÁÐàÃç§ÍØºÅÃÒª¸Ò¹Õ ¤³Ð·Ó§Ò¹
15. ¼ÙÍÓ¹ÇÂ¡ÒÃâÃ§¾ÂÒºÒÅÁÐàÃç§ÍØ´Ã¸Ò¹Õ âÃ§¾ÂÒºÒÅÁÐàÃç§ÍØ´Ã¸Ò¹Õ ¤³Ð·Ó§Ò¹
16. ¼ÙÍÓ¹ÇÂ¡ÒÃâÃ§¾ÂÒºÒÅÁÐàÃç§ÊØÃÒÉ®Ã¸Ò¹Õ âÃ§¾ÂÒºÒÅÁÐàÃç§ÊØÃÒÉ®Ã¸Ò¹Õ ¤³Ð·Ó§Ò¹
17. ¼ÙÍÓ¹ÇÂ¡ÒÃâÃ§¾ÂÒºÒÅ âÃ§¾ÂÒºÒÅÁËÒÇªÔÃÒÅ§¡Ã³ ¸ÑºØÃÕ ¤³Ð·Ó§Ò¹
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19. ¹ÒÂá¾·ÂÇÔ·ÂÒ ¼´Ø§ªÑÂâªµÔ âÃ§¾ÂÒºÒÅÁÐàÃç§Å¾ºØÃÕ ¤³Ð·Ó§Ò¹
20. ¹ÒÂá¾·Âª¹Ô¹·Ã ÍÀÔÇÒ³ÔªÂ Ê¶ÒºÑ¹ÁÐàÃç§áË§ªÒµÔ ¤³Ð·Ó§Ò¹
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1. ÈÒÊµÃÒ¨ÒÃÂá¾·ÂËÔ§ÁÒÅÑÂ ÁØµµÒÃÑ¡É ¤³Ðá¾·ÂÈÒÊµÃÁËÒÇÔ·ÂÒÅÑÂàªÕÂ§ãËÁ

2. ÃÍ§ÈÒÊµÃÒ¨ÒÃÂá¾·ÂËÔ§ÇÔäÅ¾Ã â¾¸ÔÊØÇÃÃ³ ¤³Ðá¾·ÂÈÒÊµÃÈÔÃÔÃÒª¾ÂÒºÒÅ
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4. ÃÍ§ÈÒÊµÃÒ¨ÒÃÂá¾·ÂËÔ§´ÃØ³Õ ºØÂ×¹àÇ·ÇÑ²¹ ¤³Ðá¾·ÂÈÒÊµÃ¨ØÌÒÅ§¡Ã³ÁËÒÇÔ·ÂÒÅÑÂ
5. È.¤ÅÔ¹Ô¡à¡ÕÂÃµÔ¤Ø³¹ÒÂá¾·Â¡ÃÔª â¾¸ÔÊØÇÃÃ³ ¤³Ðá¾·ÂÈÒÊµÃÈÔÃÔÃÒª¾ÂÒºÒÅ
6. ÈÒÊµÃÒ¨ÒÃÂ¹ÒÂá¾·Â¾Ô·ÂÀÙÁÔ ÀÑ·Ã¹Ù¸Ò¾Ã ¤³Ðá¾·ÂÈÒÊµÃÈÔÃÔÃÒª¾ÂÒºÒÅ
7. ÃÍ§ÈÒÊµÃÒ¨ÒÃÂ¹ÒÂá¾·ÂÇÔªÒ ËÅÍÇÔ·ÂÒ ¤³Ðá¾·ÂÈÒÊµÃÁËÒÇÔ·ÂÒÅÑÂàªÕÂ§ãËÁ
8. ¼ÙªÇÂÈÒÊµÃÒ¨ÒÃÂ¹ÒÂá¾·ÂÇÔâÃ¨¹ ÈÃÕÍØÌÒÃ¾§È ¤³Ðá¾·ÂÈÒÊµÃ¨ØÌÒÅ§¡Ã³ÁËÒÇÔ·ÂÒÅÑÂ
9. ¼ÙªÇÂÈÒÊµÃÒ¨ÒÃÂ¹ÒÂá¾·ÂàÍ¡À¾ ÊÔÃÐªÑÂ¹Ñ¹· ¤³Ðá¾·ÂÈÒÊµÃâÃ§¾ÂÒºÒÅÃÒÁÒ¸Ôº´Õ
10. á¾·ÂËÔ§ªÕ¾ÊØÁ¹ ÊØ·¸Ô¾¹Ô ·ÐÇ§È ¼Ù·Ã§¤Ø³ÇØ²Ô ¡ÃÁ¡ÒÃá¾·Â
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¤³Ð¼Ù·Ã§¤Ø³ÇØ²Ô´Ò¹ÃÑ§ÊÕÇÔ¹Ô¨©ÑÂ (Radiologic Diagnosis)
1. ÃÍ§ÈÒÊµÃÒ¨ÒÃÂá¾·ÂËÔ§ÅÑ´´ÒÇÑÅÂ ÇÑªÃÐ¤Ø»µ ¤³Ðá¾·ÂÈÒÊµÃ¨ØÌÒÅ§¡Ã³ÁËÒÇÔ·ÂÒÅÑÂ

2. ÃÍ§ÈÒÊµÃÒ¨ÒÃÂá¾·ÂËÔ§¨ÔÃÒÀÃ³ ÈÃÕ¹Ñ¤ÃÔ¹·Ã ¤³Ðá¾·ÂÈÒÊµÃÁËÒÇÔ·ÂÒÅÑÂ¢Í¹á¡¹
3. ÃÍ§ÈÒÊµÃÒ¨ÒÃÂá¾·ÂËÔ§¾Ã¾ÔÁ¾ ¡Íá¾Ã¾§È ¤³Ðá¾·ÂÈÒÊµÃÈÔÃÔÃÒª¾ÂÒºÒÅ
4. ¼ÙªÇÂÈÒÊµÃÒ¨ÒÃÂá¾·ÂËÔ§ªÅ·Ô¾Â ÇÔÃÑµ¡¾Ñ¹¸ ¤³Ðá¾·ÂÈÒÊµÃâÃ§¾ÂÒºÒÅÃÒÁÒ¸Ôº´Õ
5. ¼ÙªÇÂÈÒÊµÃÒ¨ÒÃÂá¾·ÂËÔ§ä¾ÅÔ¹ ¤§ÁÕ¼Å ¤³Ðá¾·ÂÈÒÊµÃÁËÒÇÔ·ÂÒÅÑÂàªÕÂ§ãËÁ
6. ¾Ñ¹àÍ¡ËÔ§àµ×Í¹µÒ ¨Ñ¹·ÃÑÈÁÕ ÇÔ·ÂÒÅÑÂá¾·ÂÈÒÊµÃ¾ÃÐÁ§¡Ø¯à¡ÅÒ
¤³Ð¼Ù·Ã§¤Ø³ÇØ²Ô´Ò¹ÈÑÅÂÈÒÊµÃ (Surgery)
1. ¾ÅµÃÕ¹ÒÂá¾·ÂÊØÃ¾§É ÊØÀÒÀÃ³ ÇÔ·ÂÒÅÑÂá¾·ÂÈÒÊµÃ¾ÃÐÁ§¡Ø¯à¡ÅÒ
2. ¾Ñ¹àÍ¡¹ÒÂá¾·ÂÇÔªÑÂ ÇÒÊ¹ÊÔÃÔ ÇÔ·ÂÒÅÑÂá¾·ÂÈÒÊµÃ¾ÃÐÁ§¡Ø¯à¡ÅÒ
3. ÈÒÊµÃÒ¨ÒÃÂ ´Ã.¹ÒÂá¾·Â¾ÃªÑÂ âÍà¨ÃÔÃÑµ¹ ¤³Ðá¾·ÂÈÒÊµÃÈÔÃÔÃÒª¾ÂÒºÒÅ
4. ÈÒÊµÃÒ¨ÒÃÂ¹ÒÂá¾·ÂÈØÀ¡Ã âÃ¨¹Ô¹·Ã ¤³Ðá¾·ÂÈÒÊµÃÈÔÃÔÃÒª¾ÂÒºÒÅ
5. ¼ÙªÇÂÈÒÊµÃÒ¨ÒÃÂ¹ÒÂá¾·ÂËÍ§ÊÔ¹ µÃÐ¡ÙÅ·ÔÇÒ¡Ã ¤³Ðá¾·ÂÈÒÊµÃÁËÒÇÔ·ÂÒÅÑÂàªÕÂ§ãËÁ
6. ÃÍ§ÈÒÊµÃÒ¨ÒÃÂ¹ÒÂá¾·ÂÇªÑ Ã¾§È ¾Ø·¸ÔÊÇÑÊ´Ôì ¤³Ðá¾·ÂÈÒÊµÃÁËÒÇÔ·ÂÒÅÑÂ¢Í¹á¡¹
7. ÃÍ§ÈÒÊµÃÒ¨ÒÃÂ¹ÒÂá¾·Â¾Ø²ÔÈÑ¡´Ôì ¾Ø·¸ÇÔºÙÅÂ ¤³Ðá¾·ÂÈÒÊµÃÁËÒÇÔ·ÂÒÅÑÂÊ§¢ÅÒ¹¤ÃÔ¹·Ã
8. ¾Ñ¹àÍ¡ ´Ã.¹ÒÂá¾·ÂÊØ¢äªÂ ÊÒ·¶Ò¾Ã ÇÔ·ÂÒÅÑÂá¾·ÂÈÒÊµÃ¾ÃÐÁ§¡Ø®à¡ÅÒ
9. ¼ÙªÇÂÈÒÊµÃÒ¨ÒÃÂá¾·ÂËÔ§àÂÒÇ¹Øª ¤§´Ò¹ ¤³Ðá¾·ÂÈÒÊµÃâÃ§¾ÂÒºÒÅÃÒÁÒ¸Ôº´Õ
10. ¹ÒÂá¾·ÂÍÒ¤Á ªÑÂÇÕÃÐÇÑ²¹Ð Ê¶ÒºÑ¹ÁÐàÃç§áË§ªÒµÔ
¤³Ð¼Ù·Ã§¤Ø³ÇØ²Ô´Ò¹ÃÑ§ÊÕÃÑ¡ÉÒ (Radiotherapy)
1. ÃÍ§ÈÒÊµÃÒ¨ÒÃÂ¹ÒÂá¾·Â»ÃÐàÊÃÔ° àÅÔÈÊ§Ç¹ÊÔ¹ªÑÂ âÃ§¾ÂÒºÒÅÇÑ²â¹Ê¶
2. ÈÒÊµÃÒ¨ÒÃÂ¹ÒÂá¾·Âä¾ÃÑª à·¾Á§¤Å ¤³Ðá¾·ÂÈÒÊµÃÈÔÃÔÃÒª¾ÂÒºÒÅ
3. ¹ÒÂá¾·ÂÂ§ÂØ·¸ ¤§¸¹ÒÃÑµ¹ âÃ§¾ÂÒºÒÅÃÒªÇÔ¶Õ
4. ¼ÙªÇÂÈÒÊµÃÒ¨ÒÃÂ¹ÒÂá¾·ÂÈÃÕªÑÂ ¤ÃØÊÑ¹¸Ôì ¤³Ðá¾·ÂÈÒÊµÃÁËÒÇÔ·ÂÒÅÑÂ¢Í¹á¡¹
5. ÃÍ§ÈÒÊµÃÒ¨ÒÃÂá¾·ÂËÔ§ÍÔèÁã¨ ªÔµÒ¾¹ÒÃÑ¡É ¤³Ðá¾·ÂÈÒÊµÃÁËÒÇÔ·ÂÒÅÑÂàªÕÂ§ãËÁ
6. ¼ªÙ Ç ÂÈÒÊµÃÒ¨ÒÃÂá¾·ÂËÔ§¹Ñ¹·¹ ÊØ¹·Ã¾§È ¤³Ðá¾·ÂÈÒÊµÃÈÔÃÔÃÒª¾ÂÒºÒÅ
7. ¼ªÙ Ç ÂÈÒÊµÃÒ¨ÒÃÂá¾·ÂËÔ§ªÁ¾Ã ÊÕµÐ¸¹Õ ¤³Ðá¾·ÂÈÒÊµÃâÃ§¾ÂÒºÒÅÃÒÁÒ¸Ôº´Õ
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¤³Ð¼Ù·Ã§¤Ø³ÇØ²Ô´Ò¹à¤ÁÕºÓºÑ´ (Chemotherapy)
1. ¼ÙªÇÂÈÒÊµÃÒ¨ÒÃÂ¹ÒÂá¾·ÂÇÔàªÕÂÃ ÈÃÕÁØ¹Ô¹·Ã¹ÔÁÔµ ¤³Ðá¾·ÂÈÒÊµÃÈÔÃÔÃÒª¾ÂÒºÒÅ
2. ÃÍ§ÈÒÊµÃÒ¨ÒÃÂá¾·ÂËÔ§ÊØ´ÊÇÒ· àÅÒËÇÔ¹Ô¨ âÃ§¾ÂÒºÒÅÃÒªÇÔ¶Õ
3. ¼ªÙ Ç ÂÈÒÊµÃÒ¨ÒÃÂá¾·ÂËÔ§¸ÔµÂÔ Ò ÊÔÃÊÔ §Ô Ë ¤³Ðá¾·ÂÈÒÊµÃâÃ§¾ÂÒºÒÅÃÒÁÒ¸Ôº´Õ
4. á¾·ÂËÔ§¨ÒÃØÇÃÃ³ àÍ¡ÇÑÅÅÀ ¤³Ðá¾·ÂÈÒÊµÃÈÔÃÔÃÒª¾ÂÒºÒÅ
5. ¼ÙªÇÂÈÒÊµÃÒ¨ÒÃÂá¾·ÂËÔ§àÍ×éÍÁá¢ ÊØ¢»ÃÐàÊÃÔ° ¤³Ðá¾·ÂÈÒÊµÃÁËÒÇÔ·ÂÒÅÑÂ¢Í¹á¡¹
6. ¹ÒÂá¾·ÂËÄÉ® ÊØÇÃÃ³ÃÑÈÁÕ âÃ§¾ÂÒºÒÅºÓÃØ§ÃÒÉ®Ã
¤³Ð¼Ù·Ã§¤Ø³ÇØ²Ô´Ò¹¾ÂÒ¸ÔÇÔ·ÂÒ (Pathology)
1. ÈÒÊµÃÒ¨ÒÃÂ¹ÒÂá¾·Â¾Ôàª° ÊÑÁ»·Ò¹Ø¡ØÅ ¤³Ðá¾·ÂÈÒÊµÃ¨ØÌÒÅ§¡Ã³ÁËÒÇÔ·ÂÒÅÑÂ
2. ¹ÒÂá¾·ÂÍ¹Ñ¹µ ¡ÃÅÑ¡É³ Ê¶ÒºÑ¹ÁÐàÃç§áË§ªÒµÔ
3. ÃÍ§ÈÒÊµÃÒ¨ÒÃÂá¾·ÂËÔ§ÈÑ¹Ê¹ÕÂ Ç§ÈäÇÈÂÇÃÃ³ ¤³Ðá¾·ÂÈÒÊµÃâÃ§¾ÂÒºÒÅÃÒÁÒ¸Ôº´Õ
4. ÃÍ§ÈÒÊµÃÒ¨ÒÃÂá¾·ÂËÔ§ÀÒÇÔ³Õ ÊØÇÃÃ³¡ÙÅ ¤³Ðá¾·ÂÈÒÊµÃÈÔÃÔÃÒª¾ÂÒºÒÅ
5. ÈÒÊµÃÒ¨ÒÃÂ¹ÒÂá¾·Â¾§ÉÈÑ¡´Ôì ÇÃÃ³ä¡ÃâÃ¨¹ ¤³Ðá¾·ÂÈÒÊµÃ¨ØÌÒÅ§¡Ã³ÁËÒÇÔ·ÂÒÅÑÂ
6. ÈÒÊµÃÒ¨ÒÃÂá¾·ÂËÔ§àº¨¾Ã äªÂÇÃÃ³ ¤³Ðá¾·ÂÈÒÊµÃÁËÒÇÔ·ÂÒÅÑÂàªÕÂ§ãËÁ
7. á¾·ÂËÔ§ÁÒÅÕ ÇÃÃ³ÔÊÊÃ ¤³Ðá¾·ÂÈÒÊµÃÈÔÃÔÃÒª¾ÂÒºÒÅ
8. ¹ÒÂá¾·Â·Ã§¤Ø³ ÇÔÙÇÃÃ¸¹ Ê¶ÒºÑ¹¾ÂÒ¸ÔÇ·Ô ÂÒ
9. ¹ÒÂá¾·Â¹Ô¾¹¸ »ÃÐ´ÔÉ°¼Å âÃ§¾ÂÒºÒÅÃÒªÇÔ¶Õ
10. ÃÍ§ÈÒÊµÃÒ¨ÒÃÂá¾·ÂËÔ§ÇÃ¹Øª ¸¹Ò¡Ô¨ ¤³Ðá¾·ÂÈÒÊµÃ¨ØÌÒÅ§¡Ã³ÁËÒÇÔ·ÂÒÅÑÂ
11. ÃÍ§ÈÒÊµÃÒ¨ÒÃÂ ´Ã.ºØÉºÒ Ä¡ÉÍÓ¹ÇÂâª¤ ¤³Ðá¾·ÂÈÒÊµÃâÃ§¾ÂÒºÒÅÃÒÁÒ¸Ôº´Õ
12. ¼ÙªÇÂÈÒÊµÃÒ¨ÒÃÂá¾·ÂËÔ§ÇÔÀÒÇÕ ¡ÔµµÔâ¡ÇÔ· ¤³Ðá¾·ÂÈÒÊµÃ¨ØÌÒÅ§¡Ã³ÁËÒÇÔ·ÂÒÅÑÂ
13. ¹ÒÂá¾·Â¹ÃàÈÃÉ° ÊÁÒ¹ä·Â ¤³Ðá¾·ÂÈÒÊµÃÈÔÃÔÃÒª¾ÂÒºÒÅ
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Lobular Carcinoma in Situ

Lobular · History and

Initial biopsy was LCIS without Surveillance

Lumpectomya without lymph node

Ductal Carcinoma in Situ

· Risk reduction therapy for ipsilateral breast

General workup including:

· Consider fertility counseling if indicated

Invasive Breast Cancer

³ 4 positive Radiation therapyd to whole breast with or without boost

Lumpectomy with Radiation therapy to whole breast with or without boost

Total mastectomy with surgical axillary See Locoregional Treatment (Ë¹Ò 8)

³ 4 positive Postchemotherapy radiation therapy to chest wall

mammary lymph nodes

Invasive Breast Cancer

HER2 positive See Systemic Adjuvant Treatment - Hormone

Tumor £ 0.5 cm or pN0 No adjuvant therapy

Node positive (one or more Adjuvant endocrine therapy

Invasive Breast Cancer

Tumor £ 0.5 cm or pN0 No adjuvant therapy (category 2B)

Node positive (one or more Adjuvant endocrine therapy

metastases > 2 mm to one or more + adjuvant chemotherapy

Tumor £ 0.5 cm or pN0 No adjuvant therapy

Node positive (one or more Adjuvant chemotherapy

Invasive Breast Cancer

Tumor £ 0.5 cm or pN0 No adjuvant therapy

Node positive (one or more Adjuvant chemotherapy

< 1 cm No adjuvant therapy

Invasive Breast Cancer

Invasive Breast Cancer

surgical axillary chemotherapy in the (category 1)

· Consider fertility counseling if indicated

Invasive Breast Cancer

and infraclavicular and supraclavicular endocrine therapy if indicated. Ë¹Ò 19

Consider additional systemic Response - See above pathway

· Intervalhistory and physical exam every · History and physical exam

Invasive Breast Cancer

recurrence Radiation therapy if possible to chest wall,

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2.2 ¡ÅØÁàÊÕèÂ§ (high risk)

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á¹Ç·Ò§¹Õéä´»ÃÑº»ÃØ§ÁÒ¨Ò¡ "á¹Ç·Ò§¡ÒÃãªà¤Ã×èÍ§¶ÒÂÀÒ¾ÃÑ§ÊÕàµÒ¹Á (mammography) ã¹

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2. à¤Ã×Íè §Á×Í (equipment)

3. ¡ÒÃºÑ¹·Ö¡¢ÍÁÙÅáÅÐ¡ÒÃÃÒÂ§Ò¹¼Å (medical records and mammography

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ª¹Ô´¤Óá¹Ð¹Ó 1 : ¤Óá¹Ð¹ÓÃÐ´Ñº¹Õé ä´¨Ò¡ËÅÑ¡°Ò¹¤Ø³ÀÒ¾ÊÙ§ (àª¹¨Ò¡ randomized clinical trials ËÃ×Í meta-

ËÁÒÂàËµØ â´Â¤Óá¹Ð¹Ó¨Ðà»¹ª¹Ô´á¹Ð¹Ó 2A Â¡àÇ¹¨ÐÃÐºØäÇà»¹ª¹Ô´Í×¹è

Total mastectomy with surgical axillary See Locoregional Treatment (Ë¹Ò 8)

and infraclavicular and supraclavicular endocrine therapy if indicated. Ë¹Ò 19

2.2 ¡ÅØÁàÊÕèÂ§ (high risk)

á¹Ç·Ò§¹Õéä´»ÃÑº»ÃØ§ÁÒ¨Ò¡ "á¹Ç·Ò§¡ÒÃãªà¤Ã×èÍ§¶ÒÂÀÒ¾ÃÑ§ÊÕàµÒ¹Á (mammography) ã¹

3. ¡ÒÃºÑ¹·Ö¡¢ÍÁÙÅáÅÐ¡ÒÃÃÒÂ§Ò¹¼Å (medical records and mammography

3. Clear description of any significant finding (s) ä´á¡

ËÁÒÂàËµØ: - á¹Ç·Ò§¡ÒÃµÃÇ¨ÇÔ¹Ô¨©ÑÂáÅÐÃÑ¡ÉÒâÃ¤ÁÐàÃç§àµÒ¹Á©ºÑº¹Õé ãªÊÓËÃÑºÊ¶Ò¹¾ÂÒºÒÅ·Õè

2. ¡Í¹ÁÕ¢¹Ò´ãË¡ÇÒ 2-3 à«¹µÔàÁµÃ ËÃ×Í¼»Ù Ç ÂµÍ§¡ÒÃàÍÒÍÍ¡

äÁä´·Ó Imaging Reassure ± Medication

äÁá¹Ð¹ÓãË·Ó axillary dissection ã¹¼Ù»ÇÂ DCIS à¾ÃÒÐâÍ¡ÒÊ·Õè¨Ð¾ºÁÕ¡ÒÃ¡ÃÐ¨ÒÂä»µÍÁ

¢ÍËÒÁ¢Í§¡ÒÃ·Ó BCT (contraindications for BCT)

¡ÒÃÃÑ¡ÉÒÁÐàÃç§àµÒ¹ÁãËä´¼Å´Õ à»¹·Õ·è ÃÒº¡Ñ¹´ÕÇÒ µÍ§ãª¡ÒÃÃÑ¡ÉÒ´ÇÂ¡ÒÃ¼ÒµÑ´

- Inferior margin : 1-2 à«¹µÔàÁµÃ ãµµÍ inframammary fold

ÃÙ»·Õè 1 ÀÒ¾áÊ´§à·¤¹Ô¤¡ÒÃ©ÒÂÃÑ§ÊÕ·àÕè µÒ¹ÁËÃ×ÍË¹ÒÍ¡ áÅÐ Supraclavicular area

ÃÙ»·Õè 2 ÀÒ¾àÍ¡«àÃÂ¢Íºà¢µ¢Í§¡ÒÃ©ÒÂ Supraclavicular area

ÃÙ»·Õè 3 ¡ÒÃ¨Ñ´·Ò¼»Ù Ç Â¢³Ð©ÒÂÃÑ§ÊÕ·àÕè µÒ¹Á