knude-i-brystet (LH Indholdsside)

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      <HtmlField Name="PageContent"><![CDATA[<h2>Basisoplysninger<a data-type="other-reference" data-value="Danish Breast Cancer Cooperative Group" data-url="http://www.dbcg.dk/" title="Danish Breast Cancer Cooperative Group" href="http://www.dbcg.dk/">1</a><sup>,</sup><a data-value-piped="Michael Dixon|ABC of Breast Diseases||MBJ Books, 4.edition|2012" data-type="book-reference" data-value="Michael Dixon. ABC of Breast Diseases. : MBJ Books, 4.edition; 2012" data-url="reference-link" title="Michael Dixon. ABC of Breast Diseases. : MBJ Books, 4.edition; 2012" href="%20">2</a></h2>
<h3>Definition</h3>
<ul>
    <li>Knude i brystet; tumor mammae</li>
</ul>
<h3>Forekomst</h3>
<ul>
    <li>Langt de fleste knuder i brystet er godartede. <a href="~/link.aspx?_id=EB231A8A67A643FC90E4F67FB0EFB403&amp;_z=z">Se fordeling af knuder p&aring; alder</a>:
    <ul>
        <li>Fibroadenom er den hyppigste benigne tumor i brystet hos kvinder</li>
        <li>Benigne v&aelig;vsfort&aelig;tninger (&rdquo;lumps&rdquo;), som er lokaliserede fort&aelig;tninger i kirtelv&aelig;vet</li>
        <li>Hos m&aelig;nd er stort set alle &rdquo;knuder&rdquo; benigne &ndash; gyn&aelig;komasti&nbsp;</li>
    </ul>
    </li>
    <li>Brystkr&aelig;ft:&nbsp;
    <ul>
        <li>Den praktiserende l&aelig;ge vil typisk m&oslash;de 1-2 kvinder med nyopst&aring;et brystkr&aelig;ft &aring;rligt</li>
        <li>En praktiserende l&aelig;ge har ca. 15 % sandsynlighed for at se &eacute;n mand med brystkr&aelig;ft i l&oslash;bet af en 30 &aring;rs karriere</li>
        <li>Brystkr&aelig;ft er den hyppigste kr&aelig;ftform i Danmark og den n&aelig;st hyppigste &aring;rsag til kr&aelig;ftd&oslash;d blandt kvinder</li>
        <li>Incidensen i Danmark er ca. 4.800 kvinder og 40 m&aelig;nd &aring;rligt</li>
    </ul>
    </li>
</ul>
<p><img alt="Graf over incidens for brystkræfttyper." src="5552131BB1B04F9491EBD71D206E7A36-240-188" style="height: 188px; width: 240px;" title="Graf over incidens for brystkræfttyper" height="188" width="240"></p>
<h3>Diagnostisk tankegang</h3>
<ul>
    <li>Brystkr&aelig;ft hos kvinder forekommer s&aring; hyppigt, at knuder i brystet hos kvinder &gt;20 &aring;r skal udredes, til kr&aelig;ftmistanken er af- eller bekr&aelig;ftet. Dog er de fleste knuder hos patienter &lt;30 &aring;r benigne, s&aring; hvis malignitetsmistanken er meget lav, kan man aftale en kontrol efter n&aelig;ste menstruation, dvs. efter 2-4 uger&nbsp;</li>
    <li>Modsat er knude i brystet hos en mand gyn&aelig;komasti, indtil det modsatte er bevist (ogs&aring; n&aring;r det er unilateralt). Udredning skal derfor rettes mod medicinsk eller endokrinologisk &aring;rsag. M&aelig;nd b&oslash;r derfor henvises til andrologisk udredning, og skal kun ved undtagelsestilf&aelig;lde henvises til kr&aelig;ftpakke (blodig eller klar/ser&oslash;s sekretion fra papil hos m&aelig;nd eller suspekt palpatorisk)</li>
</ul>
<h4>12-25 &aring;r</h4>
<ul>
    <li>Fibroadenomer&nbsp;</li>
    <li>Kr&aelig;ft er ekstremt sj&aelig;lden</li>
    <li>Infektion (piercing, partner, rygning)</li>
</ul>
<h4>26-35 &aring;r</h4>
<ul>
    <li>Fibroadenomer&nbsp;</li>
    <li>Hormonelt betinget h&aelig;velse med eller uden sekretion fra brystvorterne (fibroadenomatose)&nbsp;</li>
    <li>Laktationsbetingede tilstande (m&aelig;lkeretention, mastit)&nbsp;</li>
    <li>Kr&aelig;ft er sj&aelig;lden</li>
</ul>
<h4>36-50 &aring;r</h4>
<ul>
    <li>Cyster og ductectasier (benigne, degenerative forandringer)&nbsp;</li>
    <li>Hormonbetinget kirtelv&aelig;vsp&aring;virkning med h&aelig;velse og &oslash;mhed&nbsp;</li>
    <li>M&aelig;lkegangspapillomer&nbsp;</li>
    <li>Fibroadenomer&nbsp;</li>
    <li>Bet&aelig;ndelse (rygere!)</li>
    <li>Maligne tumorer forekommer, og tumorer skal henvises/udredes</li>
</ul>
<h4>Over 50 &aring;r</h4>
<ul>
    <li>Alle palpatorisk suspekte knuder (er typisk h&aring;rd, irregul&aelig;rt afgr&aelig;nset og fikseret til omgivende v&aelig;v, hud eller fascie) og nyopst&aring;ede fortykkelser i brystv&aelig;vet hos kvinder &gt;50 &aring;r skal udredes. Enhver nyopdaget tumor hos postmenopausale kvinder m&aring; imidlertid opfattes som suspekt for malignitet</li>
    <li>M&aelig;nd henvises til endokrinologer og skal ikke have foretaget billeddiagnostik af mammae/axiller&nbsp;</li>
    <li>Bet&aelig;ndelsestilstande forekommer, men cyster og fibroadenomer er sj&aelig;ldne efter menopausen</li>
    <li>Ved hormonsubstitutionsbehandling kan hormonelle forandringer og cyster forekomme</li>
</ul>
<h4>Uanset alder:</h4>
<p>Baseret p&aring; vurdering af sandsynligheden for cancer anbefales f&oslash;lgende prioritering:</p>
<h4>Prioriteringsgruppe 1 (Udredes i pakkeforl&oslash;b)</h4>
<ul>
    <li>Palpatorisk suspekt tumor&nbsp;</li>
    <li>Nytilkommen papilretraktion</li>
    <li>Nytilkommen hudindtr&aelig;kning</li>
    <li>Papil-areolaeksem/ulceration, obs. Morbus Paget</li>
    <li>Klinisk suspekte aksill&aelig;re lymfeknuder</li>
    <li>Billeddiagnostisk suspekt forandring, eksempelvis fundet ved mammografiscreening eller ved unders&oslash;gelser hos privatpraktiserende radiolog</li>
    <li>S&oslash;gen efter ukendt prim&aelig;rtumor (bioptisk verificerede aksilmetastaser)</li>
    <li>Blodig eller klar/ser&oslash;s sekretion fra papil hos m&aelig;nd&nbsp;</li>
    <li>Ukendt prim&aelig;r tumor med bioptisk verificerede aksilmetastaser&nbsp;</li>
    <li>Klinisk suspekte lymfeknuder&nbsp;</li>
    <li>Nytilkommen papil-/areola- og/eller hudindtr&aelig;kning&nbsp;</li>
</ul>
<p>En palpatorisk suspekt tumor h&aring;rd, irregul&aelig;rt afgr&aelig;nset og fikseret til omgivende v&aelig;v, hud eller fascie. Enhver nyopdaget tumor hos postmenopausale kvinder m&aring; imidlertid opfattes som suspekt for malignitet.&nbsp;</p>
<h4>Prioriteringsgruppe 2 (Udredningsgaranti)</h4>
<ul>
    <li>Palpatorisk benign tumor&nbsp;</li>
    <li>Blodig eller klar/ser&oslash;s sekretion fra papil hos kvinder&nbsp;</li>
    <li>H&aelig;vede aksill&aelig;re lymfeknuder uden kendt &aring;rsag&nbsp;</li>
    <li>Vedvarende (&gt;3m&aring;neder)&nbsp;fokal mastalgi (mindre end en kvadrant) eller ved ledsagende symptomer&nbsp;</li>
</ul>
<h4>Prioriteringsgruppe 3 (Screening)</h4>
<ul>
    <li>Fokal mastalgi (mindre end en kvadrant) hos kvinder &ge;40 &aring;r&nbsp;</li>
    <li>Mastitis </li>
    <li>Billeddiagnostik forud for planlagt kosmetisk operation&nbsp;</li>
</ul>
<h3>Hvorfor henvender patienten sig?</h3>
<ul>
    <li>Palpabel knude&nbsp;</li>
    <li>Frygt for kr&aelig;ft</li>
    <li>Papilsekretion eller -indtr&aelig;kning</li>
</ul>
<h3>Diagnostiske faldgruber</h3>
<ul>
    <li><a href="about://~/link.aspx?_id=E04E0DBEA64F4062A19CF67D1ADA2D8E&amp;_z=z">Brystkr&aelig;ft</a></li>
</ul>
<h3>ICPC-2</h3>
<p>[ICPC]</p>
<h3>ICD-10/SKS-koder</h3>
<p>[ICD10]</p>
<h2>Differentialdiagnoser</h2>
<h3>Cyster</h3>
<ul>
    <li>Degenerativ tilstand i kvinders brystv&aelig;v, typisk hos kvinder 35-50 &aring;r, men meget sj&aelig;ldent hos helt unge piger</li>
</ul>
<h3>Aterom</h3>
<ul>
    <li>Ansamling i talgkirtel p&aring; huden. Kan blive inficeret</li>
    <li>Er ikke en proces i eller med relation til mammav&aelig;vet, og aterom p&aring; huden kr&aelig;ver s&aring;ledes ikke udredning for brystsygdom</li>
</ul>
<h3><a href="about://~/link.aspx?_id=F6F1EF1866894D61BCF2B0358119F31A&amp;_z=z">Fibroadenom</a></h3>
<ul>
    <li>Godartet tumor hos kvinder oftest under 40 &aring;r, men kan ogs&aring; i sj&aelig;ldne tilf&aelig;lde forekomme hos &aelig;ldre</li>
    <li>10-15 % af kvinderne har multiple fibroadenomer</li>
    <li>Oftest ingen gener</li>
    <li>Tv&aelig;rlejret, oval, fast, velafgr&aelig;nset og bev&aelig;gelig mod hud og underlag, oftest u&oslash;m</li>
    <li>Skal kun fjernes, hvis tumor er symptomgivende med &oslash;mhed, vokser hastigt, eller udredning rejser mistanke om phylloidestumor</li>
</ul>
<h3><a href="about://~/link.aspx?_id=F6F1EF1866894D61BCF2B0358119F31A&amp;_z=z">Fibroadenomatose</a></h3>
<ul>
    <li>Uregelm&aelig;ssige kirtel- og bindev&aelig;vsomr&aring;der, oftest bilateralt&nbsp;</li>
    <li>Forekommer hos 1/3 af kvinder 30-50 &aring;r</li>
    <li>Ofte blandet med cystedannelse i kirtelv&aelig;vet (cystisk fibroadenomatose), hvor cyster kan veksle meget i st&oslash;rrelse og antal</li>
    <li>Oftest lokaliseret i &oslash;vre, laterale mammakvadrant</li>
    <li>Pr&aelig;menstruel smerte, &oslash;mhed og h&aelig;velse i brystv&aelig;vet er typisk. Der kan forekomme m&aelig;lkehvid, gulgr&oslash;n eller brunfarvet sekretion fra papillerne (ofte bilateralt)&nbsp;</li>
    <li>Diffust afgr&aelig;nset resistens i brystet kan forekomme&nbsp;
    <ul>
        <li>Cyster er velafgr&aelig;nsede, faste, evt. fluktuerende&nbsp;</li>
        <li>Fibrose giver fast kirtelv&aelig;v&nbsp;</li>
        <li>Adenomatose giver knudret kirtelv&aelig;v</li>
    </ul>
    </li>
    <li>Palpation, mammografi, ultralyd og biopsi differentierer dem fra kr&aelig;ft</li>
</ul>
<h3>M&aelig;lkegangspapillomer</h3>
<ul>
    <li>Oftest blandt kvinder 30-60 &aring;r&nbsp;</li>
    <li>Medf&oslash;rer bl&oslash;dning med blodig og spontan papilsekretion</li>
    <li>Kan give palpabel udfyldning under papil/areola&nbsp;</li>
    <li>Biopsi kan give diagnosen, men endelig diagnose kr&aelig;ver tit resektion af den bl&oslash;dende ductus og tilh&oslash;rende kirtelsegment (Babcocks operation). Dette er oftest n&oslash;dvendigt for at identificere de patienter, hvor papilbl&oslash;dning skyldes underliggende malignitet eller pr&aelig;malign tilstand</li>
</ul>
<h3>M&aelig;lkeretention</h3>
<ul>
    <li>Kvinde, som ammer eller netop har gjort det&nbsp;</li>
    <li>&Oslash;mhed og sp&aelig;nding i brystet, ingen infektionstegn&nbsp;</li>
    <li>Palpable omr&aring;der af brystet, som er "infiltreret" med m&aelig;lk</li>
</ul>
<h3>Puerperal mastit</h3>
<ul>
    <li>Forekommer hos kvinder, som ammer eller netop har gjort det&nbsp;</li>
    <li>Debut gerne et par uger efter f&oslash;dsel&nbsp;</li>
    <li>Brystsp&aelig;nding, retention, smerter, h&aelig;velse, varme og r&oslash;dme i huden, feber, kulderystelser, hovedpine, reduceret madlyst, pustilblanding af m&aelig;lken&nbsp;</li>
    <li>Lokal h&aelig;velse, &oslash;mhed, varme og r&oslash;dme i huden; absces og forst&oslash;rrede lymfeknuder kan af og til palperes</li>
    <li>Skyldes stafylokokinfektion</li>
</ul>
<h3>Nonpuerperal mastit/brystbet&aelig;ndelse/absces</h3>
<ul>
    <li>Typisk cigaretrygere 30-50 &aring;r</li>
    <li>Hyppigt blandingsflora med stafylokokker og f.eks. anaerobe bakteriestammer</li>
    <li>Sidder altid t&aelig;t p&aring; areolakanten</li>
    <li>Udtalt recidivtilb&oslash;jelighed, hvis kvinden forts&aelig;tter cigaretrygning</li>
    <li>Leder ofte til fistler (i areolakanten), papilinvertering, fibrose, ar, smerter og andre f&oslash;lger</li>
    <li>Klassisk rygermastit kr&aelig;ver ikke supplerende udredning, n&aring;r infektionen er behandlet. Kun ikke-rygere, hvor &aring;rsagen ikke er indlysende, b&oslash;r udredes n&aelig;rmere for &aring;rsag, som kan v&aelig;re inficeret cyste, liponekrose eller malignitet (meget sj&aelig;ldent!)</li>
    <li>Operation for fistler er udsigtsl&oslash;st, hvis kvinden forts&aelig;tter med at ryge</li>
</ul>
<h3><a href="about://~/link.aspx?_id=E04E0DBEA64F4062A19CF67D1ADA2D8E&amp;_z=z">Brystkr&aelig;ft</a></h3>
<ul>
    <li>Den hyppigste kr&aelig;ftform blandt kvinder, ca. 4.800 nye tilf&aelig;lde hvert &aring;r i Danmark&nbsp;</li>
    <li>Ofte tilf&aelig;ldigt fund af knude i brystet, evt. knude i aksillen, hyppigst findes tumor i &oslash;vre laterale kvadrant</li>
    <li>Symptomer: Palpabel knude, sekretion, eksem p&aring; brystvorten eller s&aring;r p&aring; papillen som ikke heler, lokal smerte eller &oslash;mhed uafh&aelig;ngig af menstruation</li>
    <li>Fund kan v&aelig;re tumor, indtr&aelig;kning af huden, papilretraktion eller deviation, lymf&oslash;dem (appelsinhud, peau d'orange), misfarvning af huden, ulceration</li>
    <li>Ved palpation findes tumor ofte h&aring;rd, knudret, uden tydelig afgr&aelig;nsning i dybden, eller der kan v&aelig;re fortykkelse eller resistens i areola</li>
</ul>
<h2>Sygehistorie</h2>
<ul>
    <li>Varighed?</li>
    <li>Forudg&aring;ende traume?</li>
    <li>Er knuden vokset?</li>
    <li>Sekretion fra brystvorterne? Klart? Farvet? Blodigt?</li>
    <li>Bruges medikamenter som kan give galaktor&eacute;?</li>
    <li>Overvej &rdquo;Runners nipple&rdquo; hos m&aelig;nd</li>
    <li>Smerter og ubehag?</li>
    <li>Forandring under menstruationscyklus? Relation til menstruationscyklus reducerer kr&aelig;ftmistanken</li>
    <li>Bryst- eller ovariecancer i sl&aelig;gten? &nbsp;Brystkr&aelig;fttilf&aelig;ldets alder ved diagnosetidspunktet?</li>
    <li>Hormonbehandling?</li>
    <li>Tidligere knuder i brystet og biopsier? Tidligere haft brystkr&aelig;ft? &nbsp;Tidligere str&aring;lebehandling eller kemoterapi?&nbsp;</li>
    <li>Andre eksponeringer for str&aring;ler?</li>
    <li>Gyn&aelig;kologiske forhold: Alder ved f&oslash;rste f&oslash;dsel? Alder ved menarche? &nbsp;Alder ved menopause? Har pt. ammet? Antal b&oslash;rn?</li>
</ul>
<h2>Klinisk unders&oslash;gelse</h2>
<h3>Generelt</h3>
<ul>
    <li>P&aring;virket almentilstand?&nbsp;</li>
</ul>
<h4>Kr&aelig;ftmist&aelig;nkelige forandringer</h4>
<ul>
    <li>Tumor som er palpabel, immobil og fikseret til omliggende hud og bl&oslash;ddele, vanskeligt afgr&aelig;nselig eller med uregelm&aelig;ssige kanter</li>
    <li>Papileksem eller papilulceration suspekt for &raquo;Paget&rsquo;s disease of the nipple&laquo;&nbsp;</li>
    <li>Spontan papilsekretion med blod eller helt klar v&aelig;ske&nbsp;</li>
    <li>Nyopst&aring;et papilretraktion, mammadeformitet eller mammaulceration</li>
    <li>H&aelig;vede lymfeknuder i aksillen uden anden forklaring&nbsp;</li>
    <li>Obs: Mastitis kan v&aelig;re en inflammatorisk mammacancer (meget sj&aelig;lden!)&nbsp;</li>
</ul>
<h4>Objektivt</h4>
<ul>
    <li>Systematisk unders&oslash;gelse af begge bryster&nbsp;
    <ul>
        <li>N&oslash;jagtig beskrivelse af tumors lokalisation&nbsp;</li>
        <li>Er knuden afgr&aelig;nset eller en del af et omr&aring;de med knudret v&aelig;v?&nbsp;</li>
        <li>Aksiller og fossae supra- og infraclaviculares palperes n&oslash;je&nbsp;</li>
        <li>Kan man presse sekret frem? Udseende?</li>
    </ul>
    </li>
    <li>Hvis malignitetsmistanken er meget lav, overvej om patienten b&oslash;r komme tilbage til ny vurdering om 2-4 uger</li>
</ul>
<h2>Supplerende unders&oslash;gelser</h2>
<h3>I almen praksis</h3>
<ul>
    <li>Papilsekret b&oslash;r testes for blod med aft&oslash;rring p&aring; hvid gaze (lavteknologisk, men effektiv)</li>
    <li>Henvis kvinder&nbsp;til klinisk mammografi eller udredning i kr&aelig;ftpakke</li>
    <li>Henvis m&aelig;nd til andrologisk udredning (og&nbsp;<strong>ikke</strong>&nbsp;til klinisk mammografi eller udredning i kr&aelig;ftpakke, medmindre det er klinisk evident, at der er cancermistanke)</li>
</ul>
<h3>Ultralyd</h3>
<ul>
    <li>Er et vigtigt supplement til mammografi og indg&aring;r derfor i den s&aring;kaldte&nbsp;<strong>kliniske mammografi</strong></li>
    <li>Kan og b&oslash;r ikke st&aring; alene i udredningen, medmindre det er gravide/ammende kvinder eller piger &lt; 25 &aring;r</li>
    <li>Er bedst til at unders&oslash;ge det t&aelig;tte kirtelv&aelig;v (hvor mammografien har d&aring;rligere sensitivitet), mens det fedtholdige brystv&aelig;v hos &aelig;ldre er vanskeligere at gennemskanne (men her er mammografiens sensitivitet desto st&oslash;rre)&nbsp;</li>
    <li>Velegnet til at adskille solide processer fra cyster og hj&aelig;lpe til at skelne maligne fra benigne forandringer</li>
</ul>
<h3>Mammografi</h3>
<ul>
    <li>Sensitivitet i forhold til p&aring;visning af kr&aelig;ft er 60-90 %, lavest hos kvinder f&oslash;r menopause&nbsp;</li>
    <li>Specificiteten er 85-90 % ved malignitetsuspekte forandringer&nbsp;</li>
    <li>Specificitet 30-40 % ved ikke palpable tumores&nbsp;</li>
    <li>Jo h&oslash;jere v&aelig;vsdensitet, jo lavere specificitet for r&oslash;ntgenunders&oslash;gelsen. V&aelig;vsdensitet type IV betyder dermed meget ringe f&oslash;lsomhed for at finde fort&aelig;tninger, men mammografi er stadig et relevant supplement til UL til diagnostik af mikroforkalkninger.&nbsp;<strong>MR-mammografi</strong>&nbsp;med kontrast eller mammografi med kontrast bruges flere steder, hvis h&oslash;j v&aelig;vsdensitet eller som supplement til den kliniske mammografi</li>
    <li>Digital mammografi giver bedre billedkvalitet og f&aelig;rre artefakter</li>
</ul>
<h3>Mammografiscreening</h3>
<ul>
    <li>I Danmark tilbydes screening med to-plans mammografi til kvinder 50-69 &aring;r hvert andet &aring;r</li>
    <li>Nyopst&aring;ede knuder mellem 2 screeningsbes&oslash;g skal udredes som vanligt, da intervalcancere kan forekomme</li>
</ul>
<h3>Biopsier</h3>
<ul>
    <li>Billeddiagnostik b&oslash;r udf&oslash;res f&oslash;r biopsi, da biopsif&oslash;lger kan tilsl&oslash;re radiologiske fund</li>
    <li>Kvinder med suspekte fund&nbsp;<strong>skal</strong>&nbsp;udredes med tripletest, dvs. klinisk unders&oslash;gelse, billeddiagnostisk unders&oslash;gelse med mammografi/ultralydsskanning og biopsi. S&aring;kaldt &rdquo;ultralydsmammografi&rdquo; (som er ultralyd alene) er ikke sufficient</li>
    <li>Excicionsbiopsi er en diagnostisk og terapeutisk procedure, som indeb&aelig;rer fjernelse af et v&aelig;vsomr&aring;de med knudedannelse, mikroforkalkninger eller lign., hvor endelig afklaring ikke kan ske med billeddiagnostik og biopsi alene&nbsp;</li>
</ul>
<h3>Rtg. thorax</h3>
<ul>
    <li>Ikke indiceret</li>
</ul>
<h3>Duktografi</h3>
<ul>
    <li>Bruges ikke</li>
</ul>
<h3>MR</h3>
<ul>
    <li>Har h&oslash;j sensitivitet (85-100 %), men noget lavere specificitet&nbsp;</li>
    <li>MR kan have en plads i diagnostikken af kvinder med implantater og hos kvinder, som er vanskelige at unders&oslash;ge med ultralyd og mammografi, f.eks. patienter, der tidligere er opereret, eller som har f&aring;et str&aring;lebehandling mod brystet</li>
    <li>Indiceret ved Paget&rsquo;s disease of the nipple og ved recidivmistanke</li>
    <li>Bruges i protokollerede unders&oslash;gelser af kvinder med BRCA-genmutationer</li>
    <li>Bruges til kvinder med BRCA-genmutationer og brystkr&aelig;ft, der ikke er bilateral mastektomeret, hvis radiologen vurderer at det vil v&aelig;re hensigtsm&aelig;ssigt. </li>
    <li>Bruges de fleste steder, som opf&oslash;lgning under neoadjuverende kemoterapi til brystkr&aelig;ft</li>
</ul>
<h3>CT-scanning eller PET-CT</h3>
<ul>
    <li>Som hovedregel kun ved mistanke om dissemineret brystkr&aelig;ft eller inden opstart af (neo)adjuverende behandling for brystkr&aelig;ft hvis knuden er &gt; 5 cm eller hvis &gt; 4 positive lymfeknuder</li>
</ul>
<h3>Tripletest</h3>
<ul>
    <li>Kombineret klinisk unders&oslash;gelse, billeddiagnostisk unders&oslash;gelse og biopsi/histologi&nbsp;</li>
    <li>Ved konkordans mellem tripletestens resultater er den diagnostiske n&oslash;jagtighed t&aelig;t p&aring; 100 %&nbsp;</li>
    <li>Diskordans kan n&oslash;dvendigg&oslash;re, at der b&oslash;r foretages excisionsbiopsi</li>
</ul>
<h2>Tiltag og r&aring;d</h2>
<h3>Henvisninger</h3>
<h4>Til mammografi</h4>
<p>Baseret p&aring; vurdering af sandsynligheden for cancer anbefales f&oslash;lgende prioritering:</p>
<p>Prioriteringsgruppe 1 (Udredes i pakkeforl&oslash;b):</p>
<ul>
    <li>Palpatorisk suspekt tumor&nbsp;</li>
    <li>Billediagnostisk suspekt forandring</li>
    <li>Papil-areolaeksem/ulceration, obs. Morbus Paget</li>
    <li>Blodig eller klar/ser&oslash;s sekretion fra papil hos m&aelig;nd&nbsp;</li>
    <li>Ukendt prim&aelig;r tumor med bioptisk verificerede aksilmetastaser&nbsp;</li>
    <li>Klinisk suspekte lymfeknuder&nbsp;</li>
    <li>Nytilkommen papil-/areola- og/eller hudindtr&aelig;kning&nbsp;</li>
</ul>
<p>Prioriteringsgruppe 2 (Udredningsgaranti):</p>
<ul>
    <li>Palpatorisk benign tumor&nbsp;</li>
    <li>Blodig eller klar/ser&oslash;s sekretion fra papil hos kvinder&nbsp;</li>
    <li>H&aelig;vede aksill&aelig;re lymfeknuder uden kendt &aring;rsag&nbsp;</li>
    <li>Vedvarende fokal mastalgi (mindre end en kvadrant) eller ved ledsagende symptomer&nbsp;</li>
</ul>
<p>Prioriteringsgruppe 3 (Screening):</p>
<ul>
    <li>Fokal mastalgi (mindre end en kvadrant) hos kvinder &ge;40 &aring;r&nbsp;</li>
    <li>Mastitis&nbsp;</li>
    <li>Billeddiagnostik forud for planlagt kosmetisk operation&nbsp;</li>
</ul>
<h2>Link til vejledninger</h2>
<ul>
    <li><a href="https://www.sst.dk/da/udgivelser/2018/~/media/4864545DA763400E9FD988FA4DA74EE5.ashx">Indgang til det nationale kr&aelig;ftpakkeforl&oslash;b</a></li>
    <li>Sundhedsstyrelsen: <a href="https://www.sst.dk/da/sygdom-og-behandling/kraeft/pakkeforloeb/~/media/1C04F012BDEF4F14AED632C457FD0CF2.ashx">Pakkeforl&oslash;b for brystkr&aelig;ft, 2018</a></li>
    <li>Forl&oslash;bsbeskrivelser og regionale pakkeforl&oslash;b [ICPC]</li>
</ul>
<h3>Til endokrinolog/medicinsk udredning:</h3>
<ul>
    <li>H&aelig;velse, &oslash;mhed og knudedannelse i mammav&aelig;vet hos m&aelig;nd. Testikler skal unders&oslash;ges</li>
</ul>
<h3>R&aring;d</h3>
<h4>Berolige patienten uden videre tiltag</h4>
<ul>
    <li>Unge patienter med &oslash;mme, knudrede bryster, hvor &oslash;mheden &aelig;ndrer sig under menstruationscyklus og uden lokaliserede forandringer</li>
    <li>Kvinder med brystsekretion, som er gullig, gr&oslash;nlig, brunlig (oftest fra multiple ducter og bilateralt)</li>
    <li>M&aelig;nd med oplagt forklaring p&aring; gyn&aelig;komasti: Personer med alkoholoverforbrug, spironbehandling, misbrugere af anabolske steroider/hash/heroin etc.</li>
</ul>
<h4>Genetisk r&aring;dgivning?&nbsp;</h4>
<ul>
    <li><a href="https://www.dmcg.dk/siteassets/forside/kliniske-retningslinjer/godkendte-kr/dbcg/dbcg_arvelig-cancer-mamma_v1_2_admgodk120121.pdf">Arvelig brystkr&aelig;ft</a></li>
</ul>
<h3>Genetisk test og r&aring;dgivning anbefales hvis der er</h3>
<p><strong><em>1. Mistanke om arvelig disposition til mammacancer i familier, hvor mindst &eacute;t af f&oslash;lgende kriterier er opfyldt</em></strong></p>
<ul>
    <li>En kvinde med mammacancer p&aring;vist f&oslash;r 40-&aring;rsalderen</li>
    <li>En kvinde med mammacancer p&aring;vist i alderen 40-50 &aring;r, som ikke allerede er unders&oslash;gt for genvarianter i BRCA1 og BRCA2 med normalt resultat</li>
    <li>En kvinde med mammacancer p&aring;vist f&oslash;r 60-&aring;rsalderen, hvor den invasive tumorkomponent er ER negativ og HER2 normal eller har basallike molekyl&aelig;r subtype i tilf&aelig;lde af lav ER status (1-9 %)</li>
    <li>En kvinde med bilateral mammacancer</li>
    <li>En kvinde med ovariecancer uanset alder og histologisk type&nbsp;</li>
    <li>&ge; to f&oslash;rstegradssl&aelig;gtninge med mammacancer</li>
    <li>En mand med mammacancer</li>
</ul>
<p><em><strong>2. I familien er p&aring;vist:</strong></em></p>
<ul>
    <li>En sygdomsdisponerende genvariant, der disponerer til mammacancer</li>
    <li>Tidligere er p&aring;vist en genvariant af ukendt betydning (VUS, variant of unknown significance, som nu &oslash;nskes revurderet for, om den disponerer til mammacancer)</li>
    <li>Det tidligere er vurderet, at der nedarves en &oslash;get risiko for mammacancer, og hvor der er indikation for ny konsultation f.eks. pga. nye cancertilf&aelig;lde i familien; at patienten n&aelig;rmer sig alderen, hvor hun tidligere er anbefalet unders&oslash;gelsesprogram; eller fordi patienten har brug for en opf&oslash;lgning</li>
</ul>
<h3>BRCA1 og BRAC2&nbsp;</h3>
<ul>
    <li>Risiko for - inden 70-&aring;rsalderen - at f&aring; brystkr&aelig;ft eller &aelig;ggestokskr&aelig;ft hvis BRCA1-positiv er ca. 60-70 %, dog lidt mindre hos kvinder med BRCA2-mutation&nbsp;</li>
    <li>Kvinder, der har disse gener, f&aring;r et&nbsp;tilbud om at deltage i et kontrolprogram, hvor de regelm&aelig;ssigt bliver tjekket for tegn p&aring; begyndende kr&aelig;ft i bryst eller &aelig;ggestokke. Kontrolprogrammet omfatter som regel en &aring;rlig unders&oslash;gelse</li>
</ul>
<h2>Illustrationer</h2>
<h3>Billeder</h3>
<ul>
    <li><a href="about://~/link.aspx?_id=3C0B2361AAFA4006B9046351B9BE45B2&amp;_z=z">Ultralyd mamma, cyste</a></li>
</ul>
<h2>Patientinformation</h2>
<h3>Hvad du b&oslash;r informere patienten om</h3>
<ul>
    <li>Vigtig at blive bekendt med egne bryster, unders&oslash;ge selv efter hver menstruation og kontakte l&aelig;ge ved fund af knuder/forandringer</li>
</ul>
<h3>Hvad findes af skriftlig patientinformation</h3>
<ul>
    <li><a href="about://~/link.aspx?_id=D73CCED678D0401F89FD5DBAC148BB66&amp;_z=z">Knude i brystet</a></li>
    <li><a href="about://~/link.aspx?_id=9D94EFB903084EAD8C8AE9C8968C510D&amp;_z=z">Brystunders&oslash;gelse</a></li>
    <li><a href="https://www.cancer.dk/brystkraeft-mammacancer/"><span>Kr&aelig;ftens Bek&aelig;mpelse</span></a></li>
</ul>
<h3>Animationer</h3>
<ul>
    <li><a href="about://~/link.aspx?_id=A12447473D8F45C4A7704FD70E5CB9E0&amp;_z=z">Brystkr&aelig;ft</a></li>
    <li><a href="about://~/link.aspx?_id=381C8868DF3A4C0CADCDBB20151249B8&amp;_z=z">Egenunders&oslash;gelse af brysterne</a></li>
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