56例隐匿性乳腺癌临床病理特征分析及诊疗策略探讨

背景与目的：隐匿性乳腺癌发病隐匿，诊断困难，治疗策略不确定，是乳腺癌领域的难点和热点。本研究探讨了隐匿性乳腺癌的临床病理特征及诊疗策略。方法：对56例隐匿性乳腺癌患者在术前采用乳腺彩超、钼靶、磁共振及PET/CT检查，对比不同检查方法对隐匿性乳腺癌可疑原发灶检出率及病理符合率的差异。治疗方案采用新辅助化疗、乳腺癌改良根治术、保乳+腋窝淋巴结清扫术、腋窝淋巴结清扫术，术后行化疗+放疗。结果：乳腺超声、X线、MRI、PET/CT对乳腺可疑原发灶的检出率分别为7.14%（4/56）、29.41%（15/51）、37.50%（18/48）和16.28%（7/43）；结合术后病理学检查发现其病理符合率分别为66.67%（2/3）、50.00%（7/14）、50.00%（9/18）和50.00%（3/6）；26例患者乳腺超声、X线及MRI均未发现可疑原发灶，其中21例接受病理学检查，阳性率为14.29%（3/21）；对39例乳腺癌改良根治术标本行乳腺病理切片检查，检出原发灶15例，检出率38.46%。根据St. Gallen指南分子分型标准，Luminal A型、Luminal B型、HER-2阳性型和三阴性型比例分别为7.14%、46.43%、12.50%和33.93%。术后随访52例，随访时间10~104个月，中位时间35个月，复发转移4例，死亡0例。检出原发灶的15例患者中，复发或转移2例；未检出原发灶的24例患者中，无复发或转移；行新辅助化疗17例，达病理学完全缓解（pathological complete response，PCR）2例，复发或转移2例；行乳腺癌改良根治术39例，复发或转移2例；行保乳+腋窝清扫8例，复发或转移2例；腋窝清扫9例，无复发或转移。结论：乳腺MRI检查在隐匿性乳腺癌的排除性诊断中有重要价值；乳腺超声、X线及MRI均未发现可疑原发灶的患者其乳腺病理原发灶检出率较低；隐匿性乳腺癌的治疗策略可选择新辅助化疗、乳腺癌改良根治术、保乳+腋窝清扫术、腋窝清扫术；乳腺病理学未检出原发灶的患者复发转移率低于检出原发灶者。

The exploration of clinical pathological characteristics and the diagnosis and treatment strategy of 56 patients with occult breast cancer

Background and purpose: Occult breast cancer is a difficult and hot spot in the field of breast cancer because of its occult onset, diagnostic difficulties, and unclear therapeutic strategies. In this study, we discussed the clinical pathological characteristics and the diagnosis and treatment strategy of occult breast cancer. Methods: Fiftysix cases of occult breast cancer received the preoperative examinations of ultrasonography, mammography, magneticresonance imaging (MRI) and PET/CT. The different detection rates and pathological coincidence rates in suspicious primary lesions of occult breast cancer were compared. Treatment options included the neoadjuvant chemotherapy, modified radical mastectomy, breast-conserving surgery with axillary lymph node dissection and axillary lymph node dissection. All patients received postoperative chemotherapy with radiotherapy. Results: The detection rates of ultrasonography, mammography, MRI and PET/CT for the suspicious breast primary tumors were 7.14% (4/56), 29.41% (15/51), 37.50% (18/48) and 16.28% (7/43). Combined with the postoperative pathological examination, we found that the pathological coincidence rates were 66.67%, 50.00%, 50.00% and 50.00%. Twenty-six cases examined with ultrasonography, mammography and MRI did not have suspicious primary tumors, 21 patients underwent breast pathology examination with a positive rate of 14.29% (3/21). Thirty-nine patients received pathology examination, and the breast primary tumors were detected in 15 patients. The detection rate by pathology examination was 38.46%. According to the St.Gallen molecular classification standards, the ratio of Luminal A, Luminal B, HER-2 positive and triple-negative breast cancer was 7.14%, 46.43%, 12.50% and 33.93%, respectively. There were 52 cases with postoperative follow-up, the median follow-up period was 35 months (10-104 months), recurrence or metastasis occurred in 4 cases, and there was no death. Among the 15 patients with primary tumors, 2 cases eventually had recurrence or metastasis; 24 patients without the primary tumors did not have recurrence or metastasis; 17 patients received neoadjuvant chemotherapy, of whom 2 patients achieved pathologic complete response (PCR) and 2 patients had recurrence or metastasis. Modified radical mastectomy was performed on 39 cases, and recurrence or metastasis occurred in 2 cases. Breast-conserving surgery with axillary lymph node dissection was performed on 8 cases, and recurrence or metastasis occurred in 2 cases. Axillary lymph node dissection with radiotherapy was performed on 9 cases, and there was no recurrence or metastasis. Conclusion: MRI examination has important value in excluding the occult breast cancer. Breast pathology of primary tumors has lower detection rate in the patients without suspicious primary tumors on ultrasonography, mammography and MRI. The treatment options for occult breast cancer include the neoadjuvant chemotherapy, modified radical mastectomy, breast-conserving surgery with axillary lymph node dissection and axillary lymph node dissection. Patients who did not have primary tumors examined by breast pathology had a lower recurrence or metastasis rate than patients with the primary tumors.