乳腺囊内乳头状癌1例并文献复习

目的 探讨乳腺囊内乳头状癌的临床病理特征.方法回顾性分析1例乳腺囊内乳头状癌的临床病理资料,并复习相关文献.方法 对1例IPC患者的临床表现及组织病理学改变进行观察和分析,并复习相关文献.结果 本例患者临床表现无特异性,大体及镜下表现均为常规囊内乳头状癌特征,免疫表型：ER（＋ ＋ ＋）、PR（＋ ＋ ＋）、Her-2（-）、SMA（-）、p53（-）、p63（-）、calponin（-）、TG（-）、TTF-1（-）.结论 乳腺囊内乳头状癌比较少见,其诊断需依赖常规病理及免疫表型检查.     

Encapsulated papillary carcinoma of the breast: A clinicopathological study of 49 cases

BackgroundEncapsulated papillary carcinoma (EPC) has been considered as a variant of ductal carcinoma in situ (DCIS). Recent studies suggest that EPC could be invasive, as it often lacks myoepithelial cells (MECs) at their periphery. The current study was performed to investigate the biological features of EPC.MethodsForty-nine EPC patients admitted to the Tai′an Central Hospital and Qilu Hospital of Shandong University from January 2004 to December 2014 were included in this study. We retrospectively analyzed the clinicopathological findings, the presence and distribution of MECs, as well as the outcomes.ResultsThe mean age at diagnosis was 68.5 years. The mean tumor size was 2.0 cm. MECs were completely absent in all the 49 cases, Most tumors were estrogen receptor (ER) and progesterone receptor (PR) positive (95.9%). HER2 1+ immunoreactivity was seen in only 8 cases. Twenty-five patients underwent lumpectomy and twenty-four underwent mastectomy. Thirty-nine received evaluation of lymph node, and three (7.7%) patients had lymph node involvement. Follow-up information was available in 29 patients (8 to 104 months, mean 47 months), among which 5 developed local recurrences and 2 distant metastases.ConclusionEPC is an indolent invasive carcinoma with biological features between in DCIS and invasive carcinoma, with predominance of the latter. EPC rarely showed lymph node involvement and was characterized by favorable prognosis. EPC can be treated with adequate local therapy and hormonal therapy, whereas, the benefit of radiation after lumpectomy remains uncertain.     

从原位癌到微小浸润：乳腺肿瘤的临床病理分析及对外科治疗的影响

背景对乳腺原位癌（CIS）是否应进行前哨淋巴结活检（SLNB）目前仍处于争议中。临床诊疗中常遇到：一些在术前穿刺或术中活检被诊断为原位癌且未进行SLNB的患者,术后却经病理确诊为乳腺微小浸润性癌（MIBC）。此时,是否二次手术进行腋窝淋巴结状态评估对外科医师来说是一个困难的选择。一方面,MIBC淋巴结转移风险尚不明确;另一方面,再次手术时SLNB的准确性及可操作性往往受到质疑,多数情况下腋窝淋巴结清扫成为唯一的选择。目的识别原位癌伴发微小浸润的危险因素;比较CIS和MIBC腋窝淋巴结的转移风险;探索选择合适的病例直接进行术中前哨淋巴结活检以避免二次手术的合理性。方法对接受手术且经病理确诊的乳腺原位癌（493例）及微小浸润癌（199例）患者的临床病历资料进行回顾性的统计分析;采用Pearson卡方检验和Fisher确切概率法进行组间比对;通过单因素分析和多因素Logistic回归识别原位癌伴发微小浸润的危险因素。结果原位癌组中出现4例小叶原位癌（LCIS）,其余均为导管原位癌（DCIS）,而MIBC所伴发的原位癌均以DCIS为主。单因素分析显示,X线片BI-RADS≥4级的钙化,肿瘤﹥2.5 cm,高级别DCIS,ER（－）,PR （－）,HER-2（+++）是原位癌伴微小浸润的危险因素（P均﹤0.05）;Ki-67≥20%也可能与发生微小浸润有关（P=0.057）。使用Logistic回归将重要协变量（年龄）与上述危险因素一起进行多因素分析显示,年龄﹥50岁（P=0.034）,肿瘤﹥2.5 cm（P=0.033）,高级别DCIS（P=0.011）等是原位癌伴微小浸润的独立危险因素。此外,相对于2.0%的原位癌淋巴结转移概率,MIBC的淋巴结转移概率为5.5%,二者比较差异具有统计学意义（P=0.029）。结论 MIBC淋巴结转移风险为5.5%,多伴发于患者年龄超过50岁的较大范围的高级别DCIS中。目前来说,对合并这些高风险因素的原位癌患者直接进行SLNB是一种合理和稳妥的诊治手段,可以有效避免二次手术的发生并为下一步治疗提供依据。     

Radiation therapy for ductal carcinoma in situ: a decision analysis

BACKGROUND:

The benefit of adding radiation therapy after excision of ductal carcinoma in situ (DCIS) is widely debated. Randomized clinical trials are underpowered to delineate long‐term outcomes after radiation.

METHODS:

The authors of this report constructed a Markov decision model to simulate the clinical course of DCIS in a woman aged 60 years who received treatment with either of 2 breast‐conserving strategies: excision alone or excision plus radiation therapy. Sensitivity analyses were used to study the influence of risk of local recurrence, likelihood of invasive disease at recurrence, surgical choice at recurrence, and patient age at diagnosis on treatment outcomes.

RESULTS:

The addition of radiation therapy was associated with slight improvements in invasive disease‐free and overall survival. However, radiation therapy decreased the chance of having both breasts intact over a patient's lifetime. Radiation therapy improved survival by 2.1 months for women who were diagnosed with DCIS at age 60 years but decreased the chance of having both breasts by 8.6% relative to excision alone. The differences in outcomes between the treatment strategies became smaller with increasing age at diagnosis. Sensitivity analyses revealed a greater benefit for radiation with an increased likelihood of invasive recurrence. The decrement in breast preservation with radiation therapy was mitigated by an increased likelihood of mastectomy at the time of recurrence or new breast cancer diagnosis.

CONCLUSIONS:

The current analysis quantified the benefits of radiation after excision of DCIS but also revealed that radiation therapy may increase the likelihood of eventual mastectomy. Therefore, the authors concluded that patient age and preferences should be considered when making the decision to add or forgo radiation for DCIS. Cancer 2012;. © 2011 American Cancer Society.     

乳腺导管原位癌的间质微浸润危险因素分析

目的：分析乳腺导管原位癌（ductal carcinoma in situ,DCIS）间质微浸润的危险因素,探讨导管原位癌伴微浸润（ductal carcinoma in situ with microinvasion,DCIS-MI）患者的腋窝淋巴结术式。方法：回顾性分析2013年2 月至2016年2 月南京大学医学院附属金陵医院经手术后病理证实为DCIS、DCIS-MI 共45例患者临床资料,依据是否伴微浸润分为DCIS与DCIS-MI 组,对患者年龄、就诊时是否绝经、肿瘤大小等因素行统计学分析。结果：就诊时未绝经（P = 0.006）、肿物直径≥ 3.15cm（P = 0.006）、有恶性肿瘤家族史（P = 0.002）的患者更易发生肿瘤间质微浸润。结论：具有可触及腋窝肿物、未绝经、乳腺巨大肿物、有恶性肿瘤家族史危险因素,同时术前行穿刺或术中冰冻提示DCIS、DCIS伴可疑微浸润的患者存在微浸润可能性大,应予前哨淋巴结活检。触及腋窝肿物为首要症状患者,腋窝淋巴结清扫术应作为首选方式。     

Ductal carcinoma in situ (DCIS) of the breast: perspectives on biology and controversies in current management

The incidence of ductal carcinoma in situ (DCIS) has increased because of increasing use of sensitive imaging modalities. MRI is commonly used for the detection of breast cancer but has not yet been validated in randomized trials. There have not been randomized trials addressing optimal margins of excision or axillary sampling. Whole breast radiation after lumpectomy decreases the risk of recurrence but may be omitted in selected patients. Adjuvant Tamoxifen reduces the risk of recurrence but has no impact on overall survival rates.     

Growth pattern of ductal carcinoma in situ (DCIS): a retrospective analysis based on mammographic findings.

The aim of this study was to obtain information concerning the direction and rates of growth of ductal carcinoma in situ (DCIS). The previous mammograms of 124 women diagnosed with DCIS were examined. If in retrospect calcifications were present on the previous examination, the exact size and position were recorded on both diagnostic and previous imaging. The rates of change and direction of change in extent of calcifications were calculated. 39 women with a diagnosis of DCIS in retrospect had calcifications visible on both their current and prior examinations; these formed the study group. For individual clusters of calcification, change occurred along an axis to the nipple at a mean of 5.5 mm y(-1)and along an axis at 90 degrees to the nipple at 2.6 mm y(-1). Increase in calcifications along the axis to the nipple occurred at 2.6 mm y(-1)toward and 2.8 mm y(-1)away from the nipple. Increase in the axis to the nipple occurred at 1.8 mm y(-1)for low grade, 4.2 mm y(-1)for intermediate grade and 7.1 mm y(-1)for high grade. DCIS growth along an axis to the nipple occurs at over twice the rate of growth in the other direction(s) and growth toward and away from the nipple occurred equally. Growth rates increased with increasing nuclear grade of DCIS. These results validate nuclear grading of DCIS. Additionally, the results suggest that increased importance should be placed on identifying the 'nipple' and 'anti-nipple' margins of DCIS represented by calcifications for both surgical excision and pathological scrutiny.     

“Revertant” mammary solid papillary carcinoma in lymph node metastasis

A case of invasive carcinoma of mixed papillary and not otherwise specified ductal type with areas of solid papillary ductal carcinoma in situ(DCIS) is reported. The solid papillary areas were predominantly of low nuclear grade, but a small area of intermediate-grade solid papillary neoplasm was also seen within the tumor, together with an area suggestive of microinvasion. The massive regional nodal tumor load consisted of invasive papillary carcinoma and revertant low-grade solid papillary carcinoma with no myoepithelial cells around the circumscribed solid papillary areas. This is the first report of a solid papillary pattern simulating intraductal carcinoma in lymph nodes, and the first time that a solid papillary carcinoma is reported in association with invasive papillary carcinoma. The case suggests that mammary carcinomas with a solid papillary pattern may sometimes be of higher grade than usual, and do not always represent a DCIS, but may be invasive.     

Serum p53 autoantibodies in patients with minimal lesions of ductal carcinoma in situ of the breast

Five of 43 patients (11.6%) with ductal carcinoma in situ of the breast presented with p53 autoantibodies at diagnosis. Three seropositive patients demonstrated tumour sizes of < or = 5 mm. There was no association of p53 autoantibody status with age, clinical presentation, histological subtype, tumour size, grading, p53 immunohistochemistry or hormone receptor status.     

A case of intracystic carcinoma of the breast: the importance of measuring carcinoembryonic antigen in aspirated cystic fluid

Summary We report a case of intracystic carcinoma of the breast in which a correct preoperative diagnosis was achieved on the basis of an increased level of carcinoembryonic antigen (CEA) in the aspirated cystic fluid.A 62-year-old woman was admitted with a 10 × 10 cm painful mass occupying the right breast. Ultrasonography revealed a cystic lesion with papillary projections arising from the cyst wall. Cytological examinations showed no malignant cells in the hemorrhagic aspirated fluid. However, the CEA level in the fluid was 5.5 times higher than the serum CEA level using a murine anti-CEA monoclonal antibody. The high level of CEA led to the preoperative diagnosis of intracystic carcinoma. Histological examinations confirmed the diagnosis of intracystic carcinoma after a modified radical mastectomy. Immunohistochemical staining by an anti-CEA monoclonal antibody elicited a strong positivity with diffuse intracytoplasmic distribution in the carcinoma cells, although heterogeneity of staining was observed.It is suggested that the measurement of the CEA value by anti-CEA monoclonal antibody in the aspirated fluid is easy, safe, and helpful for the definitive diagnosis of intracystic carcinoma of the breast.     

A case of male noninvasive intracystic papillary carcinoma forming a tumor in the nipple duct

Epithelial tumors forming a mass in the male nipple are very rare. Paget's disease, adenoma of the nipple (AON), and breast cancer must be considered for differential diagnosis. This report presents a 72-year-old man with spontaneous serous nipple discharge and an enlarged nipple measuring 2 cm in diameter. Ultrasonography provided no useful information regarding the nipple lesion. Nipple discharge cytology was negative and without any inflammatory cells. Since it is extremely uncommon for Paget's disease and breast cancer to cause tumor in the nipple, AON was suggested. However, histopathological examination of the nipple resection revealed noninvasive intracystic papillary carcinoma of the nipple. Biopsy of the nipple is often necessary to diagnose this disease. Moreover, excisional biopsy of the tumor is recommended when possible, since it can accomplish both diagnosis and treatment in cases of AON or noninvasive intracystic papillary carcinoma.     

Surgery in papillary thyroid carcinoma: a review of 730 patients

Between 1956 and 1978, 1143 patients with thyroid cancer, nearly half of all patients with thyroid carcinomas in Norway in this period, were seen in our hospital. Of 730 papillary cancer patients, 447 were operated with total thyroidectomy (TT), 179 with hemi-thyroidectomy (HT), while 104 patients had minor thyroid resections (RT). Survival and recurrence rates were similar in the TT- and HT-groups. Local recurrences were seen in 15.2% of the patients following total thyroidectomy and in 16.2% following hemi-thyroidectomy; distant metastases were seen in 10.7% and 11.2%, respectively. Beyond the seventh year of follow-up the cumulative survival was similar following total thyroidectomies, hemi-thyroidectomies, and thyroid resections. Unless grossly malignant residues were left behind, the impact of the surgical procedure on prognosis in papillary thyroid cancer seems minor.     

A case of intracystic papillary carcinoma with a multilocular cyst of the breast in male

Intracystic papillary carcinoma of the breast in males is a very rare disease but has an excellent prognosis. We report the case of a 68-year-old man who had a right subareolar soft mass. Imaging examinations showed a multilocular cyst with an intracystic component, and benign disease was diagnosed. Fine needle aspiration of the cyst fluid revealed many malignant cells, and modified radical mastectomy was performed under general anesthesia. Histological examination showed intracystic papillary carcinoma with a multilocular cyst. No positive lymph nodes were involved. The diagnosis of intracystic papillary carcinoma of male breast should be made carefully to avoid misdiagnosing benign disease.     

Residual disease after re-excision for tumour-positive surgical margins in both ductal carcinoma in situ and invasive carcinoma of the breast: The effect of time

BACKGROUND AND OBJECTIVES: To assess the effect of time on finding residual breast cancer in re-excision specimens after non-radical breast-conserving surgery for both DCIS and invasive breast carcinoma. METHODS: 315 breast-conserving surgical procedures with tumour-positive margins were retrospectively reviewed. The significance of association between the presence of finding residual tumour in the re-excision specimen and mean time interval was calculated with Student's t-test. A multivariate logistic regression model was used to assess the independent relative risk of time on presence of residual tumour. RESULTS: Residual tumour was found in 240 (76.2%) of the re-excision specimens. For primary invasive carcinomas time was a risk-reducing factor for finding residual disease (OR 0.89, 95% CI 0.82-0.98, P = 0.01). If invasive carcinoma was transected, the absence of residual disease was significantly related with a longer mean time interval (OR 0.98, 95% CI 0.95-0.99, P = 0.04). CONCLUSIONS: An increased time interval between primary surgery and re-excision for tumour-positive surgical margins for invasive carcinoma is associated with a decreased incidence of finding residual tumour. This could be explained by inflammatory responses after surgical trauma. For DCIS there was no influence of time on finding residual tumour, which could be explained by a more protective microenvironment of DCIS or re-growth of surviving malignant cells.     

Invasive breast cancer following ductal and lobular carcinoma in situ of the breast

We considered the risk of subsequent invasive breast cancer in a population-based series of 579 carcinomas in situ (CIS) of the breast (482 ductal, 88 lobular) registered between 1977 and 2002 in the Swiss Canton of Vaud. A total of 55 cases of invasive breast cancer were observed vs. 12.3 expected, corresponding to a standardized incidence ratio (SIR) of 4.5 (95% confidence interval [CI], 3.4-5.8). The SIR was 4.6 after ductal and 4.2 after lobular CIS, was similar with passing time since CIS diagnosis, but was higher (SIR = 5.5) for women aged <55 years. At 20 years following CIS, the cumulative risk of invasive breast cancer was 26%, similar for lobular and for ductal CIS. The incidence of invasive breast cancer following CIS showed no consistent pattern of trends with age, all rates in subsequent age groups ranging between 10 and 18 in 1,000. This is compatible with the occurrence of a single mutational event in a population of susceptible women.     

乳腺包被性乳头状癌的临床病理特征及预后分析

背景与目的：乳腺包被性乳头状癌是一种少见的乳腺恶性肿瘤,术前诊断较困难。本研究旨在探讨乳腺包被性乳头状癌患者的资料,探讨临床病理特征、治疗及预后。方法：回顾性分析2005—2010年在宁波市医疗中心李惠利医院甲乳外科就诊的11例乳腺包被性乳头状癌患者的临床资料。结果：11例乳腺包被性乳头状癌患者的中位年龄为64岁;肿块直径1.5~10 cm,多位于乳头乳晕区;B超表现为“囊性肿块伴有囊壁乳头状结节”。11例患者中3例肿瘤周围伴有导管内癌,3例伴有浸润性癌;所有患者ER、PR阳性,HER-2阴性,囊壁的肌上皮细胞标志物Actin、SMA、S-100、p63均为阴性,腋下淋巴结未见转移。在随访时间内,11例患者均存活,未发现肿瘤复发和转移。结论：乳腺包被性乳头状癌是一种好发于老年女性的恶性肿瘤,预后良好,肿瘤周围常伴发导管原位或浸润性癌。单独发生或伴发导管原位癌时,按照导管原位癌的原则治疗;伴发浸润性癌时按照浸润性癌的原则治疗。