病理性乳头溢液的细胞病理诊断特点分析

背景与目的:细胞病理检查与诊断以微创或无创、价廉、耗时短、诊断准确率较高等优点,成为疾病筛查或/和诊断的手段之一,在临床各专业领域广泛开展。本文探讨细胞病理检查与诊断在病理性乳头溢液诊断中的特点及临床应用价值。方法:回顾性分析湖南省人民医院病理科2014年12月—2018年9月期间162例行病理性乳头溢液细胞病理诊断标本及其中55例行乳腺活检组织病理诊断标本。通过与组织病理对照,观察溢液的肉眼特性、细胞病理诊断特点及乳腺肿物情况,并分析其与乳腺病变的关系。结果:细胞学诊断导管内乳头状瘤/乳头状肿瘤的准确率为90.9%(20/22),诊断乳腺癌、乳腺增生性病变、乳腺炎症性病变的准确率分别为100%(4/4,10/10,4/4)。浆液性溢液49.4%(80/162),血性33.3%(54/162),水样12.3%(20/162),乳汁样4.94%(8/162);55例组织活检病例中血性溢液67.3%(37/55),由导管内乳头状瘤导致者48.6%(18/37),乳腺癌导致27.0%(10/37);90.9%(10/11)乳腺癌溢液表现为血性溢液。溢液伴可触及乳腺结节者19例(19/55),未触及乳腺结节但影像学检查异常者36例(36/55);乳腺癌占溢液伴可触及乳腺结节者的42.1%(8/19);导管内乳头状瘤占溢液伴未触及乳腺结节者的61.1%(22/36),乳腺癌占8.3%(3/36)。结论:结合乳头溢液的肉眼性状、乳腺肿物的体查或(和)影像学检查及溢液细胞病理诊断的较高准确率,溢液细胞病理检查与诊断可以作为病理性乳头溢液临床筛查及诊断的方法。     

不同临床及影像学特征对良恶性乳头溢液疾病鉴别诊断价值分析

目的 探讨不同临床及影像学特征对良性及恶性乳头溢液疾病的诊断价值。 方法 回顾性分析2011年1月至2016年2月上海交通大学医学院附属瑞金医院因乳头溢液行手术治疗的233例病人的临床资料。乳腺癌33例（14.2%）,乳腺良性疾病200例（85.8%）。分析不同临床及影像学特征病人良性及恶性乳头溢液的检出率,计算乳腺X线摄影、乳腺超声、乳腺MRI及联合检查对乳腺癌诊断的灵敏度。 结果 血性溢液（P=0.008）、乳腺X线摄影伴可疑恶性钙化（P<0.001）、MRI表现为段样强化（P=0.003）、流出型时间-信号强度曲线（P=0.023）的病人乳腺癌检出率明显增高,差异有统计学意义。乳腺X线摄影对恶性乳头溢液诊断的灵敏度较低（57.6%）,劣于超声检查（87.9%,P=0.012）及MRI检查（93.9%,P=0.001）。乳腺X线摄影联合超声或MRI诊断的灵敏度分别为90.9%及100.0%,显著高于单用乳腺X线检查（P=0.004,P<0.001）。结论 对于不伴肿块的乳头溢液,血性溢液、乳腺X线摄影伴可疑恶性钙化、MRI段样强化、时间-信号强度曲线为流出型的病人患乳腺癌的风险较高。乳腺X线摄影对乳头溢液潜在恶性病变的检出率较低,联合超声或MRI检查可提高检出率。     

乳头溢液病因诊断进展

乳头溢液病因诊断进展湖南医科大学附属第二医院普外科（４１００２１）唐中华，李允山在妇女非哺乳期间，发生乳头溢液多属病理性表现。这种异常乳腺分泌是乳房疾病中较为常见的症状，发生率仅次于乳房肿块和乳房疼痛。大宗文献报道，乳头溢液占乳房疾病的３％～１３．７...     

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乳头溢液在乳腺疾病中并非少见(5%～10%),随乳腺疾病发病率的不断增加,乳头溢液就成为乳腺疾病的常见临床症状。重要的是由此症状查找病因(原因),从而恰当处理、正确治疗。乳头溢液既可因乳腺导管本身病变引起,也可源于周身的某些疾病或原因。有的溢液属病理性的,有的属生理性的。病理性溢液中又有良、恶性之分,多须外科治疗;而生理性溢液则无须治疗。当溢液同时有乳房内肿块时,借助影像学(X线、超声等)检查易于作出临床诊断,需要时行肿块活检可确诊。但对未扪及乳房肿块而单以乳头溢液就诊病人的诊断,则是长期困扰临床医生的一个难题。医…     

病理性乳头溢液诊疗现状

乳头溢液(nipple discharge,ND)是乳腺疾病的三大常见症状之一。本文仅就病理性乳头溢液的病因、临床检查诊断、治疗现状和进展作一综述,以提高对其正确认识和乳腺癌的一级预防。     

乳管镜在乳头溢液诊治中的临床应用价值

目的:探讨乳管镜在病理性乳头溢液诊断中的临床应用价值。方法:回顾性分析1 606例经乳管镜检查并行手术切除的病理性乳头溢液患者患者的临床资料。结果:乳管镜检查结果与病理结果尚不完全符合,但两种方法一致性较高(Κ=0.828)。乳管镜诊断的灵敏度为95.5%,特异度为88.6%,与病理诊断的符合率为94.0%。结论:乳管镜在乳头溢液检测中具有良好的灵敏性和特异性,且与病理结果具有高度的一致性,可作为临床诊断乳腺疾病的重要手段。     

乳头溢液180例诊断和手术治疗

目的探讨科学合理、便于推广的乳头溢液的诊断及治疗方案。方法回顾性分析180例乳头溢液的临床资料,对溢液性质、B超、乳导管造影、手术病理结果进行总结分析。结果180例乳头溢液中血性溢液94例,非血性溢液86例病理结果:导管内乳头状瘤112例,占62%,乳腺腺病35例,占19%,导管扩张症14例,占8%,乳腺癌19例,占11%。其中血性溢液中乳腺癌发生率8.4%(15/180),非血性溢液中乳腺癌发生率2.2%(4/180),乳腺癌中同时有血性溢液及肿块者11例,占乳腺癌总数的57.9%。结论B超对伴有乳腺肿瘤的病人有一定的诊断意义;乳管造影有较高的临床价值。影像学检查只可做出病灶的定位诊断,术中冰冻片才是定性诊断的惟一方法。病变区乳腺的区段切除应成为大多数乳头溢液病人的手术方法。     

乳管镜对以病理性乳头溢液为首发症状乳腺癌诊断价值分析

目的 评估乳管镜在以病理性乳头溢液为首发症状乳腺癌中的诊断价值。方法 回顾性分析2016年8月至2019年8月中国医科大学附属第四医院（380例）和新疆塔城地区人民医院（30例）收治的共410例以病理性乳头溢液为首发症状病人的临床资料，所有病人术前均行乳管镜、超声及钼靶检查。分析乳管镜检查中与乳腺癌诊断密切相关的因素，比较不同检查方式对乳腺癌诊断的敏感度、特异度、阳性预测值及阴性预测值。结果 410例病人均接受手术治疗，并进行术后病理学诊断，其中乳腺癌31例（7.6%）。乳管镜检查结果中，良性病例与恶性病例的溢液颜色、溢液量及病灶深度差异有统计学意义（P<0.05）。乳管镜对于乳腺癌术前评估诊断的敏感度为90.3%，明显高于超声（61.3%）和钼靶检查（48.4%），三者特异度差异无统计学意义（P>0.05）。超声联合钼靶检查敏感度为71.0%，而在此基础上联合乳管镜检查可使诊断的敏感度提高至93.5%。结论 在以病理性乳头溢液为首发症状乳腺癌的诊断中，乳管镜检查的敏感度显著高于超声和钼靶，增加乳管镜检查能够显著提高乳腺癌诊断的敏感度，避免漏诊。     

乳管镜在乳管内病变诊治中的临床研究

探讨乳管镜在病理性乳头溢液诊断中的临床价值,分析乳头溢液病理结果与其临床特征的关系。回顾性分析177例经乳管镜检查后接受手术的乳头溢液患者的临床资料,分析乳管镜诊断与术后病理诊断的符合率以及溢液颜色性状、年龄等各项临床特征与术后病理结果的关系。乳管镜与术后病理结果符合率为75.1%,血性溢液中重度非典型增生或导管内癌率高于非血性溢液(P<0.05),外周型乳头状瘤中重度不典型增生率高于中央型乳头状瘤(P<0.05),年龄、单孔/多孔溢液,单侧/双侧溢液各病理结果比率并无显著区别(P>0.05)。纤维乳管镜与术后病理有较高的符合率,具有重要的临床价值,血性溢液患者的中重度不典型增生或导管内癌的发生率较非血性溢液高,临床上应提高警惕。     

乳头溢液200例临床病理分析

目的探讨乳头溢液的临床病理特征。方法回顾性分析1984年11月～2004年8月乳头溢液病人临床病理资料，并结合文献进行探讨。结果200例乳头溢液病人中，105例为浆液性，75例血性，15例乳汁性，5例脓性。病理切片证实，61例乳腺增生(61／200，30．5%)，71例导管内乳头状病(71／200，35．5％)，47例导管扩张(47／200，23．5％)，21例乳腺癌(21／200，10．5％)。结论乳头溢液病因，良性乳腺病为最常见(179／200，89．5％)，乳腺癌少见(21／200，10．5％)。乳头溢液伴有肿物的病因诊断中，细针穿刺细胞学检查的方法有高敏感性及特异性。     

乳腺导管原位癌的MRI特点分析

目的:分析乳腺导管原位癌的影像学表现及MRI的诊断价值,以进一步提高对乳腺导管原位癌的影像学认识。材料和方法:回顾性分析18例经病理证实为乳腺导管原位癌病人的临床资料,研究其乳腺磁共振图像的形态学特点、动态增强方式及扩散加权成像特点。结果:18例导管原位癌的形态学表现及增强方式大体可分为两类。一类是非肿块型13例(72.2%),包括不规则片状6例和段状改变7例,其时间-信号强度曲线呈Ⅱ型者12例,Ⅲ型者1例;另一类表现为肿块型,5例(27.8%),时间-信号强度曲线呈Ⅰ型者1例,Ⅱ型者2例,Ⅲ型者2例。弥散加权成像发现病灶15例,检出率达83.3%,表面扩散系数(ADC)1.30×10-3mm2/s有10例。结论:乳腺导管原位癌MR图像上多表现为非肿块的段状分布及片状分布的异常强化,少数也可表现为肿块型改变,弥散加权成像在定性诊断上能起重要的辅助作用。     

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??Value analysis of different clinical and imaging features in the diagnosis of benign and malignant nipple discharge HUANG Jia-hui??CHEN Xiao-song, WU Jia-yi, et al. Comprehensive Breast Health Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
Corresponding author: SHEN Kun-wei, E-mail: kwshen@medmail.com.cn
Abstract Objective To analyze the value of different clinical and imaging features in the diagnosis of benign and malignant nipple discharge. Methods The clinical data of 233 patients treated with surgery for nipple discharge from January 2011 to February 2016 in Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine were analyzed retrospectively. A total of 233 cases without palpable mass were enrolled in the analysis. Thirty-three patients (14.2%) were diagnosed as breast cancer, and the other 200 patients (85.8%) were diagnosed as benign disease. The sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) of mammogram, ultrasound, MRI and their combination in predicting malignant disease were calculated. Results Patients with bloody nipple discharge (P=0.008), with suspicious calcification on mammography (P<0.001)??with segmental enhancement (P=0.003) or with washout-pattern kinetic curve (P=0.023) on MRI had higher risk of breast cancer. The sensitivity of mammography in diagnosing breast cancer was 57.6%, significantly lower than that of ultrasound (87.9%,P=0.012) and MRI (93.9%??P=0.001). The sensitivity of mammography combined with ultrasound or with MRI was 90.9% and 100% respectively, significantly higher than that of mammography alone (P=0.004, P<0.001) .Conclusion Bloody nipple discharge, with suspicious calcification on mammography, with segmental or with washout-pattern kinetic curve on MRI are risk factors for predicting breast cancer in patients with nipple discharge without palpable disease. The sensitivity of breast cancer can be elevated with ultrasound or MRI comparing with mammography alone.     

The utility of breast MRI as a problem-solving tool

Breast magnetic resonance imaging (MRI) is routinely used as a problem-solving tool, but its benefit for this indication remains unclear. The records of 3001 consecutive breast MR examinations between January 1, 2003 and June 6, 2007 were reviewed to identify all those performed for the clinical indication of problem solving. Details of clinical presentation, mammography and ultrasound (US) findings, follow-up recommendations, and pathology outcomes were recorded. Benign versus malignant outcomes were determined by biopsy or 12 months of follow-up imaging and linkage with the regional tumor registry. Problem solving was the clinical indication for 204 of 3001 (7%) of all examinations. Forty-two of 204 examinations (21%) had suspicious or highly suspicious MRI assessments with recommendation for biopsy and 62 of 204 (79%) examinations were assessed as negative, benign, or probably benign. Thirty-six biopsies were performed based on MRI findings and 14 cancers were diagnosed. Biopsy was indicated for 11 of 14 (79%) cancers based on suspicious mammographic or US findings identified prior to MRI. One incidental cancer was detected by MRI alone in a patient at high risk for breast cancer, and two cancers were detected in patients with suspicious nipple discharge and negative mammogram and US. A single false-negative MRI occurred in a patient whose evaluation for a palpable lump prompted biopsy. Problem-solving breast MRI rarely identifies otherwise occult cancer and can be falsely negative in patients with suspicious findings on mammogram and US. Until the benefits and risks of problem-solving MRI are clarified, it should be used judiciously.     

3D‐MR Ductography and Contrast‐Enhanced MR Mammography in Patients with Suspicious Nipple Discharge; a Feasibility Study

We evaluated contrast‐enhanced magnetic resonance (ce‐MR) imaging and an indirect MR galactogram (MRG) sequence against conventional galactography (CG) in women with suspicious nipple discharge who underwent histologic diagnosis. This study was Institutional Review Board approved and HIPAA compliant. Women with suspicious nipple discharge recommended for CG were recruited for our study. Patients underwent both a ce‐MR as well as MRG (MRG‐1 and MRG‐2, variations in isotropic spatial resolution) followed by CG within 60 days. The ce‐MR and MRG studies were interpreted together by a single radiologist separately from CG. Pathology was used as our gold standard and was obtained via image‐guided core needle biopsy or surgery with papilloma, atypia, and malignancy considered positive. Of the 21 patients recruited for the study, 20 patients had known histology results for 26 lesions; 18 patients (90.0%) had successful CG, 20 (100.0%) ce‐MRI, 20 (100.0%) MRG‐1, and 19 (95.0%) MRG‐2. Histology showed 5 cancers (4 women), 15 papillomas (2 with atypia) (11 women), and 6 additional benign lesions (6 women). Five patients (25.0%) had additional lesions detected by ce‐MR that influenced surgical management. Sensitivity, specificity, positive (PPV), and negative predicted values (NPV) for CG, ce‐MRI, MRG‐1 were 65.0, 33.3, 76.5, and 22.2; 95.0, 66.7, 90.5, and 80.8; 55.0, 66.7, 84.6, and 30.8, respectively. ce‐MR had the highest sensitivity, PPV, and NPV compared with CG or MRG. Our MRG protocols show promise, but were not as sensitive as ce‐MRI for women with suspicious nipple discharge.     

X线检查阴性乳腺导管原位癌的临床病理特点

【摘要】〓目的〓探讨乳腺X线检查(MG)阴性的乳腺导管原位癌(DCIS)及DCIS伴微浸润(DCIS-MI)的临床及诊断特点。方法〓对我院2012年1月~2013年8月32例MG检查阴性的DCIS及DCIS-MI的临床病理资料进行回顾性分析。结果〓MG阴性导管原位癌临床表现为单纯乳头溢液占71.9%(23/32),乳腺肿块占15.6%(5/32)例,良性钙化12.5%(4/32)例。MG检查阴性导管原位癌中腺体高密度、低核分级、PR阳性、HER2(-)或(+)病例的比例明显高于同期MG检查阳性组,且差异有统计学意义(P<0.05)。补充其他诊断检查的结果显示,乳腺超声敏感性为18.7%(6/32),磁共振(MRI)敏感性可达为87.5%(28/32),对表现为乳头溢液的病例,乳管镜诊断的敏感性为52.2%(12/23)。结论〓MG阴性的导管原位癌临床病理生物学指标相对较好,MRI检查可进一步提高其检出率,乳管镜对于乳头溢液的病例是有益的补充检查手段。     

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??Clinical pathological features and treatment modalities of mammary papillary lesions??An analysis of 507 cases PANG Hao, LIANG Yue, FEI Xiao-chun, et al. Comprehensive Breast Health Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
Corresponding author:SHEN Kun-wei,E-mail: kwshen@medmail.com.cn; CHEN Xiao-song, E-mail: chenxiaosong0156@163.com
Abstract Objective To explore the clinical pathological features and corresponding treatments among different breast papillary lesions. Methods The clinical data of patients diagnosed as breast papillary lesion between January 2013 and December 2015 in Comprehensive Breast Health Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine were analyzed retrospectively. Clinical pathological features and corresponding multidisciplinary treatments were collected to analysis. Results A total of 507 patients were diagnosed as breast papillary lesions. There were 389 (76.7%), 22 (4.3%), 24 (4.7%), 27 (5.3%), 12 (2.4%), 20 (3.9%) and 13 cases (2.6%) diagnosed as intraductal papilloma (IP), IP with atypical ductal hyperplasia, IP with carcinoma in situ, intraductal papillary carcinoma, encapsulated papillary carcinoma, solid papillary carcinoma in situ and invasive papillary carcinoma, respectively. Analysis of clinical-pathological features among papillary lesions showed that breast imaging test BI-RADS (Breast Imaging Reporting And Data System) classification of mammography, ultrasound and magnetic resonance imaging was associated with the pathology result of breast papillary lesions significantly. BI-RADS no less than 4B implied higher chance of malignancy breast papillary lesions (P < 0.05). Analysis of clinical pathological features and treatment regimens among different malignant breast papillary lesions showed there was no significant difference. There was no statistical difference in terms of age, nipple discharge, character of nipple discharge, tumor size, hormonal receptor, Ki-67, pattern of surgery and adjuvant therapies (P > 0.05).Conclusion IP is the dominant pathology type among breast papillary lesions. Mammography, ultrasound and magnetic resonance imaging are sensitive to identify early breast malignant papillary lesions. Regarding low incidence of malignant breast papillary lesions, the tumors have similar clinical-pathological features, which warrants further large cohort study.     

乳腺乳头状病变507例临床病理学特点及相关治疗分析

目的 探讨不同种类乳腺乳头状病变的临床特点以及相应的治疗方法。 方法 回顾性分析2013年1月至2015年12月在上海交通大学医学院附属瑞金医院乳腺疾病诊治中心行手术治疗,并经病理学检查证实为乳腺乳头状病变病人的临床资料。 结果 共有507例病人诊断为乳腺乳头状病变,其中导管内乳头状瘤（IP）不伴非典型性增生、IP伴非典型性增生、IP伴原位癌、导管内乳头状癌、包膜内乳头状癌、实性乳头状癌以及浸润性乳头状癌分别为389例（76.7%）、22例（4.3%）、24例（4.7%）、27例（5.3%）、12例（2.4%）、20例（3.9%）和13例（2.6%）。对乳腺良恶性乳头状病变相关临床因素分析发现,乳腺超声、X线检查和磁共振检查的乳腺影像学报告与数据系统（BI-RADS）分类与乳腺乳头状病变性质显著相关,BI-RADS分类为≥4B类提示恶性病变可能性较大（P < 0.05）。对不同乳腺恶性乳头状病变相关临床及治疗方案分析,发现年龄、有无溢液、溢液性状、肿块大小、激素受体状态、Ki-67表达、手术方式及辅助治疗的选择,在上述乳腺恶性乳头状病变病人中差异无统计学意义（P > 0.05）。 结论 IP是乳腺乳头状病变发生率最高的肿瘤;乳腺超声、X线检查和磁共振检查可作为乳腺良恶性乳头状病变早期诊断的方法;不同乳腺恶性乳头状病变发病率较低,其具有相似的临床特征,须待大规模队列数据进一步验证。     

乳腺X线摄影、超声与MRI增强检查在乳腺疾病诊断中的比较

目的:比较乳腺X线摄影、超声与磁共振增强检查在乳腺良恶性病变中的诊断价值。方法:回顾分析2008年1月至2009年1月107例乳腺疾病病人的影像学资料,所有病人均进行乳腺X线摄影、超声与MRI动态增强检查,按照美国放射学会推荐的"乳腺影像报告和数据系统"(BI-RADS)进行分类,以手术病理诊断为金标准,应用受试者工作特征曲线(ROC)评价不同检查方法及联合检测的价值。结果:107例病人共检出117个病灶,以BI-RADS分级4类以上为检查阳性,结果显示MRI增强检查的灵敏度优于乳腺X线摄影(97.06%比80.88%,P=0.003)和超声(97.06%比88.24%,P=0.049),而其特异度不低于乳腺X线摄影和超声(P=0.274和P=0.798)。ROC分析结果显示,MRI增强检查的曲线下面积明显大于乳腺X线摄影(0.935比0.867,P=0.001)和超声(0.935比0.886,P=0.001),而联合3种检查方法曲线下面积最大,明显大于单独行乳腺X线摄影(P=0.001)、超声(P=0.005)和MRI增强检查(P=0.008)。结论:MRI增强检查在有症状的乳腺疾病病人中的诊断价值高于乳腺X线摄影和超声,联合运用三种检查方法,诊断价值可进一步提高。     

多模态乳腺肿瘤图像特征提取与分级诊断的研究进展

乳腺癌是女性最常见的恶性肿瘤之一。影像学检查是诊断乳腺肿瘤的重要方法,其主要包括超声、钼靶、核磁共振成像（MRI）检查等。单一医学影像技术存在诸多的局限性,使用多种影像学技术联合诊断能提高分级诊断效率。临床亟需一个高度智能的乳腺肿瘤诊断系统,有望帮助临床医生提高整体诊断效率,降低漏诊误诊率。而图像特征提取是乳腺肿瘤诊断系统研制中的第一步,也是最关键的一步。本文回顾了超声、钼靶和MRI之间联合使用对乳腺癌进行分级诊断的研究方法,就多模态乳腺肿瘤图像特征提取与分级诊断的研究进展进行综述。