乳腺纤维上皮性肿瘤内癌临床病理学观察

Clinicopathologic observation of carcinomas arising in fibroepithelial neoplasms of the breast

目的 探讨乳腺纤维上皮性肿瘤内癌的病理形态学、诊断及鉴别诊断.方法 收集2003年1月至2014年2月确诊的54例乳腺纤维上皮性肿瘤内癌,应用光镜观察、免疫组织化学MaxVision法进行分析.结果 38例诊断为纤维腺瘤内癌;12例为经典型小叶原位癌;21例为导管原位癌,低级别、中级别、高级别与大汗腺型分别为4、10、6、1例;1例为混合型导管-小叶原位癌;3例为浸润性导管癌伴导管原位癌;1例为梭形细胞化生性癌.16例诊断为叶状肿瘤内癌;6例为良性叶状肿瘤,其中4例为低级别、1例为高级别导管原位癌,1例出现经典型小叶原位癌伴微浸润（最大径0.9 mm）;3例为交界性叶状肿瘤,其中经典型小叶原位癌、中级别导管原位癌、浸润性小叶癌伴小叶原位癌各1例;7例为恶性叶状肿瘤,其中低级别和中级别各2例、高级别与大汗腺型导管原位癌各1例;1例出现浸润性导管癌伴导管原位癌.免疫组织化学染色显示,纤维上皮性肿瘤内小叶原位癌与（微）浸润性小叶癌雌激素受体（ER）、孕激素受体（PR）弥漫一致阳性.低级别导管原位癌ER、PR弥漫一致阳性（＞90％）,中级别ER、PR阳性率70％～90％,高级别ER阴性、PR阳性率20％～30％,大汗腺型ER、PR均阴性.浸润性导管癌ER、PR阳性率40％～90％,梭形细胞化生性癌ER、PR均阴性,CK5/6、p63弥漫或散在阳性.结论 纤维上皮性肿瘤内癌的形态特点为纤维上皮性肿瘤的背景上出现原位癌或浸润癌.识别纤维上皮性肿瘤背景与准确判断上皮增生性质及类型是正确诊断的关键,必要时需辅以免疫组织化学.

Objective To investigate the pathology,diagnosis and differential diagnosis of carcinomas arising in fibroepithelial neoplasms of the breast.Methods Morphological observation and immunohistochemistry using MaxVision method were performed in fifty-four cases of carcinoma arising from fibroepithelial neoplasms of the breast from January 2003 to February 2014.Results Thirty-eight cases of carcinoma arose from fibroadenomas.Twelve cases were classical lobular carcinoma in situ （LCIS）.Twentyone cases were ductal carcinoma in situ （DCIS）,including four cases of low-grade,ten cases of intermediate-grade,six cases of high-grade and one case of apocrine.One case was mixed DCIS and LCIS.Three cases were infiltrating ductal carcinoma （IDC） accompanied with DCIS.One case was spindle cell metaplastic carcinoma.Sixteen cases arose from phyllodes tumours.Six cases arose from benign phyllodes tumours,including four cases of low-grade DCIS,one case of high-grade DCIS,and one case of classical LCIS with micro-invasion （diameter 0.9 mm）.Three cases arose from borderline phyllodes tumours,including one case of classical LCIS,one case of intermediate-grade DCIS,and one case of invasive lobular carcinoma （ILC） with LCIS.Seven cases arose from malignant phyllodes tumours,including two cases each of low-grade DCIS and intermediate-grade DCIS,one case of high-grade DCIS,one case of apocrine DCIS,and one case of mixed IDC with DCIS.By immunohistochemistry,LCIS and ILC were diffusely positive for ER and PR.Low-grade DCIS was diffusely positive for ER and PR （〉 90%）,intermediate-grade DCIS was 70%-90% positive,high-grade DCIS was negative for ER and 20%-30% positive for PR,apocrine DCIS was both negative,and IDC was 40%-90% positive.The spindle cell metaplastic carcinoma was negative for ER and PR,but showed diffuse or scattered positivity for CK5/6 and p63.Conclusions Carcinomas arising from fibroepithelial neoplasms of the breast are rare,showing unusual clinical presentation,and are characterized by in situ or invasive carcinomas in a background of fibroepithelial neoplasms.The accurate diagnosis depends on the recognition of the background fibroepithelial neoplasms and assessment of the nature of the epithelial proliferation,supplemented by immunohistochemistry when necessary.