細針吸取細胞學診斷乳腺導管病變的細胞學指標

Cytologic criteria of the breast ductal lesion:diagnosis by fine needle aspiration cytology

目的探討形態學上診斷乳腺細針吸取細胞學(FNAC)導管病變的最有效和聯合細胞學指標,從而建立有效的乳腺導管病變的細針吸取細胞學診斷模式。方法收集本院6年内的400例有隨訪活檢結果的乳腺FNAC病例,作回顧性病例分析。按手術組織學結果分為導管上皮非增生性乳腺病變(104例),導管上皮增生性乳腺病變(163例)和癌(133例)3組。回顧性分析塗片的60個細胞學指標,對各指標的評估根據其程度或量採用半定量分級評估。以手術組織學結果為金標準對病變分類,指標分析採用Logistic多重回歸模型(統計軟件SPSS)和分類樹模型(統計軟件SAS)統計學分析,研究各指標對診斷導管病變的意義。結果1.400例良、惡性病變組,上皮細胞團中摻雜肌上皮細胞(P<0.05)、上皮細胞排列成大的細胞團(P<0.05)、上皮細胞排列成小的細胞團(P<0.05)、細胞漿内空泡(P<0.05)和細胞套細胞(P<0.1)為統計學上有意義的鑒別診斷指標。最重要的鑒別指標為上皮細胞團中有無摻雜有肌上皮細胞。考慮良性病變的診斷指標為上皮細胞團中摻雜有肌上皮細胞,聯合大量的上皮細胞排列成大的細胞團,94.4%為良性病變,中等至大量的上皮細胞排列成小的細胞團,傾向為增生性病變;考慮癌的診斷指標為上皮細胞團中無摻雜肌上皮細胞,上皮細胞排列成小的細胞團,細胞漿内空泡和細胞套細胞。上皮細胞團中無摻雜肌上皮細胞時,癌佔81.3%。2.267例良性的導管上皮非增生性和增生性病變組,上皮細胞團中見不規則的細胞間腔隙(P=0.001)、上皮細胞團成鬆散排列(P<0.05)和細胞核深染(P<0.1)為診斷增生性病變的有意義指標。兩結構指標在塗片中出現的量越多,越提示為增生性病變,單一出現上皮細胞團中見不規則的細胞間腔隙,增生性病變佔70.1%,當其為中等至大量時,增生性病變佔82.7%,同時伴上皮細胞團成鬆散排列,均為中等至大量時,診斷增生性病變的陽性預測價值為87.5%。3.35例伴不典型細胞學改變的FNAC病例,活檢結果26例為增生性病變,多為導管上皮增生的纖維腺瘤,極少數為不典型增生或癌。結論乳腺細針吸取細胞學對乳腺病變的診斷,結構指標較細胞指標更重要,聯合指標和對其量的評估,更可有效地診斷良、惡性病變,良性病變中非增生性和增生性病變;對伴不典型細胞學改變的病例,應避免誤診為癌,但需作活檢明確診斷。

Objective To find out the most effective and combined cytomorphologic criteria for breast ductal lesion in fine needle aspiration cytology(FNAC),trying to set up an effective diagnostic model of fine needle aspiration cytology in the breast ductal lesion.Methods Total 400 breast fine needle aspiration cytology cases with a follow-up biopsy-confirmed diagnosis over six years were collected for a retrospective analysis.They included 104 non-proliferative breast diseases,163 proliferative breast diseases and 133 carcinomas based on surgical results.This study evaluated 60 cytomorphologic variables for each case,including 4 main categories:cellularity and components,natures of background,cellular arrangements and cellular features.Variables were coded as semiquantitative scoring according to their amount or degree.Multiple step-wise logistic regression and classification tree model were performed to determine significant variables and combined variables predictive of non-proliferative lesion,proliferative breast diseases and carcinoma.Results 1.Among 400 benign and malignant cases studied,the multiple step-wise logistic regression selected myoepithelial cells intermingling within the epithelial cluster(P<0.05),large epithelial cell cluster(P<0.05),small epithelial cell cluster(P<0.05),cytoplasmic vacuoles(P<0.05)and cell in cell(P<0.1)as the effectively differential diagnostic criteria associated with benign and malignant diseases.Furthermore,the classification tree model found that the most useful variable associated with benign lesion is myoepithelial cells intermingling within epithelial cluster,combining with the secondary useful variable:large amount of large epithelial cell clusters,benign lesion occupied 94.4%;moderate to large amount of small epithelial cell clusters were indicative of proliferative lesion.Positive presences of no myoepithelial cells intermingling within epithelial cluster,small epithelial cell cluster,cytoplasmic vacuoles and cell in cell were suggestive of carcinoma.When no myoepithelial cell intermingling within epithelial cluster was observed,carcinoma occupied 81.3%.2.Among 267 benign non-proliferative and proliferative breast diseases studied,the multiple step-wise logistic regression and classification tree model selected irregular intercellular space within epithelial cluster(P=0.001),loose epithelial cluster(P<0.05)and hyperchromasia(P<0.1)as the significant differential diagnostic criteria associated with the proliferative lesion.The architectural variables and the presence of the amount were more important.The more presents of irregular intercellular space within epithelial cluster and looser epithelial cluster indicate the higher possibility of proliferative lesion.Single variable of irregular intercellular space within epithelial cluster pointed out 70.1%proliferative breast diseases among the total,furthermore when the amount up to moderate to large degree,82.7%cases would be a proliferative breast diseases.The combined presences of both variables and their amount up to moderate to large degree,the positive predictive value of diagnose of a proliferative breast disease reached to 87.5%.3.The biopsy results of 35 lesions with atypical cytological features in fine needle aspiration cytology were predominant a proliferative breast disease(26 cases),and most of them were fibroadenoma with ductal hyperplasia.But it could occasionally be a manifestation of benign disease with atypical hyperplasia or carcinoma.Conclusion In breast fine needle aspiration cytology,the combining evaluation of significant variables and their amounts can effectively diagnose benign/malignant and non-proliferative/proliferative lesion.The lesion with atypical cellular features should avoid overdiagnosis of carcinoma,but biopsy was indicative.