乳腺导管内乳头状病变诊治的临床研究

发布时间：2018-12-28 09:39

【摘要】：背景:乳腺导管内乳头状病变(Intraductal Papillary Lesion)是指以上皮细胞增殖被覆于乳头状纤维血管轴结构为特征的一类病变,伴或不伴有肌上皮细胞被覆。病患多因发现乳头溢液、乳房包块就诊。由于导管内乳头状病变涵盖良恶性病变,处理方式及预后各不相同,故对其作出准确的诊断是必要的。但由于其临床表现多样,组织病理学复杂,对临床医生和病理医生的准确诊断存在着巨大挑战,各种辅助检查的方法层出,尤其是术中冰冻病理对于术中指导乳腺病变的手术方式具有重大的意义,已是临床上必不可缺的辅助诊断方法。目的:探乳腺导管内乳头状病变的临床特征及术前良恶性判断及术中冰冻病理对此病变的诊疗作用。方法:对齐鲁医院自2010.1—2016.9住院行手术治疗的石蜡病理诊断为乳腺导管内乳头状病变的1169名女性患者的临床及病理资料行回顾性分析。结果:1.构成比:石蜡病理证实为导管内乳头状变的患者1169名,占女性乳腺疾病就诊的10.51%,其中恶性病变占1.35%。2.临床表现及辅助检查:此病主要以乳头溢液和乳房肿物为主要表现,其中良性者以乳头溢液(41.20%)为主要临床表现,恶性者以乳房肿块(63.83%)主要临床表现。超声是敏感性最高的检查手段。存在乳头溢液的病例,行乳头溢液细胞学检查者,存在一定的假阳性率,故不能作为病理依据指导手术。3.恶性病变的高危因素:各组病变的年龄差异具有统计学意义(p0.001),提示高龄是恶性病变的高危因素。部分涉及女性内分泌改变的生物学特性,包括初潮年龄、月经周期、孕次、产次具有统计学差异(p0.05),提示女性内分泌改变与恶性者发展相关。吸烟史、糖尿病史、高血压病史具有统计学差异(p0.05),提示周围环境及代谢改变是恶性病变的高危因素。4.良恶性病变的鉴别诊断:良恶性病变间临床表现为肿块、钼靶有恶性表现者提示为恶性病变;对存在溢液的病例,单孔、血性溢液、乳头溢液肿瘤标志物提示恶性病变(p0.05)。5.术中冰冻病理的价值:术中冰冻病理做出诊断与石蜡病理相同的有851例(66.64%),术中冰冻病理诊断为导管内乳头状肿瘤而需要等待石蜡病理或免疫组化确诊的病例147例(11.51%)。石蜡病理与之不符合的279例(21.85%),此中病理等级升高者79例(28.32%),病理等级一致者178例(63.80%),病理等级降低者22例(7.89%)。20侧病例行二次手术。6.特殊的包裹性或实性乳头状癌的临床特征:相较特殊的包裹性或实性乳头状癌与导管内乳头状癌,在年龄、溢液性质、绝经期、平均月经周期、DM病史、HBP病史等临床特征上具有统计学差异(p0.05);相较包裹性或实性乳头状癌不伴浸润者与该病变伴浸润成分者,在这些方面未见明显差异。结论:良性病变以溢液多见,恶性病变以乳房肿物多见。彩超对该病的检出有重要意义,钼靶具有提示良恶性的作用,病理性溢液的细胞学检查不能作为病理诊断或手术的依据。高龄,初潮年龄小、月经周期长、多产、多孕等涉及女性内分泌的改变,周围环境及代谢改变是恶性导管内乳头状癌的高危因素。肿块的存在、钼靶异常表现,对存在乳头溢液的病例,单孔、血性溢液、溢液中肿瘤标志物的高低在良恶性鉴别有意义。术中冰冻病理存在延迟诊断及误诊的现象,部分病例需要行二次手术,该病变的准确诊断还需依靠术后石蜡病理及免疫组化的支持。包裹性或实性乳头状癌在临床特征上与导管内乳头状癌有较大差异。
[Abstract]:BACKGROUND: The intraductal papillary lesion of the breast refers to a class of lesions characterized by the proliferation of epithelial cells to the vascular axis of the papillary fiber, with or without the coating of the myoepithelial cells. The patient was seen to see the nipple overflow and the breast-bag block for a visit. Since the intraductal papillary lesion covers benign and malignant lesions, the treatment and the prognosis vary, it is necessary to make an accurate diagnosis. However, due to the various clinical manifestations and the complex of the tissue pathology, there is a great challenge to the accurate diagnosis of the clinician and the pathologist, the method layer of various auxiliary examinations, in particular the intraoperative frozen pathology, has great significance for guiding the operation mode of the breast lesion during the operation, It is an auxiliary diagnostic method in clinic. Objective: To investigate the clinical features of intraductal papillary lesions of the breast and the diagnosis and treatment of preoperative benign and malignant tumors. Methods: The clinical and pathological data of 1169 female patients with intraductal papillary lesions were analyzed retrospectively. Results: 1. The composition ratio: paraffin pathology proved to be 1169 of the patients with intraductal papillary change, accounting for 10.51% of the women's breast diseases. Among them, the malignant lesions account for 1.35%. Clinical manifestation and auxiliary examination: The main manifestations of the disease are the nipple discharge and the breast mass, among which the benign ones are the main clinical manifestation of the nipple-overflow liquid (41.1%), and the malignant is the main clinical manifestation of the breast mass (63. 83%). Ultrasound is the most sensitive means of examination. There was a case of nipple discharge, and there was a certain false positive rate in the case of nipple discharge, so it could not be used as a pathological basis to guide the operation. High risk factors of malignant lesions: the age difference of each group was statistically significant (p0.001), suggesting that the advanced age was a high risk factor for malignant lesions. The part concerned with the biological characteristics of the change of the female's endocrine, including the first-wave age, the menstrual cycle, the pregnancy time and the second-generation time, which was statistically different (p0.05), suggesting that the change of the female endocrine is related to the development of the malignant. The history of smoking, the history of diabetes, and the history of hypertension were statistically different (p0.05), indicating that the surrounding environment and the metabolic changes were high risk factors for malignant lesions. The differential diagnosis of benign and malignant lesions: the clinical manifestation of the benign and malignant lesions was the mass, and the malignant lesion was indicated by the malignant phenotype of the target, and the malignant lesions (p0.05) were indicated in the case of the overflow liquid, the single hole, the overflow liquid and the nipple overflow tumor marker. The value of the frozen and pathological changes in the operation: the diagnosis of the intraoperative frozen pathology was the same as that of the paraffin pathology (66. 64%), and the intraoperative frozen and pathological diagnosis was the intraductal papillary tumor, and there were 147 cases (11.51%) to be diagnosed by paraffin pathology or immunohistochemistry. The pathological grade of paraffin in 279 cases (21. 85%), in which 79 (28. 32%), 178 (63. 80%), 22 (7.89%), 20-side case, and 6. The clinical characteristics of special package or real papillary carcinoma: the specific inclusion or real papillary carcinoma and intraductal papillary carcinoma have a statistically significant difference in the clinical features such as age, fluid nature, perimenopausal, mean menstrual cycle, DM history, and history of HBP (p0.05); There were no significant differences in these aspects of the non-invasive or real-sex papillary carcinoma without the infiltration of the patients with the lesion. Conclusion: The benign lesions can be seen in the overflow, and the malignant lesions are seen more in the breast. Color Doppler ultrasound is of great significance to the detection of the disease, and the target has the function of indicating good and malignant, and the cytological examination of pathological overflow can not be used as the basis for pathological diagnosis or operation. The changes of the endocrine of the female, the changes of the surrounding environment and the metabolic changes are the high risk factors of the intraductal papillary carcinoma. The presence of the mass and the abnormal performance of the target target showed that the high and low of the tumor markers in the case, single-hole, overflow and overflow of the nipple-overflow liquid were of great significance in the differentiation of benign and malignant. In the operation, there is a delay in the diagnosis and misdiagnosis of the frozen pathology. In some cases, the secondary operation is required, and the accurate diagnosis of the lesion also depends on the pathology of the paraffin and the support of the immunohistochemistry. Parcel or real papillary carcinoma has a large difference in clinical features with intraductal papillary carcinoma.
【学位授予单位】：山东大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R737.9

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