Masood Shahla, Silverstein Melvin J
Department of Pathology and Laboratory Medicine. University of Florida College of Medicine, Jacksonville.
UF Health Jacksonville Breast Center.
Adv Anat Pathol. 2023 Nov 1;30(6):361-367. doi: 10.1097/PAP.0000000000000418. Epub 2023 Sep 25.
As the leading cause of cancer morbidity and the second leading cause of cancer mortality among women, breast cancer continues to remain a major global public health problem. Consequently, significant attention has been directed toward early breast cancer detection and prevention. As a result, the number of image-detected biopsies has increased, and minimally invasive diagnostic procedures have almost replaced open surgical biopsies. Therefore, pathologists are expected to provide more information with less tissue and diagnose increasing numbers of atypical proliferative breast lesions, in situ lesions, and small breast carcinomas. This is a difficult task, as reflected by continuous reports highlighting the challenges associated with morphologic distinction between atypical ductal hyperplasia and low-grade ductal carcinoma in situ. The current interobserver variability among pathologists to accurately define these two entities often leads to silent overdiagnosis and overtreatment. Up to now, there are no reproducible morphologic features and/or any reliable biomarkers that can accurately separate the above-mentioned entities. Despite these reports, patients diagnosed with low-grade ductal carcinoma in situ are subject to cancer therapy regardless of the fact that low-grade ductal carcinoma in situ is known to be an indolent lesion. Studies have shown that low and high-grade ductal carcinoma in situ are genetically different forms of breast cancer precursors; however, the term ductal carcinoma in situ is followed by cancer therapy regardless of the grade and biology of the tumor. In contrast, patients with the diagnoses of atypical ductal hyperplasia do not undergo cancer therapy. In the current article, attempts are made to highlight the continuous dilemma in distinction between atypical ductal hyperplasia and low-grade ductal carcinoma in situ. Going forward, we suggest that low-grade ductal carcinoma in situ be referred to as ductal neoplasia. This alternative terminology allows for different management and follow-up strategies by eliminating the word carcinoma.
作为女性癌症发病率的首要原因和癌症死亡率的第二大原因，乳腺癌仍然是一个重大的全球公共卫生问题。因此，早期乳腺癌的检测和预防受到了极大关注。结果，影像引导下活检的数量增加，微创诊断程序几乎取代了开放性手术活检。因此，病理学家需要用更少的组织提供更多信息，并诊断越来越多的非典型增生性乳腺病变、原位病变和小乳腺癌。这是一项艰巨的任务，不断有报告强调非典型导管增生和低级别导管原位癌在形态学鉴别上存在挑战，这也反映了这一点。目前病理学家之间在准确界定这两种病变方面的观察者间差异，常常导致隐匿性过度诊断和过度治疗。到目前为止，尚无可重复的形态学特征和/或任何可靠的生物标志物能够准确区分上述病变。尽管有这些报告，但被诊断为低级别导管原位癌的患者仍要接受癌症治疗，尽管已知低级别导管原位癌是一种惰性病变。研究表明，低级别和高级别导管原位癌是乳腺癌前体的不同基因形式；然而，无论肿瘤的级别和生物学行为如何，导管原位癌这一术语都意味着要接受癌症治疗。相比之下，被诊断为非典型导管增生的患者则不接受癌症治疗。在本文中，我们试图强调非典型导管增生和低级别导管原位癌鉴别方面持续存在的困境。展望未来，我们建议将低级别导管原位癌称为导管瘤形成。这种替代术语通过消除“癌”这个词，允许采用不同的管理和随访策略。
