Böcker W, Decker T, Ruhnke M, Schneider W
Gerhard-Domagk-Institut für Pathologie der Universität, Münster.
Pathologe. 1997 Jan;18(1):3-18. doi: 10.1007/s002920050191.
This review emphasizes the pathology of premalignant ductal breast diseases and its practical relevance to the patients management. The histological criteria for recognizing Ductal Hyperplasia (DH) are now well established. These include an intraluminal heterogeneous proliferation of glandular cells positive for keratins 8/18/19 and epithelial cells with expression of keratins 5/6/14. As a hyperplastic process the epithelial cells disclose an haphazard irregular growth with slit like irregular lumina (fenestrated growth pattern). The florid DH indicates a slight subsequent increased risk for cancer development. Our knowledge of the nature of noninvasive ductal neoplasia continues to evolve. Recent molecular genetic and immunohistochemical efforts have disclosed that atypical ductal hyperplasia (ADH) constituted a clonal neoplastic proliferation of an epithelial cell. Histological hallmarks of ADH are their cytologic features of uniformity and monotony of proliferation of cells and its micropapillary, cibriform or solid growth pattern. So from histology ADH simulates the highly differentiated DCIS, but can be distinguished from the latter quantitatively by the aggregate cross sectional diameter or the number of ducts that are completely involved by the atypical proliferation. ADH indicates a few fold subsequent increased risk for developing carcinoma. So this lesion requires a close follow up with 3 to 4 examinations per year and annual mammograms. Ductal carcinoma in situ (DCIS) consists of cytologically malignant cells in the parenchyma that have not invaded into the stroma. Recent studies have shown that DCIS is a heterogeneous group of tumors. Attempts have been made to classify it into histologic patterns, nuclear grades, tumors with or without comedo-necroses etc. We can draw the conclusion from several studies that the most important histologic feature is the nuclear grade. Holland et al. have suggested a very useful classification scheme that includes nuclear grade and histological features. The modifiers of treatment are as follows: 1. nuclear grade or differentiation of the DCIS 2. extension of the lesion 3. excision with clear margins So efforts to classify DCIS underscore the central role of pathology in determining the grade of the DCIS, its size and the adequacy of the surgical excision in terms of free margins. All three parameters are included in a score system of the Van Nuys Prognostic Index.
本综述着重介绍了乳腺导管癌前病变的病理学及其在患者管理中的实际意义。目前，识别导管增生（DH）的组织学标准已经明确。这些标准包括腔内角蛋白8/18/19阳性的腺细胞的异质性增殖以及角蛋白5/6/14表达的上皮细胞。作为一种增生性病变，上皮细胞呈现出杂乱无章的不规则生长，伴有裂隙状不规则管腔（筛状生长模式）。活跃的DH表明随后发生癌症的风险略有增加。我们对非侵袭性导管肿瘤本质的认识仍在不断发展。最近的分子遗传学和免疫组织化学研究表明，非典型导管增生（ADH）是上皮细胞的克隆性肿瘤增殖。ADH的组织学特征是其细胞增殖的细胞学特征均匀且单一，以及其微乳头、筛状或实性生长模式。因此，从组织学角度来看，ADH类似于高分化的导管原位癌（DCIS），但可以通过非典型增殖完全累及的导管的总横截面积或数量在数量上与后者区分开来。ADH表明随后发生癌变的风险增加了几倍。因此，对于这种病变需要密切随访，每年进行3至4次检查以及年度乳房X线摄影。导管原位癌（DCIS）由实质内未侵入间质的细胞学恶性细胞组成。最近的研究表明，DCIS是一组异质性肿瘤。人们尝试将其分为组织学模式、核分级、有无粉刺样坏死的肿瘤等。我们可以从多项研究中得出结论，最重要的组织学特征是核分级。Holland等人提出了一种非常有用的分类方案，其中包括核分级和组织学特征。治疗的影响因素如下：1. DCIS的核分级或分化程度；2. 病变范围；3. 切缘阴性的切除。因此，对DCIS进行分类的努力强调了病理学在确定DCIS分级、其大小以及手术切除切缘是否足够方面的核心作用。这三个参数都包含在Van Nuys预后指数评分系统中。
