乳腺导管内癌诊治的研究现状

随着医学影像技术的发展及人们对乳腺癌认识的提高，乳腺导管内癌患者的检出率明显增高，导管内癌的诊治成为早期乳腺癌研究的重点。本文就乳腺导管内癌的流行病学、临床表现、病理特征及诊断治疗等问题作一综述。     

乳管内窥镜在乳头溢液诊治中的临床应用(附1 000例分析)

背景与目的：乳头溢液是乳腺科门诊常见的症状，而临床上大约有1％的乳腺癌是乳头溢液为首发症状，大量临床摸不到的肿块的乳头溢液患者进行筛检可以早起发现乳腺癌，1997年国内发展新科技一乳腺纤维导管内视镜，用一根外径0．7mm光导镜，自乳头溢液管151插入，用过内视镜成像技术观察并记录乳腺导管内正常及异常病变情况，优势在于不仅诊断敏感性较高（〉90％），而且还行准确定位，用于早期诊断乳腺导管内疾病及早期乳腺癌。本研究评估纤维导管内窥镜在无肿块的乳头溢液诊断及治疗的临床价值。方法：用纤维导管内窥镜对1000例乳腺溢液患者进行检查和治疗。结果：本研究对1000例无肿块乳头溢液患者检查发现早期乳腺癌33例（3．3％），乳头状瘤392例（39．2％），乳头状瘤病20例（2％），导管扩张伴慢性炎症480例（48％），正常导管75例（7．5％），活检吸取肿块8例，3例报告导管内癌，导管慢性炎药物冲洗220例（22％），手术患者453例。经病理证实与导管镜检查符合率90．7％。结论：乳管内窥镜可插入到5级乳腺导管，能早期发现乳腺癌，对部分导管慢性炎症可用药物冲洗治疗，乳管内窥镜定位、定性准确，乳管内窥镜对早期乳腺癌的诊断和治疗具有深远价值。     

彩超引导下麦默通系统诊治乳腺疾病的价值探讨

在彩色超声引导下,利用麦默通(Mammotome)系统对107例患者的216个乳腺病灶进行切除,并记录术后病理及其随访情况,以探讨彩超引导下使用麦默通系统对乳腺病灶进行微创切除及其活检的临床应用价值.107例患者216个乳腺病灶完整切除,切除组织足够用于病理诊断,141例次病理结果为纤维腺瘤,62例次为乳腺腺病,其中2例次为导管上皮不典型增生,3例次为导管内乳头状瘤,8例次为乳腺癌.3例出现局部血肿,6例次出现皮下淤血.初步研究结果提示,麦默通技术是一项准确、有效、安全、创伤小、并发症少并且美容效果好的乳腺微创切除、活检技术,可对乳腺良性病灶进行切除,并且能够早期发现乳腺癌.     

纤维乳管镜对乳腺导管内占位性病变的诊断及辅助手术治疗的应用价值

目的评价纤维乳管镜（FDS）对伴有乳头溢液的乳腺导管内占位性病变的诊治的应用价值。方法2005年9月至2009年12月本院采用FDS检查乳头溢液患者523例,发现乳腺导管内占位性病变209例（39．96％）。209例乳腺导管内占位性病变患者中,193例良性病变,均行手术治疗;16例恶性病变（乳头状瘤恶变6例,导管原位癌3例,浸润性导管癌6例,乳腺导管内乳头状瘤伴钙化、乳腺腺病重度非典型增生、局部癌变1例）分别行保留乳房手术5例,单纯乳腺切除术3例,乳腺癌改良根治术4例,乳腺癌改良根治术加假体即时置入术4例;所有手术采用FDS结合扩张探针定位法。所有病例均经病理证实。随访时间5～56个月（中位随访时间25月）。结果193例良性病变患者全部治愈,除2例患者失访外,其余无复发。16例恶性病变患者经治疗后,未发现复发、转移及死亡。结论应用FDS诊断乳腺导管内占位性病变有临床参考价值,辅助手术定位准确,有助于获得满意的手术治疗效果。     

乳腺导管内癌与乳腺浸润性导管癌的超声特征及病理对照分析

目的探讨乳腺导管内癌与乳腺浸润性导管癌的超声特征及病理情况。方法选取2014年2月至2016年1月间广东省肇庆市第一人民医院收治的45例乳腺导管内癌患者与45例乳腺浸润性导管癌,分析两种乳腺癌患者的超声声像特点与病理情况的差异。结果两种乳腺癌患者的病灶大小、形状、血流信号、病灶周边毛刺与边界情况比较,差异均有统计学意义(均P<0.05)。结论乳腺导管内癌与乳腺浸润性导管癌的超声特征及病理情况上有差异明显,有助于临床疾病的鉴别诊断。     

数字化X线定位系统下Mammotome微创活检在乳腺癌早期诊断中的应用

目的:探讨数字化俯卧式X线定位系统下Mammotome微创切除不可触及乳腺病灶在乳腺癌早期诊断的临床应用价值。方法:2004年12月~2005年5月,应用LORAD数字化俯卧式穿刺床X线立体定位系统引导下Mammotome系统对67例患者73个临床不可触及乳腺钼靶X线片表现为可疑病灶进行微创切除活检。73个病灶中X线摄片:42例为孤立簇状聚集钙化,27例为不规则致密影并簇状钙化,4例为局部腺体结构扭曲。术前BIRADS评级Ⅲ、Ⅳ和Ⅴ级分别为51、17和5个。结果:67例患者73个病灶,乳腺癌13个(17.8%),其中4个为乳腺导管内癌,3个导管内癌并早期浸润,6个浸润性导管癌。良性病变60个(82.1%)。13个乳腺癌术后分期:2个为0期,9个为Ⅰ期,2个为ⅡA期,13个中11个为早期乳腺癌(84.6%)。结论:应用LORAD数字化俯卧式X线立体定位系统引导下Mammotome系统微创活检不可触及乳腺X线摄片发现的微小病灶,是一种确诊早期乳腺癌的微创方法。     

乳腺导管内癌及小叶原位癌的治疗策略

早期乳腺癌是指发生于乳腺导管或小叶的原位癌，有关早期乳腺癌的治疗策略争议较大，本文复习有关文献对其治疗策略进行了评述。１局部处理１．１导管内癌乳腺导管内癌（ductalcarcinomainsitu，DCIS）是指肿瘤局限于乳腺导管系统，未侵犯基底膜和周围间质阶段的乳腺癌。８０％的DCIS是由钼靶摄片诊断，随着钼靶摄片检查技术的改进与应用的普及，DCIS的检出率大大提高。在美国，自广泛开展乳腺钼靶检查以来，DCIS的临床检出率提高了７倍。１９９６年，DCIS占乳腺癌的１２％，占钼靶摄影检查检出乳腺癌的３０％犤１犦。既往通常按组…     

单发性乳腺导管内乳头状瘤的微创诊治

目的探讨超声引导下麦默通旋切术在单发性乳腺导管内乳头状瘤微创诊治中的意义。方法 回顾性分析63例行超声引导下麦默通旋切术切除单发性乳腺导管内乳头状瘤病例的临床资料。结果 61例患者术后病理示导管内乳头状瘤。随访2-4年,未见复发。1例患者术后病理示导管内乳头状瘤伴重度不典型增生,行乳腺单切术。1例冷冻病理提示导管内乳头状瘤癌变,行乳腺癌改良根治术。旋切术后2例患者出现皮下血肿,无特殊处理,半年后消失。结论 超声引导下麦默通旋切术可作为一种新的微创切除单发性导管内乳头状瘤的手术方式。     

中国抗癌协会乳腺癌诊治指南与规范(2011版)

一乳腺癌筛查指南二常规乳腺X线检查和报告规范三乳腺超声检查和报告规范四常规乳腺MRI检查和报告规范五影像引导下的乳腺组织学活检指南六乳腺癌术后病理诊断报告规范七浸润性乳腺癌保乳治疗临床指南八乳腺癌前哨淋巴结活检临床指南九乳腺癌全乳切除术后放射治疗临床指南十乳腺癌全身治疗指南十一乳腺癌患者康复治疗共识十二乳房重建与整形临床指南十三乳腺导管原位(内)癌治疗指南     

数字化X线定位系统下Mammotome微创活检在乳腺癌早期诊断中的应用

目的：探讨数字化俯卧式X线定位系统下Mammotome微创切除不可触及乳腺病灶在乳腺癌早期诊断的临床应用价值.方法：2004年12月～2005年5月,应用IORAD数字化俯卧式穿刺床X线立体定位系统引导下Mammotome系统对67例患者73个临床不可触及乳腺钼靶X线片表现为可疑病灶进行微创切除活检.73个病灶中X线摄片：42例为孤立簇状聚集钙化,27例为不规则致密影并簇状钙化,4例为局部腺体结构扭曲.术前BIRADS评级Ⅲ、Ⅳ和Ⅴ级分别为51、1 7和5个.结果：67例患者73个病灶,乳腺癌1 3个（1 7.8%）,其中4个为乳腺导管内癌.3个导管内癌并早期浸润.6个浸润性导管癌.良性病变60个（82.1%）.13个乳腺癌术后分期：2个为0期.9个为Ⅰ期.2个为ⅡA期.13个中11个为早期乳腺癌（84.6%）.结论：应用LORAD数字化俯卧式X线立体定位系统引导下Mammotome系统微创活检不可触及乳腺X线摄片发现的微小病灶.是一种确诊早期乳腺癌的微创方法.     

Significance of histopatholoaical evaluation in primary therapy for breast cancer-recent trends in primary modality with pathological complete response(pCR) as endpoint

In recent years, primary therapy has been used to improve the prognosis of patients with locally advanced breast cancer and to expand the indication for breast conserving treatment for patients with a relatively early stage of breast cancer. In addition, the therapeutic efficacy of primary therapy has been evaluated on the basis of pathological findings and pathological complete response (pCR)is considered to be a main target of primary therapy. The results of NSABP protocol B-18 and B-27, and the Aberdeen trials confirmed the prognostic significance of pCR in primary therapy and indicated the significance of minute pathological assessment. However, the criteria of pathological response is not yet universal, but the evaluation of the main invasive tumor, intraductal component and the regional lymph nodes, is thought to be necessary, shown by the "Histopathological Criteria for Assessment of Therapeutic Response in Breast Cancer" compiled by the Japanese Breast Cancer Society. Among these criteria, there exist methodological variations as to the evaluation of residual disease of intraductal carcinoma, thus some controversies exist. The presence of intraductal component might be negligible with regard to prognosis, but might be an important risk factor for local recurrence after breast conserving therapy. In the future, participation by the pathologist in the field of primary therapy for breast cancer will be a matter of course in most clinical studies.     

Positron emission mammography: high-resolution biochemical breast imaging

Positron emission mammography (PEM) provides images of biochemical activity in the breast with spatial resolution matching individual ducts (1.5 mm full-width at half-maximum). This spatial resolution, supported by count efficiency that results in high signal-to-noise ratio, allows confident visualization of intraductal as well as invasive breast cancers. Clinical trials with a full-breast PEM device have shown high clinical accuracy in characterizing lesions identified as suspicious on the basis of conventional imaging or physical examination (sensitivity 93%, specificity 83%, area under the ROC curve of 0.93), with high sensitivity preserved (91%) for intraductal cancers. Increased sensitivity did not come at a cost of reduced specificity. Considering that intraductal cancer represents more than 30% of reported cancers, and is the form of cancer with the highest probability of achieving surgical cure, it is likely that the use of PEM will complement anatomic imaging modalities in the areas of surgical planning, high-risk monitoring, and minimally invasive therapy. The quantitative nature of PET promises to assist researchers interested studying the response of putative cancer precursors (e.g., atypical ductal hyperplasia) to candidate prevention agents.     

Ductal access for prevention and therapy of mammary tumors

In cancer patients and in those at high risk, systemic exposure to agents for therapy or prevention is accompanied by undesirable side effects. We hypothesized that it is possible to prevent and treat breast cancer by introducing anticancer agents into the mammary ductal network. Here, we show the efficacy of intraductally administered anticancer agents 4-hydroxytamoxifen and pegylated liposomal doxorubicin (PLD) in the prevention and treatment of breast cancer using the rat N-methyl-N'-nitrosourea-induced and spontaneous HER-2/neu transgenic mouse (neu-N) models of breast cancer. Intraductal administration of PLD to neu-N mice caused regression of established tumors and prevented tumor development more effectively than i.v. injection (P < 0.0001). Intraductal administration resulted in lower circulating levels of PLD compared with i.v. administration, with no evidence of systemic toxicity or long-term histopathologic changes in the mammary gland. Compared with systemic administration, intraductal injection provides direct access to breast lesions with higher local and lower systemic drug exposure. These studies suggest that this approach has potential for application to prevention and neoadjuvant therapy of early breast cancer.     

Therapeutic strategies for breast cancer based on histological type

Breast cancer has various histological types that reflect not only morphological features but also biological characteristics. Therefore, it is not an exaggeration to say that breast cancers of different histological types are different diseases. It is generally accepted that the histological types of breast cancer are clinically significant because they serve as prognosticators and as the common language for improving the accuracy of clinical diagnosis. It is necessary to diagnose breast cancer at the level of not only histological findings by needle biopsy, but also the histologic type based on diagnostic imaging and cytological diagnosis. From the viewpoint of treatment, preoperative drug therapy is being performed more frequently to shrink tumors before breast-conserving therapy or to determine treatment sensitivity. The prognosis is favorable for patients who respond completely or patients in whom interstitial infiltration is completely eliminated histopathologically, and, as a result, it is important to assess therapeutic efficacy clinically and pathologically. Past experience has shed some light on differentiating cancers responsive to drug therapy from those unresponsive to drug therapy, as well as differentiating cancers in which therapeutic efficacy can be easily ascertained from those in which therapeutic efficacy cannot be easily ascertained. Preoperative drug therapy can be planned by making a histological diagnosis based on needle biopsy findings. Preoperative drug therapy is not indicated for noninvasive carcinoma and papillotubular carcinoma (invasive carcinoma with predominant intraductal components). While complete loss of interstitial infiltration can be expected with solid-tubular carcinoma, it cannot be expected with other histological types, such as invasive lobular carcinoma, adenoid cystic carcinoma, or metaplastic carcinoma (squamous-cell carcinoma and spindle-cell carcinoma). On therapeutic response assessment, the clinical and pathological findings generally match for solid-tubular carcinoma but not for scirrhous carcinoma and invasive lobular carcinoma. With mucinous carcinoma, mucus accumulation can remain, even though most cancer cells disappear; as a result, assessment based on tumor diameter changes is difficult. Histological diagnosis is also significant from the viewpoint of drug sensitivity, and it is important to maintain the accuracy of histological diagnosis.     

乳导管镜联合麦默通在微创切除乳腺管内微小肿物中的应用

目的：探讨超声引导下乳导管镜联合麦默通微创旋切系统在切除乳腺导管内微小肿物中的应用价值。方法：60例于我科就诊的乳头溢液病例,溢液涂片中见到增生细胞,细胞学1—2级。经乳管镜诊断为乳腺导管内微小肿物的女性患者,在超声引导下行乳导管镜联合麦默通微创旋切术,术后随访3—6个月。结果：60例乳腺导管内微小肿块在乳导管镜及彩超指引下麦默通微创旋切完整切除,病理结果阳性率100％,其中2例为导管内原位癌,1例为浸润性导管癌,其余均为导管内乳头状瘤,术后59例患者无手术疤痕。结论：超声引导下乳腺导管镜联合麦默通微创旋切乳腺导管内微小肿物具有定位准确、病理诊断明确、切除完整率高、创伤小、美观等优点。     

乳管镜用于乳腺导管内乳头状瘤的临床诊治研究

目的:评价纤维乳管镜对乳管内乳头状瘤类疾病的诊断及治疗作用。方法:选取我科2009年8月-2011年8月经乳管镜诊断为导管内乳头状瘤患者144例,其中血性溢液78例,褐色溢液51例,深黄色溢液15例。回顾性分析其术前诊断及治疗过程。结果:所有病例在乳管镜下可见导管内肿物,并经镜下定位行病变腺叶切除,术后病理132例诊断为乳管内乳头状瘤,7例诊断为原位癌,3例为早期浸润性癌。结论:纤维光导乳管镜可准确诊断乳管内乳头状瘤,并进行定位切除。对此类疾病的诊治有重要应用价值。     

Non-invasive breast carcinoma

Summary Non-invasive breast cancer is comprised of two distinct entities: lobular carcinoma in-situ (LCIS) and ductal carcinoma in-situ (DCIS). The natural history of each clinical entity is described and a biologic interpretation of the available data is offered. Lobular carcinoma in-situ is considered only a risk marker rather than a precursor for the subsequent development of invasive cancer, so that once the diagnosis is established, further operative intervention is unnecessary and serial follow-up alone is recommended. The treatment of ductal carcinoma in-situ must take into account that breast-preserving therapy is now considered optimal treatment of invasive cancer of the breast, the disease we are trying to prevent. The pitfalls of recommending treatment based on retrospective data is emphasized and the need to support clinical trials designed to determine the optimal therapeutic management of intraductal carcinoma is affirmed.     

The intraductal component of breast cancer is poorly responsive to neo-adjuvant chemotherapy

Neo-adjuvant chemotherapy has been used for locally advanced breast cancers. With special attention to the proportion of intraductal component, we pathologically studied 25 patients that underwent neo-adjuvant chemotherapy via intra-arterial infusion or intravenous injection. In general, neo-adjuvant chemotherapy had a favorable effect on tumor reduction. The effectiveness varies depending on the predominance of intraductal component. The cases with a high proportion of intraductal component had lower response to the chemotherapies. The larger number of cancer cells remained within the mammary ducts. The residual cancer cells conserved proliferative activity. Intraductal component is poorly responsive to neoadjuvant chemotherapy.     

Clinical management of minimal breast cancer

Minimal breast cancer includes three different entities: lobular carcinoma in situ, noninfiltrating intraductal carcinoma, and invasive carcinoma less than 0.5 cm. The common feature is their small dimensions and the fact that they are often clinically occult. For lobular carcinoma in situ the risk of developing an invasive carcinoma varies from seven to nine times compared with the general population and a careful follow-up of the patients with frequent mammograms is therefore suggested. Intraductal noninfiltrating carcinoma should be locally treated as an invasive carcinoma of small size, and therefore an extensive mammary resection like the quadrantectomy, plus radiotherapy is the recommended form of treatment, while the axillary dissection may be avoided. Finally, small invasive carcinomas should be treated with conservative procedures, including a total axillary dissection.