应用细针吸取细胞技术诊断乳腺导管病变的细胞学指标

目的 探讨采用细针吸取细胞学(FNAC)诊断乳腺导管病变的有效和联合的指标,以建立有效的乳腺导管病变FNAC诊断模式.方法 收集澳门镜湖医院6年内400例有随访结果的乳腺FNAC病例作回顾性分析.按组织学诊断结果分为导管上皮非增生性病变(104例)和增生性病变(163例)及癌(133例)三组,对涂片进行60个细胞学指标分析,再根据各指标的程度或量采用半定量分级评估.以组织学诊断结果为金标准对病变分类,研究各指标对诊断导管病变的意义.采用Logistic多重回归模型和分类树模型进行统计学分析.结果 (1)400例良、恶性病变组,上皮细胞团中掺杂肌上皮细胞(P<0.05)、上皮细胞排列成大的细胞团(P<0.05)、上皮细胞排列成小的细胞团(P<0.05)、细胞质内空泡(P<0.05)和细胞套细胞(P<0.1)为有统计学意义的鉴别诊断指标.最重要的鉴别指标为上皮细胞团中有无掺杂有肌上皮细胞.良性病变的诊断指标为上皮细胞团中掺杂有肌上皮细胞,联合大量的上皮细胞排列成大的细胞团,94.4%为良性病变,中等至大量的上皮细胞排列成小的细胞团,倾向为增生性病变;癌的诊断指标为上皮细胞团中无掺杂肌上皮细胞,上皮细胞排列成小的细胞团,细胞质内空泡和细胞套细胞.上皮细胞团中无掺杂肌上皮细胞时,癌占81.3%.(2)267例非增生性和增生性良性导管上皮病变组,上皮细胞团中见不规则的细胞间腔隙(P=0.001)、上皮细胞团成松散排列(P<0.05)和细胞核深染(P<0.1)为诊断增生的有意义指标.两结构指标在涂片中出现的量越多,越提示为增生.单一上皮细胞团中见不规则的细胞间腔隙,增生性病变占70.1%;当中等至大量时增生占82.7%,若同时伴上皮细胞团成松散排列,诊断增生的阳性预测价值为87.5%.(3)伴不典型细胞学改变的35例中,组织学诊断26例增生,多为导管上皮增生性纤维腺瘤,极少数为不典型增生或癌.结论 在乳腺病变FNAC诊断中,结构指标较细胞指标更重要,联合指标和对其量的评估可更有效地鉴别良恶性病变、非增生性和增生性良性病变;对伴不典型细胞学改变的病例应避免误诊为癌,均应组织活检.

Fine needle aspiration cytology diagnosis of ductal lesions of breast

Objective To find out the most effective and combined cytomorphologic criteria trying to set up an effective diagnostic model for breast ductal lesion in fine needle aspiration cytology (FNAC).Methods A total of 400 breast FNAC cases were collected with follow-up information of more than six years. A retrospective analysis including 104 non-proliferative breast diseases,163 proliferarive breast diseases and 133 carcinomas basing on the diagnostic results of surgical biopsies. Altogether,60 cytomorphologic variables were counted for the evaluation of each case,including 4 main categories: the cellularity and components,natures of background,cellular arrangements and the cellular features. According to the quantity or the classification stage,the variables were semi-quantitatively scored. Multiple step-wise logistic regression (SPSS)and classification tree model (SAS)were performed to determine the significant and combined variables predictive for the diagnosis of non-proliferative lesion,proliferative breast diseases and carcinoma,respectively. Results (1)Among 400 benign and malignant cases studied,and basing on the result of analyses of multiple step-wise logistic regression system,intermingling of myoepithelial cells within the epithelial cluster (P < 0. 05 ),presence of large epithelial cell cluster (P < 0. 05),presence of small epithelial cell cluster (P < 0. 05),cytoplasmic vacuoles (P < 0.05)and figures of "progressive intussusception" of cells (P <0. 1)were selected as the effectively differential diagnostic criteria for the benign and malignant lesions. However,according to the classification tree model,the most useful variable selected associating with the benign lesion was intermingling of myoepithelial cells within epithelial cluster. The diagnostic accuracy will be increased to 94. 4% ,if another criterion,presence of a big amount of large epithelial clusters,was used as the second useful variable in combination. Presence of a moderate to large amount of small epithelial cell clusters were indicative of proliferative lesion. If the criterion of myoepithelial cells intermingling within epithelial cluster was not found in the sample and associating with presence of small epithelial cell clusters,cytoplasmic vacuoles and figures of " progressive intussusception" of cells,mostly (81. 3% ),it would be considered as a case of carcinoma. (2)Among 267 benign non-proliferative and proliferative breast diseases studied,both the multiple step-wise logistic regression and classification tree model,presence of irregular intercellular spaces within the epithelial clusters (P =0. 001),loose epithelial clusters (P < 0.05)and hyperchromasia (P < 0. 1)were selected as the significant differential diagnostic criteria for the proliferative lesion. The architectural variables and the amount of the abnormal cell features such as cell cluster formation were considered to be more important. A high frequency of presence of irregular intercellular spaces within the epithelial clusters and the amount of loose epithelial clusters indicatd a higher possibility of a proliferative lesion. Presence of a single variable of irregular intercellular spaces within the epithelial clusters had the possibility of a benign lesion diagnosis up to 70. 1 % in all the proliferative breast disease cases collected in this series. If the frequency of irregular intercellular spaces increased to a moderate degree or even higher,the possibility of a benign lesion would be increased to 82. 7%. The possibility of a proliferative breast disease would be reached to 87.5% ,if both the criteria of irregular intercelluaar spaces and loosely arranged epithelial cell clusters were counted in combination. (3)The histological results of 35 lesions with atypical cytological features in FNAC specimens were predominanty a proliferative lesion of the breast (26 cases),and most of them we a refibroadenoma with ductal hyperplasia. Occasionally,there might be a few benign casea complicating with lesions of atypical hyperplasia or carcinoma. Conclusions In breast FNAC diagnosis,a combined evaluation of significant variables and the amount of the variable involved are effective for the differential diagnosis between benign/malignant and non-proliferative/proliferative lesions. Lesion accompanying with atypical cellular features should avoid to be overdiagnosed as carcinoma,and biopsy for a histological diagnosis is indicative.