乳腺病例浅谈.ppt

乳腺病例浅谈,聊城二院kkmm007,乳腺肿瘤,一位84的老太太由于乳腺结节做了乳腺切除及腋窝淋巴结清扫，大体检查有2个结节，一个5x3.5，另一个直径2cm。An84yearoldwomanhadatotalmastectomywithaxillarydissectionforabreastnodule.Themainmasswas5x3.5cm,anda2cmmasswasnearby.,Whatisyourdiagnosis?,伴有导管原位癌成份的浸润性分泌性癌Invasiveapocrinecarcinomawithaninsitucomponent,浸润性分泌性癌在乳腺癌中是一个不太常见的类型，约占所有乳腺癌的1-4%，在老年妇女中比浸润性导管癌更为常见。通常显示一个囊内结节，镜下，肿瘤由界限较清的细胞组成，具有颗粒状嗜伊红的细胞质，多具有泡状细胞核和明显的核仁和可以见到的猪嘴样的腺体，这种诊断仅限于具有明显顶浆分泌改变和明显恶性的肿瘤中。,Invasiveapocrinecarcinomaisanuncommonsubtypeofbreastcarcinoma,representing1-4%ofallcarcinomas.Ittypicallyaffectsolderwomenthaninfiltratingductalcarcinoma(BreastCancer2019;9:43).Grossly,itmaypresentasamuralnodulewithinacyst.Microscopically,thetumorsarecomposedofcellswithdistinctcellmargins,eosinophiliccytoplasmandgranules.Theyhavevesicularnucleiwithprominentnucleoli,andmayhaveglandswithapocrinesnouts.Thisdiagnosisshouldbelimitedtotumorswithwidespreadapocrinechangeandobviousmalignancy.,CaseoftheWeek#62,一位22岁的女性伴有逐渐增大的右侧乳腺结节，2个月病史，无乳头溢液，本人否认曾用过激素或其它药物，肿块外观无炎症改变，切除肿块重540克，14x11x4cm,实性，卵圆形，边界较清，切面白色，质较硬，散在裂隙样改变，A22yearoldCaucasianwomanhadatwo-monthhistoryofanenlargingrightbreastmass.Therewasnonippledischargeandshedenieduseofhormonesorotherdrugs.Themasswastendertopalpationwithoutanyexternalsignsofinflammation.Theresectedspecimenwas540grams,14x11x4cm,solid,ovoidandwell-circumscribed.Thecutsurfacewaswhite,firmandhomogenouswithafewscatteredslit-likespaces(Figures1,2).Lowandmediumpowershowedlargehyperplasticlobuleswithaproliferationofductulesandacini.Fewductsweredilated(Figure3,4,5).Theenlargedlobuleswerestronglyimmunoreactiveforcytokeratin8(Figure6).,中低倍观察可见到较大的扩张的小叶伴有小叶内腺管和核的增生，几乎没有导管扩张，扩张小叶组化CK8阳性。,硬化似乎开始于小叶的中央并向周围放射，腺泡周围纤维化明显，马氏三色染色可见小叶内纤维化，Thesclerosisseemedtostartatthecenterofthelobuleandradiatetowardstheperiphery,incarceratingtheaciniwithseverefibrosisandatrophy(Figure7,8).TheTrichromestainhighlighteddenseinterlobularfibrosisandapeculiarperiacinarsclerosiswithaglomeruloidpattern(Figure9,10).Themyoepithelialcellswereprominentintheseareas,asdemonstratedbyCalponinimmunoreactivity(Figure11),Whatisyourdiagnosis?,乳腺硬化性小叶增生Sclerosinglobularhyperplasiaofthebreast,硬化性小叶增生是一个不太常见的病变，多表现为小叶显蓍增生和小叶内间质的弥漫性纤维化，几乎均发生于年青女性，病人通常短期内可发生一个无痛性的边界较清的包块，此类病变首先被KOYI报道了18例，多发生于28-32的年龄。,Sclerosinglobularhyperplasiaisanuncommonlesionofthefemalebreastcharacterizedbyprominenthyperplasiaofthelobuleswithsevereandextensivefibrosisoftheintralobularstroma,andtoalesserdegree,theinterlobularparenchyma.Itoccursalmostexclusivelyinyoungwomen.Patientsgenerallycomplainofapalpable,painlessorslightlytenderandwell-definedlumpinthebreastofshortduration.ThislesionwasfirstreportedbyKovietal(1)whodescribeditinagroupof18patients,mainlyyoungwomen.ItispossiblethatCheatle(2)in1922wasreferringtothesamelesion.Themeanageofpatientsis28to32years,witharangeof12to46years(3).,在最初的文章中此类病变多被描述为伴有增生小叶的纤维性肿瘤，另一些作者认为是乳腺腺病，临床鉴别诊断包括青少年巨大纤维腺瘤或青少年乳腺发育，和叶状囊肉瘤，但这些病变均没有小叶的硬化。病理上，切除标本从小的卵圆形的1cm实体性肿瘤到大的实体性肿瘤均可见到，FNAC无特异性改变并与乳腺纤维性肿瘤有重叠，包括平铺的片状卵圆形的导管上皮细胞呈腺泡样排列，在干净的背景下散在裸核细胞和不定数目的基质碎片。硬化性小叶性增生的自然病程不清，但没有恶性或切除后复发的报道,Itsrelationtofibroadenomaorfibroadenomatoidchangesaroundthehyperplasticlobuleswasnotedintheoriginalarticle,andsomeauthorshaveredefinedthislesionasfibroadenomatosis,fibroadenoidmastopathy,orfibroadenomatoidhyperplasia(1,4).Inourcase,thisfeatureisnotpresent.Theclinicaldifferentialdiagnosisincludesgiantjuvenilefibroadenomaandjuvenilehypertrophyinyoungerpatients,andphyllodestumorinolderpatients.Noneoftheselesionshavebeenassociatedwithlobularsclerosis.Pathologically,theresectedspecimensvaryfromsmallovoidandwhitesolidtumorsof1cmuptolargesolidtumors.Fineneedleaspirationfindingsarenonspecificandoverlapwithfibroadenoma,includingflatsheetsofovalductalepithelialcellsinanacinararrangement,afewbarenucleiinacleanbackgroundandvariablestromalfragments(5,6).Thenaturalcourseofsclerosinglobularhyperplasiaisnotknown.However,noassociationwithmalignancyorrecurrencehasbeendocumented.,CaseoftheWeek#45,Clinicalhistory一位72的女性病人由于X线发现钙化行乳腺切除术，过去史无异常A72yearoldwomanwithnopriorhistoryunderwentalumpectomyforcalcificationsonhermammogram,Whatisyourdiagnosis?,伴有神经内分泌分化的低级别导管内癌LowgradeDCISwithneuroendocrinefeatures,免疫组化Syn证实肿瘤细胞伴有神经内分泌分化Animmunostainforsynaptophysinconfirmedtheneuroendocrinenatureofthetumorcells(image9,image10,神经内分泌型导管内癌较少见，它亦被称做管内型乳头状癌。它特征性的出现于60岁或以上的老年妇女，总伴有乳腺肿块或乳头溢液，它通常与伴有派杰氏病样的导管内乳头状瘤一起出现，尽管是一个低级别肿瘤，但也可伴有浸润性成分，浸润性成分多可见粘液或神经内分泌特征。,Neuroendocrine-typeDCISisararevariant,thatisalsocalledintraductalpapillarycarcinoma.Ittypicallyoccursinwomenage60yearsorgreater,andisoftenaccompaniedbyabreastmassornippledischarge.Itisfrequentlyassociatedwithintraductalpapillomawithpagetoidinvolvementbythetumorcells,anddespiteitslowgradenature,mayhaveaninvasivecomponent,whichoftenhasmucinousorendocrinefeatures,显微镜下，肿瘤呈实性生长，或可见菊形团样改变，细胞呈多角形，卵圆形或细长型，具有温和和、卵圆形的细胞核，也可伴有胞质内嗜碱性粘液聚集，间质纤维多少不定但通常常没有坏死。细胞学涂片显示单一的浆细胞样细胞和乳头状分叉样结构。,Microscopically,thetumorhasasolidgrowthpattern,ormayhaveneuroendocrine-likefestoonsandrosettesandaprominentfibrovascularsepta.Thecellsarepolygonal,ovalorspindled,withabundantgranulareosinophiliccytoplasmandbland,ovalnuclei.Theremaybeaccumulationofbasophilicintracellularmucin.Stromalfibrosisisvariable.Thereisusuallynonecrosis.Cytologicsmearsshowplasmacytoidtumorcellsandarborizingpapillaryfronds,CaseoftheWeek#37,临床病史Clinicalhistory一位49岁的中年妇女因以前组织学诊断为乳腺低级别导管原位癌而行乳腺肿块的针吸活检，穿出9mm病变，但并没有多灶性DCIS的改变，上皮显示了典型的纤维性肿瘤特点，但存在一些不典型细胞，没发现核分裂像。,A49yearoldhealthywomanunderwentneedlelocalizationexcisionofabreastmassforbiopsyprovenlowgradeductalcarcinomainsitu.A9mmlesionwasidentifiedhistologicallyadjacentto,butnotinvolvedby,multifocalDCIS.Theepithelialcomponentinthenoduleshowedthetypicalcytoarchitectureoffibroadenoma,butalsohadsomeatypicalcells.Nomitoticfigureswerefound.,Whatisyourdiagnosis?,伴有奇异型间质巨细胞的纤维腺瘤(对于此标本的这部分区域)Fibroadenomawithbizarrestromalgiantcells(forthisportionofthespecimen),显微镜下显示间质细胞显著增大，核染色较深伴有多形性核，很多间质细胞内可见核内假包含体，同时乳腺亦显示了小灶性低级别DCIS的特点，也包含在了此病变的诊断中。,Themicroscopicimagesshowstromalcellswithmarkedlyenlargedandhyperchromatic,pleomorphicnuclei.Manyofthestromalcellsshowedmultinucleatedformsorprominentround,intranuclearpseudoinclusions.TheremainingbreastshowedfociofDCISwithlowgradenuclearfeatures,whichofcoursewasincludedwithinthefinaldiagnosis.,组织学特点往往是区分良恶性实体性病变的可靠指标，明显增大的多形性的核通常被视为恶性的特点，但偶尔此类病变会存在于明显良性的肿瘤中，这种核呈恶性样改变但病变呈良性的形态有时在多形性子宫平滑肌瘤中会遇到(称为退行性改变)。退行性型异型还可在以下病变中见到，如成骨性肿瘤，软骨粘液纤维瘤，肾嗜酸细胞肿瘤，间质增生的前列腺癌，子宫内膜息肉，唾液腺腺瘤多形性腺瘤（1-4），以及在内分泌肿瘤。在乳腺纤维腺瘤中类似的核的变化很少看到。,Well-definedhistologicalparameterstypicallyarereliableindicatorstodifferentiatebenignfrommalignantentities.Thepresenceofenlargedandpleomorphicnucleiisclassicallyregardedasafeatureofmalignancy,butmayonoccasionbeevidentinlesionswithcompletelybenignbehavior.Thisdiscordancebetweennuclearatypiaandbehaviorischaracteristicallyencounteredinuterineleiomyomas(referredtoas“symplastic”change),orschwannomas(describedas“ancientchange”).Degenerativetypeatypiahasalsobeendescribedinosteoblastoma,chondromyxoidfibroma,fibrodysplasia,renaloncocytoma,stromalhyperplasiaoftheprostate,endometrialpolyps,andsalivarypolymorphicadenoma(1-4),aswellasinendocrineneoplasms.Similarnuclearchangesarisinginmammaryfibroadenomasareonlyseenrarely.,组织学结构上，伴有奇异巨大间质细胞的纤维腺瘤通常如此例所见，这种奇异的巨间质细胞通常具有细胞质，没有核分裂像，在乳腺病变中其它具有非典型性间质细胞的病变包括叶状肿瘤、肉瘤、化生性乳腺癌，鉴别诊断中包括缺乏基质的过度生长，细胞拥挤重叠和核分裂像，最重要的是，细胞核呈“粉尘”样改变。当多核的巨细胞出现核分裂，坏死，基质过度生长或其它的明显病变时，通常要考虑叶状肿瘤,Architecturally,theoverallpatternoffibroadenomawithbizarrestromalgiantcellsisthatoftheusualfibroadenoma,butwithdiffusestrikingnucleomegalyofthestromalcells,accompaniedbyadequatecytoplasm.Mitoticfiguresarenotablyabsent.Otherneoplasticlesionsinthebreastthatshowatypicalstromalcellsincludephyllodestumor,sarcoma,andmetaplasticbreastcarcinoma.Distinctionfromtheseotherlesionscanbemadebyrecognitionofthelackofstromalovergrowth,cellularcrowdingandmitoticfigures,andmostimportantly,thelackofcrispnucleardetails(i.e.thechromatinis“smudgy”).Thepresenceofmultinucleatedgiantcellsincombinationwithmitoticactivity,necrosis,stromalovergrowthorhypercellularityraisesthequestionofanotherlesion,usuallyphyllodestumor(5).Thedegreeofatypiainfibroadenomawithbizarrestromalgiantcellsactuallyexceedsthatwhichtypifiesmalignantprocessesinthebreast,anotherdiagnosticclue.,伴有丰富细胞质的奇异性核的改变亦可见于放射治疗后，由于射线可抑制核分裂，细胞核变得很大，甚至可见核内假包含体，与放射引起的不同，伴有奇异巨细胞核的纤维腺瘤不伴有上皮和间质的异常，非典型性仅仅见于局灶性区域，且没有放射病史。,Bizarrenuclearalterationinthepresenceofabundantcytoplasmmayalsobeseenfollowingexternalbeamradiationtherapy.Duetoradiation-inducedinhibitionofcelldivision,thenucleusbecomesenlarged,acquiringbizarrefeaturesincludingpseudoinclusions.Unlikeradiationeffect,fibroadenomawithbizarrestromalgiantcellsshowsnoepithelialorvascularabnormalities,theatypiaiswell-localized,andthereisnohistoryofradiationexposure.,伴有奇异基质细胞的纤维腺瘤是一个不太常见的乳腺病变，很易于与叶状囊肉瘤等其它恶性变病相混淆，尤其在FNAC中，这种奇异核的改变与基质的退行性变有关，它们并不代表侵略性或恶性改变，治疗以保守切除为主。,Fibroadenomawithbizarrestromalcellsisanuncommonbenignentityinthebreastwhichcanbeeasilyconfusedwithphyllodestumororotherlesionswithmalignantstromalcells,particularlyinfineneedleaspirations(6).Thebizarrenuclearchangesarerelatedtodegenerativealterations,andtheydonotindicateaggressiveormalignantbehavior.Treatmentisconservativelocalexcision,whichiscompletelycurative.,CaseoftheWeek#35,ClinicalHistory一位54岁妇女左乳腺外上限有一个较大的肿块伴有乳头间断性溢液，皮肤及腋窝检查均阴性,她姐姐55岁患乳腺癌。切除送检。,A54yearoldwomanpresentedwithalargepalpableleftbreastmassintheupperouterquadrantandmildintermittentnippledischarge.Examinationwasnegativeforoverlyingskinchangesoraxillarynodalenlargement.Heroldersisterhadbreastcanceratage55.Anexcisionalbiopsywasperformed,大小不一的囊性扩张性病变，其内包含似甲状腺滤泡内胶质样的嗜伊红物质。Multiplevariablysizedcysts,containinganeosinophilichomogeneoussecretionsimilartocolloidinthyroidglandfollicles,大多数囊腔周围覆扁平的似良性的上皮，伴有腔内浓稠的基质。Manyofthecystsarelinedbybenign-lookingflattenedepithelium,withdenseinterveningintracysticstroma,镜下可见腔内分泌物显示与周围扇形排列的上皮有分隔Theintraluminalsecretionsshowcharacteristicmicroscopicartifacts-fine,parallelcracksandshrinkageofthecystcontentwithperipheralscalloping,其它囊腔内可见多层乳头状上皮细胞，核无明显异型性Othercystswerelinedbymultilayeredmicropapillaryintracysticproliferationscomposedofatypicalductalepithelialcellswithhighlypleomorphicnucle,Whatisyourdiagnosis?,囊性高分泌性导管内癌Cystichypersecretoryductalcarcinomainsitu,1984年，RosenandScott描述了一类特殊的，较少见的管内型乳腺癌，称做囊性分泌性导管癌，至今，仅有40余例囊性分泌性癌被报道，且大多为个案报道。大多数的此类病变都是管内型癌。但是，良性增生性病变，被称做管内型分泌性增生，也曾被报道过。一些导管分泌性癌可见到确切的上皮浸润到间质去，转移到腋窝淋巴结的也有报道。In1984RosenandScottdescribedadistinctive,rareformofintraductalcarcinomaofthebreast,whichtheycalledcystichypersecretoryductcarcinoma(1).Todate,lessthan40casesofcystichypersecretorylesionshavebeendescribed,mostlyascasereports.Mostoftheselesionsareintraductalcarcinomas;however,benignproliferativelesions,calledcystichypersecretoryhyperplasia,havealsobeendescribed.Somecasesofhypersecretoryductcarcinomademonstrateinvasiveareasoffranklymalignantepithelialcellsintothestroma(2-4).Metastasestoaxillarylymphnodehavealsobeenreported,囊性高分泌性癌的临床表现或乳腺X线摄片无特殊性。它们由可触及的明显结节组成，偶尔会有乳头间断性溢液，乳腺X线摄片不均匀的密度值或偶见和微小钙化偶尔可见到,Theclinicalmanifestationsormammographicfeaturesofcystichypersecretorylesionsarenon-specific.Theyconsistofapalpablebreastmassandoccasionallynippledischarge.Thereisamammographicasymmetricdensity,withoccasionalmicrocalcifications.,通常，乳腺囊性高分泌性癌和增生无法区分，它们类似于青少年多发性乳头状瘤，通常由较大的边界不太清楚的较韧的结节组成。纤维组织内可见多个小囊泡状物。诊断线索是囊泡内可见丰富的粘稠的液体。Grossly,cystichypersecretoryhyperplasiaandcarcinomaareindistinguishableandtheyresemblejuvenilepapillomatosisofthebreast.Thereisalarge,ill-definedfirmtorubberyspongymassoffibroustissuecontainingmultiplesmallcysts.Onediagnostichintisthepresenceofabundantthick,stickymucinwithinthecysts,囊性高分泌性病变完全由不同大小的囊泡样结构组成，一些相当大且呈螺旋状，囊内呈胶状物，腔内物边缘凝集且收缩，可能是由于标本处理所致。囊内壁衬覆上皮从较低平的温和的上皮到成簇的微小乳头状的增殖不等，而后面的病变形态可提示导管原位癌，当没见到后面这些形态时，可诊断囊内高分泌性增生，这些病变必须广泛取材以排除浸润性成分。,Cystichypersecretorylesionsarecomposedentirelyofcysticstructuresofvarioussizes,somequitelargeandconvoluted.Thecysticmaterialresemblescolloid,oftenwithparallelfracturelines,aretractionhaloaroundtheintraluminalcontents,andoverlappingduetoprocessing.Thecystwallliningvariesfromabland,attenuatedlowcuboidal,simpleepitheliumtoahighlytufted,micropapillaryproliferation.Theselatterareaswarrantadiagnosisofductalcarcinomainsitu.Intheirabsence,adiagnosisofcystichypersecretoryhyperplasiaisrendered.Theselesionsshouldbegenerouslysampledtoexcludethepresenceofaninvasivecomponent,组织学鉴别诊断包括良性管内柱状病变、青少年多发性乳头状纤维腺瘤、假性粘液囊肿、粘液腺癌、分泌性癌、哺乳期乳腺增生、但镜下改变足可以与以上区分。,Thehistologicaldifferentialdiagnosisincludesbenignintraductalproliferativelesions,juvenilepapillomatosis,mucocele-likelesions,mucinouscystadenocarcinoma,columnarcelllesions,secretorycarcinoma,andpregnancy-likehyperplasia.However,themicroscopicfeaturesonexcisionareinvariablyspecificenoughtoavoidmisinterpretation.,囊性高分泌性导管癌在FNA中无法诊断，囊性外观和温和的细胞形态总会造成纤维囊性改变的假阴性诊断。大多数的FNA在此类病变中的诊断不是阴性的就是提示恶性的，没有确切的指标来诊断，如果在FNA中见到丰富的甲状腺胶质样物同时伴有细胞的非典型性，此诊断可以考虑。,Cystichypersecretoryductalcarcinomaofthebreastrepresentsadiagnosticpitfallonfineneedleaspiration(FNA).Themulticysticappearanceandoftenblandcytologicalfeaturescancauseafalse-negativediagnosisoffibrocysticchanges.MostreportedFNAcytologycasesareeithernegativeorrevealcellssuggestiveofmalignancy,withoutthepossibilityofestablishingaspecificdiagnosis(3,4).Ifabundantthyroidcolloid-likesecretionsaccompanyingatypicalcellsareaspirated,thisdiagnosiscanbeconsidered.,总结：乳腺囊性高分泌性导管癌在乳腺管内癌中是一个较少见的类型，具有低级别的特点，但具有潜在性浸润和转移，应和乳腺其它病变相区分，重视细胞学检查，并对乳腺的分泌性病变做全面细致的检查是最重要的。,Insummary,cystichypersecretoryductalcarcinomaofthebreastisararedistinctivevariantofductalcarcinomainsituthattypicallybehavesinalow-gradefashionformanyyears,butneverthelesshasapotentialforinvasivegrowthandmetastases.Challengesincludedifferentiationfromotherbreastlesions,recognitionbycytologicexamination,andavoidingunderdiagnosisasabenignproliferativebreastlesiononlimitedhistologicalmaterial,Week315:Case4,一位45岁妇女X线检查发现乳腺高密度影，行局灶切除。ClinicalHistory:A45yearoldwomanwithasuspiciousdensityonmammographicexam.Anopenbiopsywasobtained.,Choosethecorrectdiagnosis:,AtypicalDuctHyperplasia(ADH)AtypicalLobularHyperplasia(ALH)腺样囊性癌(Adenoidcysticcarcinoma)胶原小体病(Mucinous/CollagenousSpherulosis),CS是一个非常少见的良性乳腺病变，在所有切除乳腺标本中要少于1%，本病特点是腔内可见嗜双色性的小球，腺腔由无异型性的上皮和肌上皮组成，CS中可存在钙化，其形态学特征与ADH或囊孔状的DCIS较难鉴别，有时其与一些浸润性病变如腺样囊性癌和浸润性筛状癌等较难鉴别。在腺样囊性癌中，小球体由基底膜样物质组成，很少看到浸润性成份和实性成分可帮助我们区分CS和ACC，最近的一组病例复习来自于MDAndersonCancerCtr，在大多数病例中CS是一个伴随性病变(41/59)，与ADH同时出现的为3/59，与LCIS同时出现的占15/59，但至今仍没有报道过CS是癌前病变。,Collagenous/Mucinousspherulosis(CS)arerarebenignbreastlesionswithanestimatedincidenceoflessthan1%inbreastsurgicalpathologyspecimens.CSarecharacterizedbythepresenceofeosinophilictobasophilicspherulesoccupyingluminathataresurroundedbymyoepithelialandepithelialcellswithoutcytologicatypia.CalcificationsmaybeassociatedwithCS.The揷ribriform?appearanceraisesthedifferentialdiagnosisofADHorcribriformDCIS.Attimes,thedifferentialdiagnosismayalsoincludeinvasivelesionssuchasadenoidcysticcarcinoma(ACC)andinfiltratingcribriformcarcinoma.LikeACC,thespherulesarecomposedofbasementmembranematerial.LackofaninfiltratingpatternandasolidcomponenthelpdifferentiateCSfromACC.InarecentstudyfromtheMDAndersonCancerCtr,CSwasassociatedwithbenignlesionsofthebreastinthemajorityofcases(41/59).AssociatedLCISwaspresentin15/59specimensandADHwasencounteredin3/59.However,thereisnoevidencetodatetoindicatethatcollagenousspherulosisisaprecancerouslesion.,Week299:Case4,ClinicalHistory:55year-oldfemalewithbreastbiopsy55岁女性行乳腺活检,Choosethecorrectdiagnosis:,a.TubularCarcinoma,Invasive浸润性管状腺癌b.Microglandularadenosis微腺性腺病c.Sclerosingadenosis硬化性腺病d.Tubularadenosis腺管性腺病,Youanswered:Microglandularadenosis,这例中可见不规则的小管状增生,这些小管呈圆形轮廓,这些单一细胞包绕粉红色的分泌物，这些小管腔结构在良性小叶之间显示浸润性改变，免疫组化显示管状周围无肌上皮细胞，这是微腺性腺病的典型特征。Histology:Inthisbreast,thereisanirregularproliferationofsmallglandularstructures.Thesesmallglandshaveroundedcontours,andconsistofasinglecelllayersurroundingdensepinksecretions.Thesmallglandsappeartoinfiltratebetweenandwithinbenignlobules.Immunohistochemicalstainsrevealanabsenceofmyoepithelialcellswithinthisglandularproliferation.Thesearethetypicalfeaturesofmicroglandularadenosis.,小管状癌也缺少肌上皮细胞，但与微腺性腺病不同，管状腺癌的腺体成角，伴有顶浆分泌，且间质纤维结缔组织增生，它们也缺少粉红色的腔内分泌物，硬化性腺病病变中央腺体稀少，外围是开放的管腔样结构，且硬化性腺病可见完整的肌上皮细胞，管状腺瘤缺少腔内分泌物且腺体周边会见到完整的肌上皮。,Discussion:Tubularcarcinomaissuggestedbytheabsenceofmyoepithelialcellswithinthisproliferation.However,incontrasttomicroglandularadenosis,theinvasiveglandsoftubularcarcinomaareangulated,frequentlyhaveapicalsnoutsandaresetinadesmoplasticstroma.Theyalsolackthepinkintraluminalsecretionsofmicroglandularadenosis.Sclerosingadenosisisalobulocentricprocessfeaturingcentrallycollapsedglandswithprominentmyoepithelialcells,andperipherallyopentubules.Sclerosingadenosishasintactmyoepithelialcellsthroughout.Tubularadenosisischaracterizedbybenignglandularproliferationwitha搒treamy?pattern.Thisproliferationlackstheluminalsecretionsofmicroglandularadenosis,andhasintactmyoepithelialcells.,Week291:Case1,53岁的HIV阳性病人乳腺结节ClinicalHistory:Thisisa53yearoldHIV+femalewithabreastmass.,Choosethecorrectdiagnosis:,a.MalignantLymphoma,DiffuseLargeCellType恶性淋巴瘤,弥漫性大细胞型b.InvasiveDuctalCarcinoma,WellDifferentiated浸润性导管癌,高分化型c.Smallcellcarcinoma小细胞癌d.InfiltratingDuctalCarcinoma,HighGrade高级别浸润性导管癌,Youanswered:InfiltratingDuctalCarcinoma,HighGrade,Week291:Case2,82岁妇女乳腺结节ClinicalHistory:Thisisan82year-oldfemalewithabreastmass.,Choosethecorrectdiagnosis:,a.Metaplasticcarcinoma化生性癌b.CystosarcomaPhyllodes,HighGradeMalignant叶状囊肉瘤,高级别c.Myofibroblastoma肌纤维母细胞肿瘤d.Gynecomastia杔ikechanges,Youanswered:Metaplasticcarcinoma,肿瘤由形态不同的梭形细胞增殖呈囊样结构,一些病变区域呈硬化的透明样变的纤维组织,在针吸活检中易误诊为非特异性的纤维性病变,但与少细胞区的纤维组织相连的是富于梭形细胞结构,伴有纤维性基质,可见席纹状结构,这些区域高分子量角蛋白34betaE12,andforp63阳性.Histology:Thetumorconsistsofavariablycellularspindlecellproliferationpunctuatedbycysts.Someofthelesionconsistsofdenselyhyalinizedfibroustissue,whichwouldbeeasytomistakeonneedlebiopsyasnon-specificbenignfibrosis.However,indirectappositiontothehypocellularfibrousareasaremorecellularareasfeaturingspindlecellssetinafibrousmatrix.Astoriformpatternisevident.Thesecellsareimmunoreactiveforhighmolecularweightcytokeratin34betaE12,andforp63.,叶状肉瘤是恶性间质环绕良性腺体呈分叶状结构,肌纤维母细胞肿瘤由温和的梭形细胞组成,基质为粘液状胶原.细胞的多型性,有丝分裂像和角蛋白阳性除外了后者的诊断,Discussio