【摘要】：背景:乳腺導(dǎo)管內(nèi)乳頭狀病變(Intraductal Papillary Lesion)是指以上皮細(xì)胞增殖被覆于乳頭狀纖維血管軸結(jié)構(gòu)為特征的一類病變,伴或不伴有肌上皮細(xì)胞被覆。病患多因發(fā)現(xiàn)乳頭溢液、乳房包塊就診。由于導(dǎo)管內(nèi)乳頭狀病變涵蓋良惡性病變,處理方式及預(yù)后各不相同,故對(duì)其作出準(zhǔn)確的診斷是必要的。但由于其臨床表現(xiàn)多樣,組織病理學(xué)復(fù)雜,對(duì)臨床醫(yī)生和病理醫(yī)生的準(zhǔn)確診斷存在著巨大挑戰(zhàn),各種輔助檢查的方法層出,尤其是術(shù)中冰凍病理對(duì)于術(shù)中指導(dǎo)乳腺病變的手術(shù)方式具有重大的意義,已是臨床上必不可缺的輔助診斷方法。目的:探乳腺導(dǎo)管內(nèi)乳頭狀病變的臨床特征及術(shù)前良惡性判斷及術(shù)中冰凍病理對(duì)此病變的診療作用。方法:對(duì)齊魯醫(yī)院自2010.1—2016.9住院行手術(shù)治療的石蠟病理診斷為乳腺導(dǎo)管內(nèi)乳頭狀病變的1169名女性患者的臨床及病理資料行回顧性分析。結(jié)果:1.構(gòu)成比:石蠟病理證實(shí)為導(dǎo)管內(nèi)乳頭狀變的患者1169名,占女性乳腺疾病就診的10.51%,其中惡性病變占1.35%。2.臨床表現(xiàn)及輔助檢查:此病主要以乳頭溢液和乳房腫物為主要表現(xiàn),其中良性者以乳頭溢液(41.20%)為主要臨床表現(xiàn),惡性者以乳房腫塊(63.83%)主要臨床表現(xiàn)。超聲是敏感性最高的檢查手段。存在乳頭溢液的病例,行乳頭溢液細(xì)胞學(xué)檢查者,存在一定的假陽性率,故不能作為病理依據(jù)指導(dǎo)手術(shù)。3.惡性病變的高危因素:各組病變的年齡差異具有統(tǒng)計(jì)學(xué)意義(p0.001),提示高齡是惡性病變的高危因素。部分涉及女性內(nèi)分泌改變的生物學(xué)特性,包括初潮年齡、月經(jīng)周期、孕次、產(chǎn)次具有統(tǒng)計(jì)學(xué)差異(p0.05),提示女性內(nèi)分泌改變與惡性者發(fā)展相關(guān)。吸煙史、糖尿病史、高血壓病史具有統(tǒng)計(jì)學(xué)差異(p0.05),提示周圍環(huán)境及代謝改變是惡性病變的高危因素。4.良惡性病變的鑒別診斷:良惡性病變間臨床表現(xiàn)為腫塊、鉬靶有惡性表現(xiàn)者提示為惡性病變;對(duì)存在溢液的病例,單孔、血性溢液、乳頭溢液腫瘤標(biāo)志物提示惡性病變(p0.05)。5.術(shù)中冰凍病理的價(jià)值:術(shù)中冰凍病理做出診斷與石蠟病理相同的有851例(66.64%),術(shù)中冰凍病理診斷為導(dǎo)管內(nèi)乳頭狀腫瘤而需要等待石蠟病理或免疫組化確診的病例147例(11.51%)。石蠟病理與之不符合的279例(21.85%),此中病理等級(jí)升高者79例(28.32%),病理等級(jí)一致者178例(63.80%),病理等級(jí)降低者22例(7.89%)。20側(cè)病例行二次手術(shù)。6.特殊的包裹性或?qū)嵭匀轭^狀癌的臨床特征:相較特殊的包裹性或?qū)嵭匀轭^狀癌與導(dǎo)管內(nèi)乳頭狀癌,在年齡、溢液性質(zhì)、絕經(jīng)期、平均月經(jīng)周期、DM病史、HBP病史等臨床特征上具有統(tǒng)計(jì)學(xué)差異(p0.05);相較包裹性或?qū)嵭匀轭^狀癌不伴浸潤者與該病變伴浸潤成分者,在這些方面未見明顯差異。結(jié)論:良性病變以溢液多見,惡性病變以乳房腫物多見。彩超對(duì)該病的檢出有重要意義,鉬靶具有提示良惡性的作用,病理性溢液的細(xì)胞學(xué)檢查不能作為病理診斷或手術(shù)的依據(jù)。高齡,初潮年齡小、月經(jīng)周期長、多產(chǎn)、多孕等涉及女性內(nèi)分泌的改變,周圍環(huán)境及代謝改變是惡性導(dǎo)管內(nèi)乳頭狀癌的高危因素。腫塊的存在、鉬靶異常表現(xiàn),對(duì)存在乳頭溢液的病例,單孔、血性溢液、溢液中腫瘤標(biāo)志物的高低在良惡性鑒別有意義。術(shù)中冰凍病理存在延遲診斷及誤診的現(xiàn)象,部分病例需要行二次手術(shù),該病變的準(zhǔn)確診斷還需依靠術(shù)后石蠟病理及免疫組化的支持。包裹性或?qū)嵭匀轭^狀癌在臨床特征上與導(dǎo)管內(nèi)乳頭狀癌有較大差異。
[Abstract]:BACKGROUND: The intraductal papillary lesion of the breast refers to a class of lesions characterized by the proliferation of epithelial cells to the vascular axis of the papillary fiber, with or without the coating of the myoepithelial cells. The patient was seen to see the nipple overflow and the breast-bag block for a visit. Since the intraductal papillary lesion covers benign and malignant lesions, the treatment and the prognosis vary, it is necessary to make an accurate diagnosis. However, due to the various clinical manifestations and the complex of the tissue pathology, there is a great challenge to the accurate diagnosis of the clinician and the pathologist, the method layer of various auxiliary examinations, in particular the intraoperative frozen pathology, has great significance for guiding the operation mode of the breast lesion during the operation, It is an auxiliary diagnostic method in clinic. Objective: To investigate the clinical features of intraductal papillary lesions of the breast and the diagnosis and treatment of preoperative benign and malignant tumors. Methods: The clinical and pathological data of 1169 female patients with intraductal papillary lesions were analyzed retrospectively. Results: 1. The composition ratio: paraffin pathology proved to be 1169 of the patients with intraductal papillary change, accounting for 10.51% of the women's breast diseases. Among them, the malignant lesions account for 1.35%. Clinical manifestation and auxiliary examination: The main manifestations of the disease are the nipple discharge and the breast mass, among which the benign ones are the main clinical manifestation of the nipple-overflow liquid (41.1%), and the malignant is the main clinical manifestation of the breast mass (63. 83%). Ultrasound is the most sensitive means of examination. There was a case of nipple discharge, and there was a certain false positive rate in the case of nipple discharge, so it could not be used as a pathological basis to guide the operation. High risk factors of malignant lesions: the age difference of each group was statistically significant (p0.001), suggesting that the advanced age was a high risk factor for malignant lesions. The part concerned with the biological characteristics of the change of the female's endocrine, including the first-wave age, the menstrual cycle, the pregnancy time and the second-generation time, which was statistically different (p0.05), suggesting that the change of the female endocrine is related to the development of the malignant. The history of smoking, the history of diabetes, and the history of hypertension were statistically different (p0.05), indicating that the surrounding environment and the metabolic changes were high risk factors for malignant lesions. The differential diagnosis of benign and malignant lesions: the clinical manifestation of the benign and malignant lesions was the mass, and the malignant lesion was indicated by the malignant phenotype of the target, and the malignant lesions (p0.05) were indicated in the case of the overflow liquid, the single hole, the overflow liquid and the nipple overflow tumor marker. The value of the frozen and pathological changes in the operation: the diagnosis of the intraoperative frozen pathology was the same as that of the paraffin pathology (66. 64%), and the intraoperative frozen and pathological diagnosis was the intraductal papillary tumor, and there were 147 cases (11.51%) to be diagnosed by paraffin pathology or immunohistochemistry. The pathological grade of paraffin in 279 cases (21. 85%), in which 79 (28. 32%), 178 (63. 80%), 22 (7.89%), 20-side case, and 6. The clinical characteristics of special package or real papillary carcinoma: the specific inclusion or real papillary carcinoma and intraductal papillary carcinoma have a statistically significant difference in the clinical features such as age, fluid nature, perimenopausal, mean menstrual cycle, DM history, and history of HBP (p0.05); There were no significant differences in these aspects of the non-invasive or real-sex papillary carcinoma without the infiltration of the patients with the lesion. Conclusion: The benign lesions can be seen in the overflow, and the malignant lesions are seen more in the breast. Color Doppler ultrasound is of great significance to the detection of the disease, and the target has the function of indicating good and malignant, and the cytological examination of pathological overflow can not be used as the basis for pathological diagnosis or operation. The changes of the endocrine of the female, the changes of the surrounding environment and the metabolic changes are the high risk factors of the intraductal papillary carcinoma. The presence of the mass and the abnormal performance of the target target showed that the high and low of the tumor markers in the case, single-hole, overflow and overflow of the nipple-overflow liquid were of great significance in the differentiation of benign and malignant. In the operation, there is a delay in the diagnosis and misdiagnosis of the frozen pathology. In some cases, the secondary operation is required, and the accurate diagnosis of the lesion also depends on the pathology of the paraffin and the support of the immunohistochemistry. Parcel or real papillary carcinoma has a large difference in clinical features with intraductal papillary carcinoma.
【學(xué)位授予單位】：山東大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R737.9

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