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1、乳腺病理要点-不典型增生,乳腺病理要点,纪小龙,(8)不典型增生,乳腺病理要点-不典型增生,已讲过,09-06-03 乳腺病理要点（7）冰冻09-03-11 乳腺病理要点（6）假浸润 08-12-03 乳腺病理系列讲座(5) 囊性病变 08-04-09 乳腺病理系列讲座(4) 增生08-03-12 乳腺病理系列讲座(3) 血管肿瘤08-01-09 乳腺病理系列讲座(2) 先天异常与炎症07-10-24 乳腺病理系列讲座（1）组织学基础,乳腺病理要点-不典型增生,女性癌症新发病例前五位,American Cancer Society, Surveillance Research, 2003,乳腺
2、病理要点-不典型增生,乳腺病理要点-不典型增生,我国女性乳癌的特点,近20余年来发病迅速上升发病年龄较西方年轻，约提前1015年高峰年龄为4549岁，且有双峰趋势乳腺较小而致密，不利X线检查,乳腺病理要点-不典型增生,病理的作用,有无癌明确的癌不难明确无癌不难够不够癌难治疗相关有条件不难无条件转诊,乳腺病理要点-不典型增生,乳腺病理要点-不典型增生,乳腺病理要点-不典型增生,Sir James Paget1st Baronet (11 January 1814 30 December 1899) a British surgeon and pathologist who is best rem
3、embered for Pagets disease and who is considered, together with Rudolf Virchow, as one of the founders of scientific medical pathology. three diseases named after him: Pagets disease of bonePagets disease of the nipple (a form of intraductal breast cancer spreading into the skin around the nipple),
4、and Extramammary Pagets diseaseAlso named for him is Pagets abscess.,乳腺病理要点-不典型增生,乳腺病理要点-不典型增生,乳腺增生病上皮细胞不典型增生程度分级,级，导管或腺泡上皮细胞增生24层，分化良好；级，上皮细胞增生超过4层，突向管腔内相互桥接或充满管腔，但极性存在，伴有轻度异型性的不典型增生；级，是导管扩张，细胞簇集成乳头状或完全充满管腔，排列紧密，有明显异型性的不典型增生。级为一般性增生、级为不典型增生。,Page, 1986,乳腺病理要点-不典型增生,David L. Page, M.D.,Professor of
5、Pathology and Preventive MedicineVICC MemberPathologistContact Information:Vanderbilt University Medical CenterC-3311 Medical Center NorthNashville, TN 37232-2561615-322-3759Research Specialty:Breast Cancer,乳腺病理要点-不典型增生,乳腺病理要点-不典型增生,乳腺病理要点-不典型增生,Dr. Susan Loves Breast Book, 2005. S. Love,乳腺病理要点-不典型增
6、生,Atlas of Breast Cancer, 2nd 2000. Hayes, ed.,乳腺病理要点-不典型增生,乳腺增生症谱系,小叶增生 腺病纤维腺病 纤维化腺病 硬化性腺病 纤维硬化症,乳腺病理要点-不典型增生,乳腺病理要点-不典型增生,DCIS,Ductal carcinoma in situ (DCIS)1. Solid type*2. Cribiform type3. Papillary type4. Comedo type*,乳腺病理要点-不典型增生,乳腺病理要点-不典型增生,乳腺病理要点-不典型增生,增生,原位癌,？,乳腺病理要点-不典型增生,乳腺病理要点-不典型增生,乳腺
7、病理要点-不典型增生,乳腺病理要点-不典型增生,乳腺病理要点-不典型增生,Tavassoli ：,“We are strong advocates, however, of the ductal intraepithelial neoplasia (DIN) and lobular intraepithelial neoplasia (LIN) terminology. ”“In summary, the terms DCIS and LCIS should be abandoned in favor of the more logical DIN and LIN terminology. ”
8、理由：临床医生、病人都不明白“原位癌”的含义而多数过治疗+精神压力其它部位已经采用the term intraepithelial neoplasia ，乳腺也不能例外,乳腺病理要点-不典型增生,从dysplasia 到 intraepithelial neoplasia(IN),Dysplasiamild moderate severe dysplasia( carcinoma-in-situ )intraepithelial neoplasia(IN)low-grade (L-IN) 单纯性增生（simple hyperplasia）不典型增生（atypical hyperplasia）再
9、生性增生（regenerative hyperplasia） 未定型异型增生(indefinite for dysplasia)high-grade (H-IN)high-grade adenoma/dysplasianoninvasive carcinoma (carcinoma in situ）suspected invasive carcinoma,乳腺病理要点-不典型增生,intraepithelial neoplasia (IN,IEN )上皮内瘤(变),Cervical intraepithelial neoplasia (CIN )Vulvar intraepithelial n
10、eoplasia (VIN )Gastric intraepithelial neoplasias (GIN) Pancreatic Intraepithelial Neoplasia (PIN )Prostatic intraepithelial neoplasia (PIN )角结膜上皮内肿瘤(conjunctiva-cornea intraepithelial neoplasia，CCIN )呼吸道、消化道、胰腺及胆管、乳腺、前列腺、泌尿道、女性生殖道和皮肤等器官组织肿瘤,乳腺病理要点-不典型增生,乳腺病理要点-不典型增生,轻度异型增生 中度异型增生 重度异型增生 原位癌,L- IN H
11、- IN,1970s,1990s,乳腺病理要点-不典型增生,Fattaneh A Tavassoli,Our first question is: If these conditions are not cancer (as stated by the authors), why are they designated as cancers? The term cancer has a tremendous impact on the patient and her family. Should all these women go through life thinking they hav
12、e cancer for lesions that are curable, and never metastasize or kill them? Our second question is: What does the term precancerous mean? Essentially all breast tissue is precancerous or pre-neoplastic given the fact that there is a potential for the development of breast carcinoma in most post-puber
13、tal breast tissuea potential that may never be realized and a risk that continuously increases with age. Are these lesions not proliferations that serve no physiologic purpose (i.e. not reversible), but display a risk (albeit of variable magnitude) for subsequent development of carcinoma? If so, the
14、n why not use the term intraepithelial neoplasia of ductal, lobular or papillary types?,乳腺病理要点-不典型增生,In all other body parts and organs, the term in situ carcinoma has been replaced by the term intraepithelial neoplasia. We have cervical intraepithelial neoplasia, vulvar intraepithelial neoplasia, p
15、rostatic intraepithelial neoplasia, pancreatic intraepithelial neoplasia, etc. Most pathologists who are using intraepithelial neoplasia for other sites would not object to the term intraepithelial neoplasia for breast lesions. Breast surgeons and oncologists who have not been exposed to this termin
16、ology and its justifications may not realize its value. These practitioners, however, follow guidelines set by societies and committees that introduce novel terms and concepts. There should not be any difficulty with the logical terminology of LIN and DIN.,乳腺病理要点-不典型增生,In summary, the terms DCIS and
17、 LCIS should be abandoned in favor of the more logical DIN and LIN terminology.,乳腺病理要点-不典型增生,Ductal intraepithelial neoplasia (DIN),DIN 1A: flat epithelial atypiaDIN 1B: atypical ductal hyperplasiaDIN 1C: DCIS grade 1DIN2: DCIS grade 2DIN3: DCIS grade 3,Adopted by new WHO book on Tumors of the Breas
18、t and Female Genital Organs,乳腺病理要点-不典型增生,乳腺病理要点-不典型增生,Intraductal Epithelial Proliferations,乳腺病理要点-不典型增生,Multilayered， no atypia,乳腺病理要点-不典型增生,florid ductal epithelial hyperplasia,乳腺病理要点-不典型增生,乳腺病理要点-不典型增生,乳腺病理要点-不典型增生,乳腺病理要点-不典型增生,乳腺病理要点-不典型增生,乳腺病理要点-不典型增生,乳腺病理要点-不典型增生,乳腺病理要点-不典型增生,乳腺病理要点-不典型增生,乳腺病理
19、要点-不典型增生,腔面上皮 CK7, CK8, CK18, CK19基底上皮 CK5/6, CK14, CK17肌上皮 CK5, CK14, CK17, SMA, calponin, p63,乳腺病理要点-不典型增生,乳腺病理要点-不典型增生,肌上皮myoepithelial cell, MEC,80年代 90年代 2000年代现在,S-100actin(肌动蛋白) muscle-specific actin,MSA(肌特异性肌动蛋白)-smooth muscle actin,-SMA (-平滑肌肌动蛋白)calponin CD10 P63(CK14和CK17 , GFAP ),乳腺病理要点-
20、不典型增生,乳腺病理要点-不典型增生,smooth muscle actin (SMA),乳腺病理要点-不典型增生,smooth muscle actin (SMA),乳腺病理要点-不典型增生,CD10,乳腺病理要点-不典型增生,CD10,乳腺病理要点-不典型增生,p63,乳腺病理要点-不典型增生,p63,乳腺病理要点-不典型增生,p63,乳腺病理要点-不典型增生,calponin,乳腺病理要点-不典型增生,calponin,乳腺病理要点-不典型增生,乳腺病理要点-不典型增生,The hyperplastic enlarged lobular unit (HELU),乳腺病理要点-不典型增生,小导管不典型增生,乳头实性筛状低乳头,乳腺病理要点-不典型增生,乳腺病理要点-不典型增生,乳腺病理要点-不典型增生,增生 不典型增生Usual ductal hyperplasia(UDH) -Atypical ductal hyperplasia(ADH),不同细胞混合腔面上皮基底上皮肌上皮admixture of cell types luminalBasalmyoepithelial,单一细胞a monomorphic, clonal appearance,