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- B1729Breast atypical papilloma (cqz 5)
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本帖最后由 于 2008-12-08 19:11:00 编辑
This case is an easy one. It is a small peripheral papilloma. The key of the case is that the focal atypical proliferation is ADH or DCIS. the differential dx of ADH and low grade DCIS is difficult for some cases. You can check my discussion with Abin's excellent translation in the topic 57岁女性，乳腺肿物 floor 77.
Criteria for distinguishing between atypical papilloma (papilloma with ADH) and papilloma with DCIS vary. Some authorities define atypical papilloma that contain linited areas of non-high grade DCIS (<3 mm in size) or in which it occupies <30 of the papilloma and render a dx of papilloma with DCIS when the foci are larger or occupy = or >30 of the papilloma. Others render a papilloma with DCIS when the atypical proliferation in papilloma demonstrates architectural and cytologic features of DCIS regardless of its size.
Clinical signigicance of ADH or DCIS in a papilloma is not well defined.Some studies indicated that a substantially increased risk (7.5 fold) for the development of breast cancer, wherase others have found that the level of breast cancer risk associated with with atypia was similar to that of patients with ADH elsewhere in the breast (4-5 fold). Now most people think papilloma with ADH or DCIS are best managed by complete excision with careful follow-up.
Now about this case: As 天山望月 described , It is easy to notice the focal atypical proliferation with uniform, monotonous, rounded cell population. Extracelluar lumens within the cell proliferation are noted . They are relatively round and rigid with a punched-out apperance. The size of the focus is very small which occupies <30% of the papilloma. I think it is a good example of atypical papilloma or papilloma with ADH.
For interesting, I showed the cases to four of my colleques. Three called atypical papilloma and one called papilloma with DCIS. He though the focal atypia was good for DCIS regardless of the size. So do not fell bad if you have some difficulty for diagnosis of these cases.
Final dx: Atpical papilloma.
Thank every one for discussing this case.
abin译：
这一例比较简单，为周围型乳头状瘤。本例的关键是局性性不典型增生为ADH或DCIS。某些病例中ADH与低级别DCIS的鉴别比较困难，参阅“57岁女性，乳腺肿物”第77楼的翻译内容（http://www.ipathology.org.cn/forum/forum_display.asp?classcode=129&keyno=93829&pageno=6）。
不典型乳头状瘤（乳头状瘤伴ADH）与乳头状瘤伴DCIS之间的区分标准不一致。一些作者定把不典型乳头状瘤定义为“有限范围的非高级别DCIS（大小<3mm，或其面积<30%）”，超过此范围即为乳头状瘤伴DCIS。当乳头状瘤中不典型增生呈DCIS的结构和细胞学牲时，另一些作者称为乳头状瘤伴DCIS，不管其大小。
乳头状瘤中ADH或DCIS的临床意义还不明确。一些研究提示以后进展为乳腺癌的风险增加（7.5倍），而另一些研究发现其与乳腺其它部位ADH的风险相似（4-5倍）。目前大多数认为乳头状瘤伴ADH或DCIS最好完整切除并密切随访。
再说本例。正如天山望月描述的，容易注意到局灶性不典型增生，一致、单调的圆细胞群。腔隙圆而僵硬，似凿出的外观。面积整个乳头状瘤的<30%。我认为这是一个不典型乳头状瘤或乳头状瘤伴ADH的好例子。
有趣的是，我的四位同事中，三位认为是不典型乳头状瘤，另一位认为是乳头状瘤伴DCIS，他认为局灶性不典型性足够DCIS而不管其范围。因此如果对这些病例诊断感到困难，也不必沮丧。
最终诊断：不典型乳头状瘤。
谢谢所有参与讨论的人。
