首先, 非常感谢Shihong医师为我提供了这样一例判断”小叶原位癌是否有早期浸润”的好教材, 能和大家一起学习、讨论、研究和提高。有以下思考, 供参考:

1)      腋下淋巴结1/22有癌转移(转移癌是否为小叶癌形态?), 表明原发灶内一定存在浸润性癌, 它要么是取材未取到或在石蜡组织块中切片未切到, 要么是我们”视而不识”, 癌细胞太”狡猾”。

2)      原发病灶5X4X2.5cm, 颗粒状? 一般认为: 小叶原位癌在临床上是难以触及到肿块的, 能否提供一张大体照片，显示一下癌灶的大小?

3)      就提供的9张镜下照片来分析:

图1低倍示2个明显扩大的被癌细胞充实的末端导管-小叶单元;

图2中倍可见小叶内部分癌巢外形不规则, 小叶内间质粘液变性和纤维增生, 细胞数量增多, 其间散在单个的异型细胞;

图3、4、5、6都有肿瘤细胞的坏死;

图7、9为癌细胞向外蘑菇形的突出,

图8血管淋巴管旁少量异型细胞。

4)      高度怀疑图2小叶间质内有微浸润, 图3图4小叶间间质有微浸润;

5)      因此, 建议IHC标记AE1/AE3和CK7来寻找浸润的癌细胞。因为小叶原位癌微浸润在常规HE切片中可很象”炎症细胞”和”间质细胞”, 靠光镜观察很难鉴别,非常容易漏诊;  有时“间质细胞的增多”是提示微浸润的唯一线索。

文献报导病理诊断为”导管原位癌/小叶原位癌”的病例, 腋窝淋巴结的转移率约为10%。因为病理医师不能常规的去检查整个肿瘤标本的全部切片, 很有可能漏掉微小的浸润灶。我们的工作越仔细, 漏诊的可能性就越小, 这就要挑战自己。

对于冰冻诊断中如何鉴别是否存在微浸润, 从技术上讲是非常困难或不可能, 与手术医师良好的沟通是关键。

如果观察到微浸润, 病理报告中应该表明最大直径(?1mm, ?2mm. ?5mm)和病灶数量(?);和鉴定微浸润的方法((HC标记?).

最后用我国一位最著名的软组织病理专家的一句格言与大家共勉”病理医师诊断不是靠眼睛看出来的, 而是靠鼻子嗅出来的”

 Definition:

1.

American Joint Committee on Cancer (AJCC) TNM staging system, microinvasive carcinoma of the breast (MICB) has been defined as follows: “the extension of cancer cells beyond the basement membrane into the adjacent tissue with no focus more than 0.1 cm in greatest dimension. In this system, the presence of multiple foci of MICB is to be noted, but the addition of sizes of individual foci of microinvasion is not allowed.

I think AJCC definition is better.

 Generally people talk about DCIS with microinvasion. LCIS with microinvasion is more rare.

Positive axillary lymph node can be present in mcroinvasive ca, but the chance is much lower than macroinvasive ca.

The reasons that patients with carcinoma in situ have positive lymph nodes include 取材不够，or invasive componnet in patients' breasts.

We need to submit all exsional biopsy specimens to confirm the absence of invasion.

 For above  case:

If it were my case I will definitely do

1. Make sure taqht  metastatic tumor in one axillary lymph node is true.

2. stain myoepithelial markers to make sure if invasive component is present.

3.  If no invasion is noted in the available slides, entire specimen should be submitted for microscopic examination. For a mass 5*4*2.5 cm, about 40 blocks may be enough.

请教楼主:

What is the size of the tumor in lymph node?

Is it lobular ca?

 但既然没有看到明显浸润性区域，如何诊断伴早期浸润

If we cannot make sure the presence of invasion or microinvasion based on H&E and IHC, we cannot call it even though the lymph node is positive. The invsive ca may be in the patient's  breast.

 至顶。

Welcome every one to share the oppinion and also 楼主provides continuous study result if you have.

 学习，谢谢分享！

期待后续结果。