学习

 很好

 乳腺纤维腺瘤.

 考虑乳腺导管周间质瘤。

 考虑纤维腺瘤

 Some basic rules in breast pathology（陈国璋）:
Rule #1
The normal breast shows a lobular architecture
If a proliferative lesion shows a lobular pattern, it is not an invasive carcinoma. It is either: –Benign or –Atypical hyperplasia/ in-situ carcinoma
The only benign lesion lacking a lobular architecture is microglandular adenosis
Rule #2
The normal breast shows a two-cell type cytologic composition: luminal cells surrounded by myoepithelium
A proliferative lesion showing a two-cell type composition is either: –Benign or –Atypical hyperplasia/ in-situ carcinoma
Exceptions to this rule: –Microglandular adenosis (benign) does not have myoepithelium –Adenoid cystic carcinoma comprises both luminal and myoepithelial cells

乳腺病理的基本规律
1 正常乳腺有小叶结构
*有小叶结构的（上皮）增生性病变，不是浸润癌，它可以是：
-良性
-或不典型增生/原位癌
*唯一例外：无小叶结构的良性病变：微腺腺病
2 正常乳腺有双层细胞：腔细胞围以腺上皮
* （上皮）增生性病变有双层细胞，可以是：
-良性
-或不典型增生/原位癌
*例外：
-微腺腺病无肌上皮
-腺样囊性癌有腔细胞和肌上皮

请注意：
这是上皮性病变的规律；
本例是残存小叶结构的间质增生性病变。
细胞丰富，异型显著，图3浸润脂肪，应该考虑恶性了。

 精彩

 

 图1：细胞核异型性十分明显，核膜厚、染色质粗、可见核仁。

图2：似乎是包膜侵犯；另一处象间质反应。

我感觉是恶性病变，但因患者太年轻，最好多请人看看。

 乳腺导管周围间质肿瘤（periductal stromal tumor）

 我想恶性的应该没问题，还是诊断恶性叶状肿瘤吧。

导管周围间质肉瘤(WHO) 

ICD-O编码 9020/3
导管周围间质肉瘤也被当作PTs的同义词，但这个概念最好限用于特征为围绕导管的梭形细胞局限性增生，并形成非常少见的一种没有界限的双向分化病变。导管周围间质肉瘤中的导管保留开放性空腔，缺乏叶状突起；此种病变常为低度恶性，可复发，但极少演变为经典的PTs。

 Am J Surg Pathol. 2003 Mar;27(3):343-8.
Periductal stromal tumor: a rare lesion with low-grade sarcomatous behavior.Burga AM, Tavassoli FA.
Department of Breast and Gynecologic Pathology, Armed Forces Institute of Pathology, Washington, DC, USA. amburga@ehmc.com
Biphasic breast tumors with benign ductal elements and a sarcomatous stroma lacking a phyllodes architecture are a source of diagnostic problems, particularly because of the lack of an appropriate designation. At the Armed Forces Institute of Pathology, we have used the term "periductal stromal sarcoma" to distinguish these from phyllodes tumors. All cases coded as periductal stromal sarcoma or PDSH were retrieved from the files of the Armed Forces Institute of Pathology. Cases that fulfilled the following criteria were included in this study. The histologic features of periductal stromal sarcoma were defined as 1) a predominantly spindle cell stromal proliferation of variable cellularity and atypia around open tubules and ducts devoid of a phyllodes pattern, 2) one or more often multiple nodules separated by adipose tissue, 3) stromal mitotic activity of >/=3/10 high power fields, and 4) stromal infiltration into surrounding breast tissue. Criteria for periductal stromal hyperplasia included 1) nodular, bland stroma growing as cuffs around normal or altered ducts, 2) no to minimal atypia, and 3) at most 0-2 stromal mitotic figures per 10 high power fields. Immunohistochemistry was used to further characterize these neoplasms. Of the cases retrieved, 20 qualified as periductal stromal sarcoma and seven as periductal stromal hyperplasia. Patients with periductal stromal sarcoma ranged in age from 37 to 89 years (mean 55.3 years). The tumors measured 0.2-6.0 cm (mean 2.97 cm). Eighteen patients had excisional biopsies and two had partial mastectomies. Overall follow-up time ranged from 1 to 72 months (mean 25.3 months) with two patients (10%) showing recurrence or probable metastasis. The neoplastic cells of periductal stromal sarcoma were at least focally immunoreactive for CD34 (13 of 15), CD117 (6 of 15), less reactive for actin (HHF35, 2 of 15), and negative for estrogen and progesterone receptors. Periductal stromal sarcoma is a useful descriptive designation for generally low-grade biphasic tumors with sarcomatous stroma that do not have features of a phyllodes tumor. The development of focal phyllodes pattern in the recurrent tumor as well as development of a specific soft tissue sarcoma in one of the above cases suggest that some and possibly all periductal stromal sarcoma may evolve into a phyllodes tumor with time. Given the presence of infiltrative margins, excision with a rim of uninvolved tissue is required.
PMID: 12604890 [PubMed - indexed for MEDLINE]
要点如下：双相性肿瘤，良性导管成分，肉瘤样间质，缺乏分叶状结构。AFIP称为导管周围间质肉瘤（periductal stromal sarcoma）。

其它参考文献：

1. 张廷缪.乳腺肉瘤的病理学诊断和研究进展.临床与实验病理学杂志.2004,20(1):11-14
要点：Rosen和Callery提出，真正的间质肉瘤指来源于小叶内，有激素反应的特殊间质的肉瘤。导管周围间质肿瘤，顾名思义是由导管上皮和周围间质组成的肿瘤。乳腺肉瘤的鉴别诊断包括：梭形细胞癌，肌纤维母细胞肉瘤，恶性肌上皮瘤。

2. 龚西騟等.乳腺上皮样型管周问质肉瘤病理特征及与叶状肿瘤比较观察.临床与实验病理学杂志.2003,19(3):229-235
要点：导管周间质肉瘤（PDSS）和导管周间质增生（PDSH）的诊断标准（Burga等）

 好,学习一次.

 感觉间质异型较为明显，同意导管周围间质肉瘤。真是碰到这样的病例，还要建议外出会诊。

冰冻片似乎厚了点儿。

 呵呵，是常规切片，不厚，病变性质就这样。

看会诊片时，我们也认为原单位切片太厚，因此借来蜡块重新切片，并做了免疫组化。

上传的是我们的片子，切片质量俺还是很自信的。各位请看高倍，明显只有一层细胞哦。

很同情患者（外省的打工妹），我们请省专家会诊了，同意此诊断（免费会诊的哦）。后来患者自己请安徽省某专家会诊也同意此诊断。

另外，我们检查了患者的乳房。另一个肿块，外观和触诊是典型的恶性肿瘤。建议她尽快到上级医院治疗。

 学习中.

 精彩