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大汗腺腺病伴有非典型增生。
挺有意思的病例,非常有讨论的价值。
乳腺病变内上皮细胞是否伴有大汗腺化生常常作为判断良恶性病变依据之一。此例病变中50%以上的上皮细胞呈现大汗腺化生,而且出现假浸润现象(图1),免疫组化结果显示完整的肌上皮着色(P63出现异常情况,不做为参考依据),此例大体又呈结节状,此例诊断乳腺大汗腺化生的结节性腺病/乳腺大汗腺腺瘤。
如果大体不是完整的结节状,则易诊断为乳腺硬化性大汗腺腺病/硬化性腺病伴大汗腺化生。
此例有争议的就是图9,诊断起来应该不会很统一。官腔内乳头状结构,细胞比较一致,免疫组化也同样显示出完整的肌上皮,胞浆显著的嗜酸性变,不是很典型的大汗腺样化生,个人认为还是比较倾向良性病变。如果不放心的话可以留个尾巴。
此例我个人意见倾向大汗腺腺病伴有非典型增生,正如雅马哈老师说的,我也是很纠结第9.10图,腔内红染的应该是分泌物不是坏死吧。会诊意见是:分泌性癌,仔细看图7.8等内确实有些分泌物,但是我感觉本例肌上皮很完整,应该不像浸润性癌,另外S-100染色基本是阴性的,只有肌上皮细胞阳性,所以有点不太明白,发上来请各位老师指点,谢谢。
刚开始我也考虑了分泌腺癌,尤其P63胞浆着色和分泌物着色这点是分泌性癌的特点,分泌性癌还应该S-100弥漫阳性,当然不是100%这样,但是必须是肌上皮标记阴性,本例肌上皮标记似乎明显是阳性的。分泌性癌在分子学上证实是基底细胞样癌亚型,但为预后极好的惰性肿瘤。正因为有基底细胞样癌的分子学特征,所以分泌性癌会不定表达基底细胞样癌的标记物如CK5/6、CK-H等等。本例正好P63和CK5/6都胞浆着色了,让人莞尔
肌上皮标记自己再加calponin、CD10看看,您的SMA特异性不好,万一是间质着色而非肌上皮咋办?
P63胞浆染色在分泌性癌中:
The aim of this study was to evaluate the pattern of p63 expression and its implication in secretory carcinoma of the breast. Immunohistochemical staining for p63, p53, MDM2, and smooth muscle actin was performed in 7 cases of secretory carcinomas. Nuclear expression of p63 was observed in 3 cases, whereas staining against cytoplasmic and intraluminal secretory material were observed in 4 cases. p53 was expressed in 3 cases and MDM2 in 2 cases. The loss of myoepithelial cells was confirmed by immunohistochemical stain for smooth muscle actin in invasive secretory carcinomas. The pattern of expression of p63 in secretory carcinoma of the breast was revealed in nuclei or cytoplasm/secretory materials.
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