我科选择：硬化性（大汗腺）腺病累及乳头状瘤伴DCIS/硬化性乳头状瘤伴低级别大汗腺型DCIS

会诊结果：考虑大汗腺导管原位癌 editUploadImages("rcontent735863", 735863, 2);

What Is Apocrine Atypia: Does It Have Clinical Significance? Apocrine atypia is generally seen in association with mass-forming, cellular sclerosing lesions that often contain papillomas and florid adenosis. Because both benign and atypical apocrine populations can involve simple microglandular units but can also form worrisome intraductal papillary and cribriform structures, the concept of apocrine atypia is essentially cytologic. Further, because even “normal” apocrine cell populations are significantly larger than “ductal” cells, it must be emphasized that criteria for apocrine atypia are derived and applied within the reference frame of apocrine cells. For example, most authors emphasize that apocrine atypia is characterized by significant (3×) nuclear enlargement, but the assessment is made relative to normal apocrine cells.
To further confuse the matter, a partial morphologic overlap nearly always exists between normal and atypical apocrine populations within individual lesions. Even clearly benign lesions may contain an occasional enlarged cell with an atypical nucleus.
Major problems have limited the clinical value of assessing apocrine atypia in daily practice. Perhaps most disturbing, from a diagnostic point of view, is the fact that atypical apocrine lesions form a histologic spectrum, such that there is partial microscopic overlap between atypical apocrine proliferations and low-grade apocrine DCIS. Second, use of the term apocrine atypia is, at the present time, descriptive; its clinical significance has yet to be unequivocally established (ie, in the sense of atypical ductal or lobular hyperplasia). Finally, because borderline apocrine atypias are relatively uncommon, it is harder to develop experience and confidence with their evaluation.
O'Malley et al have attempted to define criteria for distinguishing benign, atypical, and low-grade malignant apocrine lesions. Apocrine atypia is cytologically characterized by (1) 3-fold nuclear enlargement (ie, compared to normal apocrine cells), (2) nucleolar enlargement or multiple nucleoli, (3) “slightly irregular” nuclear membranes, and (4) fine (versus coarse) nuclear chromatin .Necrosis is absent, although focal apoptosis may be identified. Importantly, the lesion is “usually of limited extent (ie, <4 mm).” Low-grade apocrine DCIS, in contrast, more noticeably demonstrates irregular nuclear membranes and coarse chromatin in addition to nuclear enlargement . Importantly, nuclear atypism is more widespread among the cell population in apocrine DCIS (>25% of cells). Finally, in low-grade apocrine DCIS, the lesion should exceed 4 mm and involve more than 2 lobular units with intervening ducts. Apoptosis may be observed, although necrosis is not present (as would be seen in high-grade lesions). A truly cribriform architecture is more characteristic of low-grade apocrine DCIS than of apocrine atypia. Fortunately, from a diagnostic perspective, apocrine DCIS is more frequently a high-grade lesion, in which case malignant features such as comedo necrosis, tumefactive growth, and overtly atypical cytologic features are readily appreciated.

As noted by O'Malley et al,the cytologic and size criteria for distinguishing apocrine atypia from low-grade DCIS are yet to be tested in a long-term follow-up study. In fact, even the clinical behavior of low-grade apocrine DCIS remains similarly undefined, especially for smaller lesions. But, as noted above, atypical apocrine lesions form a relatively broad morphologic continuum, and quite a generous degree of heterogeneity exists even within individual cases. Although the criteria enumerated above are no doubt useful, some features may not be present or a mixture of “atypical” and “malignant” cytologic findings may be present. For this reason, an indeterminate or borderline category has been proposed, consisting of proliferations with worrisome cytologic features that extend 4 to 8 mm; unfortunately, the clinical significance of such cases, which comprised the truly problematic diagnoses, is also unclear.

名称：图1
描述：360截图20130912143232296

 IHC：CK8/18（2-3+）、Her-2（1+）、PR、ER均（-）、CK-HMW（1+）、Ki-67<5%，PAS分泌物、基底膜、部分胞浆均阳性

目前没有AR和GCDFP-15的抗体

您的诊断：

非典型大汗腺腺病

大汗腺型DCIS

硬化性腺病伴大汗腺化生

硬化性腺病累及乳头状瘤伴ADH/硬化性乳头状瘤伴ADH

硬化性腺病累及乳头状瘤伴DCIS/硬化性乳头状瘤伴DCIS

分泌性癌

包裹性乳头状癌

大汗腺癌

富脂细胞癌