乳腺硬化性腺病是以乳腺小葉為中心的良性病變，表現(xiàn)為乳腺間質(zhì)纖維增生，伴有小葉內(nèi)末梢導(dǎo)管上皮、腺泡上皮、肌上皮細(xì)胞增生。病理和影像學(xué)表現(xiàn)常與惡性腫瘤類似，且常與導(dǎo)管內(nèi)乳頭狀瘤、導(dǎo)管上皮增生、纖維腺瘤、浸潤(rùn)性導(dǎo)管癌、導(dǎo)管原位癌等乳腺良惡性腫瘤同時(shí)發(fā)生，因此術(shù)前診斷困難。
2017年2月，英國(guó)《分子與臨床腫瘤學(xué)》正式發(fā)表復(fù)旦大學(xué)附屬腫瘤醫(yī)院陳雅玲、陳嘉健、常才、高毅、吳炅、楊文濤、顧雅佳的研究報(bào)告，探討了乳腺硬化性腺病的聲像圖與X線特征，比較超聲與X線的診斷價(jià)值。
本研究收集2009年7月～2012年12月因乳腺疾病于復(fù)旦大學(xué)附屬腫瘤醫(yī)院手術(shù)，且病理證實(shí)存在硬化性腺病的191例患者的臨床資料，其中46例患者49個(gè)病灶為其他乳腺良惡性腫瘤伴少量硬化性腺病成分，不入組本研究。選取乳腺硬化性腺病為主要成分的145例患者151個(gè)病灶為研究對(duì)象，回顧分析其超聲和X線特征，根據(jù)乳腺影像與數(shù)據(jù)報(bào)告系統(tǒng)（BI-RADS）進(jìn)行分類。
結(jié)果發(fā)現(xiàn)共151個(gè)病灶，超聲表現(xiàn)為片狀低回聲型9.3%，結(jié)節(jié)或腫塊型65.6%，局部聲影型4.0%，陰性21.2%。
136例行X線檢查，鈣化型31.6%，腫塊影23.5%，非對(duì)稱性致密影14.7%，局部結(jié)構(gòu)扭曲22.8%，7.4%陰性。
超聲、X線對(duì)良惡性判斷的準(zhǔn)確率分別為53.6%、40.4%。
盡管硬化性腺病不屬于癌前病變，但文獻(xiàn)報(bào)道硬化性腺病患者發(fā)生乳腺癌的風(fēng)險(xiǎn)比正常人顯著增加。本研究中，13.4%（20/151）患者在硬化性腺病基礎(chǔ)上出現(xiàn)惡性成分，其中1例同時(shí)發(fā)生對(duì)側(cè)乳腺癌。Moritani等報(bào)道23例硬化性腺病伴導(dǎo)管原位癌患者，其中5例同期或后期發(fā)生對(duì)側(cè)乳腺癌。Yoshida等報(bào)道合并硬化性腺病成分的導(dǎo)管原位癌患者對(duì)側(cè)乳腺癌發(fā)生率（9/24，38%）顯著高于不合并硬化性腺病成分的導(dǎo)管原位癌患者（22/174，13%）。陳嘉健等先前一項(xiàng)研究也顯示，硬化性腺病是同期雙側(cè)乳腺癌的獨(dú)立危險(xiǎn)因素，且發(fā)生于硬化性腺病基礎(chǔ)上的乳腺癌常具有雙側(cè)乳腺癌的生物學(xué)特征。因此，盡管術(shù)前診斷存在困難，認(rèn)識(shí)該疾病的影像學(xué)表現(xiàn)十分必要。
本研究將硬化性腺病的聲像圖特征分為3型：片狀低回聲型、結(jié)節(jié)或腫塊型、局部聲影型。片狀低回聲型無(wú)明顯邊界，與正常腺體相互交錯(cuò)，占位效應(yīng)不明顯，與乳腺病、炎性病變、導(dǎo)管原位癌難以鑒別。結(jié)節(jié)或腫塊型大部分表現(xiàn)為形態(tài)不規(guī)則，邊界不清，尤其是出現(xiàn)鈣化時(shí)易誤診為惡性。本研究中，各超聲觀察指標(biāo)在伴有與不伴有惡性成分的硬化性腺病病灶中差異無(wú)統(tǒng)計(jì)學(xué)意義。局部聲影型既往觀點(diǎn)不一，Günhan-Bilgen等認(rèn)為局部聲影是硬化性腺病的特異表現(xiàn)之一，Taskin等則認(rèn)為在多種良性及惡性病變中可見(jiàn)到這一征象，因此并不是硬化性腺病的特異性表現(xiàn)。本研究中，6例表現(xiàn)為局部聲影，病理證實(shí)1例伴有惡性成分，局部聲影在伴有與不伴有惡性成分的硬化性腺病病灶中差異無(wú)統(tǒng)計(jì)學(xué)意義（P=0.519）。結(jié)果不一致可能與硬化性腺病病理發(fā)展過(guò)程復(fù)雜有關(guān)。在腺病基礎(chǔ)上發(fā)生小葉間纖維組織增生，膠原纖維變性，聲像圖上則可能表現(xiàn)為片狀低回聲，即局部腺體結(jié)構(gòu)紊亂，無(wú)明顯邊界，回聲減低，與正常腺體相互交錯(cuò)。間質(zhì)纖維繼續(xù)增生，并將增生的腺體分隔成團(tuán)塊狀，聲像圖上則可能表現(xiàn)為結(jié)節(jié)型或團(tuán)塊狀。間質(zhì)纖維增生、腺上皮增生，并伴顯著纖維化則表現(xiàn)為局部聲影型；若纖維組織向小葉內(nèi)伸展，或侵及周圍脂肪組織，則出現(xiàn)類似惡性腫瘤的聲像圖表現(xiàn)。值得注意的是，本研究中32例患者硬化性腺病超聲檢查無(wú)異常發(fā)現(xiàn)，其中25例（78.1%）為單純性硬化性腺病，因此這類硬化性腺病可能是導(dǎo)致超聲假陰性的主要原因。
硬化性腺病的X線表現(xiàn)多變，有研究表明微鈣化是硬化性腺病一個(gè)重要征象，以不定形、多形性或點(diǎn)狀鈣化最為常見(jiàn)，呈簇狀及散在分布。與既往報(bào)道一致，本研究中硬化性腺病表現(xiàn)為微鈣化型43個(gè)，占31.6%，其中點(diǎn)狀鈣化29個(gè)（占67.4%）、多形性鈣化7個(gè)（占16.3%）。當(dāng)硬化性腺病表現(xiàn)為微鈣化時(shí)，X線不易漏診，但導(dǎo)致BI-RADS評(píng)估級(jí)別較高。也有文獻(xiàn)指出，硬化性腺病可伴有粗大鈣化。與超聲顯著不同的是，X線顯示結(jié)節(jié)或腫塊32個(gè)，占23.5%，而超聲顯示結(jié)節(jié)或腫塊型99個(gè)，占65.6%，均高于文獻(xiàn)報(bào)道。這可能與病程有關(guān)，東西方女性乳腺結(jié)構(gòu)存在差異也是原因之一。6例超聲表現(xiàn)為局部聲影型患者中，2例X線陰性、4例X線表現(xiàn)為非對(duì)稱致密影。此外，本研究中局部結(jié)構(gòu)扭曲也是一種較多見(jiàn)的X線征象，可能與腺泡增生、周圍間質(zhì)纖維化牽拉有關(guān)。盡管硬化性腺病X線表現(xiàn)國(guó)內(nèi)外文獻(xiàn)報(bào)道較多，但多為小樣本研究，目前尚無(wú)統(tǒng)一觀點(diǎn)。
超聲及乳腺X線診斷硬化性腺病診斷各有優(yōu)缺點(diǎn)。超聲對(duì)致密型乳腺內(nèi)病變有顯著優(yōu)勢(shì)，可發(fā)現(xiàn)乳腺X線漏診的病例，但診斷準(zhǔn)確率低，且對(duì)微鈣化病變不敏感。乳腺X線對(duì)微鈣化非常敏感，但對(duì)性質(zhì)的判斷存在困難，兩者綜合應(yīng)用或應(yīng)用超聲造影、彈性成像等技術(shù)可能提高診斷準(zhǔn)確率，但硬化性腺病影像學(xué)表現(xiàn)多樣，確診仍依賴病理結(jié)果。
總之，硬化性腺病缺乏典型的聲像圖及X線表現(xiàn)，影像科醫(yī)師對(duì)該病的認(rèn)識(shí)有待提高。
Mol Clin Oncol. 2017 Feb;6(2):157-162.
Sclerosing adenosis: Ultrasonographic and mammographic findings and correlation with histopathology.
Chen YL, Chen JJ, Chang C, Gao Y, Wu J, Yang WT, Gu YJ.
Fudan University Shanghai Cancer Center, Shanghai, P.R. China; Shanghai Medical College, Fudan University, Shanghai, P.R. China.
The present study was conducted to evaluate the radiological findings, particularly the ultrasonographic (US) characteristics of sclerosing adenosis (SA), and their correlation with histopathological results. A retrospective review identified 191 patients with a total of 200 lesions histopathologically confirmed as SA following breast surgery between July 2009 and December 2012. Of the 191 patients, 145 (151 lesions) with SA as the major component were included for US and mammographic (MG) analysis. All 145 patients analyzed were female, with a mean age ± standard deviation of 46.8±7.8 years (range, 25-71 years). All 145 patients underwent US examination and the imaging findings included heterogeneously echogenic areas in 9.3% (14/151), masses in 51.7% (78/151), masses with calcifications in 13.9% (21/151), focal acoustic shadowing in 4.0% (6/151) and were negative in 21.2% (32/151) patients. Among the 119 lesions with visible abnormalities, 87.4% (104/119) were hypoechoic, 58.0% (69/119) were irregular in shape, 52.1% (62/119) had an ill-defined margin, calcifications were found in 17.6% (21/119) and 7.6% (9/119) were hypervascular, while none of the characteristics mentioned above were significantly correlated with histopathology. A total of 136 patients underwent MG at the Fudan University Shanghai Cancer Center, and the imaging findings included microcalcifications in 31.6% (43/136), masses in 23.5% (32/136), asymmetric focal density in 14.7% (20/136), focal architectural distortion in 22.8% (31/136), and were negative in 7.4% (10/136). The mass lesions were fewer on MG compared with US (23.5 vs. 65.6%, respectively). The area under the curve of US distinguishing between benign and malignant lesions was significantly larger compared with that of MG (0.547 vs. 0.497, respectively; P=0.036). In the 60 lesions that were overestimated by Breast Imaging Reporting and Data System US category, one or more characteristics of malignancy were found on US imaging. The most common finding of SA was masses with or without calcifications on US and microcalcifications on MG. The accuracy of US was limited, but higher compared with that of MG; however, SA mimicking the characteristics of malignancy may contribute to misdiagnosis with US.
KEYWORDS: breast; histopathology; mammography; sclerosing adenosis; ultrasonography
PMID: 28357084
PMCID: PMC5351743
DOI: 10.3892/mco.2016.1108
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