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How to determine breast cancer in situ from pathological examination

1. Incidence

Breast carcinoma in situ is a special type of breast cancer that is relatively rare in clinical practice. As we all know, the growth and expansion of cancer start from carcinoma in situ to early infiltration and then to extensive infiltration. Therefore, it is not difficult to understand that breast cancer is also a kind of invasive cancer that starts from in situ and gradually develops into a common clinical invasive cancer. Therefore, breast cancer in situ does not have a real low prevalence, but a low clinical diagnosis rate and is clinically rare. Literature reports that the incidence of breast cancer in situ accounted for 3.3c, to ~5.6% of breast cancer in the same period. Among them, intraductal carcinoma in situ is the main type, while lobular carcinoma in situ is relatively rare.

2. Pathological characteristics

Breast carcinoma in situ is divided into two categories according to its different origins and histological characteristics: intraductal carcinoma in situ and lobular carcinoma in situ. They are generally considered to be separate and independent diseases.

1. The pathological characteristics of lobular carcinoma in situ are that normal acini are filled with proliferating cells, and the boundaries of the proliferating cells are unclear. Individually, the hyperplastic cells are larger, but maintain a normal nuclear-cytoplasmic ratio, and mitoses are relatively rare. The hyperplastic cells are limited to the acini and do not exceed the basement membrane. The phenomenon that the lesions are multicentric or occur in both breasts at the same time can be as high as 70% to 80%.

2 The histological characteristics of intraductal carcinoma are malignant proliferation of ductal epithelium without infiltration into the surrounding normal stroma. There are three types of pathology: comedo, papillary, and cribriform. Comedo-type intraductal carcinoma in situ is more invasive, while papillary and meshwork-type ductal carcinoma in situ are relatively less invasive. Ductal carcinoma in situ is often solitary, but may also occur in multiple centers.

3. Clinical manifestations

Breast carcinoma in situ often has no obvious positive signs clinically, and most of them do not have obvious breast lumps. However, clinically, the following signs related to carcinoma in situ can be seen: local glandular thickening of the breast and rapid development; nipple discharge, which is often fresh or old bloody discharge from a single fixed milk duct; nipple eczema Similar changes, often recurring, with a long medical history; breast glands are localized, nodular hyperplasia, and have a tendency to form masses, etc.

4. Diagnosis

Middle-aged women who are clinically found to have some of the above positive signs related to carcinoma in situ should be alert to the possibility of breast carcinoma in situ. The following auxiliary examinations are helpful for the early detection and diagnosis of breast cancer in situ.

1. Mammography

This method is the main method for detecting breast cancer in situ. Its main X-ray feature is tiny calcifications. These calcifications are characterized by large numbers, clusters, variable sizes and shapes, and may also appear as linear or branched calcifications. There are also X-rays that show no calcification, but only show disordered gland structure and asymmetric gland density. Compared with the original X-ray film, one or more new large milk duct lesions can be seen. In X-ray examination, some scholars have also reported that fully digital mammography has certain clinical value in diagnosing breast cancer in situ.

2. The role of fine-needle aspiration excisional biopsy in the early diagnosis of breast cancer has been confirmed. This method is relatively safe, less invasive, has a high diagnosis rate, and has been widely used clinically. The indication for puncture is that if microcalcification or irregular gland density is found to be increased during X-ray examination, a fine needle can be punctured into the suspicious site under Pathological examination can often obtain satisfactory diagnostic results. When using this method, attention should be paid to the accuracy of fine needle aspiration positioning, and the scope of resected tissue should be appropriately expanded to avoid missed diagnosis.

This method of 3-needle aspiration cytology examination is simple to operate, less painful for the patient, and the results are more reliable. For patients with clinically palpable and suspicious sheet-like thickening of the breast, needle aspiration can be performed, and a smear of the aspirated exfoliated cells can be subjected to pathological examination, which can often lead to a higher diagnostic rate. If diagnosis is difficult, immunopathological staining of these exfoliated cells with monoclonal antibodies can be used to increase the detection rate of malignant cells. This method can puncture the lesion at multiple points and in multiple directions during operation to achieve the purpose of increasing the positive rate.

4. Near-infrared scanning In recent years, many scholars have used near-infrared scanning to conduct research on the early diagnosis of breast cancer, and have achieved certain results. Especially in breast cancer screening, it shows certain advantages.

5-catheter endoscopy This method was invented by Japanese scholar Okazaki in the 1990s and is the latest detection method for diagnosing the cause of nipple discharge. Endoscopy can visually inspect micro-J lesions in the milk ducts, and has the advantages of high diagnostic rate and repeatable inspection.

6. Other examinations such as LCD thermogram diagnosis, B-ultrasound diagnosis, pathological examination of nipple discharge smears, CT and MRI breast scans, etc. are all of certain value in the diagnosis of breast cancer in situ.

5. Treatment

The treatment of breast carcinoma in situ is mainly surgical. There are still some differences in whether chemotherapy, radiotherapy, endocrine and other treatments are needed after surgery. Surgical treatment mainly includes the following methods:

1. Simple mastectomy. Mastectomy can cure nearly 100% of patients. It is a traditional surgical method for treating breast cancer in situ. However, this method is relatively invasive and brings a certain psychological burden to the patient.

Currently, there is a trend in foreign countries to use breast-conserving surgery instead of simple mastectomy to treat breast cancer in situ. However, due to different national conditions and different people's ideologies, simple mastectomy is still the first choice for the treatment of breast cancer in situ in my country, and axillary lymph node dissection is generally not required. This surgery is more suitable for lobular carcinoma in situ due to its multifocal nature.

2. Breast-conserving surgery is a 1/4 mastectomy or a partial mastectomy that removes normal glands more than 1 cm away from the edge of the tumor. This surgery retains the overall shape of the breasts and is relatively beautiful, so it is accepted by most beauty-loving women. In recent years, breast-conserving surgery has been increasingly used in the treatment of breast cancer in situ. The theoretical basis for advocating the use of this surgery is that although there is a certain recurrence rate after breast-conserving surgery, the overall survival of patients who undergo local recurrence after local resection and radiotherapy or mastectomy is compared with those who initially undergo mastectomy. There is no significant difference in rates. The key to this surgery is to achieve radical tumor cure while retaining a good breast shape. Therefore, before surgery, the size and location of the tumor, the size and shape of the breast itself, the design of the surgical incision, and breast reconstruction and plastic surgery after resection must be carried out. aspects to be considered. Patients whose X-ray films show microcalcifications are the best candidates for breast-conserving surgery.

Breast-conserving surgery is not suitable for the following situations:

(1) The lesion is located in the central area of ??the breast, especially near the nipple.

(2) There are 2 or more primary lesions, especially those distributed in different quadrants.

(3) Mammography shows extensive sandy calcification.

(4) Pathological examination shows extensive intraductal cancer lesions.

(5) In the first trimester of pregnancy, those who require postoperative radiotherapy.

(6) Small breasts, it is difficult to maintain a perfect breast appearance after surgery.

Data show that invasive cancer after local resection of ductal carcinoma in situ mainly occurs in the primary site on the affected side. The probability of sentinel lymph node metastasis in ductal carcinoma in situ is very small, only 3%, and sentinel lymph node biopsy is generally not considered. However, when histological characteristics suggest possible invasion and metastasis, sentinel lymph node biopsy should be considered after the patient undergoes mastectomy. Paul et al reported that in 4853 patients with lobular carcinoma in situ, the incidence rate of breast invasive cancer 10 years after resection of lobular carcinoma in situ was 0. i% ± 0.5%, which is much higher than that of the general population. These diffuse carcinomas do not necessarily occur at the site of original lesion resection, but can occur at any site on the affected side or the contralateral side. Although lobular carcinoma in situ has been treated with surgery, the patient is still more likely to develop invasive cancer than the general population. Lobular carcinoma in situ is one of the high risk factors for invasive breast cancer. Therefore, some scholars believe that lobular carcinoma in situ is a precancerous lesion of invasive cancer and requires regular follow-up after surgery.

6. Prognosis

The prognosis of breast carcinoma in situ is much better than that of invasive carcinoma. For carcinoma in situ treated with mastectomy, the cure rate can reach 98% to 100%, and the local recurrence rate is very low. According to literature reports, the recurrence rate after mastectomy is less than 0.75%, and the mortality rate related to primary cancer is only 1_7%. There is a certain recurrence rate when breast-conserving surgery is used, so regular follow-up should be conducted and attention should be paid to the incidence of the contralateral breast.