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乳腺硬化性腺病是以乳腺小叶为中心的良性病变，表现为乳腺间质纤维增生，伴有小叶内末梢导管上皮、腺泡上皮、肌上皮细胞增生。病理和影像学表现常与恶性肿瘤类似，且常与导管内乳头状瘤、导管上皮增生、纤维腺瘤、浸润性导管癌、导管原位癌等乳腺良恶性肿瘤同时发生，因此术前诊断困难。 2017年2月，英国《分子与临床肿瘤学》正式发表复旦大学附属肿瘤医院陈雅玲、陈嘉健、常才、高毅、吴炅、杨文涛、顾雅佳的研究报告，探讨了乳腺硬化性腺病的声像图与X线特征，比较超声与X线的诊断价值。 本研究收集2009年7月～2012年12月因乳腺疾病于复旦大学附属肿瘤医院手术，且病理证实存在硬化性腺病的191例患者的临床资料，其中46例患者49个病灶为其他乳腺良恶性肿瘤伴少量硬化性腺病成分，不入组本研究。选取乳腺硬化性腺病为主要成分的145例患者151个病灶为研究对象，回顾分析其超声和X线特征，根据乳腺影像与数据报告系统（BI-RADS）进行分类。 结果发现共151个病灶，超声表现为片状低回声型9.3%，结节或肿块型65.6%，局部声影型4.0%，阴性21.2%。 136例行X线检查，钙化型31.6%，肿块影23.5%，非对称性致密影14.7%，局部结构扭曲22.8%，7.4%阴性。 超声、X线对良恶性判断的准确率分别为53.6%、40.4%。 尽管硬化性腺病不属于癌前病变，但文献报道硬化性腺病患者发生乳腺癌的风险比正常人显著增加。本研究中，13.4%（20/151）患者在硬化性腺病基础上出现恶性成分，其中1例同时发生对侧乳腺癌。Moritani等报道23例硬化性腺病伴导管原位癌患者，其中5例同期或后期发生对侧乳腺癌。Yoshida等报道合并硬化性腺病成分的导管原位癌患者对侧乳腺癌发生率（9/24，38%）显著高于不合并硬化性腺病成分的导管原位癌患者（22/174，13%）。陈嘉健等先前一项研究也显示，硬化性腺病是同期双侧乳腺癌的独立危险因素，且发生于硬化性腺病基础上的乳腺癌常具有双侧乳腺癌的生物学特征。因此，尽管术前诊断存在困难，认识该疾病的影像学表现十分必要。 本研究将硬化性腺病的声像图特征分为3型：片状低回声型、结节或肿块型、局部声影型。片状低回声型无明显边界，与正常腺体相互交错，占位效应不明显，与乳腺病、炎性病变、导管原位癌难以鉴别。结节或肿块型大部分表现为形态不规则，边界不清，尤其是出现钙化时易误诊为恶性。本研究中，各超声观察指标在伴有与不伴有恶性成分的硬化性腺病病灶中差异无统计学意义。局部声影型既往观点不一，Günhan-Bilgen等认为局部声影是硬化性腺病的特异表现之一，Taskin等则认为在多种良性及恶性病变中可见到这一征象，因此并不是硬化性腺病的特异性表现。本研究中，6例表现为局部声影，病理证实1例伴有恶性成分，局部声影在伴有与不伴有恶性成分的硬化性腺病病灶中差异无统计学意义（P=0.519）。结果不一致可能与硬化性腺病病理发展过程复杂有关。在腺病基础上发生小叶间纤维组织增生，胶原纤维变性，声像图上则可能表现为片状低回声，即局部腺体结构紊乱，无明显边界，回声减低，与正常腺体相互交错。间质纤维继续增生，并将增生的腺体分隔成团块状，声像图上则可能表现为结节型或团块状。间质纤维增生、腺上皮增生，并伴显著纤维化则表现为局部声影型；若纤维组织向小叶内伸展，或侵及周围脂肪组织，则出现类似恶性肿瘤的声像图表现。值得注意的是，本研究中32例患者硬化性腺病超声检查无异常发现，其中25例（78.1%）为单纯性硬化性腺病，因此这类硬化性腺病可能是导致超声假阴性的主要原因。 硬化性腺病的X线表现多变，有研究表明微钙化是硬化性腺病一个重要征象，以不定形、多形性或点状钙化最为常见，呈簇状及散在分布。与既往报道一致，本研究中硬化性腺病表现为微钙化型43个，占31.6%，其中点状钙化29个（占67.4%）、多形性钙化7个（占16.3%）。当硬化性腺病表现为微钙化时，X线不易漏诊，但导致BI-RADS评估级别较高。也有文献指出，硬化性腺病可伴有粗大钙化。与超声显著不同的是，X线显示结节或肿块32个，占23.5%，而超声显示结节或肿块型99个，占65.6%，均高于文献报道。这可能与病程有关，东西方女性乳腺结构存在差异也是原因之一。6例超声表现为局部声影型患者中，2例X线阴性、4例X线表现为非对称致密影。此外，本研究中局部结构扭曲也是一种较多见的X线征象，可能与腺泡增生、周围间质纤维化牵拉有关。尽管硬化性腺病X线表现国内外文献报道较多，但多为小样本研究，目前尚无统一观点。 超声及乳腺X线诊断硬化性腺病诊断各有优缺点。超声对致密型乳腺内病变有显著优势，可发现乳腺X线漏诊的病例，但诊断准确率低，且对微钙化病变不敏感。乳腺X线对微钙化非常敏感，但对性质的判断存在困难，两者综合应用或应用超声造影、弹性成像等技术可能提高诊断准确率，但硬化性腺病影像学表现多样，确诊仍依赖病理结果。 总之，硬化性腺病缺乏典型的声像图及X线表现，影像科医师对该病的认识有待提高。 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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