陈金璋1,张继平2,殷宪刚3,李国霞4,徐流河5,杨艳丽6,赵澄泉7,任兴昌8,薛德彬9【作者单位】1.安徽省界首市人民医院病理科,236500;2.河南省焦作市中医院病理科,454000;3.浙江省宁波市妇儿医院病理科,315016;4.上海市松江区中心医院病理科,201600;5. 河南省开封市中医院病理科,475100;6. 浙江大学附属第二医院病理科,310058;7.Department of Pathology, Magee-Womens Hospital, University of Pittsburgh Medical Center;8.浙江省杭州市中医院病理科,310006;9.福建省莆田市附属医院病理科,351100 (通信作者)【作者简介】陈金璋(出生年-),男,副主任医师.【摘要】目的:检测乳腺浸润性大汗腺癌的雌激素受体(ER)、孕激素受体(PR)和人表皮生长因子受体2(HER2)免疫组织化学表达情况,探讨其临床病理意义。方法:回顾性分析满足组织学诊断标准的33例乳腺大汗腺癌的存档蜡块HE切片、光镜观察,免疫组织化学检测ER、PR和HER2表达情况。结果:病例均为女性,年龄35~86岁,临床表现均为发现乳房肿块和(或)影像学筛查发现肿块,其中1例伴乳头溢血。肿瘤最大径0.5~8.0 cm。15例伴原位癌,10例伴腋淋巴结转移癌,9例伴脉管内癌栓,1例累及乳头和基底,12例浸润皮肤真皮。所有病例用免疫组织化学法检测ER/PR/HER2表达,进行初步分子分型,其中18例为三阴(TN)型,11例为HER2型,4例归入其他类型。结论:乳腺大汗腺癌具有独特的形态学特征和免疫组织化学表达模式,分子分型多为TN型和HER2型。已往文献认为,乳腺浸润性大汗腺癌不是独特的病变实体,预后与相同分期的乳腺浸润性导管癌预后相似,而最近研究表明此癌具有独特的分子特征和分子分型,其发病机制可能与AR受体代谢异常有关。【关键词】乳腺;浸润性大汗腺癌;激素受体;人表皮生长因子受体2;免疫组织化学Estrogen Receptor, Progesterone Receptor and Human Epidermal Growth Factor Receptor 2 Expression in Invasive Apocrine Carcinomas of the BreastCHEN Jin-zhang1, ZHANG Ji-ping2, YIN Xian-gang3, LI Guo-xia4, XU Liu-he5, YANG Yan-li6,ZHAO Chen-quan7, REN Xing-chang8, XUE De-bin91 Department of Pathology, People’s Hospital of Jieshou City, Anhui Province, Jieshou 236500, 2 Department of Pathology, TCM Hospital of Jaozuo City, Henan Province, Jaozuo 454000, 3 Department of Pathology, Wemen and Children’s Hospital of Ningbo City, Zhejiang Province, Ningbo 315016, 4 Department of Pathology, People’s Hospital of Songjiang District of Shanghai City, Shanghai 201600, 5 Department of Pathology, TCM Hospital of Kaifeng City, Henan Province, Kaifeng 475100, 6 Department of Pathology, Second Affiliated Hospital of Zhejiang University College of Medicine, Zhejiang Province, Hangzhou 310058, 7 Department of Pathology, Magee-Womens Hospital, University of Pittsburgh Medical Center, USA, 8 Department of Pathology, TCM Hospital of Hangzhou City, Zhejiang Province, Hangzhou 310006 9 Department of Pathology, Affiliated Hospital of PuTian University, Fujian Province, Putian 351100 (Corresponding Author)【Abstract】 Objective To determine estrogen receptor (ER), progesterone receptor (PR) and human epidermal growth factor receptor 2 (HER2) expression by immunohistochemistry in invasive apocrine carcinomas (IACs), and to analyze the clinico-pathological significance. Methods 33 cases of IACs which contented histological diagnostic criteria was collected by retrospective analysis. Their HE sections and clincal data were reviewed. ER, PR and HER2 expression was determined by immunohistochemistry. Results All patients were female, aged from 35 to 86 years old. Breast lumps were discovered by physical exmaninatiion and/or radiological screening, and nipple haemorrhagia was found in one case. The tumor size was from 0.5 to 8cm in maximum diameter. Carcinoma in situ was found additionally in 15 patients, axillary lymph node metastases in 10 cases, vascular thrombosis in 9 case, and the nipple and base was positive for cancer in one case, and the skin was involved in 12 cases. ER/PR/HER2 expression was detected immunohistochemically in all cases for molecular typing. For that 18 cases of TN type, 11 cases of HER2 type, and 4 cases of other types was classed. Conclusions IACs showed unique morphological features and immunohistochemical expression patterns. For molecular typing, most of them were classed into TN type and HER2 type. Previous literature suggested that IACs were not a unique pathological entity compared with the invassive ductal carcinomas, NOS with same prognosis. But recent studies indicated that the cancer has unique molecular characteristics and molecular typing, the carcinogenesis may be related to metabolic abnormalities in androgen receptor (AR) receptor.【Keywords】 Breast, Invasive apocrine carcinomas, Hormone receptor, human epidermal growth factor receptor 2, Immunohistochemistry乳腺浸润性大汗腺癌(invasive apocrine carcinoma, IAC)为乳腺癌的一种少见特殊亚型,于1916年由Krompecher等[1]最先报道。IAC发生率从<1%~4%(差异较大,主要因为诊断标准不一致)[2]。IAC的定义和准确分类缺乏可重复性并且持续存在争议,迄今IAC仍无广泛接受的组织学和分子学指标用于指导诊断,因此无法确定其真正的临床意义。本研究搜集IAC 33例,观察其组织学特征与雌激素受体(ER)、孕激素受体(PR)和人表皮生长因子受体2(HER2)免疫组织化学表达情况,探讨其临床病理意义,并复习文献,以提高对IAC的认识。1资料与方法1.材料来源 回顾本院病理科近3年所有乳腺癌病例的常规病理切片,筛选细胞学特征具有丰富嗜酸性颗粒性胞质的病例,根据文献诊断标准[3],选择乳腺“纯”浸润性大汗腺癌("pure" invasive apocrine carcinoma, PIAC)纳入研究。均由2位富有诊断经验的乳腺病理学专家确诊或会诊,均有典型免疫组织化学表达。1.2方法 获取存档蜡块,重新制作苏木精-伊红(HE)切片和免疫组织化学染色。根据文献[3]中的3条诊断标准:(1)HE染色切片内>90%的癌细胞显示大汗腺细胞学特征;(2)巨囊性病液体蛋白15(GCDFP-15)阳性数>50%;(3)雄激素受体(AR)阳性数>20%,将同时符合上述标准的病例纳入研究。商用免疫组织化学试剂盒,一抗包括ER、PR、HER2、AR和GCDFP-15。分析肿瘤的临床病理特征、形态学表现、免疫组织化学表达和分子分型。2结果2.1临床病理特征 本组病例中,PIAC占所有乳腺癌病例数的2.02%。患者均为女性,年龄35~86岁。临床表现均为发现乳房肿块,其中4例通过乳腺影像学筛查而检出。均为单侧发生,其中左侧16例,右侧17例。25例位于外上象限,7例位于内上象限,1例位于乳头乳晕部位。其中1例伴乳头溢血,细胞学涂片检查发现可疑癌细胞。肿瘤最大径0.5~8.0 cm。其中4例通过粗针穿刺活检诊断,26例肿块切除活检诊断。2.2形态学特征 大体检查,IAC与浸润性导管癌并无明显不同,均表现为浸润性质硬肿块。伴原位癌者可有坏死。镜下,IAC与非特殊型浸润性导管癌(invasive ductal carcinoma, not other specified, IDC NOS)具有相同的结构特征,区别仅为细胞学表现不同。细胞特征为丰富的嗜酸性颗粒状胞质,细胞核可呈低、中或高级别,细胞核通常较大,常有1个或多个显著的嗜酸性大核仁。大汗腺型导管原位癌(apocrine ductal carcinoma in situ, ADCIS)具有上述相同细胞学特征,肿瘤细胞排列成实性、筛状或微乳头状,可见坏死(点状或粉刺状),受累的管腔内可见钙化。常有1个或多个明显的核仁。本组病例中,15例伴原位癌,10例伴腋淋巴结转移癌,9例伴脉管内癌栓,1例累及乳头和基底,12例浸润皮肤真皮。2.3免疫组织化学 用免疫组织化学法检测ER/PR/HER2进行初步分子分型,ER/PR阴性且HER2免疫组织化学为2+者再用荧光原位杂交(fluorescence in situ hybridisation,FISH)检测有无HER2基因扩增,无基因扩增者纳入三阴(triple negative, TN)型,否则为HER2型。其中18例为TN型,11例为HER2型,4例归入其他类型。2.4分期、临床治疗和随访 I期11例采取肿块扩大切除术+放疗,II期18例行乳房切除术+腋淋巴结清扫+放疗+化疗,晚期(III期3例和IV期1例)1例行新辅助化疗后改良根治术+腋淋巴结清扫+放疗+化疗,另3名IV期患者采用放化疗。随访9~40个月,平均35.8个月。1例III期患者术后7个月死于全身多处转移,4例术后皮肤复发(分别为术后19、24、28和36个月),其余病例均无病存活。3讨论曾经认为,几乎各种类型与组织级别的乳腺癌都可显示大汗腺分化,包括普通型浸润性导管癌、小管癌、髓样癌、乳头状癌、微乳头状癌、神经内分泌癌以及经典型和多形型浸润性小叶癌等,因此,识别大汗腺癌仅有学术价值,并无重要的临床意义[4]。并且,大汗腺癌的预后取决于传统预后因素(组织学分级、肿瘤大小和淋巴结状态等),预后与相同分期的非大汗腺癌相似。一些学者[2]认为,大汗腺分化应作为病变的描述性特征,似无重要的预后和治疗意义。然而,由于诊断标准不一致,上述研究结果可能有争议。如果严格规定大汗腺癌的诊断标准[3],PIAC可能具有独特的临床病理特征。Japaze等[5]最近定义了PIAC的组织病理学诊断标准,属于大汗腺肿瘤的中间群,成为一种独特的临床病理实体。PIAC比高级别非特殊型浸润性导管癌(IDC-NOS)的侵袭性弱。大汗腺癌的免疫组织化学表达谱具有相对特异性。大汗腺癌多为TN型[6],并且HER-2蛋白过表达率也大于非特殊型浸润性导管癌。HER-2蛋白表达率54%;HER-2基因扩增率52% [7],我们的结果与之相似:TN占54.5%,HER-2蛋白表达率57.6%。新近研究发现了一种“大汗腺分子(molecular apocrine,MA)”亚型。最初的分子分型(Stanford分类)[8]及其修订[9]包括5种亚型:管腔A型、管腔B型、基底样型、正常导管型和HER2型。然而这一分类并非详尽无遗,Farmer等[10]发现另一亚型,其特征为雄激素信号通路上调和表达大汗腺标志物,称为MA型,它们并不表现为经典型大汗腺癌的所有组织学特征。MA型肿瘤与HER2型肿瘤具有部分共同特征,也具有基底样型的部分特征[10],具有形态学异质性。MA型与大汗腺癌之间的联系,MA型是否具有相应的临床病理特征和预后意义,是否可能选择用于靶向治疗,值得进一步研究。乳腺IAC中的AR表达率较高,文献[11]报道其表达率高达56–100%,而在浸润性导管癌仅为62%或22%,并且AR阳性的乳腺癌多为ER阴性(典型的乳腺浸润性大汗腺癌表现为ER-/PR-/AR+)。较多证据[12]表明,AR信号通路在乳腺癌发生中具有与ER无关的重要作用。体外研究[12]表明,雄激素抑制剂可通过AR抑制ER阴性的乳腺癌细胞生长,但癌细胞表达ER时却刺激其生长。因此,雄激素类药物的作用可能依赖于激素受体状态,ER/PR阴性的乳腺癌并非真的对激素治疗“不敏感”,因而可能开发出基于雄激素的激素治疗新方法[12]。总之,由于目前对大汗腺乳腺癌缺乏统一的组织学和分子标准,其准确分类和定义缺乏可重复性并持续争议,仍无法确定其真实的临床意义。正如Zagorianakou[13]所言:“大汗腺癌目前仍然是一个谜”,今后收集大宗病例进行多中心长期随访结合分子学研究,有可能解开这个谜,并可能发现新的治疗途径。参考文献[1] Krompecher E. Zur Histogenese und Morphologie der Cystenmamma (maladie Kystique recluse, cystadenoma schimmelbuscin, mastitis chronica cystic Konig) des intrakanaliken Kystadenom und der Kystadenokarzinome der Brustdrse[J]. Beitr Pathol Anat,1916,62: 403 –410.[2] Rosen PP. Rosen’s breast pathology [M]. 3ed, Philadephia: Lippincott Wilkins, 2009:537-550.[3]邵牧民,孟刚,龚西騟. 乳腺大汗腺癌的形态学与免疫表型特征[J]. 临床与实验病理学杂志,2005,21(1):14-19.[4] Tavassoli FA, Devilee P. World Health Organization classification of tumours, pathology and genetics of tumours of the breast and female genital organs[M]. Lyon: IARC Press,2003:36-37.[5] Japaze H, Emina J, Diaz C,et al. ‘Pure’ invasive apocrine carcinoma of the breast: a new clinicopathological entity?[J]Breast,2005,14(1):3-10.[6] Iwase H, Kurebayashi J, Tsuda H, et al. Clinicopathological analyses of triple negative breast cancer using surveillance data from the Registration Committee of the JBCC [J]. Breast Cancer,2010,17(2):118–124.[7]Vranic S, Tawfik O, Palazzo J, et al. EGFR and HER-2/neu expression in invasive apocrine carcinoma of the breast[J].Mod Pathol, 2010,23(5):644-653.[8] Perou CM, Sorlie T,Eisen MB, et al. Molecular portraits of human breast tumours[J]. Nature,2000,406(6797):747–752.[9] Sorlie T, Tibshirani R, Parker J, et al. Repeated observation of breast tumor subtypes in independent gene expression data sets[J]. Proc Natl Acad Sci USA,2000,100(14):8418–8423.[10] Farmer P, Bonnefoi H, Becette V, et al. Identification of molecular apocrine breast tumours by microarray analysis[J]. Oncogene,2005,24(29): 4660–4671.[11] O'Malley FP, Bane A. An update on apocrine lesions of the breast[J]. Histopathology, 2008,52 (1): 3–10.[12] Nahleh Z. Androgen receptor as a target for the treatment of hormone receptor-negative breast cancer: an unchartered territory[J]. Future Oncol,2008,4(1):15-21.[13] Zagorianakou P, Zagorianakou N, Stefanou D, et al. The enigmatic nature of apocrine breast lesions[J]. Virchows Arch,2006,448(5): 525–531.