乳腺囊肿：诊断与处理---陈前军编译

 

 

乳腺囊肿是一种发生于于导管末梢-小叶单位（TDLU）的圆形或球形的充满液体的肿物。源于输出导管的堵塞、肿胀，然后在 导管末梢-小叶单位形成液体聚集而成 [1]。

 

乳腺囊肿受性激素功能影响，因此一般发生于绝经前与围绝经期女性[2]。很少发生于绝经后女性，除非采用激素替代疗法的患者。广东省中医院乳腺科陈前军

【临床表现】

 乳腺囊肿可以表现为可触及的肿块或影像检查发现的小囊肿。囊肿的迅速增大会导致乳房突然严重的疼痛。

 

【影像检查】

怀孕的女性或小于30岁的女性首选超声检查，超过30岁的女性应选择超声联合钼靶X线摄片（根据临床具体情况）[3]。超声诊断有助于判断肿物是囊性、实性或两者兼有、彩色多普勒检查有助于判断囊性病变[4]。但是多普勒没有血流信号并不能排除恶性可能。钼靶摄片用乳腺影像与数据系统(BI-RADS)进行分类，这种分类也适用于超声检查[5-8]。

 

BI-RADS 1 与2级分别考虑为正常与良性，一般建议随访。 BI-RADS 3 级考虑可能是良性，建议短期密切观察。 BI-RADS 4 与5 级表示可疑有恶性病变，建议病理活检。

 

【囊性病变的分类与处理】

基于影像特征，囊性病变大致可分为3类：单纯囊肿、复杂囊肿、混合囊肿

【单纯囊肿】

单纯囊肿超声表现为边界清楚，后部回声增强，内部无回声、实性占位以及血流信号。簇状囊肿与间隔囊肿考虑单纯囊肿的亚型。簇状囊肿是2 - 3 mm单纯无回声囊肿呈现聚集性。分隔囊肿是指囊肿中出现小于0.5mm的分隔。

如果囊肿疼痛可以进行细针穿刺（FNA）。建议在超声引导下进行穿刺可以确定是否完全穿刺，完全穿刺可以减少复发的机会。

 囊肿积液的颜色可以是黄色、棕色、灰色、蓝色、甚至是黑色[11]。但是颜色没有诊断意义。囊肿的液体可以是稀薄容易吸出，也可以是稠厚或粘稠。如果液体不是血性可以不必进行病理检查进行丢弃[12-14]。细胞病理通常发现非典型改变但并不必因此而进行活检[11,15-18]。

 

血性液体应该送检细胞学分析，如果经过穿刺后病灶并未消失，应该进行病理活检。

 

如果穿刺后完全消失，2-4个月应该进行超声复检[12]。然后患者应该进行常规的年度检查[19]。

如果复发，建议第二次穿刺[12]。 如果囊肿复发多次（3次以上），应用钼靶与超声再次评估该部位，对于可疑病变或不再愿意穿刺的患者考虑手术切除 [20]。如果进行切除，要求完整切除，不能残留包膜。

 

【复杂囊肿】

复杂囊肿是指回声低但无实性占位、厚壁囊肿或稠液囊肿，且内部无血流信号 [12]。需要与脓肿、血肿以及脂肪坏死等进行鉴别。

 

复杂囊肿中恶性很罕见（0.4%），但应该进行穿刺确诊或影像与临床观察 [21]。随访包括临床检查、超声与钼靶检查（如果钼靶上可见病灶）观察其是否有进展，每6个月1次，观察2年 。

 

如果病灶增大、影像特征改变或不能确定是否有实性病灶时应考虑在影像引导下进行细针穿刺或活检 [12]。

 

【混合囊肿】

混合囊肿包括囊壁超过0.5mm以及囊内含有液体与实体的囊肿。超声改变同时具有无回声与回声改变。良性的混合囊肿包括脓肿、炎症、血肿、皮脂腺囊肿以及脂肪坏死等 [24,25]。混合囊肿中恶性病变的发生率20%-43%，所以应该进行活检[26]。

 

如果不能确定肿块是囊性还是小的实性肿物应在影像引导下进行细针穿刺。如果没有液体抽出应考虑在影像引导下进行粗针穿刺活检。对于含有实性占位的混合囊肿或不确定病变，在超声引导下的粗针活检是一种安全准确的诊断技术[27-29]。如果粗针穿刺技术上有难度，建议进行手术活检。

 

影像发现与病理结果应该进行对比 [30]。如果影像特征与粗针病理活检不一致，应在钢丝针定位下进行手术活检。

 

乳腺癌发生风险 ? 单纯囊肿并不增加乳腺癌发生风险[31,32]。但复杂囊肿与混合囊肿发生恶性肿瘤可能性在逐渐增加 [13,16,21,33-35]。

 

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