Ductal carcinoma in situ: Difference between revisions

From patholines.org
Jump to navigation Jump to search
← Older edit
VisualWikitext
Mikael Häggström (talk | contribs)
Administrators, Editors, Image-reviewer, csmoderator, Interface administrators, Administrators, Upload Wizard campaign editors
7,148 edits
Mikael Häggström (talk | contribs)
Administrators, Editors, Image-reviewer, csmoderator, Interface administrators, Administrators, Upload Wizard campaign editors
7,148 edits
Templated
 
(16 intermediate revisions by the same user not shown)
Line 1: Line 1:
{{Top
<noinclude>{{Top
|author1=[[User:Mikael Häggström|Mikael Häggström]]
|author1=[[User:Mikael Häggström|Mikael Häggström]]
|author2=
|author2=
}}
}}
Ductal carcinoma in situ (DCIS):
Ductal carcinoma in situ (DCIS):
{{Comprehensiveness}}
{{Comprehensiveness}}</noinclude>
==Gross examination==
==Gross examination==
As per:
As per:
Line 15: Line 15:


===Differential diagnoses===
===Differential diagnoses===
;[[Invasive ductal carcinoma]]: Has invasion through the basement membrane.<ref name="Siziopikou2013"/> In uncertain cases, use immunohistochemistry stain for '''calponin''' (has the highest sensitivity) and '''p63''' (has the highest specificity).
;[[Invasive ductal carcinoma]]: Has invasion through the basement membrane of over 1 mm in size.<ref>{{cite web|url=https://documents.cap.org/protocols/Breast.DCIS_4.4.0.0.REL_CAPCP.pdf|title=Protocol for the Examination of Resection Specimens from Patients with Ductal Carcinoma In Situ (DCIS) of the Breast, Version: 4.4.0.0. Protocol Posting Date: June 2021|website=College of American Pathologists}}</ref>
 
<gallery mode=packed heights=200>
<gallery mode=packed heights=200>
File:Histopathology of microinvasive ductal carcinoma in situ.png|'''DCIS with microinvasion''', defined as DCIS with focus of invasive cancer measuring up to 1.0 mm in size.<ref>Image annotation by Mikael Häggström, MD, using source image from:<br>{{cite journal| author=Moatasim A, Mamoon N| title=Primary Breast Mucinous Cystadenocarcinoma and Review of Literature. | journal=Cureus | year= 2022 | volume= 14 | issue= 3 | pages= e23098 | pmid=35464581 | doi=10.7759/cureus.23098 | pmc=8997314 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=35464581  }}<br>- "This is an open access article distributed under the terms of the Creative Commons Attribution License CC BY 4.0."<br>'''Source for microinvasion''': {{cite web|url=https://documents.cap.org/protocols/Breast.DCIS_4.4.0.0.REL_CAPCP.pdf|title=Protocol for the Examination of Resection Specimens from Patients with Ductal Carcinoma In Situ (DCIS) of the Breast, Version: 4.4.0.0. Protocol Posting Date: June 2021|website=College of American Pathologists}}</ref>
</gallery>
In uncertain cases, use immunohistochemistry stain for myoepithelial markers{{Myoepithelial marker note}}.
<gallery mode=packed heights=220>
File:Immunohistochemistry with calponin in ductal carcinoma in situ.jpg|Immunohistochemistry for the myoepithelial marker{{Myoepithelial marker note}} calponin in '''ductal carcinoma in situ''', highlighting myoepithelial cells around all tumor cells, thereby ruling out [[invasive ductal carcinoma]].
File:Immunohistochemistry with calponin in ductal carcinoma in situ.jpg|Immunohistochemistry for the myoepithelial marker{{Myoepithelial marker note}} calponin in '''ductal carcinoma in situ''', highlighting myoepithelial cells around all tumor cells, thereby ruling out [[invasive ductal carcinoma]].
File:Invasive ductal carcinoma with tubular features - combined.jpg|'''[[Invasive ductal carcinoma]] with tubular features''' can look like benign tubules, but calponin and p63 shows no surrounding myoepithelial cells.
File:Invasive ductal carcinoma with tubular features - combined.jpg|'''[[Invasive ductal carcinoma]] with tubular features''' can look like benign tubules, but calponin and p63 shows no surrounding myoepithelial cells.
Line 28: Line 31:


;[[Lobular carcinoma in situ]] (LCIS)
;[[Lobular carcinoma in situ]] (LCIS)
<gallery mode=packed heights=180>
<gallery mode=packed heights=220>
File:Histopathology of lobular carcinoma in situ.jpg|Lobular carcinoma in situ (LCIS) displays discohesive cells, often a feathery clear space between cells, solid growth pattern, intracytoplasmic vacuoles, and lack of polarization around luminal spaces.<ref>{{cite web|url=https://www.pathologyoutlines.com/topic/breastmalignantDCIS.html|title=Breast - Ductal carcinoma in situ - DCIS|author=Gary Tozbikian, M.D.|website=pathologyOutlines}} Topic Completed: 20 May 2020. Minor changes: 6 May 2021</ref>
File:Histopathology of lobular carcinoma in situ.jpg|Lobular carcinoma in situ (LCIS) displays discohesive cells, often a feathery clear space between cells, solid growth pattern, intracytoplasmic vacuoles, and lack of polarization around luminal spaces.<ref>{{cite web|url=https://www.pathologyoutlines.com/topic/breastmalignantDCIS.html|title=Breast - Ductal carcinoma in situ - DCIS|author=Gary Tozbikian, M.D.|website=pathologyOutlines}} Topic Completed: 20 May 2020. Minor changes: 6 May 2021</ref>
File:Histopathology of DCIS with lobular cancerization.jpg|LCIS typically fills smaller lobules rather than ducts, but '''DCIS can display lobular cancerization''' as shown at bottom of image.{{MH}}
File:Histopathology of DCIS with lobular cancerization.jpg|LCIS typically fills smaller lobules rather than ducts, but '''DCIS can display lobular cancerization''' as shown at bottom of image.{{MH}}
</gallery>
</gallery>
When unsure, perform immunohistochemistry for E-cadherin and p120. Both E-cadherin (left image below) and p120 (right) have a '''membranous''' staining pattern in ductal carcinoma in situ:
When unsure, perform immunohistochemistry for E-cadherin and p120. Both E-cadherin (left image below) and p120 (right) have a '''membranous''' staining pattern in ductal carcinoma in situ:
<gallery mode=packed>
<gallery mode=packed heights=200>
Immunohistochemistry for E-cadherin in ductal carcinoma in situ.jpg
Immunohistochemistry for E-cadherin in ductal carcinoma in situ.jpg
Immunohistochemistry for p120 in ductal carcinoma in situ.jpg
Immunohistochemistry for p120 in ductal carcinoma in situ.jpg
</gallery>
</gallery>
In contrast:
In contrast:
<gallery mode=packed>
<gallery mode=packed heights=200>>
File:Immunohistochemistry for E-cadherin in lobular carcinoma in situ.jpg|thumb|'''E-cadherin''' is '''negative''' in '''lobular''' carcinoma in situ.
File:Immunohistochemistry for E-cadherin in lobular carcinoma in situ.jpg|thumb|'''E-cadherin''' is '''negative''' in '''lobular''' carcinoma in situ.
File:Immunohistochemistry for p120 in lobular carcinoma in situ.jpg|'''p120''' has a '''cytoplasmic''' staining in '''lobular''' carcinoma in situ.
File:Immunohistochemistry for p120 in lobular carcinoma in situ.jpg|'''p120''' has a '''cytoplasmic''' staining in '''lobular''' carcinoma in situ.
Line 51: Line 54:
;Intermediate grade DCIS
;Intermediate grade DCIS
*Same nuclear features as low grade
*Same nuclear features as low grade
[[File:Histopathology of ductal carcinoma in situ with comedo necrosis.jpg|thumb|220px|Ductal carcinoma in situ with '''comedo necrosis''' spanning 30% of its diameter, which is generally regarded as the minimal size to classify it as comedo.<ref name="pmid30980039">Image by Mikael Häggström, MD.<br>- Reference for most common definition of comedo necrosis by size:<br>- {{cite journal| author=Harrison BT, Hwang ES, Partridge AH, Thompson AM, Schnitt SJ| title=Variability in diagnostic threshold for comedo necrosis among breast pathologists: implications for patient eligibility for active surveillance trials of ductal carcinoma in situ. | journal=Mod Pathol | year= 2019 | volume= 32 | issue= 9 | pages= 1257-1262 | pmid=30980039 | doi=10.1038/s41379-019-0262-4 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30980039  }}</ref>]]
*Substantial tumor cell (comedo) necrosis is present
*Substantial tumor cell (comedo) necrosis is present
[[File:Histopathology of high-grade DCIS.png|thumb||220px|High-grade DCIS. H&E stain.<br>RBC = red blood cell.<ref>Image by Mikael Häggström, MD. References for features:<br>- {{cite web|url=http://surgpathcriteria.stanford.edu/breast/dcis/grading.html|title=Ductal Carcinoma in Situ of the Breast|website=Stanford Medical School|date=2020-08-27}}<br>- {{cite journal| author=Hayward MK, Louise Jones J, Hall A, King L, Ironside AJ, Nelson AC | display-authors=etal| title=Derivation of a nuclear heterogeneity image index to grade DCIS. | journal=Comput Struct Biotechnol J | year= 2020 | volume= 18 | issue=  | pages= 4063-4070 | pmid=33363702 | doi=10.1016/j.csbj.2020.11.040 | pmc=7744935 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33363702  }}</ref>]]
;High grade DCIS
;High grade DCIS
*Nuclei >15 microns (over 3 times the size of a red blood cell)
*Nuclei >15 microns (over 2.5<ref name=Hayward2020>{{cite journal| author=Hayward MK, Louise Jones J, Hall A, King L, Ironside AJ, Nelson AC | display-authors=etal| title=Derivation of a nuclear heterogeneity image index to grade DCIS. | journal=Comput Struct Biotechnol J | year= 2020 | volume= 18 | issue=  | pages= 4063-4070 | pmid=33363702 | doi=10.1016/j.csbj.2020.11.040 | pmc=7744935 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33363702  }} </ref> times the size of a red blood cell)
*Nuclei are pleomorphic with clumped chromatin
*Nuclei are pleomorphic with clumped chromatin
*Nucleoli are prominent, enlarged
*Nucleoli are prominent, enlarged
Line 83: Line 88:
*10 - 12 points: '''Grade 3'''
*10 - 12 points: '''Grade 3'''
{{Moderate-end}}
{{Moderate-end}}
===Extent===
*In '''biopsies''', do not state the extent of DCIS.
*In '''excisions''', state the distance to the closest margin. {{Moderate-begin}}Additional extent specification is optional. If there is invasive tumor in addition to DCIS, you may give the DCIS extent in terms of the number of blocks containing DCIS. If an excision has DCIS without any invasive component, consider stating the total size in terms of the greatest distance between any DCIS foci.{{Moderate-end}}
[[File:Histopathology of dystrophic microcalcifications in ductal carcinoma in situ.jpg|thumb|170px|Histopathology of dystrophic microcalcifications in DCIS.]]
{{Microcalcifications in breast cancer}}
===Estrogen and progesterone receptors===
[[File:Immunohistochemistry of ductal carcinoma in situ (DCIS) with necrosis.jpg|thumb|200px|In DCIS with necrosis, only use the areas of viable DCIS for the calculation of hormone receptors on immunohistochemistry.]]
{{Estrogen and progesterone receptors in breast cancers}}
===HER2===
{{Comprehensive-begin}}HER2 testing is not necessary, but can be done for prognostic profiling.<ref>{{cite web|url=https://www.uptodate.com/contents/ductal-carcinoma-in-situ-treatment-and-prognosis|title=Ductal carcinoma in situ: Treatment and prognosis|website=UpToDate|author=Laura C Collins, MD, Christine Laronga, MD, FACS, Julia S Wong, MD}} Literature review current through: Sep 2022. | This topic last updated: Aug 19, 2022.</ref>{{Comprehensive-end}} See '''[[invasive ductal carcinoma]]''' for how to evaluate HER2.
==Reporting==
==Reporting==
[[File:Histopathologic architectural patterns of DCIS.png|thumb|Architectural patterns of DCIS.<ref>Top and bottom left images by Mikael Häggström, MD. Bottom right image from:<br>{{cite journal| author=Kulka J, Madaras L, Floris G, Lax SF| title=Papillary lesions of the breast. | journal=Virchows Arch | year= 2022 | volume= 480 | issue= 1 | pages= 65-84 | pmid=34734332 | doi=10.1007/s00428-021-03182-7 | pmc=8983543 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34734332  }}<br> - "This article is licensed under a Creative Commons Attribution 4.0 International License"</ref>]]
Example:
Example:
{|class=wikitable
{|class=wikitable
Line 90: Line 110:
{{CAP}}
{{CAP}}
{{Reporting}}
{{Reporting}}
{{Bottom}}
<noinclude>{{Bottom}}
</noinclude>

Latest revision as of 14:34, 2 June 2025

Author: Mikael Häggström [note 1]
Ductal carcinoma in situ (DCIS):

Comprehensiveness

On this resource, the following formatting is used for comprehensiveness:

  • Minimal depth
  • (Moderate depth)
  • ((Comprehensive))

Gross examination

As per:

or mastectomy.

Microscopic evaluation

DCIS.

Malignant epithelial cells confined to the ductal system of the breast.[1] The cells are cohesive and have high grade atypia.[2]

Differential diagnoses

Invasive ductal carcinoma
Has invasion through the basement membrane of over 1 mm in size.[3]
  • DCIS with microinvasion, defined as DCIS with focus of invasive cancer measuring up to 1.0 mm in size.[4]
    DCIS with microinvasion, defined as DCIS with focus of invasive cancer measuring up to 1.0 mm in size.[4]

In uncertain cases, use immunohistochemistry stain for myoepithelial markers[note 2].

  • Immunohistochemistry for the myoepithelial marker[note 3] calponin in ductal carcinoma in situ, highlighting myoepithelial cells around all tumor cells, thereby ruling out invasive ductal carcinoma.
    Immunohistochemistry for the myoepithelial marker[note 3] calponin in ductal carcinoma in situ, highlighting myoepithelial cells around all tumor cells, thereby ruling out invasive ductal carcinoma.
  • Invasive ductal carcinoma with tubular features can look like benign tubules, but calponin and p63 shows no surrounding myoepithelial cells.
    Invasive ductal carcinoma with tubular features can look like benign tubules, but calponin and p63 shows no surrounding myoepithelial cells.
Atypical ductal hyperplasia

There is no single definite cutoff, but the following are suggested cutoffs defining a ductal carcinoma in situ:[5]

  • Size over 2 mm.
  • Involving more than one duct.
Lobular carcinoma in situ (LCIS)
  • Lobular carcinoma in situ (LCIS) displays discohesive cells, often a feathery clear space between cells, solid growth pattern, intracytoplasmic vacuoles, and lack of polarization around luminal spaces.[6]
    Lobular carcinoma in situ (LCIS) displays discohesive cells, often a feathery clear space between cells, solid growth pattern, intracytoplasmic vacuoles, and lack of polarization around luminal spaces.[6]
  • LCIS typically fills smaller lobules rather than ducts, but DCIS can display lobular cancerization as shown at bottom of image.[image 1]
    LCIS typically fills smaller lobules rather than ducts, but DCIS can display lobular cancerization as shown at bottom of image.[image 1]

When unsure, perform immunohistochemistry for E-cadherin and p120. Both E-cadherin (left image below) and p120 (right) have a membranous staining pattern in ductal carcinoma in situ:

In contrast:

  • E-cadherin is negative in lobular carcinoma in situ.
    E-cadherin is negative in lobular carcinoma in situ.
  • p120 has a cytoplasmic staining in lobular carcinoma in situ.
    p120 has a cytoplasmic staining in lobular carcinoma in situ.

Grading

At least a low/intermediate/high grading (by Van Nuys criteria) as follows:[7]

Low grade DCIS
  • Nuclei 10-15 microns (2-3 times the size of a red blood cell)
  • Nuclei oval, round, regular, evenly dispersed chromatin up to mildly irregular and minimally pleomorphic
  • Nucleoi, if present, are small and indistinct
Intermediate grade DCIS
  • Same nuclear features as low grade
Ductal carcinoma in situ with comedo necrosis spanning 30% of its diameter, which is generally regarded as the minimal size to classify it as comedo.[8]
  • Substantial tumor cell (comedo) necrosis is present
High-grade DCIS. H&E stain.
RBC = red blood cell.[9]
High grade DCIS
  • Nuclei >15 microns (over 2.5[10] times the size of a red blood cell)
  • Nuclei are pleomorphic with clumped chromatin
  • Nucleoli are prominent, enlarged
  • Necrosis is almost universal and lumenal

(Numerical grading

Use the low/intermediate/high grade to give a numerical grading as follows:[11]

Feature Points
1 2 3
Nuclear grade Low Intermediate High
Glands/papillae >75% 10% - 75% <10%
Mitotic rate (per 10 HPF) <1 1 - 2 >2
Central necrosis <10% 10% - 50% >50%

The points for each feature are added together, giving the following result:[11]

  • 4 - 7 points: Grade 1
  • 8 - 9 points: Grade 2
  • 10 - 12 points: Grade 3

)

Extent

  • In biopsies, do not state the extent of DCIS.
  • In excisions, state the distance to the closest margin. (Additional extent specification is optional. If there is invasive tumor in addition to DCIS, you may give the DCIS extent in terms of the number of blocks containing DCIS. If an excision has DCIS without any invasive component, consider stating the total size in terms of the greatest distance between any DCIS foci.)
Histopathology of dystrophic microcalcifications in DCIS.

Microcalcifications

Microcalcifications of non-neoplastic breast glands.[image 1]

If invasive ductal carcinoma is seen, make at least a low power screening for microcalcifications (to correlate with imaging), but there's no need to look carefully (as tiny microcalcifications would unlikely correlate with imaging anyways).

Estrogen and progesterone receptors

In DCIS with necrosis, only use the areas of viable DCIS for the calculation of hormone receptors on immunohistochemistry.

Generally perform immunohistochemistry for estrogen and progesterone receptors and calculate the percentage of positive tumor cells.

HER2

((HER2 testing is not necessary, but can be done for prognostic profiling.[12])) See invasive ductal carcinoma for how to evaluate HER2.

Reporting

Architectural patterns of DCIS.[13]

Example:

Left breast mass, 2:00, 1 cm from nipple, ultrasound-guided vacuum assisted core needle biopsy:
Ductal carcinoma in situ.
Negative for invasive carcinoma.

For cancers, generally include a synoptic report, such as per College of American Pathologists (CAP) protocols at cap.org/protocols-and-guidelines.

  See also: General notes on reporting


Notes

  1. ↑ For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.
  2. ↑ For myoepithelial markers, a combination of p63 (higher specificity) with either SMM or calponin (both have higher sensitivity) is generally recommended for breast lesions. D2-40 is useful for highlighting lymphatics for invasion.
  3. ↑ For myoepithelial markers, a combination of p63 (higher specificity) with either SMM or calponin (both have higher sensitivity) is generally recommended for breast lesions. D2-40 is useful for highlighting lymphatics for invasion.

Main page

References

  1. ↑ Siziopikou, Kalliopi P. (2013). "Ductal Carcinoma In Situ of the Breast: Current Concepts and Future Directions ". Archives of Pathology & Laboratory Medicine 137 (4): 462–466. doi:10.5858/arpa.2012-0078-RA. ISSN 0003-9985. 
  2. ↑ Sucheta Srivastava, M.D.. Breast - Noninvasive lobular neoplasia - LCIS classic (Differential diagnosis section). Topic Completed: 1 September 2017. Minor changes: 17 May 2021
  3. ↑ . Protocol for the Examination of Resection Specimens from Patients with Ductal Carcinoma In Situ (DCIS) of the Breast, Version: 4.4.0.0. Protocol Posting Date: June 2021. College of American Pathologists.
  4. ↑ Image annotation by Mikael Häggström, MD, using source image from:
    Moatasim A, Mamoon N (2022). "Primary Breast Mucinous Cystadenocarcinoma and Review of Literature. ". Cureus 14 (3): e23098. doi:10.7759/cureus.23098. PMID 35464581. PMC: 8997314. Archived from the original. . 
    - "This is an open access article distributed under the terms of the Creative Commons Attribution License CC BY 4.0."
    Source for microinvasion: . Protocol for the Examination of Resection Specimens from Patients with Ductal Carcinoma In Situ (DCIS) of the Breast, Version: 4.4.0.0. Protocol Posting Date: June 2021. College of American Pathologists.
  5. ↑ Tozbikian, Gary; Brogi, Edi; Vallejo, Christina E.; Giri, Dilip; Murray, Melissa; Catalano, Jeffrey; Olcese, Cristina; Van Zee, Kimberly J.; et al. (2016). "Atypical Ductal Hyperplasia Bordering on Ductal Carcinoma In Situ ". International Journal of Surgical Pathology 25 (2): 100–107. doi:10.1177/1066896916662154. ISSN 1066-8969. 
  6. ↑ Gary Tozbikian, M.D.. Breast - Ductal carcinoma in situ - DCIS. pathologyOutlines. Topic Completed: 20 May 2020. Minor changes: 6 May 2021
  7. ↑ . Ductal Carcinoma in Situ of the Breast. Stanford Medical School (2020-08-27).
  8. ↑ Image by Mikael Häggström, MD.
    - Reference for most common definition of comedo necrosis by size:
    - Harrison BT, Hwang ES, Partridge AH, Thompson AM, Schnitt SJ (2019). "Variability in diagnostic threshold for comedo necrosis among breast pathologists: implications for patient eligibility for active surveillance trials of ductal carcinoma in situ. ". Mod Pathol 32 (9): 1257-1262. doi:10.1038/s41379-019-0262-4. PMID 30980039. Archived from the original. . 
  9. ↑ Image by Mikael Häggström, MD. References for features:
    - . Ductal Carcinoma in Situ of the Breast. Stanford Medical School (2020-08-27).
    - Hayward MK, Louise Jones J, Hall A, King L, Ironside AJ, Nelson AC (2020). "Derivation of a nuclear heterogeneity image index to grade DCIS. ". Comput Struct Biotechnol J 18: 4063-4070. doi:10.1016/j.csbj.2020.11.040. PMID 33363702. PMC: 7744935. Archived from the original. . 
  10. ↑ Hayward MK, Louise Jones J, Hall A, King L, Ironside AJ, Nelson AC (2020). "Derivation of a nuclear heterogeneity image index to grade DCIS. ". Comput Struct Biotechnol J 18: 4063-4070. doi:10.1016/j.csbj.2020.11.040. PMID 33363702. PMC: 7744935. Archived from the original. . 
  11. ↑ 11.0 11.1 Allred, D. C. (2010). "Ductal Carcinoma In Situ: Terminology, Classification, and Natural History ". JNCI Monographs 2010 (41): 134–138. doi:10.1093/jncimonographs/lgq035. ISSN 1052-6773. 
  12. ↑ Laura C Collins, MD, Christine Laronga, MD, FACS, Julia S Wong, MD. Ductal carcinoma in situ: Treatment and prognosis. UpToDate. Literature review current through: Sep 2022. | This topic last updated: Aug 19, 2022.
  13. ↑ Top and bottom left images by Mikael Häggström, MD. Bottom right image from:
    Kulka J, Madaras L, Floris G, Lax SF (2022). "Papillary lesions of the breast. ". Virchows Arch 480 (1): 65-84. doi:10.1007/s00428-021-03182-7. PMID 34734332. PMC: 8983543. Archived from the original. . 
    - "This article is licensed under a Creative Commons Attribution 4.0 International License"

Image sources

  1. ↑ 1.0 1.1 Image(s) by: Mikael Häggström, M.D. Public Domain
    - Author info
    - Reusing images
Retrieved from "https://patholines.org/index.php?title=Ductal_carcinoma_in_situ&oldid=7192"