Ductal carcinoma in situ: Difference between revisions
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===Differential diagnoses=== | ===Differential diagnoses=== | ||
;[[Invasive ductal carcinoma]]: Has invasion through the basement membrane.<ref | ;[[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> In uncertain cases, use immunohistochemistry stain for '''calponin''' (has the highest sensitivity) and '''p63''' (has the highest specificity). | ||
<gallery mode=packed heights=220> | <gallery mode=packed heights=220> | ||
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> | |||
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. | ||
Revision as of 14:55, 12 October 2022
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
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] In uncertain cases, use immunohistochemistry stain for calponin (has the highest sensitivity) and p63 (has the highest specificity).
-
DCIS with microinvasion, defined as DCIS with focus of invasive cancer measuring up to 1.0 mm in size.[4]
-
Immunohistochemistry for the myoepithelial marker[note 2] 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.
![DCIS with microinvasion, defined as DCIS with focus of invasive cancer measuring up to 1.0 mm in size.[4]](/index.php?title=Special:Upload&wpDestFile=Histopathology_of_microinvasive_ductal_carcinoma_in_situ.png){kind=link}
![Immunohistochemistry for the myoepithelial marker[note 2] calponin in ductal carcinoma in situ, highlighting myoepithelial cells around all tumor cells, thereby ruling out invasive ductal carcinoma.](/index.php?title=Special:Upload&wpDestFile=Immunohistochemistry_with_calponin_in_ductal_carcinoma_in_situ.jpg){kind=link}
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]
-
LCIS typically fills smaller lobules rather than ducts, but DCIS can display lobular cancerization as shown at bottom of image.[image 1]
![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]](/index.php?title=Special:Upload&wpDestFile=Histopathology_of_lobular_carcinoma_in_situ.jpg){kind=link}
![LCIS typically fills smaller lobules rather than ducts, but DCIS can display lobular cancerization as shown at bottom of image.[image 1]](/index.php?title=Special:Upload&wpDestFile=Histopathology_of_DCIS_with_lobular_cancerization.jpg){kind=link}
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.
-
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
- Substantial tumor cell (comedo) necrosis is present
- High grade DCIS
- Nuclei >15 microns (over 3 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:[8]
| 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:[8]
- 4 - 7 points: Grade 1
- 8 - 9 points: Grade 2
- 10 - 12 points: Grade 3
)
Estrogen and progesterone receptors
_with_necrosis.jpg){kind=link}
Generally perform immunohistochemistry for estrogen and progesterone receptors and calculate the percentage of positive tumor cells.
Reporting
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
- ↑ 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.
- ↑ 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
- ↑ 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:. ISSN 0003-9985.
- ↑ Sucheta Srivastava, M.D.. Breast - Noninvasive lobular neoplasia - LCIS classic (Differential diagnosis section). Topic Completed: 1 September 2017. Minor changes: 17 May 2021
- ↑ . 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.
- ↑ 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:. 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. - ↑ 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:. ISSN 1066-8969.
- ↑ Gary Tozbikian, M.D.. Breast - Ductal carcinoma in situ - DCIS. pathologyOutlines. Topic Completed: 20 May 2020. Minor changes: 6 May 2021
- ↑ . Ductal Carcinoma in Situ of the Breast. Stanford Medical School (2020-08-27).
- ↑ 8.0 8.1 Allred, D. C. (2010). "Ductal Carcinoma In Situ: Terminology, Classification, and Natural History ". JNCI Monographs 2010 (41): 134–138. doi:. ISSN 1052-6773.
Image sources
- ↑ Image(s) by: Mikael Häggström, M.D. Public Domain
- Author info
- Reusing images