Difference between revisions of "Ductal carcinoma in situ"

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#redirect [[Non-invasive_breast_carcinoma#Ductal_carcinoma_in_situ]]
'''Ductal carcinoma in situ''', abbreviated '''DCIS''', in a common type of [[non-invasive breast carcinoma]].
 
==General==
*Diagnosis based on nuclear abnormalities ''and/or'' architecture.
**Low-grade DCIS does '''not''' have a malignant cytology.
*It is typically picked-up during radiologic screening.
 
==Microscopic==
Features:
*Architectural changes:
**Equal spacing of cells - "cookie cutter" look.
**Cells line-up along lumen/glandular spaces - form "Roman briges".
**Architecture suggestive of DCIS - see ''[[Subtypes of DCIS]]''.
*Nuclear changes:
**Nuclear enlargement - at least 2-3x size of [[RBC]] - '''key feature'''.
***Compared to RBCs to grade DCIS - see ''[[Grading DCIS]]''.
****Compare sizes of nuclei if you cannot find RBCs.
**Nuclear pleomorphism - important feature.
*+/-Mitoses.
 
Note:
*Apocrine changes of cytoplasm -- several sets of criteria exist -- any of the following:
*#Nuclei should be ~4x RBC for low grade, 5x RBC for high grade.<ref>URL: [http://surgpathcriteria.stanford.edu/breast/dcis/apocrinedcis.html http://surgpathcriteria.stanford.edu/breast/dcis/apocrinedcis.html]. Accessed on: 4 August 2011.</ref>
*#Nuclear enlargement of 3x +/- nucleolar enlargement.<ref name=pmid18171412/>
*#Multiple nucleoli + nuclear size variation.<ref name=pmid18171412>{{Cite journal  | last1 = O'Malley | first1 = FP. | last2 = Bane | first2 = A. | title = An update on apocrine lesions of the breast. | journal = Histopathology | volume = 52 | issue = 1 | pages = 3-10 | month = Jan | year = 2008 | doi = 10.1111/j.1365-2559.2007.02888.x | PMID = 18171412 }}</ref>
 
===Subtypes of DCIS===
The subtypes are based on architecture.
 
Note:
*''Comedonecrosis'' used to be considered a separate subtype.  [[Necrosis]] is seen most often in the context of ''solid ductal carcinoma in situ''.
====Solid ductal carcinoma in situ====
Features:
*Sheet of cells fills the duct
*No spaces between cells.
 
<gallery>
Image:Breast DCIS Solid IntermediateGrade SNP.jpg|Breast - Ductal carcinoma in situ -  Solid variant-  Intermediate grade - Medium power (SKB)
Image:Breast DCIS Solid SNP.jpg|Breast - Ductal carcinoma in situ -  Solid variant-  Intermediate grade - Low power (SKB)
Image:Breast DCIS Solid PA.JPG|Breast - Ductal carcinoma in situ -  Solid variant - Medium power (SKB)
Image:Breast DCIS Comedonecrotic 2 PA.JPG|Breast - Ductal carcinoma in situ - Solid variant - Comedonecrosis (SKB)
Image:Breast DCIS Comedonecrosis MP PA.JPG|Breast - Ductal carcinoma in situ - Solid variant - Comedonecrosis (SKB)
</gallery>
 
DDx:
*[[LCIS]].
**May show dyscohesion
**More monomorphic population of cells
 
====Cribriform ductal carcinoma in situ====
Features:
*Honeycomb-like appearance: circular holes.
*"Cookie cutter" appearance/"punched-out" appearance/"Roman bridges" -- cells surround the circular holes.
 
<gallery>
Image:Breast DCIS Cribriform MP CTR.jpg|Breast - Ductal carcinoma in situ - cribriform varient  - medium power (SKB)
Image:Breast DCIS Cribriform PA.JPG|Breast - Ductal carcinoma in situ - cribriform varient  - medium power (SKB)
</gallery>
 
DDx:
*[[Collagenous spherulosis]].
*[[Adenoid cystic carcinoma of the breast]].
*Invasive cribriform carcinoma of the breast
 
====Papillary ductal carcinoma in situ====
Features:
*Papillae with fibrovascular cores.
*Papillae lack a myoepithelial layer
*Papillae are lined by atypical cells.
*Papillae within a ductal space lined by myoepithelial cells.
 
<gallery>
Image:Breast DCIS PapillaryVariant LP PA.JPG|Breast - Ductal carcinoma in situ -  Papillary variant - low power (SKB)
Image:Breast DCIS Papillary PA.JPG|Breast - Ductal carcinoma in situ - Papillary variant - Medium power (SKB)
</gallery>
 
DDX:
 
*[[Intraductal papilloma]]
*Ductal carcinoma in situ arising within an intraductal papilloma
*[[Intracystic papillary breast carcinoma]]
*[[Invasive papillary breast carcinoma]]
 
====Micropapillary ductal carcinoma in situ====
Features:
*Small papillae without fibrovascular cores.
*Have "drum stick" shape.
 
DDx:
*[[Gynecomastoid hyperplasia]].
 
<gallery>
Image:Breast DCIS MicropapillaryType MP CTR.jpg|Breast - Ductal carcinoma in situ - micropapillary variant - Medium power - (SKB)
Image:Breast DCIS Micropapillary SNP.jpg|Breast - Ductal carcinoma in situ - micropapillary variant - High power - (SKB)
Image:Breast DCIS Apocrine PA.JPG|Breast  - Ductal carcinoma in situ - Micropapillary type with apocrine features - High power  - (SKB)
</gallery>
 
===Grading DCIS===
Graded 1-3 (low-high)<ref>URL: [http://surgpathcriteria.stanford.edu/breast/dcis/ http://surgpathcriteria.stanford.edu/breast/dcis/]. Accessed on: 4 August 2011.</ref> - compare lesional nuclei to one another.
*Grade 1:
**Nuclei 2-3x size of [[RBC]].
**No necrosis.
*Grade 2:
**Nuclei 2-3x size of RBC.
**+/-[[Necrosis]].
*Grade 3:
**Nuclei >3x size of RBC.
**Necrosis usually present.
 
Notes:
*It is often hard to find RBCs when you want 'em. DCIS is pleomorphic.
*If no RBCs are present to compare with compare the nuclei to one another.
*If you see nuclei >3x larger than their neigbour you're ready to call DCIS Grade 3.
 
===Size criteria for low-grade DCIS===
ADH is diagnosed if the lesion is small - specifically:<ref name=Ref_BP168>{{Ref BP|168}}</ref><ref>{{Ref DCHH|258}}</ref>
# < Two membrane-bound spaces.
# < 2 mm extent. ‡
 
The treatment is similar; ADH and DCIS are both excised. 
 
The differences are:
*DCIS is cancer, i.e. this has life insurance implications.
*Radiation treatment - DCIS is irradiated; ADH does ''not'' get radiation.
 
Notes:
* ‡ 3 mm is used in papillary lesions.{{fact}}
 
===Micrometastasis in DCIS===
Micrometastasis in DCIS - not significant.<ref name=pmid14601079>{{Cite journal  | last1 = Lara | first1 = JF. | last2 = Young | first2 = SM. | last3 = Velilla | first3 = RE. | last4 = Santoro | first4 = EJ. | last5 = Templeton | first5 = SF. | title = The relevance of occult axillary micrometastasis in ductal carcinoma in situ: a clinicopathologic study with long-term follow-up. | journal = Cancer | volume = 98 | issue = 10 | pages = 2105-13 | month = Nov | year = 2003 | doi = 10.1002/cncr.11761 | PMID = 14601079 }}</ref><ref name=pmid16569492>{{Cite journal  | last1 = Broekhuizen | first1 = LN. | last2 = Wijsman | first2 = JH. | last3 = Peterse | first3 = JL. | last4 = Rutgers | first4 = EJ. | title = The incidence and significance of micrometastases in lymph nodes of patients with ductal carcinoma in situ and T1a carcinoma of the breast. | journal = Eur J Surg Oncol | volume = 32 | issue = 5 | pages = 502-6 | month = Jun | year = 2006 | doi = 10.1016/j.ejso.2006.02.006 | PMID = 16569492 }}</ref>
 
==See also==
*[[Non-invasive breast carcinoma]].
 
==References==
{{Reflist|1}}


[[Category:Diagnosis]]
[[Category:Diagnosis]]
[[Category:Breast pathology]]
Michael
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