Ductal carcinoma in situ

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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:
    1. Nuclei should be ~4x RBC for low grade, 5x RBC for high grade.[1]
    2. Nuclear enlargement of 3x +/- nucleolar enlargement.[2]
    3. Multiple nucleoli + nuclear size variation.[2]

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.

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.

DDx:

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.

DDX:

Micropapillary ductal carcinoma in situ

Features:

  • Small papillae without fibrovascular cores.
  • Have "drum stick" shape.

DDx:

Grading DCIS

Graded 1-3 (low-high)[3] - compare lesional nuclei to one another.

  • Grade 1:
    • Nuclei 2-3x size of RBC.
    • No necrosis.
  • Grade 2:
  • 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:[4][5]

  1. < Two membrane-bound spaces.
  2. < 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:

Micrometastasis in DCIS

Micrometastasis in DCIS - not significant.[6][7]

See also

References

  1. URL: http://surgpathcriteria.stanford.edu/breast/dcis/apocrinedcis.html. Accessed on: 4 August 2011.
  2. 2.0 2.1 O'Malley, FP.; Bane, A. (Jan 2008). "An update on apocrine lesions of the breast.". Histopathology 52 (1): 3-10. doi:10.1111/j.1365-2559.2007.02888.x. PMID 18171412.
  3. URL: http://surgpathcriteria.stanford.edu/breast/dcis/. Accessed on: 4 August 2011.
  4. O'Malley, Frances P.; Pinder, Sarah E. (2006). Breast Pathology: A Volume in Foundations in Diagnostic Pathology series (1st ed.). Churchill Livingstone. pp. 168. ISBN 978-0443066801.
  5. Tadrous, Paul.J. Diagnostic Criteria Handbook in Histopathology: A Surgical Pathology Vade Mecum (1st ed.). Wiley. pp. 258. ISBN 978-0470519035.
  6. Lara, JF.; Young, SM.; Velilla, RE.; Santoro, EJ.; Templeton, SF. (Nov 2003). "The relevance of occult axillary micrometastasis in ductal carcinoma in situ: a clinicopathologic study with long-term follow-up.". Cancer 98 (10): 2105-13. doi:10.1002/cncr.11761. PMID 14601079.
  7. Broekhuizen, LN.; Wijsman, JH.; Peterse, JL.; Rutgers, EJ. (Jun 2006). "The incidence and significance of micrometastases in lymph nodes of patients with ductal carcinoma in situ and T1a carcinoma of the breast.". Eur J Surg Oncol 32 (5): 502-6. doi:10.1016/j.ejso.2006.02.006. PMID 16569492.