Non-invasive breast carcinoma

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Non-invasive breast carcinoma is a type of breast cancer and a common entity... since the introduction of radiologic breast screening.

Viewed simplistically, it can neatly be divided into the discussion of two entities:

  1. Ductal carcinoma in situ (DCIS).
  2. Lobular carcinoma in situ (LCIS).

Invasive breast cancer is dealt with in the article invasive breast cancer. An introduction to the breast is found in the breast pathology article.

Ductal neoplasia

Overview

This category includes:

  1. Atypical ductal hyperplasia (ADH).
  2. Ductal carcinoma in situ (DCIS).

The difference between ADH and DCIS is:

  1. The degree of nuclear atypia; high grade is DCIS.
  2. The extent; small lesions are ADH, large lesions (low-grade) DCIS.

Is it ductal neoplasia?

FEHUT versus ADH versus DCIS

  • Breast duct lumen with too many cells; this is common problem is breast pathology.[1]
    • The general DDx for this scenario is: FEHUT versus ADH versus DCIS.

Notes:

Tabular comparison - histomorphology

Comparison of FEHUT, ADH and DCIS (memory device: CLEAN = cell spacing, luminal spaces, extent/size, arch., nuclei):

Morphology FEHUT ADH DCIS
Cell spacing varied, streaming focal uniformity uniform
Lumina slits/irregular spaces;
cells haphazardly
arranged around lumen
irregular spaces, no slits circular "punched-out";
cells side-by-side +
equally spaced @ interface
Extent usually lobulocentric limited extent extensive
Architecture irregular/swirling DCIS-like DCIS architecture (solid,
cribriform, papillary, micropapillary)
Nuclei variable, no nucleolus hyperchromatic
& uniform, usu. no nucleolus
evenly spaced +/-nucleolus

Treatment - implications:

  • FEHUT - nothing; FEHUT is benign.
  • ADH - simple excision, i.e. lumpectomy.
  • DCIS - excision (lumpectomy) + radiation.
  • Invasive ductal carcinoma - excision with sentinel lymph node biopsy (for staging)[2] and radiation.
  • Positive sentinel node - systemic chemotherapy. (???)

IHC

Usual ductal hyperplasia (AKA FEHUT) vs. ADH/DCIS:[3][4]

  • FEHUT: ER-low/CK5-high profile.
  • ADH/DCIS: ER-high/CK5-low.

Where:

  • ER-high = diffuse strong staining in >90% of cells.
  • CK5-high = mosaic pattern of staining in >20% of cells
  • CK5-low = absent or staining in <20% of cells.

Atypical ductal hyperplasia

  • Abbreviated ADH.

Ductal carcinoma in situ

  • Abbreviated DCIS.

Lobular neoplasia

Overview

Includes:

  1. Atypical lobular hyperplasia (ALH).
  2. Lobular carcinoma in situ (LCIS).
  • These entities (ALH, LCIS) are near identical from a histomorphologic perspective.
  • The difference is extent of involvement:
    • ALH <50% of terminal duct lobular unit (TDLU) is involved.
    • LCIS >=50% of TDLU is involved.

Atypical lobular hyperplasia

  • Abbreviated ALH.

Lobular carcinoma in situ

  • Abbreviated LCIS.

General

  • Management is currently some matter of debate.
    • Association of Breast Surgery (UK) guidelines recommend excision of LCIS on biopsy,[5] as does a smaller (US) study.[6]
    • In the UK, most surgeons (~60%) excise LCIS seen on biopsy; however, a significant minority considers followup appropriate.[5]
  • Not detected radiologically - it is an incidental pathologic finding.
  • The precursor to invasive ductal carcinoma of the breast.

Microscopic

Features[7][8] - memory device ABCDEF:

  • Atypia minimal - usually.
    • Relatively small ~1-2x size lymphocyte.
  • Borders of cells distinct/visible - dyscohesive.
  • Clear cytoplasm (focal).
    • May have a signet ring cell-like appearance.
  • Distend duct.
  • Eccentric nucleus, usu. round.
  • Filled ducts.
    • No luminal spaces - key feature.
      • Partially filled ducts are not LCIS.

DDx:

Images:

Subclassification[8]

  • Non-PLCIS.
    • Type A.
      • Nucleus 1-1.5x lymphocyte.
      • No nucleolus.
    • Type B.
      • Nucleus ~2x lymphocyte.
      • Nucleolus present.
  • PLCIS (pleomorphic lobular carcinoma in situ).

DDx:

IHC

  • E-cadherin -ve or incomplete membrane staining.
  • p120 catenin +ve cytoplasmic.[9]
    • Membranous staining in DCIS.

See also

References

  1. O'Malley, Frances P.; Pinder, Sarah E. (2006). Breast Pathology: A Volume in Foundations in Diagnostic Pathology series (1st ed.). Churchill Livingstone. pp. 167-8. ISBN 978-0443066801.
  2. Sentinel Lymph Node Biopsy: What Breast Cancer Patients Need to Know. cancernews.com. URL: http://www.cancernews.com/data/Article/202.asp. Accessed on: 9 October 2009.
  3. Rabban, JT.; Koerner, FC.; Lerwill, MF. (Jul 2006). "Solid papillary ductal carcinoma in situ versus usual ductal hyperplasia in the breast: a potentially difficult distinction resolved by cytokeratin 5/6.". Hum Pathol 37 (7): 787-93. doi:10.1016/j.humpath.2006.02.016. PMID 16784976.
  4. Grin, A.; O'Malley, FP.; Mulligan, AM. (Nov 2009). "Cytokeratin 5 and estrogen receptor immunohistochemistry as a useful adjunct in identifying atypical papillary lesions on breast needle core biopsy.". Am J Surg Pathol 33 (11): 1615-23. doi:10.1097/PAS.0b013e3181aec446. PMID 19675450.
  5. 5.0 5.1 Chester, R.; Bokinni, O.; Ahmed, I.; Kasem, A. (Nov 2015). "UK national survey of management of breast lobular carcinoma in situ.". Ann R Coll Surg Engl 97 (8): 574-7. doi:10.1308/rcsann.2015.0037. PMID 26492902.
  6. O'Neil, M.; Madan, R.; Tawfik, OW.; Thomas, PA.; Fan, F. (Aug 2010). "Lobular carcinoma in situ/atypical lobular hyperplasia on breast needle biopsies: does it warrant surgical excisional biopsy? A study of 27 cases.". Ann Diagn Pathol 14 (4): 251-5. doi:10.1016/j.anndiagpath.2010.04.002. PMID 20637429.
  7. Weedman Molavi, Diana (2008). The Practice of Surgical Pathology: A Beginner's Guide to the Diagnostic Process (1st ed.). Springer. pp. 188. ISBN 978-0387744858.
  8. 8.0 8.1 O'Malley, Frances P.; Pinder, Sarah E. (2006). Breast Pathology: A Volume in Foundations in Diagnostic Pathology series (1st ed.). Churchill Livingstone. pp. 170. ISBN 978-0443066801.
  9. Sarrió, D.; Pérez-Mies, B.; Hardisson, D.; Moreno-Bueno, G.; Suárez, A.; Cano, A.; Martín-Pérez, J.; Gamallo, C. et al. (Apr 2004). "Cytoplasmic localization of p120ctn and E-cadherin loss characterize lobular breast carcinoma from preinvasive to metastatic lesions.". Oncogene 23 (19): 3272-83. doi:10.1038/sj.onc.1207439. PMID 15077190.