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'''Non-invasive [[breast cancer]] | '''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: | |||
#[[Ductal carcinoma in situ]] (DCIS). | |||
#[[Lobular carcinoma in situ]] (LCIS). | |||
Invasive breast cancer is dealt with in the article ''[[invasive breast cancer]]''. | 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: | |||
#[[Atypical ductal hyperplasia]] (ADH). | |||
#[[Ductal carcinoma in situ]] (DCIS). | |||
== | |||
The difference between ADH and DCIS ''is'': | |||
#The degree of '''nuclear atypia'''; high grade is DCIS. | |||
#The '''extent'''; small lesions are ADH, large lesions (low-grade) DCIS. | |||
==FEHUT | ==Is it ductal neoplasia?== | ||
*Breast duct lumen with too many cells | ===FEHUT versus ADH versus DCIS=== | ||
*Breast duct lumen with too many cells; this is common problem is breast pathology.<ref name=Ref_BP167-8>{{Ref BP|167-8}}</ref> | |||
**The general DDx for this scenario is: ''FEHUT'' versus ''ADH'' versus ''DCIS''. | |||
Notes: | |||
* | *FEHUT = florid epithelial hyperplasia of the usual type, [[AKA]] ''epithelial hyperplasia'' (EH). | ||
*ADH = atypical ductal hyperplasia. | *ADH = [[atypical ductal hyperplasia]]. | ||
*DCIS = ductal carcinoma in situ. | *DCIS = [[ductal carcinoma in situ]]. | ||
====Tabular comparison - histomorphology==== | |||
Comparison of FEHUT, ADH and DCIS (memory device: ''CLEAN'' = cell spacing, luminal spaces, extent/size, arch., nuclei): | |||
{| class="wikitable sortable" | |||
! Morphology | |||
! [[FEHUT]] | |||
! [[ADH]] | |||
! [[DCIS]] | |||
{| class="wikitable" | |||
|- | |- | ||
| ''' | | '''Cell spacing''' | ||
| varied, streaming | |||
| focal uniformity | |||
| uniform | |||
|- | |- | ||
| '''Lumina''' | | '''Lumina''' | ||
| slits/irregular spaces; <br>cells haphazardly <br>arranged around lumen | |||
| irregular spaces, no slits | |||
| circular "punched-out"; <br>cells side-by-side + <br>equally spaced @ interface | |||
|- | |- | ||
| '''Extent''' | | '''Extent''' | ||
| usually lobulocentric | |||
| limited extent | |||
| extensive | |||
|- | |- | ||
| '''Architecture''' | | '''Architecture''' | ||
| irregular/swirling | |||
| DCIS-like | |||
| DCIS architecture (solid, <br>cribriform, papillary, micropapillary) | |||
|- | |- | ||
| '''Nuclei''' | | '''Nuclei''' | ||
| variable, no nucleolus | |||
| hyperchromatic<br>& uniform, usu. no nucleolus | |||
| evenly spaced +/-nucleolus | |||
|- | |- | ||
|} | |} | ||
Treatment - implications: | Treatment - implications: | ||
* | *[[FEHUT]] - nothing; FEHUT is benign. | ||
*ADH - simple excision, i.e. lumpectomy. | *[[ADH]] - simple excision, i.e. lumpectomy. | ||
*DCIS - excision (lumpectomy) + radiation. | *[[DCIS]] - excision (lumpectomy) + radiation. | ||
*Invasive ductal carcinoma - excision with sentinel lymph node | *Invasive ductal carcinoma - excision with sentinel lymph node biopsy (for staging)<ref>Sentinel Lymph Node Biopsy: What Breast Cancer Patients Need to Know. cancernews.com. URL: [http://www.cancernews.com/data/Article/202.asp http://www.cancernews.com/data/Article/202.asp]. Accessed on: 9 October 2009.</ref> and radiation. | ||
*Positive sentinel node - systemic chemotherapy. (???) | |||
====IHC==== | |||
Usual ductal hyperplasia (AKA FEHUT) vs. [[ADH]]/[[DCIS]]:<ref>{{Cite journal | last1 = Rabban | first1 = JT. | last2 = Koerner | first2 = FC. | last3 = Lerwill | first3 = MF. | title = Solid papillary ductal carcinoma in situ versus usual ductal hyperplasia in the breast: a potentially difficult distinction resolved by cytokeratin 5/6. | journal = Hum Pathol | volume = 37 | issue = 7 | pages = 787-93 | month = Jul | year = 2006 | doi = 10.1016/j.humpath.2006.02.016 | PMID = 16784976 }}</ref><ref name=pmid19675450>{{Cite journal | last1 = Grin | first1 = A. | last2 = O'Malley | first2 = FP. | last3 = Mulligan | first3 = AM. | title = Cytokeratin 5 and estrogen receptor immunohistochemistry as a useful adjunct in identifying atypical papillary lesions on breast needle core biopsy. | journal = Am J Surg Pathol | volume = 33 | issue = 11 | pages = 1615-23 | month = Nov | year = 2009 | doi = 10.1097/PAS.0b013e3181aec446 | PMID = 19675450 }}</ref> | |||
*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''. | |||
{{Main|Atypical ductal hyperplasia}} | |||
==Ductal carcinoma in situ== | |||
*Abbreviated ''DCIS''. | |||
{{Main|Ductal carcinoma in situ}} | |||
=Lobular neoplasia= | |||
==Overview== | |||
Includes: | |||
#Atypical lobular hyperplasia (ALH). | |||
#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''. | |||
{{Main|Atypical lobular hyperplasia}} | |||
==Lobular carcinoma in situ== | ==Lobular carcinoma in situ== | ||
*Abbreviated ''LCIS''. | *Abbreviated ''LCIS''. | ||
===General=== | |||
*Management is currently some matter of debate. | *Management is currently some matter of debate. | ||
**''Association of Breast Surgery'' (UK) guidelines recommend excision of LCIS on biopsy,<ref name=pmid26492902/> as does a smaller (US) study.<ref name=pmid20637429>{{Cite journal | last1 = O'Neil | first1 = M. | last2 = Madan | first2 = R. | last3 = Tawfik | first3 = OW. | last4 = Thomas | first4 = PA. | last5 = Fan | first5 = F. | title = Lobular carcinoma in situ/atypical lobular hyperplasia on breast needle biopsies: does it warrant surgical excisional biopsy? A study of 27 cases. | journal = Ann Diagn Pathol | volume = 14 | issue = 4 | pages = 251-5 | month = Aug | year = 2010 | doi = 10.1016/j.anndiagpath.2010.04.002 | PMID = 20637429 }}</ref> | |||
**In the UK, most surgeons (~60%) excise LCIS seen on biopsy; however, a significant minority considers followup appropriate.<ref name=pmid26492902>{{Cite journal | last1 = Chester | first1 = R. | last2 = Bokinni | first2 = O. | last3 = Ahmed | first3 = I. | last4 = Kasem | first4 = A. | title = UK national survey of management of breast lobular carcinoma in situ. | journal = Ann R Coll Surg Engl | volume = 97 | issue = 8 | pages = 574-7 | month = Nov | year = 2015 | doi = 10.1308/rcsann.2015.0037 | PMID = 26492902 }}</ref> | |||
*Not detected radiologically - it is an incidental pathologic finding. | *Not detected radiologically - it is an incidental pathologic finding. | ||
*The precursor to [[invasive ductal carcinoma of the breast]]. | |||
===Microscopic=== | |||
Features<ref name=Ref_TPoSP188>{{Ref TPoSP|188}}</ref><ref name=Ref_BP170>{{Ref BP|170}}</ref> - memory device ''ABCDEF'': | |||
*'''A'''typia minimal - usually. | |||
**Relatively small ~1-2x size lymphocyte. | |||
*'''B'''orders of cells distinct/visible - ''dyscohesive''. | |||
*'''C'''lear cytoplasm (focal). | |||
**May have a signet ring cell-like appearance. | |||
*'''D'''istend duct. | |||
*'''E'''ccentric nucleus, usu. round. | |||
*'''F'''illed ducts. | |||
**'''No''' luminal spaces - '''key feature'''. | |||
***Partially filled ducts are ''not'' LCIS. | |||
DDx: | |||
*[[Invasive ductal carcinoma of the breast|Invasive ductal carcinoma]]. | |||
*[[Atypical ductal hyperplasia]]. | |||
Images: | |||
*[http://www.webpathology.com/image.asp?n=3&Case=291 LCIS (webpathology.com)]. | |||
*[http://www.webpathology.com/image.asp?n=5&Case=291 LCIS (webpathology.com)]. | |||
*[http://www.webpathology.com/image.asp?n=6&Case=291 LCIS - high mag. (webpathology.com)]. | |||
====Subclassification<ref name=Ref_BP170>{{Ref BP|170}}</ref>==== | |||
*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: | |||
*Low-grade DCIS. | |||
*High-grade DCIS for ''pleomorphic lobular carcinoma in situ''. | |||
*[[Atypical lobular hyperplasia]]. | |||
===IHC=== | |||
*[[E-cadherin]] -ve ''or'' incomplete membrane staining. | |||
*p120 catenin +ve cytoplasmic.<ref name="Sarrió-2004">{{Cite journal | last1 = Sarrió | first1 = D. | last2 = Pérez-Mies | first2 = B. | last3 = Hardisson | first3 = D. | last4 = Moreno-Bueno | first4 = G. | last5 = Suárez | first5 = A. | last6 = Cano | first6 = A. | last7 = Martín-Pérez | first7 = J. | last8 = Gamallo | first8 = C. | last9 = Palacios | first9 = J. | title = Cytoplasmic localization of p120ctn and E-cadherin loss characterize lobular breast carcinoma from preinvasive to metastatic lesions. | journal = Oncogene | volume = 23 | issue = 19 | pages = 3272-83 | month = Apr | year = 2004 | doi = 10.1038/sj.onc.1207439 | PMID = 15077190 }}</ref> | |||
**Membranous staining in DCIS. | |||
=See also= | |||
*[[Breast]] | *[[Breast]]. | ||
*[[Invasive breast cancer]] | *[[Invasive breast cancer]]. | ||
=References= | |||
{{reflist|2}} | {{reflist|2}} | ||
[[Category:Breast pathology]] | [[Category:Breast pathology]] |
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