- Dr. Yao-Shi Fu
- Department of
Pathology
- Providence Saint
Joseph Medical Center
- Burbank,
California
- Pathologic
Definition of Ductal carcinoma in situ
(DCIS)
- Malignant cells proliferate within
the pre-existing ductal structures
and basement membranes (Slide 1)
to replace benign lining cells
located within the ducts proximally
and the lobules distally (Slide 2).
The risk for progression to invasive
carcinoma and for local recurrence is
closely related to the pathology of
DCIS.
By gross examination, most lesions of DCIS
do not present with a distinct appearance.
The background breast tissue may be fatty or
fibrous, and slightly firm on palpation (Slide 3). Only
extensive comedo type of DCIS depicts visible
abnormality raising the possibility of
malignancy. The involved area has a granular
character. By squeezing the area, necrotic
material exudes from the ducts (Slide 4).
Because of the lack of obvious abnormality in
most DCIS lesions, all excisional specimens
should be handled properly right from the
outset.
- Classification of DCIS is based on
the microscopic characters of
- 1. architecture (growth pattern)
- 2. nuclear features
| Classification
of DCIS by the Predominant Architecture |
1.
Papillary/micropapillary type
| |
- - Multiple
isolated papillary
projections, most of
which lack fibrovascular
stalks (Slide 5 and Slide 6)
- - Papillae
become fused to form
Roman bridges and arches
giving the impression of
rigidity (Slide 7 and Slide 8)
- - Most
tumor cells have low
nuclear grade
- - The
tumor can be quite
extensive
|
|
2. Cribriform
type
| |
- - Tumor
cells are arranged in a
sieve-like pattern,
multiple small round
glands growing in a
larger gland or duct.
These glands are
confluent without fibrous
walls. Sometimes the
glands grow in a back to
back fashion with only
one layer of fibroblasts
between them (Slide 9)
- - Most
tumor cells have low
nuclear grade (Slide 10)
|
|
3. Solid type
| |
- - Tumor
cells fill the ducts and
ductules as solid sheets
(Slide 11)
- - Nuclear
grade is predominantly
intermediate or high
grade (Slide 12)
- - Necrosis
is usually focal
|
|
4. Comedo type
| |
- Solid growth
pattern (Slide 13 and Slide 14)
- - Central
necrosis of the involved
ducts is a prominent
feature (Slide 13)
- -
Calcification occurs
within the necrosis (Slide 14)
- - High
nuclear grade in most
tumors, less commonly
intermediate nuclear
grade (Slide 15)
|
|
It should be noted that several
different grow patterns may occur within the same
lesion, for example in papillary and cribriform
types cribriform glands often occur. The
classification is based on the most prevalent
pattern. Necrosis, a prominent feature in comedo
type, also occurs in other types focally.
| Classification
of DCIS by Nuclear Features |
1. Low grade (SLIDE
16)
| |
- - Nuclear
size 1-1.5 times the size
of red blood cells
- - Uniform
in size and shape
- - Finely
granular chromatin even
distributed
- - Nucleoli
small, indistinct, few in
number
- - Mitotic
activity low
|
|
2.
Intermediate grade (SLIDE
17)
| |
- - Nuclear
size up to 2 times the
size of red blood cells
- - Mild to
moderate variation in
nuclear size and shape
- - Coarsely
granular chromatin,
evenly distributed
- - Nucleoli
small to medium in size
- - Mitotic
activity between the low
and high grades
|
|
3. High grade (SLIDE
18 and SLIDE
19)
| |
- - Nuclear
size more than 2 times of
red blood cells
- - Marked
variation in nuclear size
and shape
- - Coarsely
granular chromatin
unevenly distributed
- - Nucleoli
large and multiple
- - Mitotic
activity high
|
|
Some authors prefer two grade
system. For example, Van Nuys system combines low
and intermediate grades into non-high category
and the remaining as high grade. (detailed in the
later section)
| SUMMARY
OF NUCLEAR GRADE |
| CRITERIA |
LOW
GRADE |
INTERMEDIATE
GRADE |
HIGH
GRADE |
| NUCLEAR SIZE
(xRBC) |
1-1.5 |
1.0-2.0 |
>2.0 |
| VARIATION IN
SIZE & SHAPE |
MILD |
MODERATE |
MARKED |
| CHROMATIN |
FINE,
EVEN |
COARSE,EVEN |
COARSE,UNEVEN |
| NUCLEOLI |
SMALL,
RARE 0-1/NUCLEUS
|
SMALL,
SOME 1-2/NUCLEUS
|
LARGE,
MANY >2/NUCLEUS
|
| MITOTIC
ACTIVITY |
LOW |
INTERMEDIATE |
HIGH |
- Prognosis of
DCIS (by pathological analysis)
- 1. Nuclear grade is more important
than architecture (growth) pattern
- 2. Status of surgical margin
- 3. Lesion size
| Van Nuys Prognostic
Classification |
| Group 1 |
Non-high nuclear grade
without necrosis |
| Group 2 |
Non-high nuclear grade
with necrosis |
| Group 3 |
High nuclear grade
with or without necrosis |
| Note:
As indicated earlier, the non-high
nuclear grade includes low and
intemediate scores |
| Van Nuys Prognostic
Index Scoring Index |
| Parameter |
1 Point |
2
Points |
3
Points |
| Van Nuys
Classification |
Group 1 |
Group 2 |
Group 3 |
| Clear Margin |
> or
= 10 mm |
1-9 mm |
<1
mm |
| Lesion Size |
< or
= 15 mm |
16-40
mm |
> 41
mm |
| Final Score |
| Group 1 |
3 - 4 points |
3.8% Recurrence |
93% 8 year disease
free |
| Group 2 |
5 - 7 points |
11.1% Recurrence |
84% 8 year disease
free |
| Group 3 |
8 - 9 points |
26.5% Recurrence |
61 % 8 year disease
free |
|
