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DCIS: Ductal Carcinoma In Situ

 
DCIS - Ductal Carcinoma In Situ
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.
  • Gross 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
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

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