Difference between revisions of "Non-invasive breast carcinoma"

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(+ADH, more on lobular hyperplasia, re-organize)
(→‎Ductal neoplasia: change hierarchy)
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#Ductal carcinoma in situ (DCIS).
#Ductal carcinoma in situ (DCIS).


*These entities (ADH, DCIS) have some over lap.
The difference between ADH and DCIS ''is'':
*The difference ''is'':
#The degree of '''nuclear atypia'''; high grade is DCIS.
*#The degree of nuclear atypia; high grade is DCIS.
#The '''extent'''; small lesions are ADH, large lesions (low-grade) DCIS.
*#The extent; small lesions are ADH, large lesions (low-grade) DCIS.


==Ductal carcinoma in situ==
==Ductal carcinoma in situ==
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NOTE: ''comedonecrosis'' - used to be considered a separate subtype -- essentially ''solid'' type DCIS with necrosis.
NOTE: ''comedonecrosis'' - used to be considered a separate subtype -- essentially ''solid'' type DCIS with necrosis.


===Histologic features===
===Microscopic===
Features:
*Nuclear pleomorphism -- most important feature.   
*Nuclear pleomorphism -- most important feature.   
*Nuclear size - compared to RBCs to grade DCIS.
*Nuclear size - compared to RBCs to grade DCIS.
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**Nuclei spaced equally.
**Nuclei spaced equally.


===Size criteria for DCIS===
====Size criteria for low-grade DCIS====
DCIS must meet the following size criteria:<ref name=Ref_BP168>{{Ref BP|168}}</ref>
DCIS must meet the following size criteria:<ref name=Ref_BP168>{{Ref BP|168}}</ref>
*2 membrane bound spaces -- OR -- 2 mm.
*Two membrane-bound spaces - ''OR'' - 2 mm.
*If it isn't DCIS... it's atypical ductal hyperplasia (ADH).  
**If it isn't (low-grade) DCIS... it's atypical ductal hyperplasia (ADH).  


The treatment is similar; ADH and DCIS are both excised.   
The treatment is similar; ADH and DCIS are both excised.   
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*Radiation treatment - DCIS is irradiated; ADH does ''not'' get radiation.
*Radiation treatment - DCIS is irradiated; ADH does ''not'' get radiation.


===Grading DCIS===
====Grading DCIS====
Graded 1-3 (low-high)<ref>[http://surgpathcriteria.stanford.edu/breast/dcis/ http://surgpathcriteria.stanford.edu/breast/dcis/]</ref> - compare lesional nuclei to one another.
Graded 1-3 (low-high)<ref>[http://surgpathcriteria.stanford.edu/breast/dcis/ http://surgpathcriteria.stanford.edu/breast/dcis/]</ref> - compare lesional nuclei to one another.
*Grade 1  
*Grade 1  

Revision as of 00:02, 29 November 2010

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

It can neatly be divided into the discussion of two entities:

  • Ductal carcinoma in situ, and,
  • Lobular carcinoma in situ.

Invasive breast cancer is dealt with in the article invasive breast cancer.

Ductal neoplasia

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.

Ductal carcinoma in situ

General

  • Abbreviated DCIS.
  • Diagnosis based on nuclear abnormalities and architecture.
  • It is typically picked-up during radiologic screening.

Subtypes

Subtypes are based on architecture:

  • Solid.
    • No spaces between cells.
  • Cribriform.
    • Honeycomb-like appearance: circular holes.
    • "Cookie cutter" appearance/"punched-out" appearance/"Roman bridges" -- cells surround the circular holes.
  • Papillary.
    • Papillae with fibrovascular cores.
  • Micropapillary.
    • Small papillae without fibrovascular cores.
    • Have "drum stick" shape.

NOTE: comedonecrosis - used to be considered a separate subtype -- essentially solid type DCIS with necrosis.

Microscopic

Features:

  • Nuclear pleomorphism -- most important feature.
  • Nuclear size - compared to RBCs to grade DCIS.
    • Compare sizes of nuclei if you cannot find RBCs.
  • +/-Mitoses.
  • Cells cohesive.
    • No spaces in between.
    • Nuclei spaced equally.

Size criteria for low-grade DCIS

DCIS must meet the following size criteria:[1]

  • Two membrane-bound spaces - OR - 2 mm.
    • If it isn't (low-grade) DCIS... it's atypical ductal hyperplasia (ADH).

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.

Grading DCIS

Graded 1-3 (low-high)[2] - compare lesional nuclei to one another.

  • Grade 1
    • Nuclei 2-3x size of RBC.
    • NO necrosis.
  • Grade 2
    • Nuclei 2-3x size of RBC.
    • +/-Necrosis.
  • 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.

FEHUT vs ADH vs DCIS

  • Breast duct lumen with too many cells.
  • This is common problem is breast pathology.[3]

Definitions:

  • EHUT = epithelial hyperplasia of the usual type, aka florid epithelial hyperplasia of the usual type (FEHUT).
  • ADH = atypical ductal hyperplasia.
  • DCIS = ductal carcinoma in situ.
  • Mnemonic CLEAN = cell uniformity, luminal spaces, extent/size, arch., nuclei.
    • Cellular composition:
      • EHUT = varied.
      • ADH = focal uniformity.
      • DCIS = uniform.
    • Lumina:
      • EHUT = slits/irregular spaces.
      • ADH = irregular spaces, no slits.
      • DCIS = circular "punched-out".
    • Extent:
      • EHUT = usually lobulocentric.
      • ADH = limited extent.
      • DCIS = extensive.
    • Architecture:
      • EHUT = irregular/swirling.
      • ADH = DCIS-like.
      • DCIS = DCIS architecture (solid, cribriform, comedo, papillary, micropapillary).
    • Nuclei:
      • EHUT = variable.
      • ADH = hyperchromatic + uniform.
      • DCIS = evenly spaced.

Tabular comparison

Comparison of EHUT, ADH and DCIS:

EHUT ADH DCIS
Cellular composition varied focal uniformity uniform
Lumina slits/irregular spaces irregular spaces, no slits circular "punched-out"
Extent usually lobulocentric limited extent extensive
Architecture irregular/swirling DCIS-like DCIS architecture (solid,
cribriform, papillary, micropapillary)
Nuclei variable hyperchromatic
& uniform		 evenly spaced

Treatment - implications:

  • EHUT - nothing; EHUT is benign.
  • ADH - simple excision, i.e. lumpectomy.
  • DCIS - excision (lumpectomy) + radiation.
  • Invasive ductal carcinoma - excision with sentinel lymph node disection[4] and radiation.

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.

Microscopic

See LCIS.

Lobular carcinoma in situ

  • Abbreviated LCIS.

General

  • Management is currently some matter of debate.
  • Not detected radiologically - it is an incidental pathologic finding.

Microscopic

Features:[5][6]

  • Cells distend the duct.
  • Dyscohesive - distinct cell border visible.
  • Clear cytoplasm (focally); may have signet ring cell-like appearance.
  • Eccentrically placed round nucleus,
    • Usually minimal atypia, relatively small ~1-2x size lymphocyte.
    • +/-Nucleolus.

Subclassification[6]

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

Main DDx:

  • Low-grade 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. 168. ISBN 978-0443066801.
  2. ↑ http://surgpathcriteria.stanford.edu/breast/dcis/
  3. ↑ 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.
  4. ↑ 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.
  5. ↑ 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.
  6. ↑ 6.0 6.1 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.
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