Ductal Carcinoma In Situ Shahla Masood, M.D. Professor of Pathology University of Florida College of...
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Transcript of Ductal Carcinoma In Situ Shahla Masood, M.D. Professor of Pathology University of Florida College of...
Ductal Carcinoma
In Situ
Shahla Masood, M.D.Professor of Pathology
University of Florida College of Medicine - Jacksonville
Chief of Pathology and Laboratory Medicine
Shands Jacksonville
Ductal Carcinoma In Situ
“DCIS is a heterogeneous disease characterized by neoplastic proliferation of ductal epithelial cells with no evidence of stromal invasion”
Atypical Ductal Hyperplasia
• Associated with moderate increase in breast cancer
risk
• Invasive cancer can occur anywhere in either breast
Distribution of DCIS in the Breast• True multicentricity in DCIS is rare:
– Holland and Hendriks/19 mastectomy specimen: in all but one case tumor was confined to a
single “segment” of the breast
– Faverly et al/60 mastectomy specimen: 90% of poorly differentiated DCIS grew in a continuous manner
– Noguchi et al/clonal analysis by PCR: most DCIS is unifocal
Distribution of DCIS in the Breast
• DCIS is a segmental disease
• Conservation therapy is justified in many patients with DCIS
Ductal Carcinoma In SituThe Facts:
• DCIS accounts for 30–40% of all mammographically-detected breast cancers
• The most frequent mammographic presentation is microcalcification
Ductal Carcinoma In Situ
Risk factors for local recurrence
• Morphologic features
• Size and extent of the lesion
• Adequacy of the excision
Ductal Carcinoma In Situ
• Morphologic Features– Traditional Classification
• Architectural Patterns» Comedo» Cribriform» Micropapillary» Papillary» Solid
Ductal Carcinoma In Situ
• Morphologic features
– Contemporary Classification:– Nuclear grade– Presence or absence of
necrosis
Ductal Carcinoma In SituAdequacy of excision• Margin width is an excellent predictor of local recurrence and the likelihood of residual tumor
• Mammograpic and pathologic evaluation is critical to determine the adequacy of the excision
Ductal Carcinoma In Situ
Treatment options• Local wide excision with and
without radiation therapy
• Mastectomy
Ductal Carcinoma In SituSize/Extent of the lesion
• Size is an important factor in selection of therapy:
- Single histologic section: the largest diameter of the lesion
- Multiple histologic sections: proportions of slides that show the lesion
- Accurate assessment requires total and sequestial embedding of the lesion
Ductal Carcinoma In Situ
Classification System
• Clinically relevant
• Reproducible
Molecular Biology of DCIS
• High grade lesions are often associated with
unfavorable biological markers
• Loss of heterozygosity at various chromosomal
loci differs according to DCIS pattern and grade
• There is no justification to perform biomarker
studies in DCIS lesions in clinical practice
Pathologic Evaluation of
Breast Specimens
Microscopic examination should include the following:
• Nuclear Grade:
• Necrosis: Absence or present
• Architectural pattern: comedo, cribriform, papillary, comedo, cribriform, papillary, micropapillary and solid.micropapillary and solid.
• Size (Extent of DCIS): the number of sections containing the number of sections containing
DCIS & the largest dimension of DCIS lesion on a glass DCIS & the largest dimension of DCIS lesion on a glass slide.slide.
• Margins of resection: Record closest margin as: Record closest margin as: >> 3-9 mm, 3-9 mm,
>> 10 mm or re-excision margin. 10 mm or re-excision margin.
• Calcifications: Correlate pathologic findings with specimenCorrelate pathologic findings with specimenx-ray and mammographic findings. x-ray and mammographic findings.
Ductal Carcinoma In Situ
Ductal Carcinoma In Situ
Low-grade DCISLow-grade DCIS
• Appearance: Monotonous (monomorphic)
• Size: 1.5 - 2.0 normal RBC or duct epithelial cell nucleus dimensions
• Features: Usually exhibit diffuse, finely
dispersed chromatin, only occasional
nucleoli and mitotic figures.
Low-grade
DCIS
Ductal Carcinoma In Situ High-grade DCIS
• Appearance: Markedly pleomorphicMarkedly pleomorphic
• Size: Nuclei usually >2.5 RBC or duct Nuclei usually >2.5 RBC or duct
epithelial cell epithelial cell
• Features: Usually vesicular and exhibit Usually vesicular and exhibit
irregular chromatin distribution and irregular chromatin distribution and
prominent, often multiple nucleoli. prominent, often multiple nucleoli.
Mitoses may be conspicuousMitoses may be conspicuous..
Ductal Carcinoma In Situ
Intermediate grade DCIS
Nuclei that are neither low-grade nor High-grade
““Excellent local control can be Excellent local control can be achieved without radiation achieved without radiation
therapy when margin widths' of therapy when margin widths' of at least 10 mm are obtained, at least 10 mm are obtained,
regardless of nuclear grade, the regardless of nuclear grade, the presence or absence of presence or absence of
comedonecrosis, or tumor size”comedonecrosis, or tumor size”
The Influence of Margin Width on Local Control of Ductal Carcinoma In Situ of The breast.
Sliverstein et al, N Engl J Med 1999; 340:1455-61
NSABP-BI 7
(mean follow-up 90 mos)
8-yr Actuarial LR rates8-yr Actuarial LR rates
AllAll Non-invasiveNon-invasive lnvasivelnvasive
Excision Excision 26.8% 13.4% 13.4% 26.8% 13.4% 13.4%
Excision + RT Excision + RT 12.1% 8.2% 3.9% % 12.1% 8.2% 3.9% %
Reduction Reduction 55% 39% 71% 55% 39% 71%
EORTC - 10853
Median Follow-up 51 Months
1,010 Patients 1,010 Patients
Excision alone 16% Excision alone 16%
Excision + RT 9% Excision + RT 9%
% Reduction 44% % Reduction 44%
The Issue
To Radiate or Not Radiate?