CASE REPORT

Extensive intraductal carcinoma breast-clinical and pathologicalconsiderations.

Dr. P.R. Rekha, Dr. Shobha C.M, Dr.Shivarudrappa, Dr P.M Subramaniam.

Institute: Vinayaka Missions Kirupananda Variyar Medical College. Salem.

INTRODUCTION: Extensive intraductalcarcinoma is proposed for tumors in whichthe intraductal component comprises 25% ormore of the area encompassed by theinfiltrating tumor.(1). Ductal carcinoma inSitu with a micro invasive componentaccounts for less than 1% of all breastcancers and 13.5% of all DCIS have amicroinvasive component.( 2). Theincreased rate of early detection of breastcancer due to widespread mammographicscreening has led to an increased incidencenot only of in situ but also microinvasivecarcinoma. DCIS with micro invasion(DCISM) results in axillary lymph nodemetastases, statistically significantindependent predictors of lymph nodemetastases in DCISM are comedo DCIS. (3)

CLINICAL DETAILS:

A 49 -year-old postmenopausal womanpresented with mass in the right breast sincethree months duration, axillary lymphnodeswere not palpable and the contralateralbreast was normal. FNAC revealeddiscohesive clusters of atypical cells withprominent nucleoli in a necrotic background.The smears were termed as positive formalignancy. Patient underwent Radicalmastectomy with axillary lymph nodeclearance.

RESULTS: On gross examination a tumormeasuring 6×4×4 cm, the tumor appeared astiny cystic spaces and grey white materialextruded on pressure. Grossly all theresected margins were free of tumor and 8lymphnodes were dissected, the largest nodemeasured 1.5 cm in diameter. H&E sectionsrevealed features of ductal carcinoma insitu-comedo type(gradeIII). All the marginsincluding the deep resected margin were freeof tumor. However 1/8 lymphnode showedcomplete replacement of the lymphnode bytumor cells. Hence with this backgroundextensive sampling of tumor was done torule out invasion which revealed a tiny fociof invasion<1mm and an intraductalmicropapillary lesion.

DISCUSSION: The American JointCommittee on Cancer defines microinvasivebreast carcinoma as the extension of cancercells beyond the basement membrane intothe adjacent tissues, with no single focuslarger than 1 mm in greatest dimension.Axillary lymph node metastasis inmicroinvasive breast carcinoma ranges from0% to 22%. (2.)Axillary lymph nodedissection in microinvasive carcinoma isconsidered the standard of care, although itis being replaced, in part, by minimallyinvasive axillary samplings.(4)

Previous studies of patients with infiltratingductal breast cancer treated withconservative surgery and radiotherapy haveindicated that the presence of an extensiveintraductal component (EIC) in the excisionspecimen is highly associated withsubsequent breast recurrence. The reason forthis association is not clear, but possibleexplanations include the presence of moreextensive disease in the breast or increasedradiation resistance among tumors with anEIC (EIC+) compared with those without(EIC-) tumors.(5)

Breast-conserving treatment has become astandard therapy for early breast cancer withthe aim of improving the quality of life ofthe patient. However, the problem of localfailure in the operated breast still remainsunresolved. Several groups have noted thatinvasive cancers accompanied by EICpositive features are associated with higherlocal recurrence rates within the breast after

breast-conserving therapy than EIC negativeinvasive cancers.(6)

Axillary lymph node dissection or selectiveaxillary node dissection has a place in thesurgical approach to DCIS with amicroinvasive component. It should beparticularly considered when the primarytumor characteristics include T1mic diseasewith a dominant comedo DCIS, which is notan unequivocal indication for adjuvantchemotherapy. (5)

Conclusions:A differential diagnosis ofintraductal carcinoma has to be consideredin FNAC before terming a case asinfiltrating ductal carcinoma,axillary nodeclearance is mandatory in DCIS andextensive sampling of the specimen isadvised to rule out invasion in DCIS.

Keywords: Extensive intraductalcarcinoma,Ductal carcinoma insitu,Comedocarcinoma.

Fig 1:Mammogram (craniocaudal view) demonstrating numerous scattered clusters ofmicrocalcifications

Fig:2 Cut surface of the breast showing involvement of the tumor, more then 50% of the area showscomedo like areas.

Fig:3 FNAC: Giemsa X 40x showing dyscohesive clusters of atypical ductal epithelial cells.

Fig :4 H&E X 40x showing Ductal carcinoma in situ,comedo type and a foci ofintraductal papillary lesion.

References:

1. MARGINS AND OUTCOME OF SCREEN-DETECTED BREAST CANCER WITH EXTENSIVEIN SITU COMPONENT

PAUL R. B. KITCHEN,*† JENNIFER N.CAWSON,† SUZANNE E. MOORE,*† PRUE A.HILL,‡ TONI M. BARBETTI,† PAMELA A.WILKINS,† ANN-MARIE POWER† MICHAELA. HENDERSON*†

* Departments of Surgery and ‡Anatomical Pathology and † St Vincent'sBreastScreen, St Vincent's Hospital,Melbourne, Victoria, Australia

2.Risk Factors for Lymph Node Metastases inBreast Ductal Carcinoma In Situ With MinimalInvasive Component.Nir Wasserberg, MD;Sarah Morgenstern, MD; Jacob Schachter, MD;

Eyal Fenig, MD; Shlomo Lelcuk, MD; HaimGutman, MD .

Arch surg. 2002;137:1249-1252.

3.Lymph Node Metastasis from DuctalCarcinoma In-Situ with Microinvasion

Jeffry Zavotsky, M.D.Nora Hansen,M.D.Meghan B. Brennan, R.N.Roderick R.Turner, M.D.

Armando E. Giuliano, M.D.

Joyce Eisenberg Keefer Breast Center of theJohn Wayne Cancer Institute at Saint John’sHealth SCenter, Santa Monica, California.

4. Axillary lymph node metastases inpatients with a final diagnosis of ductalcarcinoma in situ . The American Journalof Surgery , Volume 186 , Issue 4 , Pages368 - 370 T . Kelly.

5.The presence of an extensive intraductalcomponent following a limited excision

correlates with prominent residual diseasein the remainder of the breast.R Holland,JL Connolly, R Gelman, M Mravunac, JHHendriks, AL Verbeek, SJ Schnitt, B Silver, JBoyages and JR HarrisDepartment of Pathology, University ofNijmegen, The Netherlands.

6.Pathological Assessment of IntraductalSpread of Carcinoma in Relation toSurgical Margin State in Breast-conserving SurgeryTakanori Ishida1, Akihiko Furuta1,2, TakuyaMoriya3 and Noriaki Ohuchi1,+

1 Division of Surgical Oncology, TohokuUniversity School of Medicine, Sendai, 2

Department of Pathology, Institute forDifferentiation, Aging and Cancer, TohokuUniversity, Sendai and 3 Department ofPathology, Tohoku University Hospital,Sendai, Japan

International Journal of Basic Medical Sciences

How to Cite this Article

Dr. P.R. Rekha, Dr. Shobha C.M, Dr.Shivarudrappa, Dr P.M Subramaniam. Extensive intraductal

carcinoma breast-clinical and pathological considerations.

Available at

Ijbms.com

Volume 1 issue 3 June 2010