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Breast-malignant, males, children
Ductal carcinoma, NOS [no specific type]
Author: Nat Pernick, M.D, PathologyOutlines.com, Inc.
Reviewer: Daniel Visscher, M.D., University of Michigan Hospitals, February 2009 (see Reviewers page)
Revised: 22 September 2009
Last major update: September 2009
Copyright: (c) 2002-2009, PathologyOutlines.com, Inc.
Definition
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● Most common type of invasive breast carcinoma (75-80%)
● Lacks features of any other subtypes (i.e. is a diagnosis of exclusion)
● Arises from terminal duct lobular unit (as does lobular carcinoma), not ductal epithelium, so nomenclature is not actually accurate
Terminology
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● Also called invasive ductal carcinoma, no special / specific type (NST)
Clinical
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● In patients >65 years, 87% of patients have “no special type” (Crit Rev Oncol Hematol 2008;67:263)
● Presence of focal neuroendocrine features has no prognostic significance (Hum Path 2003;34:1001)
Case reports
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● With neuroendocrine carcinoma in morphologically composite tumor (Archives 2003;127:e131)
Gross description
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● Firm, poorly circumscribed, contracts from surrounding tissue, hard cartilaginous consistency, grating sound when scraped, streaks of chalky white elastotic stroma penetrating surrounding stroma (“crab like”), calcification
● Large tumors have hemorrhage, necrosis and cystic degeneration
● May be fixed to chest wall and cause skin dimpling or nipple retraction
Gross images
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Irregular borders, infiltrating into adjacent tissue
Central necrosis and hemorrhage AFIP image Large irregular mass
Possible central necrosis Chalky streaks
Micro description
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● Sheets, nests, cords or individual cells
● Tubular formations are prominent in well differentiated tumors but absent in poorly differentiated tumors
● Tumor cells are more pleomorphic than lobular carcinoma
● Stroma usually desmoplastic and may obscure tumor cells
● Calcification in 60% of cases, variable necrosis
● Elastosis involves wall of vessels and ducts and causes grossly noted chalky streaks
● Often DCIS (up to 80%), perineural invasion (28%)
● Mitotic figures are often prominent
● Mast cells are associated with low grade tumors
● Uncommon features: eosinophils (BMC Cancer 2007;7:165), intraluminal crystalloids (Archives 1997;121:593)
● No myoepithelial cell lining (as seen in DCIS or benign lesions)
Angiolymphatic invasion:
● In 35% - differs from tissue retraction because:
● (a) occurs outside margin of carcinoma
● (b) does not conform precisely to space it is in
● (c) endothelial lining is present and is CD31+, Factor VIII+
● (d) blood vessels are in vicinity
● (e) see also Prognostic Factors-Angiolymphatic invasion
Micro images
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See other subtypes and topics for more images
Common histologic features
Infiltration of fibroadipose DCIS and microcalcifications With cribriform DCIS
Occult invasive carcinoma Primary tumor with lymphocytic infiltration and fibrous stromal
and DCIS (arrows) - AFIP reaction that contains invasive carcinoma around a duct with DCIS
Chalky streaks correspond
to elastic fibers (van Gieson stain)
Resembling comedo DCIS but negative for myoepithelial markers (cocktail)
Desmoplastic stroma Focal lobular features Multinucleated giant cells (arrows)
Minimal tumor in core biopsy (fig 3a and 3b) Perineural invasion (AFIP)
Angiolymphatic invasion
Arrow points to possible blood vessel #2-elastic stain accentuates the venous
invaded by carcinoma #1 (AFIP) elastica involved by carcinoma and an artery below
Not angiolymphatic invasion, but shrinkage artifact with partly necrotic tumor in space created by shrinkage, no endothelial cells are present, elastic stain highlights elastic tissue in walls of vessels; marked lymphoplasmacytic infiltrate
Not angiolymphatic invasion
Grading:
Low grade
Intermediate Grade
High grade
Stains:
ER+ E-cadherin+
CD10 and smooth muscle actin
Stromal mast cells (c-kit/CD117+) Topoisomerase
Mast cells (stained with tryptase) are associated with low grade ER+ tumors
Other images: PR+, calponin negative (normal ducts are positive)
Cytology description
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● Can use cellular pleomorphism, nuclear size, nuclear margin, nucleoli, naked tumor nuclei and mitoses to assess cytologic tumor grade, which correlates with histologic grade (Diagn Cytopathol 2003;29:185)
Cytology Images
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Ductal carcinoma Figure A
Poorly differentiated ductal carcinoma
Virtual Slides
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Core biopsy
Invasive ductal carcinoma
Other: With cancerization of lobules
Positive stains
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● CK8/18, CK19, CK7, EMA, E-cadherin (AJCP 2006;125:377), ER (70%)
● Also milk fat globule, lactalbumin, CEA, B72.3, BCA-225
● Glycogen (60%), mucin (moderate/marked in 20%), cytokeratin 5/6 (30%)
● S100 (10-45%), HER2 (15-30%), RCC Ma (renal cell carcinoma marker)
● CD5 clone 4C7 (Archives 2001;125:781)
● Note: laminin, collagen IV and myoepithelial markers often show no or discontinuous staining
Negative stains
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● CK20
● Myoepithelial markers - p63 (positive in benign lesions, AJSP 2001;25:1054), CD10 (Mod Path 2002;15:397), calponin
Electron Microscopy
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● Glandular differentiation (microvilli and terminal bars on luminal side)
Differential Diagnosis
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● Cases with necrosis may resemble DCIS (J Med Case Reports 2007 Sep 8;1:83)
Videos
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Additional References
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End of Breast – Malignant, Males, Children > Ductal carcinoma, NOS [no specific type]
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