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Breast malignant, males, children

Carcinoma subtypes

Ductal carcinoma, NOS - general


Reviewers: Nat Pernick,, M.D., Monika Roychowdhury, M.D. (see Reviewers page)
Revised: 16 April 2014, last major update September 2009
Copyright: (c) 2001-2013, PathologyOutlines.com, Inc.

General
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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 description
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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 Pathol 2003;34:1001)

Case reports
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● 50 year old woman with neuroendocrine carcinoma in morphologically composite tumor (Arch Pathol Lab Med 2003;127:e131)
● 71 year old woman with poorly differentiated tumor containing central necrosis, and resembling comedo DCIS (Case of the Week #236)

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

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 (Arch Pathol Lab Med 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


With cribriform DCIS


Occult invasive carcinoma and DCIS (arrows) - AFIP


Primary tumor with lymphocytic infiltration and fibrous stromal reaction that contains invasive carcinoma around a duct with DCIS

           
Resembling comedo DCIS but negative for myoepithelial markers (cocktail)


Desmoplastic stroma


Focal lobular features


Multinucleated giant cells (fig 3c, arrows)


Minimal tumor in core biopsy (fig 3a and 3b)


Perineural invasion



Angiolymphatic invasion:


Various image


Arrow points to possible blood vessel invaded by carcinoma #1 (AFIP)


#2-elastic stain accentuates the venous 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+


HER2 (3+)


E-cadherin+


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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47 year old woman with 3 x 2 cm painless retroareolar mass and ipsilateral axillary lymphadenopathy
(contributed by Dr. Abdulaziz Mohamed, Aga Khan University Hospital, Nairobi, Kenya)


   
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 (Am J Clin Pathol 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 (Arch Pathol Lab Med 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, Am J Surg Pathol 2001;25:1054), CD10 (Mod Pathol 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;8:83)

Videos
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Additional references
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Stanford University

End of Breast malignant, males, children > Carcinoma subtypes > Ductal carcinoma, NOS - general


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