General
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• High grade DCIS with central expansile comedonecrosis (central necrosis within involved ducts)
• Necrosis is due to apoptosis and oncosis (passive cell death, Ultrastruct Pathol 2000;24:135)

Epidemiology
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• Has similar hormonal and reproductive risk factors as invasive ductal carcinoma, unlike non-comedo DCIS (Cancer Epidemiol Biomarkers Prev 2009;18:1507)

Clinical
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• 1/3 appear multicentric, but many are actually continuous in 3 dimensions, as demonstrated by serial section mapping studies
• 10% are bilateral
• 1-3% of patients have axillary nodal metastases, even without evidence of invasive carcinoma
• Lesions may be extensive (>5 cm); must examine carefully for invasive carcinoma

Radiology
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• Mammography usually shows linear and branching microcalcifications due to calcification of necrotic material, more often central than other tumors
• Occasionally lacks calcifications

Gross description
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• Cheesy appearance (resembling comedones) due to plugging of thick walled ducts with necrotic material

Micro description
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• Solid growth of large, pleomorphic, high grade cells with central expansile necrosis
• Frequent mitotic figures
• Myoepithelial cell layer may be attenuated
• Coarse microcalcifications are common
• Periductal fibrosis and inflammation are common
• Often cancerization of lobules
• May have branching and budding

Micro images
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Central necrosis

High nuclear grade and necrosis

Central necrosis with dystrophic calcifications

 

Classic features

Periductal fibrosis

Involving lobules

Cancerization of lobules

 

HER2+

Androgen receptor+

Cytology images
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Low power

   

Atypical cells with large nuclei

Positive stains
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DCIS and LCIS

Calponin

Positive stains
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• HER2 amplification (Cancer 2000;89:2153), p53 (Lab Invest 1994;71:67)
• Also P-cadherin (Virchows Arch 2007;450:73)

Negative stains
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• ER, PR (Br J Surg 2005;92:429)

Molecular / cytogenetics description
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• Aneuploid
• Multicentric tumors were monoclonal in one study (Hum Pathol 2003;34:1163)

Molecular / cytogenetics images
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Tetraploid DNA

Aneuploid DNA

Differential diagnosis
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• Invasive ductal carcinoma with central necrosis (J Med Case Rep 2007;1:83)
• Intraductal papilloma with comedo-like necrosis (Ann Diagn Pathol 2004;8:276)

Additional references
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• Arch Pathol Lab Med 1996;120:81

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