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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Intermediate grade, courtesy of Dr. Mark R. Wick

High grade, courtesy of Dr. Mark R. Wick

 

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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