- 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
- Also called invasive ductal carcinoma, no special / specific type (NST)
- 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)
- 50 year old woman with diffuse neuroendocrine differentiation in a morphologically composite mammary infiltrating ductal carcinoma (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)
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Images courtesy of Mark R. Wick, M.D.
Invasive
Mammogram
Fungating, breast skin
Spot film
- 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
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Courtesy of Mark R. Wick, M.D.
AFIP image
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Irregular borders, infiltrating into adjacent tissue
Central necrosis and hemorrhage
- 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:
- Occurs outside margin of carcinoma
- Does not conform precisely to space it is in
- Endothelial lining is present and is CD31+, Factor VIII+
- Blood vessels are in vicinity
- See also Prognostic factors - Angiolymphatic invasion
- In 35% - differs from tissue retraction because:
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Images courtesy of Mark R. Wick, M.D.
Cancerization of lobules
Ductal NOS
Involving skin
Pseduo DCIS
Cadherin
Desmin
Estrogen receptor
HER2
Ki-67
p53
Popoplanin
Progesteron receptor
Common histologic features
Occult invasive carcinoma and DCIS (arrows) - AFIP
Perineural invasion
Primary tumor, lymphocytic
infiltration & fibrous stromal
reaction, contains invasive
carcinoma around duct with DCIS
Angiolymphatic invasion
Courtesy of Mark R. Wick, M.D.
Podoplanin, courtesy of Mark R. Wick, M.D.
Arrow: possible blood vessel invaded by carcinoma (AFIP)
Elastic stain accentuates venous elastica involved by carcinoma and artery below
Not angiolymphatic invasion, 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
Grading
Grade I, courtesy of Mark R. Wick, M.D.
Low grade, mixed, courtesy of Mark R. Wick, M.D.
Grade II, courtesy of Mark R. Wick, M.D.
Grade III, courtesy of Mark R. Wick, M.D.
High grade, courtesy of Mark R. Wick, M.D.
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Common histologic features
Perineural invasion
Stains
HER2 (3+)
Topo II IHC
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Common histologic features
Infiltration of fibroadipose
With cribriform DCIS
Desmoplastic stroma
Resembling comedo DCIS but negative for myoepithelial markers (cocktail)
Multinucleated giant cells (fig 3c, arrows)
Minimal tumor in core biopsy (fig 3a and 3b)
Angiolymphatic invasion
Vein invaded by tumor cells
Not angiolymphatic invasion
Grading
Low grade
High grade
Stains
Mast cells (stained with tryptase)
PR+
Calponin negative (normal ducts are positive)
- 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)
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Courtesy of Mark R. Wick, M.D.:
Needle biopsy
FNAB
Diff quik
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47 year old woman with 3 x 2 cm painless retroareolar mass and ipsilateral axillary lymphadenopathy, courtesy of Dr. Abdulaziz Mohamed
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Ductal carcinoma, Figure A
Poorly differentiated ductal carcinoma
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Core biopsy
With cancerization of lobules
- CK8 / 18, CK19, CK7, EMA, e-cadherin (Am J Clin Pathol 2006;125:377), ER (70%)
- Also milk fat globule, lactalbumin, CEA, B72.3, BCA225
- 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
- CK20
- Myoepithelial markers: p63 (positive in benign lesions, Am J Surg Pathol 2001;25:1054), CD10 (Mod Pathol 2002;15:397), calponin
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HER2 amp FISH, courtesy of Mark R. Wick, M.D.
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TOP2A CEP17 FISH -
no gene amplification,
courtesy of Dr. Semir Vranic
- Glandular differentiation (microvilli and terminal bars on luminal side)
- Cases with necrosis may resemble DCIS (J Med Case Reports 2007;8:83)
