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Thanks to Dr. Jamie Shutter, East Carolina University Brody School of Medicine, North Carolina (USA), for contributing this case and part of the discussion.
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Case #236
Clinical history:
A 71 year old woman with invasive breast cancer underwent a mastectomy and sentinel lymph node excision.
Microscopic images:
Mastectomy
Sentinel lymph node
What is your diagnosis?
Diagnosis: Invasive ductal carcinoma, poorly differentiated, with central necrosis, resembling comedo DCIS
Discussion:
The microscopic images show large areas of atypical cells with central comedo-like necrosis that mimics DCIS. However, these are actually large foci of invasive cancer. In some images, typical invasive carcinoma is present at the edge of the mass and within the lymph node. The lymph node was entirely replaced by tumor of the same morphology.
These cases are difficult on biopsy because they resemble DCIS and the juxtaposed typical invasive tumor may not be present. A key to the diagnosis is the presence of tumor of identical morphology in the lymph node. For determining tumor maximum dimension in T staging, it is important to include DCIS appearing tumor as invasive carcinoma (J Med Case Reports 2007 Sep 8;1:83).
The differential diagnosis includes central acellular carcinoma, which has one large foci of central necrosis. As noted above, DCIS is also in the differential.
