Promise of a beautiful day
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1 Promise of a beautiful day
2 Ductal carcinoma in Situ Lobular Carcinoma in Situ Natural History Manosmed Tartous Oct 2009 Gérard ABADJIAN MD Pathology Department Hôtel-Dieu de France. Associate Professor Faculty of Medicine St Joseph University Beirut LEBANON
3 Natural History Definitions: Precancerous lesions? The breast tissue, a crash histology review Lobular carcinoma in situ : Classifications ( Birth Origin, Family picture) Clinical significance ( Growth - Evolution) Ductal carcinoma in situ: Classifications ( Birth Origin, Family picture) Clinical significance ( Growth - Evolution) Take home messages
4 Histology revisited: Skin Breast tissue Nipple
5 Nipple Lobes Galactophores (Ducts) Lactiferous Sinus
6 Histology: the epithelial tissue of the breast
7 Lobes Nipple Galactophores (Ducts) Lactiferous Sinus
8 Lobule Ductule HISTOLOGY Interlobular fibrous tissue Adipose Tissue
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12 Origin of the epithelial neoplasia in breast
13 Synonyms Lobular Neoplasia Atypical lobular Hyperplasia Carcinoma lobular in situ Definition, Grades (I - III) Proliferation of small loosely cohesive cells originating in terminal duct-lobular unit LN constitutes a risk factor and a non obligatory precursor for the development of invasive carcinoma in either breast, either ductular or lobular type
14 Lobular neoplasia Grade III (Lobular carcinoma in situ)
15
16 Lobular Neoplasia 85 % multicentric, 30 % bilateral No mammographic pattern, with rare exceptions Immunoprofile ECadherin CK5.6 HMW + Molecular genetics: Study of LOH on different chromosomes Specially mutational analysis of the Ecad. gene: direct evidence for a precursor role of LN in invasive lobular carcinoma.
17 Lobular Neoplasia Prognosis and predictive factors: Relative risk for invasive carcinoma: 7 to 12 times 18 Retrospective studies: LN in 1174 women treated by biopsy alone: 181 (15.4%) eventually dev. Invasive carcinoma: 102 (8.7%) ipsilateral 79 (6.7%) controlateral Prospective study: 100 cases of LN > 10 years: 11/13 Ipsilateral invasive carcinoma Carcinoma in situ of the female breast. 10 year follow-up of a prospective nationwide study. Ottesen GL et Al (2000) Breast Cancer Res Treat 62:
18 Intraductal proliferative lesions Definition Proliferation originating and confined to the ductular system Associated with and increased risk of subsequent development of invasive carcinoma with greatly different magnitudes. Site of origin Terminal duct-lobular unit Small proportion from large ducts Route of progression Duct system toward the nipple (Paget)
19 Intraductal proliferative lesions Terminology (WHO) Standardization of histopathological criteria: Problem area ADH DIN1 C
20 Ductal Carcinoma In Situ Definition Neoplastic Intraductal lesion with subtle to marked epithelial atypia Not necessary obligate tendency for progression to invasive carcinoma Synonyms: DIN1C DIN3 Risk progression: 8-11 Conservative treatment usually curative
21 Ductal Carcinoma In Situ Basis of grading (to be documented in the pathology report) 1. Nuclear grade 2. Necrosis 3. Architectural pattern Associated features Margins, Distance Size (extent and distribution) Microcalcifications > Low, Intermediate, High Grade
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23 Ductal Carcinoma In Situ Epidemiology Increase in detection Screening mammography Facts: Annual increase incidence WHO: 4% ( ) > 17.5 % ( ) HDF: 7 cases (2004) > 16 Cases (2006) > 28 (2008) 90% DCIS: Comedo in the premammographic era 60% non comedo with mammography, and increasing
24 Facts Ductal Carcinoma In Situ DCIS Mortality declining even with limited surgical excision: < 1983: 3.4 % died at 10 years (mastectomy) : 2 % died at 10 years (lumpectomy) Clinical findings 85 % Mammography 10 % Palpable abnormality Discharge Paget
25 Ductal Carcinoma In Situ Prognosis Retrospective studies: Predictive factors for local recurrence High nuclear grade Large lesion size Comedonecrosis Involved margins
26 Take home Messages Lobular neoplasia Risk factor non obligatory precursor Recommendations Lifelong follow-up (+/- Tamoxifen) Re-excision considered in massive acini distension or pleomorphic variant with close margins.
27 Take home Messages Ductal carcinoma in Situ Classification: interobserver reproductibility poor with no appropriate criteria DIN proposal: avoid overtreatment RR 8 to 11 Increase in incidence (mammographic screening era) Precursor lesions not necessarily an obligate tendency for progression to invasive carcinoma Not a life threatening disease: mastectomy represents an overtreatment for many patients Reserved for some patients with large extensive lesions
28 End of Presentation Thank you for your Attention Promise of a beautiful evening
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