Invasive ductal carcinoma
- 1 Gross examination
- 2 Microscopic evaluation
- 2.1 Characteristics
- 2.2 Differential diagnosis
- 2.3 Staging
- 2.4 Distant Metastases (M)
- 2.5 Grading
- 2.6 Immunohistochemistry
- 2.7 Neoadjuvant cases
- 3 Report
- 4 Notes
- 5 Main page
- 6 References
- Sheets, nests, cords or individual cells
- Prominent tubular formations in well differentiated tumors, but absent when poorly differentiated
- The stroma is usually desmoplastic
High power typically shows tumor cells that are more pleomorphic than in lobular carcinoma.
Invasive versus in situ
In invasive ductal carcinoma, malignant cells have penetrated the basement membrane, in contrast to ductal carcinoma in situ. In uncertain cases, use immunohistochemistry stain for calponin (has the highest sensitivity) and p63 (has the highest specificity).
Immunohistochemistry for calponin in ductal carcinoma in situ, highlighting myoepithelial cells around all tumor cells.
Fibroadenoma may have small cell clusters, but lacks the cellular atypia of invasive ductal carcinoma.
Ductal versus lobular
- Invasive lobular carcinoma typically has single files of tumor cells rather than duct-forming tumor cells. In uncertain cases, stain for E-cadherin and p120:
Invasive lobular carcinoma, in this case with a targetoid pattern
p120 has cytoplasmic staining in invasive lobular carcinoma (shown), but has membranous staining in invasive ductal carcinoma
Stage by the TNM system as follows in sections below.
Also, look for any angiolymphatic invasion. If present, check whether it reaches outside the tumor, and if so, how far. Give greatest dimension (,or 3 dimensions, generally by adding up the estimated thicknesses of involved slices)).
Primary Tumor (T)
Tumor – Depends on the tumor at the primary site of origin, as follows:
Regional Lymph Nodes (N)
Lymph Node – The lymph node values depend on the number, size and location of breast cancer cell deposits in various regional lymph nodes, such as the armpit (axillary lymph nodes), the collar area (supraclavicular lymph nodes), and inside the chest (internal mammary lymph nodes.) Each stage is as follows:
Critical numbers of involved nodes: 1-3, 4-9, and 10 and over. Note any extranodal extension.
Distant Metastases (M)
A combination of T, N and M, as follows:
- Further information: Evaluation of tumors
The Nottingham system is recommended for breast cancer grading. The Nottingham system is also called the Bloom–Richardson–Elston system (BRE), or the Elston-Ellis modification of the Scarff-Bloom-Richardson grading system. It grades breast carcinomas by adding up scores for tubule formation, nuclear pleomorphism, and mitotic count, each of which is given 1 to 3 points. The scores for each of these three criteria are then added together to give an overall final score and corresponding grade as follows.
The overall appearance of the tumor is considered.
- 1 point: tubular formation in more than 75% of the tumor (it may in addition be termed "majority of tumor")
- 2 points: tubular formation in 10 to 75% of the tumor ("moderate")
- 3 points: tubular formation in less than 10% of the tumor ("little or none")
Such as nuclei being larger, darker, or irregular/pleomorphic. Note: The cancer areas having cells with the greatest atypia should be evaluated.
- 1 point: Nuclei are small or mildly increased in size compared to normal breast epithelial cells. They have uniform nuclear chromatin and only mild pleomorphism.
- 2 points: nuclei with moderate variation in size and shape. Cells are larger than normal, display open vesicular nuclei, have visible nucleoli.
- 3 points: nuclei with marked variation in size and shape. Cells display vesicular nuclei, often prominent nucleoli. Often very large and bizarre cells.
Mitotic figures are counted only at the periphery of the tumor, and counting should begin in the most mitotically active areas.
- 1 point: Between 0-5 and 0-11 mitotic counts per 10 high-power fields (HPFs), depending on type of microscope used.[notes 2]
- 2 points: Between 6-10 and 12-22 mitotic counts per 10 HPFs.[notes 2]
- 3 points: Over 10 to 22 mitotic counts per 10 HPFs.[notes 2]
The scores for each of these three criteria are added together to give a final overall score and a corresponding grade as follows:
- 3-5 Grade 1 tumor (well-differentiated). Best prognosis.
- 6-7 Grade 2 tumor (moderately differentiated). Medium prognosis.
- 8-9 Grade 3 tumor (poorly differentiated). Worst prognosis.
For Ki-67 index, there are two main methods, a faster "hot spot" method and the more comprehensive IKWG global average:
- Hot spot:
Hot spots are areas in which Ki-67 staining is particularly higher relative to the adjacent tumor areas. Usually, the invasive edge of a tumor is a hot spot. When a tumor had several hot spots, the “hottest” spot is selected. Aim to count at least 500 cells in each case, but this is not always possible in cases with low tumor cell density and small tumor size. Also aim to include at least three high-power (×40 objective) fields.
- IKWG global average:
- Before first use, access the IKWG website (https://www.ki67inbreastcancerwg.org/) and complete the Ki67 calibration exercise
- From Tools, link to the Online scoring app (or download and install the Ki67 counting app) and use the global method
- Using a regular light microscope, review the Ki67-stained breast cancer slide and input estimates of the percent area with negligible, low, medium, or high Ki67 index
- Score 100 nuclei negative or positive in each field type (as directed by the app)
- Record “Weighted global score” output as the Ki67 index for that slide
Regardless of method:
- If a comparisons must be made between core biopsies and sections from an excision, evaluation of the latter should be across the whole tumor.
- Only nuclear staining counts. Staining intensity of a positive nucleus is not relevant.
|0 to 1+||HER2 negative |
In neoadjuvant cases (patient has received chemotherapy, endocrine therapy and/or radiotherapy before the excision), perform:
- Measurement of the tumor bed which generally manifests as a fibroelastic area.
- Classification of residual cancer, for which there are multiple systems, mainly Residual Cancer Burden (RCB)[notes 3] and the American Joint Committee on Cancer post-neoadjuvant therapy staging system (yAJCC).
- Further information: Evaluation of tumors
- Tumor size, if not already given from gross report. Give 3 dimensions or greatest dimension.
- Histopathologic subtype if apparent, but "invasive carcinoma" is acceptable.
- Grade, preferably by overall BRE grade. Optionally, give scores for the components thereof.
- Extent of any angiolymphatic invasion.
- Margins of resection, either as minimal distance to margin, or as radical vs. not radical excision.
- Results of any immunohistochemistry and other tests
- HER2 as a score or status.
- Ki-67, preferably as labeling index
|Breast excision with 70 x 55 x 18 mm ductal invasive breast cancer. Nottingham grade II. Estrogen receptor positive, progesterone receptor negative, HER2 receptor score 0, Ki-67 index 17%, T1b. Radically removed.|
Needle or core biopsy
- Histopathologic subtype if apparent, but "invasive carcinoma" is acceptable.
- Results of any immunohistochemistry and other tests, as per excision
- Presence of absence of angiolymphatic invasion
- Optionally: Provisional grading. Grading can alternatively be deferred to excision.
- State if studies are deferred for a later excision sample
- For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.
- Mitotic count:
- 1 point: 0-9 mitotic counts per 10 fields under X25 objective using the Leitz Ortholux microscope, 0-5 mitotic counts per 10 fields under X40 objective using the Nikon Labophot microscope, or 0-11 mitotic counts per 10 fields under X40 objective using the Leitz Daiplan microscope
- 2 points: 10-19 mitotic counts per 10 fields under X25 objective using the Leitz Ortholux microscope, 6-10 mitotic counts per 10 fields under X40 objective using the Nikon Labophot microscope, or 12-22 mitotic counts per 10 fields under X40 objective using the Leitz Daiplan microscope
- 3 points: Over 19 mitotic counts per 10 fields under X25 objective using the Leitz Ortholux microscope, over 10 mitotic counts per 10 fields under X40 objective using the Nikon Labophot microscope, or over 22 mitotic counts per 10 fields under X40 objective using the Leitz Daiplan microscope
- A calculator and explanations for calculating RCB is found at: http://www3.mdanderson.org/app/medcalc/index.cfm?pagename=jsconvert3
- Monika Roychowdhury. Breast - Invasive breast carcinoma of no special type and variants - NST (ductal). Pathology Outlines. Topic Completed: 1 September 2009. Minor changes: 17 September 2020
- . Infiltrating Ductal Carcinoma of the Breast (Carcinoma of No Special Type). Stanford Medical School. Retrieved on 2019-10-02.
- Originally copied from Fadi M. Alkabban; Troy Ferguson. Cancer, Breast. National Center for Biotechnology Information. Last Update: June 4, 2019. Creative Commons Attribution 4.0 International License
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- Image by: Mikael Häggström, M.D. Public Domain
- Author info
- Reusing images
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