Invasive ductal carcinoma: Difference between revisions

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{{Comprehensiveness}}</noinclude>
==Gross examination==
==Gross examination==
[[File:Breast cancer gross appearance.jpg|thumb|Gross appearance of invasive ductal carcinoma.]]
[[File:Breast cancer gross appearance.jpg|thumb|Gross appearance of invasive ductal carcinoma.]]
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==Microscopic evaluation==
==Microscopic evaluation==
[[File:Invasive ductal carcinoma, with occasional entrapped normal ducts.jpg|thumb|Invasive ductal carcinoma, with occasional entrapped normal ducts (arrow).]]
Malignant cells having penetrated the basement membrane.


===Staging===
===Characteristics===
TNM staging is the most common system for invasive carcinomas.<ref name=Stanford>{{cite web|url=http://surgpathcriteria.stanford.edu/breast/infductcabr/grading.html|title=Infiltrating Ductal Carcinoma of the Breast (Carcinoma of No Special Type)|website=Stanford Medical School|accessdate=2019-10-02}}</ref>
Low power:<ref name=PathologyOutlines>{{cite web|url=http://www.pathologyoutlines.com/topic/breastmalignantductalNOS.html|title=Breast - Invasive breast carcinoma of no special type and variants - NST (ductal)|website=Pathology Outlines|author=Monika Roychowdhury}} Topic Completed: 1 September 2009. Minor changes: 17 September 2020</ref>
*Sheets, nests, cords or individual cells, but generally ratherplump tumor nests (rather than the single-file linear pattern of [[invasive lobular carcinoma]])
*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.<ref name=PathologyOutlines/>
<gallery mode=packed heights=180>
File:Histopathology of invasive ductal carcinoma, intermediate magnification.jpg|IDC, intermediate magnification. The presence in adipose tissue strongly favors invasiveness.
File:Histopathology of adenocarcinoma.png|High magnification shows non-specific adenocarcinoma features.
File:Invasive ductal carcinoma, with occasional entrapped normal ducts.jpg|IDC, with occasional entrapped normal ducts (arrow).
</gallery>
 
===Differential diagnosis===
====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).
 
<gallery mode=packed heights=180px>
File:Invasive ductal carcinoma with tubular features - combined.jpg|'''Invasive ductal carcinoma with tubular features''' can look like benign tubules, but the myoepithelial marker{{Myoepithelial marker note}} calponin and p63 shows no surrounding myoepithelial cells.
File:Immunohistochemistry with calponin in ductal carcinoma in situ.jpg|Immunohistochemistry for calponin in '''[[ductal carcinoma in situ]]''', highlighting myoepithelial cells around all tumor cells.
File:Histopathology of fibroadenoma with small cell clusters.jpg|'''[[Fibroadenoma]]''' may have small cell clusters, but lacks the cellular atypia of invasive ductal carcinoma.
</gallery>
In case of both invasive and in situ carcinoma, separately describe the in situ component. Report as "'''extensive intraductal component'''" (EIC) if DCIS is occupying 25% or more of the area encompassed by the invasive tumor and DCIS present in grossly normal adjacent breast tissue.<ref name=Hurd1997>{{cite journal| author=Hurd TC, Sneige N, Allen PK, Strom EA, McNeese MD, Babiera GV | display-authors=etal| title=Impact of extensive intraductal component on recurrence and survival in patients with stage I or II breast cancer treated with breast conservation therapy. | journal=Ann Surg Oncol | year= 1997 | volume= 4 | issue= 2 | pages= 119-24 | pmid=9084847 | doi=10.1007/BF02303793 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9084847  }} </ref>
 
====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:
<gallery mode=packed heights=180>
File:Classic Invasive Lobular Carcinoma of the Breast (6813147194).jpg|'''[[Invasive lobular carcinoma]], in this case with a targetoid pattern
File:Chromogenic immunohistochemistry for E-cadherin in invasive lobular carcinoma, annotated.jpg|'''E-cadherin''' is '''negative''' in invasive '''lobular''' carcinoma (shown), but has membranous staining in invasive ductal carcinoma
File:Chromogenic immunohistochemistry for p120 in invasive lobular carcinoma.jpg|'''p120''' has '''cytoplasmic''' staining in invasive lobular carcinoma (shown), but has membranous staining in [[invasive ductal carcinoma]]
</gallery>
{{Breast cancer staging}}
{{Evaluation of tumors}}
 
=== Grading ===
The '''Nottingham system'''<ref>{{cite journal |last1= Elston |first1= CW |last2= Ellis |first2= IO |title= Pathologic prognostic factors in breast cancer. I. The value of histological grades in breast cancer. Experience from a large study with long-term follow-up |journal= Histopathology |year= 1991 |volume= 19 |issue= 5 |pages= 403–10 |pmid= 1757079 |doi=10.1111/j.1365-2559.1991.tb00229.x}} {{cite journal |title= Republished |year= 2002 |doi= 10.1046/j.1365-2559.2002.14892.x | volume=41 |journal=Histopathology |pages=154–161}}</ref> is recommended for breast cancer grading.<ref>{{cite web|title=What is the Nottingham combined histologic grade (modified Scarff-Bloom-Richardson grade) system for breast tumors?|url=https://www.medscape.com/answers/1668113-181367/what-is-the-nottingham-combined-histologic-grade-modified-scarff-bloom-richardson-grade-system-for-breast-tumors|author=Oudai Hassan|website=Medscape}} Updated: Mar 20, 2019</ref> The Nottingham system is also called the Bloom–Richardson–Elston system ('''BRE''')<ref>{{cite journal | last1= Al-Kuraya| first1= Khawla| last2=Schraml | first2=Peter |display-authors=et al | title= Prognostic relevance of gene amplifications and coamplifications in breast cancer | journal=Cancer Research| volume=64 | issue=23 | year=2004| pages= 8534–8540}}</ref>, or the Elston-Ellis modification<ref>Elston CW, Ellis IO. Pathologic prognostic factors in breast cancer. I. The value of histological grades in breast cancer. Experience from a large study with long-term follow-up. Histopathology 1991, 19:403-410.</ref> of the Scarff-Bloom-Richardson grading system.<ref name="BloomRichardson1957">{{Cite journal | last1 = Bloom | first1 = H.J. | last2 = Richardson | first2 = W.W. | title = Histological grading and prognosis in breast cancer; A study of 1409 cases of which 359 have been followed for 15 years | journal = British Journal of Cancer | volume = 11 | issue = 3 | pages = 359–77 | year = 1957 | pmid = 13499785 | pmc = 2073885 | doi=10.1038/bjc.1957.43}}</ref><ref name="Genestie1998">{{Cite journal | last1 = Genestie | first1 = C. | last2 = Zafrani | first2 = B. | last3 = Asselain | first3 = B. | last4 = Fourquet | first4 = A. | last5 = Rozan | first5 = S. | last6 = Validire | first6 = P. | last7 = Vincent-Salomon | first7 = A. | last8 = Sastre-Garau | first8 = X. | title = Comparison of the prognostic value of Scarff-Bloom-Richardson and Nottingham histological grades in a series of 825 cases of breast cancer: Major importance of the mitotic count as a component of both grading systems | journal = Anticancer Research | volume = 18 | issue = 1B | pages = 571–6 | year = 1998 | pmid = 9568179}}</ref> 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.
 
==== Tubule formation ====
[[File:Nottingham tubular score.jpg|thumb|500px|Tubule formation score in the Nottingham system:<br>&nbsp; 1. A cribriform pattern also counts as tubules<br>&nbsp; 2. Between 10 and 75% of tumor is tubule forming.<br>&nbsp; 3. Almost all clear (white) spaces here are entrapped fat cells which do not count as tubules.{{MH}}]]
The overall appearance of the tumor is considered.<ref name="PujaniSharma2014">{{cite journal|last1=Pujani|first1=Mukta|last2=Sharma|first2=KiranLata|last3=Srivastava|first3=AN|last4=Singh|first4=US|last5=Bansal|first5=Cherry|title=Grading systems in the cytological diagnosis of breast cancer: A review|journal=Journal of Cancer Research and Therapeutics|volume=10|issue=4|year=2014|pages=839|issn=0973-1482|doi=10.4103/0973-1482.140979}}</ref>
* 1 point: tubular formation in more than 75% of the 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")


For lymph nodes (N):<ref name=Stanford/>
==== Nuclear pleomorphism ====
*Clusters <0.2mm can be called "isolated tumor cell clusters"
[[File:Histopathology of invasive ductal carcinoma with high nuclear pleomorphism (3 points).jpg|thumb|190px|IDC with high nuclear pleomorphism (3 points).]]
*Clusters 0.2 - 2.0 mm: "Micrometastasis"
Such as nuclei being larger, darker, or irregular/pleomorphic.
*At least one carcinoma focus over 2.0 mm: "Metastasis". If one node qualifies as metastasis, count all other nodes even with smaller foci as metastases.
Note: The cancer areas having cells with the greatest atypia should be evaluated.
Critical numbers of involved nodes: 1-3, 4-9, and 10 and over. Note any extranodal extension.<ref name=Stanford/>
* '''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 (usually 1.5 - 2 times larger)<ref name="pmid34196797">{{cite journal| author=van Dooijeweert C, van Diest PJ, Ellis IO| title=Grading of invasive breast carcinoma: the way forward. | journal=Virchows Arch | year= 2022 | volume= 480 | issue= 1 | pages= 33-43 | pmid=34196797 | doi=10.1007/s00428-021-03141-2 | pmc=8983621 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34196797  }} </ref>, 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.


===Grading===
==== Mitotic count ====
{{Grading of breast cancer}}
{{Mitotic count in invasive breast cancer}}
==== Overall grade ====
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.
[[File:Histopathology of a calcification in an invasive ductal carcinoma.png|thumb|200px|A conventional calcification in invasive ductal carcinoma.]]
{{Microcalcifications in breast cancer}}
{{Immunohistochemistry evaluation of invasive breast cancer}}
====Estrogen and progesterone receptors====
{{Estrogen and progesterone receptors in breast cancers}}
===Neoadjuvant cases===
[[File:Histopathology of invasive ductal carcinoma with partial response to chemotherapy.jpg|thumb|Invasive ductal carcinoma with partial response to chemotherapy, seen as fibroelastic areas between tumor nests.{{MH}}]]
{{Microscopic evaluation of neoadjuvant invasive cancer}}
{{Evaluation of tumors}}
{{Evaluation of tumors}}
===Report===
{{Reporting of invasive breast cancer}}
*Tumor size, if not already given from gross report<ref name=Stanford/>
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