Intraductal papillary-mucinous neoplasms: a new and evolving entity among the pancreatic tumors

The intraductal papillary-mucinous neoplasms of the pancreas have only recently been recognized as a clinical and pathological entity. They show an adenoma-carcinoma sequence, but have a much more favorable prognosis than ductal adenocarcinoma. Moreover, it has become clear that they constitute a heterogeneous group with at least four histopathological subtypes that have different biological properties with different prognostic implications.

Challenges in the stratification of breast tumors for tailored therapies

Studying the molecular stratification of breast carcinoma is a real challenge considering the extreme heterogeneity of these tumors. Many patients are now treated following recommendation established at several NIH and St Gallen consensus conferences. However a significant fraction of these breast cancer patients do not need adjuvant chemotherapies while other patients receive inefficacious therapies. High density gene expression arrays have been designed to attempt to establish expression profiles that could be used as prognostic indicators or as predictive markers for response to treatment. This review is intended to discuss the potential value of these new indicators, but also the current weaknesses of these new genomic and bioinformatic approaches. The combined analysis of transcriptomic and genomic alteration data from relatively large numbers of well annotated tumor specimens may offer an opportunity to overcome the current difficulties in validating recently published non overlapping gene lists as prognostic or therapeutic indicators. There is also hope for identifying and deciphering signal transduction pathways driving tumor progression with newly developed algorithms and semi quantitative parameters obtained in simplified in vitro or in vivo models for specific transduction pathways.

C-KIT expression in ductal carcinoma in situ of the breast: co-expression with HER-2/neu

The proto-oncogene c-KIT (CD117) is highly expressed in normal breast epithelium and is decreased in invasive breast cancer. In this study, we analyzed the protein expression and the mutational status of c-KIT in ductal carcinoma in situ (DCIS) of the breast and correlated these findings with nuclear grade, architectural pattern, and expression of HER-2, estrogen receptor (ER)-alpha, and progesterone receptor (PR). C-KIT, HER-2, ER, and PR expression were analyzed immunohistochemically in 106 cases of paraffin-embedded DCIS (85 pure DCIS and 21 DCIS with concurrent carcinoma). Direct sequencing of exons 9 and 11 of the c-KIT gene was performed to analyze the hot spot mutational regions in representative cases. C-KIT expression was found in 55 (52.8%) of all DCIS, correlating with high nuclear grade (P < .0001), comedonecrosis (P < .0001), and solid growth pattern (P = .001). Furthermore, c-KIT expression was strongly associated with HER-2 positivity (P < .0001) and was significantly lower in ER- or PR-positive cases (P = .001 and P = .006, respectively). C-KIT expression alone or co-expression with HER-2 in pure DCIS did not differ significantly from DCIS with invasive component (P = .09). Mutational analysis in 6 c-KIT-positive DCIS revealed no activating mutations in exons 9 or 11. Our findings suggest that the expression of c-KIT protein might define a subset of poorly differentiated, HER-2-positive DCIS with decreased expression of steroid hormone receptors, comedonecrosis, and a solid growth pattern. The implications of c-KIT and HER-2 co-expression for breast carcinogenesis should be further evaluated.

Tubular carcinoma of the breast and associated intra-epithelial lesions: a comparative study with invasive low-grade ductal carcinomas

Ductal intra-epithelial lesions of the breast are associated with invasive neoplasms and comprise a large spectrum of histological patterns. We have examined 23 cases of pure tubular carcinomas (TCs) of the breast and 53 cases of invasive ductal low-grade carcinomas to determine the relationship and distribution of intra-epithelial lesions, mainly of ductal in situ carcinoma type, but including also lobular intra-epithelial neoplasia (LIN) in both entities. Eleven cases of TC showed flat epithelial atypia (FEA) (47.8%), and, in 14 and 6 cases, micropapillary and cribriform low-grade ductal carcinoma in situ (DCIS) were present (60.7 and 26.1%, respectively). On the opposite, in ductal grade I invasive carcinomas, the most frequent architectural pattern was low-grade DCIS growing in arcades in 26 cases (49%). While absent in TCs, low-grade DCIS of solid type was found in five (9.4%) cases of ductal invasive carcinomas, where FEA were present in seven (13.2%) cases. LIN lesions were present in four (17.4%) cases of TC, whereas they represented 7.5%, as reported by Carstens et al. (Am J Clin Pathol 58:231-238, 1972), of cases of low-grade carcinomas. These results suggest that invasive pure TC and low-grade ductal carcinomas of the breast are different lesions, and support the fact that TC, of low histopathological grade, is a particular distinct tumoural entity.

Time-domain optical mammography SoftScan: initial results

RATIONALE AND OBJECTIVES

Near-infrared (NIR) technology appears promising as a noninvasive technique for breast cancer screening and diagnosis. The technology capitalizes on the relative transparency of human tissue in this spectral range and its sensitivity to the main components of the breast: water, lipid, and hemoglobin. In this study, the authors report quantitative measurements of these components and the functional contrast between healthy and diseased tissue.

MATERIALS AND METHODS

A four-wavelength time domain optical imaging system was used to perform noninvasive NIR measurements in the breast of 49 women both pre- and postmenopausal, ages 24-80. Algorithms based on a diffusive model of light transport provided absolute bulk and local values of breast constituent concentrations.

RESULTS

Important variations in the functional and structural NIR properties of the breast were observed. Demographics trend were noticed in accordance with breast physiology. In the 23 cases imaged with suspicious masses, the optical images were consistent with the mammographic findings. Substantial contrast between masses and adjacent tissue is observed. Moreover, consistent differences between malign and benign cases are found with optical imaging.

CONCLUSION

The results of this pilot study illustrate the sensitivity of optical techniques to the composition of the breast. In addition, preliminary data suggest that benign and malignant tumors can potentially be noninvasively differentiated with optical imaging. Moreover, statistically significant discrimination based on deoxy-hemoglobin content between malign and benign cases was found with optical imaging (P = .0184, one-tailed t test).

DCIS, cytokeratins, and the theory of the sick lobe

We postulate that ductal carcinoma in situ (DCIS), and consequently breast carcinoma in general, is a lobar disease, as the simultaneously or asynchronously appearing, often multiple, in situ tumor foci are localized within a single lobe. Although the whole lobe is sick, carrying some form of genetic instability, the malignant transformation of the epithelial cells may appear localized to a part or different parts of the sick lobe at the same time or with varying time difference. It may be confined to terminal ductal lobular units (TDLUs), to ducts or both. The malignant transformation is often associated with aberrant branching and/or aberrant lobularization within the sick lobe. Involvement of a single individual TDLU or of a group of adjacent TDLUs generates a unifocal lesion. Multifocal lesions appear if distant TDLUs are involved. Diffuse growth pattern in DCIS indicates involvement of the larger ducts. The extent of the involved area in multifocal or diffuse cases varies considerably. Diffuse growth pattern with or without evidence of aberrant arborisation within the sick lobe seems to characterize a subgroup of DCIS with unfavourable prognosis. In this paper, we discuss the anatomical, embryological and pathological background of the theory of the sick lobe and present supporting evidence from modern radiological breast imaging, long-term follow-up studies and from our own series of 108 DCIS cases.

Histological markers that predict clinical recurrence in ductal carcinoma in situ of the breast: an Australian population-based study

AIMS

The incidence of ductal carcinoma in situ (DCIS) has increased substantially since the advent of widespread screening mammography. Identification of histological markers that predict recurrent disease is essential for optimal treatment management. To assist the clinico-pathological stratification of DCIS, we sought to determine histological markers of recurrence in DCIS in an Australian population-based series.

METHODS

In a study of all DCIS reported in Victoria between 1988 and 1992, managed by breast conserving therapy (wide local excision or subtotal mastectomy) with or without adjuvant radiotherapy and/or hormonal therapy, the histological features of DCIS lesions with subsequent ipsilateral recurrence as in situ or invasive breast cancer were compared with a similarly managed control group of DCIS without recurrence.

RESULTS

Large lesion size, presence of nuclear pleomorphism, absence of cellular polarisation and extensive necrosis were all significant predictors of recurrence (P<0.05). Primary and recurrent DCIS lesions had similar morphological features, and invasive recurrence was characterised by ductal type with high nuclear grade.

CONCLUSION

This study identifies histological markers in DCIS associated with recurrence in an Australian population, and demonstrates similar histological appearances between primary and secondary lesions. These histological characteristics may be used to stratify DCIS subtypes and facilitate the future optimisation of disease management.

Assessment of lesions coexisting with various grades of ductal intraepithelial neoplasia of the breast

Ductal intraepithelial neoplasia (DIN) is descriptive of in situ breast lesions from usual ductal hyperplasia (UDH) to advanced ductal carcinoma in situ (DCIS). A total of 2628 cases of DIN diagnosed at the Armed Forces Institute of Pathology were separated based on their grade. These were assessed for the presence of invasive carcinoma (ductal or lobular) and lobular intraepithelial neoplasia (LIN) grades 1-3. The frequency of invasive cancer (ductal and lobular) appearing with DIN increased with increasing DIN grade from 2% in low-risk DIN (UDH) to 37% in DIN 2-3 (DCIS grades 2-3). The frequency of these invasive carcinomas, which were either lobular or displayed lobular features, however, decreased with increasing grade of DIN with a peak of 28% in DIN 1-flat type, (flat epithelial atypia) to a low of 2% in DIN 3. Likewise, the frequency of LIN appearing with DIN decreased as the grade of DIN increased, with a peak of 26% in DIN 1-flat type to a low of 9% in DIN 3. Lower-grade LIN 1 comprised 14% of the LIN in low-risk DIN cases, but only 4% of the LIN seen in DIN 3 cases. Conversely, higher-grade LIN 3 comprised only 6% of the LIN seen in low-risk DIN cases, while accounting for 15% of the LIN in DIN 3 cases. The frequency of invasive carcinoma in DIN 1 ranged from 4% in quantitatively limited DIN 1 less than or equal to 2 mm (atypical ductal hyperplasia) to 27% among the more abundant DIN 1 greater than 2 mm (DCIS grade 1). The frequency of LIN associated with DIN 1 less than or equal to 2 mm was 13.4%, and the frequency of LIN associated with DIN 1 greater than 2 mm was 16.6% when there was no DIN 1-flat type present. However, the frequency of the LIN seen in combination with DIN 1-flat type was reduced by 50% as the quantity of DIN exceeded 2 mm. Based on this retrospective analysis of DIN, we noted that: (1) invasive carcinoma is most frequently associated with the higher grades of DIN; (2) the grade of LIN parallels the grade of coexisting DIN; (3) a relationship exists between DIN 1-flat type and the occurrence of LIN and (4) this relationship in association with DIN less than or equal to 2 mm is not maintained in DIN greater than 2 mm.

Columnar cell lesions: current classification and controversies

"Columnar cell lesions" is a general descriptive term referring to disparate lesions having in common cells with a columnar configuration but not necessarily identical histologic or biologic characteristics. Within this large category, a group of lesions having in common a population of atypical cells (frequently columnar shaped) is emerging as early neoplastic lesions. This article reviews the histological features, differential diagnosis, associated lesions, biologic potential, clinical significance, and management of atypical columnar cell lesions.

Differential diagnosis of solid carcinoma in situ

Although most cases of carcinoma in-situ are easily classified as either ductal or lobular on the basis of their pattern of involvement and the nature of their cell-to-cell relation, a few pose diagnostic problems. Attention to the presence of associated lesions and the results of immunohistochemical staining for E-cadherin and, to a lesser extent, cytokeratin can help to categorize problematic cases. This article reviews the histological criteria employed to separate ductal carcinoma in situ from lobular carcinoma in situ, the role of immunohistochemistry in the diagnosis of equivocal lesions, and the evidence suggesting the existence of combined and truly hybrid forms.

Histological margin assessment for breast ductal carcinoma in situ: precision and implications

Local recurrence after lumpectomy for ductal carcinoma in situ (DCIS) is a major concern and is related to residual disease in the breast. We studied the predictive value of lumpectomy margins for residual DCIS and compared our results and pathological processing techniques with those published in the literature. Margin status was determined for 89 patients with screen-detected DCIS who had lumpectomy and re-excision, for the presence and extent of residual disease. Margin width was defined as the narrowest distance between tumor and any inked margin or, where margins were positive, classified into focal involvement (<1 mm of the inked surface involved), minimal (>or=1<15 mm) and extensive (>or=15 mm). The amount of residual tumor was quantified according to the number of ducts involved with tumor: small (fewer than 10 ducts) or large (10 or more ducts) residuum. The initial margin status was a significant predictor for the presence of residual tumor in re-excision specimens (P=0.006). There was residual tumor in 44 and 45% of close non-involved (>1 and <or=1 mm width) margins, 67% of focally, 71% of moderately and 94% of extensively positive margins. The pathologic tumor size was also a predictor for the presence of residual tumor with 27, 68 and 74% of lesions measuring <or=10, 11-25, >25 mm,respectively, showing residual disease. The presence of residual tumor was not significantly related to age, mammographic appearance, nuclear grade or intraductal necrosis. The initial margin status was found to predict for the amount of residual tumor. With careful margin assessment, margin status after lumpectomy for DCIS can be used to predict for the presence and amount of residual tumor in the breast and is a guide to further management decisions. A standard for margin status reporting and pathological processing of screen-detected DCIS in situ lesions will help in the interpretation of data from different institutions.

[Management of ductal carcinoma in situ by the pathologist: current questions]

As a consequence of increased screening mammography, ductal carcinoma in situ represents a growing percentage of breast cancer diagnoses. The management of per-cutaneous biopsies as well as wire-localized surgical biopsies is a difficult task for pathologists. In this Article, we describe the diagnostic criteria of these lesions as well as the histopathological characteristics of their two principal differential diagnoses: atypical ductal hyperplasia and micro-infiltrating carcinoma. We also detail the utility of immunohistochemistry in the diagnosis of these lesions. This paper reviews the accepted prognostic factors for ductal carcinoma in situ and describes the important techniques needed to characterize them (grade and extent, status of margins and exclusion of microinvasion). Correct handling of pathological specimens, as detailed here, is one of the main keys for therapeutic success with ductal carcinomas in situ. Indeed, if dealt with adequately, such lesions should almost never affect the patient's long-term survival.

Tissue microarray study for classification of breast tumors

Clinical and pathological heterogeneity of breast cancer hinders selection of appropriate treatment for individual cases. Molecular profiling at gene or protein levels may elucidate the biological variance of tumors and provide a new classification system that correlates better with biological, clinical and prognostic parameters. We studied the immunohistochemical profile of a panel of seven important biomarkers using tumor tissue arrays. The tumor samples were then classified with a monothetic (binary variables) clustering algorithm. Two distinct groups of tumors are characterized by the estrogen receptor (ER) status and tumor grade (p = 0.0026). Four biomarkers, c-erbB2, Cox-2, p53 and VEGF, were significantly overexpressed in tumors with the ER-negative (ER-) phenotype. Eight subsets of tumors were further identified according to the expression status of VEGF, c-erbB2 and p53. The malignant potential of the ER-/VEGF+ subgroup was associated with the strong correlations of Cox-2 and c-erbB2 with VEGF. Our results indicate that this molecular classification system, based on the statistical analysis of immunohistochemical profiling, is a useful approach for tumor grouping. Some of these subgroups have a relative genetic homogeneity that may allow further study of specific genetically-controlled metabolic pathways. This approach may hold great promise in rationalizing the application of different therapeutic strategies for different subgroups of breast tumors.

Cytologic findings with histologic correlation in 43 cases of mammary intraductal adenocarcinoma diagnosed by aspiration biopsy

OBJECTIVE

To review the cytologic and subsequent histologic findings in intraductal mammary adenocarcinoma (ductal adenocarcinoma in situ) (DCIS) to evaluate the role of aspiration biopsy (AB) in identifying and grading the disease.

STUDY DESIGN

AB smears and tissue sections from 43 women with pure DCIS who underwent preoperative AB were reviewed. Smears were assessed for cellularity, cellular arrangement (including dissociation, nuclear size and pleomorphism), and presence of nucleoli and necrosis.

RESULTS

Of the 43 cases, 22 were high grade (HG) DCIS, 7 cases were intermediate grade (IG), and 14 cases were low grade (LG). Cytologic findings of HG DCIS was as follows: high cellularity (22/22), clusters of pleomorphic cells with large nuclei and increased nuclear/cytoplasmic ratios (22/22), single cells (20/22), prominent nucleoli (22/22) and necrosis (diffuse in 15/22, focal in 7/22). All LG cases had moderately to highly cellular smears with cohesive, 3-dimensional sheets of uniform, small cells with inconspicuous nucleoli arranged around a central lumen, forming "punched-out" spaces. Single cells were prominent in 2 of 14 cases. IG DCIS showed intermediate features between LG and HG DCIS: 3-dimensional sheets with punched-out spaces, abundant single cells, moderate pleomorphism and focal necrosis.

CONCLUSION

HG DCIS is easily identifiable on AB smears; however, distinction from invasive carcinoma may not be possible. The cytologic diagnosis of LG DCIS is difficult, and 50% of our cases were called atypical on AB. Recognition of cohesive cellular arrangements with crowding and punched-out spaces is crucial as single cells and prominent atypia are often lacking.

Diagnosis of Tis/T1 breast cancer extent by multislice helical CT: a novel classification of tumor distribution

PURPOSE

To evaluate the clinical usefulness of multislice helical CT (MSCT) for assessing breast cancer extent.

MATERIALS AND METHODS

MSCT was performed in 70 patients with Tis/T1 breast cancer [12 ductal carcinoma in situ (DCIS) and 58 invasive carcinoma]. The distribution pattern of contrast enhancement (CE) was classified into five categories: solitary lesion (localized area of CE), grouped lesion (satellite: localized CE with linear and/or spotty enhancement; crowded: clustered spotty enhancement), separated lesion (multifocal foci of CE), mixed lesion (grouped lesion with multifocal foci), and diffuse lesion (diffuse CE).

RESULTS

Solitary lesion was seen in five cases of DCIS, 27 invasive carcinomas without intraductal spread (IDS), six invasive carcinomas with IDS, and one multicentric cancer. Grouped lesion was seen in six DCIS and 15 invasive carcinomas with IDS. Separated lesion was seen in one case of invasive carcinoma and fibroadenoma, and three multifocal/multicentric cancers. Mixed lesion was seen in two multicentric cancers. Diffuse lesion was seen in one case of DCIS and three invasive carcinomas. The coincident rate between MSCT pattern and histologic distribution was 85.7% (60/70). In solitary and grouped lesions, accuracy for the detection of tumor extent with a deviation of less than 2 cm in length was 91.7% (55/60).

CONCLUSION

MSCT is extremely accurate in the diagnosis of IDS and the multicentricity of breast cancer.

Oestrogen receptor negativity as a marker for high-grade ductal carcinoma in situ of the breast

AIMS

To compare the morphological and immunohistochemical characteristics of oestrogen receptor (ER)-negative and ER-positive ductal carcinoma in situ (DCIS) of the breast, in an attempt to establish more objective criteria for the classification of DCIS.

METHODS AND RESULTS

Sections of 64 cases of in-situ carcinoma of the breast were stained for ER, progesterone receptors (PgR), androgen receptors (AR), c-erbB-2 and p53, using the immunoperoxidase technique. The cases included 60 DCIS and four lobular carcinoma in situ (LCIS). Four DCIS lesions were associated with foci of microinvasion. The 60 DCIS cases included 31 high grade, 23 intermediate grade and six low grade. Twenty-four DCIS cases (40%) were ER-negative and 36 were positive. ER negativity was significantly associated with high nuclear grade (88% versus 27% for ER-positive cases, P < 0.001), PgR negativity (100% versus 25%, P < 0.001), c-erbB-2 positivity (79% versus 14%, P < 0.001) and p53 positivity (58% versus 6%, P < 0.001). There was no difference between ER-negative and -positive DCIS as regards AR expression, with 91% of cases in each group being AR-positive. Of the four cases of DCIS with microinvasion, three were ER- and PgR-negative, all four were c-erbB-2-positive and AR-positive and one was p53-positive. None of the four LCIS was ER, PgR or AR-negative and none was c-erbB-2- or p53-positive.

CONCLUSIONS

There is a highly significant direct relationship between ER negativity in DCIS and high nuclear grade, PgR negativity and c-erbB-2 and p53 positivity. We suggest that immunohistological assessment of ER status may help in providing a more objective way of classifying DCIS.

[Ductal carcinoma in situ: current anatomo-pathologic data]

Ductal carcinoma in situ (DCIS), accounting for 15-25% of all breast cancers, is frequently diagnosed by mammographic examination. This heterogeneous disease requires a rigorous local treatment based, in about two-third of cases, on conservative surgery and radiotherapy. DCIS are currently classified on the basis of nuclear grade. Most lesions, and especially high nuclear grade DCIS, are limited to one quadrant. Micropapillary DCIS are likely to be of larger size/extent and thus a conservative approach is often difficult. A careful pathological examination of an oriented excisional biopsy is a pre-requisite for optimal therapy.

The diagnosis and management of pre-invasive breast disease: ductal carcinoma in situ (DCIS) and atypical ductal hyperplasia (ADH)--current definitions and classification

Intraductal epithelial proliferations of the breast are at present classified into three groups; distinction is made histologically and clinically between usual epithelial hyperplasia and atypical ductal hyperplasia (ADH) and between ADH and ductal carcinoma in situ (DCIS). Although evidence indicates that these boundaries are not ideal on a morphological, immunohistochemical, or genetic basis, this three-tier system is accepted and used at present. The current definitions, histological features, and system of classification of ADH and DCIS are described in this manuscript.

Histologic classification of ductal carcinoma in situ

Prior to the current mammographic era, ductal carcinoma in situ (DCIS) usually presented as a large mass, was classified morphologically by architecture, and treated by mastectomy. The introduction of screening mammography led to an increase in the incidence of DCIS, a decrease in the average size of DCIS, and an increased emphasis on its heterogeneous nature. Thus, a reproducible and prognostically relevant classification system for DCIS is necessary. The ultimate goal of this classification is proper selection of patients for whom lumpectomy would suffice rather than mastectomy. Features to evaluate include: extent and size of disease, adequacy of resection margins, and histology. While none of the proposed histological classification systems were endorsed at the recent Consensus Conference on the Classification of DCIS, nuclear grade was the most important feature common to most of them. Architecture was given secondary importance. By definition, DCIS is a non-invasive clonal proliferation of epithelial cells originating in the terminal duct lobular unit, which would be expected to be monomorphic; however, it is the degree of nuclear pleomorphism that is primarily used to separate DCIS into low, intermediate, and high grades. Architecturally, DCIS has been divided into the following types: comedo, solid, cribriform, micropapillary, and papillary. Different architectural patterns and grades may be present in a given particular case; however, some combinations of patterns occur more frequently than others. Interobserver studies have shown nuclear grading to be interpreted with greater consistency than architecture, and nuclear grading methods have correlated with biological and molecular marker studies.

Ductal carcinoma in situ of the breast: a new phenotype classification system and its relation to prognosis

In a study of invasive breast cancer, multiple correspondence analysis (MCA) revealed clustering of eight pathobiological variables. Two different phenotypes were distinguished by an index calculated on the basis of the variables (histologic grade, necrosis, lymphoid infiltration, number of mitosis and expression of c-erbB-2, p53, progesterone receptor and Bcl-2). Phenotype A lesions share most of the features of normal breast tissue. Phenotype B looks more malignant, has a higher early recurrence rate and is more frequently seen in younger patients. Our aim was to see if ductal breast carcinoma in situ (DCIS) could be divided into the same phenotypes. One hundred and eighty DCIS were investigated. Association between the eight variables was studied in 2 x 2 models. The phenotype index was calculated by summing weights for the variables in the MCA. All variables were associated, except Bcl-2. DCIS was divided in two phenotypes. Thirty-three tumours were Phenotype A and 147 Phenotype B. The mean age at diagnosis was 65.5 and 58.4 years for Phenotypes A and B, respectively (p = 0.0012). No difference regarding local relapse free survival was seen. Two phenotypes were distinguished in DCIS, similar to invasive breast cancer. In an earlier study, 45% of the invasive cancers were classified as Phenotype B. In this study, 82% of DCIS were Phenotype B. This may indicate that invasive breast cancer of Phenotype B is derived from DCIS of Phenotype B. The distribution of DCIS phenotypes with a small proportion of Phenotype A DCIS may be due to that Phenotype A DCIS is less likely to be detected by mammography, or that some invasive breast cancers of Phenotype A progress to invasiveness without passing the in situ phase.