This page gives an introduction to ductal carcinoma in situ - pre-invasive breast cancer.



Incidence

DCIS was very unmcommon before the introduction of population-based breast screening and the overwhlming majority of cases of this condition encountered in developed world clinical practice is screen-detected. The chart below from a recent publication by Elshof et al illustrates this point very well.


The imact of breast screening on the detection of DCIS

The imact of breast screening on the detection of DCIS.

Source: Lotte E. Elshof, Michael Schaapveld, Emiel J. Rutgers, Marjanka K. Schmidt, Linda de Munck Flora E. van Leeuwen, Jelle Wesseling. The method of detection of ductal carcinoma in situ has no therapeutic implications: results of a population-based cohort study. Breast Cancer Research (2017) 19:26. DOI 10.1186/s13058-017-0819-4. With kind permission from the authors, The Netherlands National Institute for Public Health and the Enviroment (RIVM), The Netherlands Public Pathology Database (PALGA) and The Netherlands Comprehensive Cancer Organisation (IKNL).

Ductal carcinoma in situ (DCIS):


 See also additional examples prepared for the Sloane Project website.



DCIS is regarded as a non-obligate precursor of invasive breast cancer; most breast cancers are believed to transition through a DCIS phase, although that phase might be very brief and there are other potential precursors of invasive disease, such as lobular carcinoma in situ, albeit that this is largely regarded as a risk lesion. Of note, the incidence of symptomatic DCIS has remained unchanged in the face of a steeply rising incidence of screen-detected DCIS, suggesting that the latter does not progress to the former. See chart above

An increased body mass index is more strongly associated with invasive carcinoma than DCIS and thus is interpreted as being more powerfully related to disease progression than incidence.

College of American Pathologists Guidelines for grading DCIS:


Low grade DCIS
Low grade DCIS (Example 1
Low grade DCIS
Low grade DCIS
This view emphasises the rigid structures seen in DCIS with apparently cleanly punched out holes
Low grade DCIS (Example 2) - Low Power;
'Mouse–over' for High Power.

This view emphasises the rigid structures seen in DCIS with apparently cleanly punched out holes, lack of 'streaming' of cells and a lack of apparent nuclear overlap. It is the uniformity of the proliferation that is typical of low and intermediate grade DCIS"
Low grade cribriform DCIS - example 3
Low grade cribriform DCIS (Example 3) - 'Mouse over' for high power view.
Low grade micropapillary DCIS
Low grade micropapillary DCIS - 'Mouse over' for high power view. Note how the tufts of DCIS sit on a peripheral rim of intact myoepithelial cells (recognized by their clear cytoplasm in this example)

Intermediate Grade DCIS

Intermediate grade DCIS with luminal calcs
Intermediate grade DCIS (Example 1) - Core biopsy showing luminal calcs
Low grade micropapillary DCIS
Intermediate grade DCIS (Example 2)- Core biopsy - medium and high power ('Mouse-over')
Cribriform pattern expansion of duct by a single population of uniform epithelial cells
Intermediate grade DCIS (example 3) - medium and high power ('Mouse-over'). This view emphasises the rigid structures seen in DCIS with apparently cleanly punched out holes, a lack of 'streaming' of cells and a lack of apparent nuclear overlap.
Intermediate grade cribriform DCIS
Intermediate grade DCIS (Example 3)- Excision biopsy - medium and high power ('Mouse-over')
Very faint peripheral rim of CK 5/6 staining around duct contents - intermediate grade DCIS   P63 immunostain highlights the myoepithelial layer around this dict expanded by intermediate grade DCIS
Intermediate grade DCIS - CK 5/6 (Left) - arrows point to small numbers of peripheral basal cells. There is no basal/myoepithelial population admixed with the cells expanding this duct; P63 staining highlights the peripheral myoepithelial population (Right)

High Grade DCIS

High grade DCIS
High grade DCIS
High grade DCIS with comedo necrosis
High grade DCIS with comedo necrosis - medium power. 'Mouse-over' for high power
Two ducts showing changes of comedo (central necrosis) DCIS - the grade cannot be assessed at this power
Strongly positive ER; Almost uniformly negative CK 5/6 on @mouse-over'
High grade DCIS
High grade DCIS with central comedo necrosis - medium power; 'Mouse-over' for high power

Cancerisation of lobules:


This is the extension of in situ carcinoma (normally DCIS) from ducts into underlying lobules. It can be mistaken for invasive carcinoma in some cases. The use of myoepithelial immunostains such as CK14 can help to deliniate an intact myoepithelium confirming the in-situ status.

High grade DCIS
High grade DCIS with cancerisation of lobules (Example 1). The duct is shown upper left with its lobules lower right. 'Mouse-over' for more detail.
Extension of DCIS tumour cells into lobules - specialised lobular stroma and non-specialised intervening stroma can be distinguished clearly in this photograph
Extension of DCIS tumour cells into lobules - specialised lobular stroma and non-specialised intervening stroma can be distinguished clearly in this photograph. 'Mouse-over' to see high cytonuclear grade

See also Image of the Quarter 2013/3 use of pan cytokeratin immunostain to identify small invasive foci accompanying DCIS.


Paget's disease of the nipple


This is uncommon and may be managed by conservation surgery if investigations show that the extent of the disease is limited.

Paget's Disease of the nipple

Infiltration of the more basal epidermis by malignant Paget's cells - usually from underlying high grade DCIS
Paget's Disease of the nipple: 'Mouse-over' for detail. Note the nests of Paget's cells extending to the superficial epidermis with early ulceration.
Infiltration of the more basal epidermis by malignant Paget's cells - usually from underlying high grade DCIS
Paget's Disease of the nipple: 'Mouse-over' for HER2 immunostain.

Toker's Cells:



Toker's cells, a mimic of Paget's Disease of the nipple Toker's cells, a mimic of Paget's Disease of the nipple - CK7 immunostain
Biopsy of nipple - Toker's cells in epidermis (arrows and insert). CK7 immunostain on right.

Return to top of page