A 68-Year-Old Woman With Weight Loss and Abdominal Pain

Nafisa Kuwajerwala, MD; Angad Pordal, MD

Disclosures

October 19, 2018

Discussion

Ductal carcinoma in situ is considered a noninvasive breast neoplasm and accounts for approximately 20% of all breast cancer cases in the United States.[1] It is characterized by abnormal cells lining one or more of the lactiferous ducts of the breast. It is classified by its pathological architecture into four discrete types: papillary, solid, cribriform, and comedo. These architectures are rarely seen alone and are usually of mixed type.

Comedo necrosis architecture, as seen in the patient in this case, has a higher grade and carries a larger malignant potential.[1] As the cells inside the ductules grow farther from the blood supply, located in the basement membrane, coagulative necrosis occurs, which results in calcifications that are often seen on mammograms that suggest breast cancer. When the degree of suspension is high for malignancy based on the BIRADS radiographic classification, core needle biopsy should be performed to provide a tissue diagnosis with the cellular architecture intact.

Although ductal carcinoma in situ progresses into invasive disease only in approximately 30% of cases, differentiating between cases that will progress into invasive disease and those that do not is impossible. Thus intervention with lumpectomy with 2-mm margins, postoperative radiation, and adjuvant hormonal treatment is warranted.[1]

Invasive ductal carcinoma accounts for 50%-70% of all invasive breast malignancies; the remainder consists of lobular, mixed, tubular, medullary, and metaplastic breast cancer. When detected, treatment along with genetic testing—when indicated—is warranted.[1] Invasive ductal carcinoma has varying degrees of estrogen and progesterone hormone receptor expression and HER2/neu tyrosine kinase expression. Tumors with hormone receptor positivity are eligible for hormonal therapy and are associated with better outcomes than those without.

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