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Revision as of 18:48, 19 April 2016

For patient information, click here

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Maria Fernanda Villarreal, M.D. [2]

Synonyms and keywords: Intraductal hyperplasia; IDH; Atypical ductal hyperplasia; Comedocarcinoma; Duct cell carcinoma; Duct carcinoma

Overview

Ductal carcinoma is the most common type of breast cancer in women. Ductal carcinoma may be classified according to the Armed Forces Institute of Pathology (AFIP) into 2 groups: large cell carcinoma in situ and small cell carcinoma in situ. The pathogenesis of ductal carcinoma is characterized by the microinvasion of cancer cells limited to the ducts with no extension beyond the basement membrane. The mutation on HER2/neu has been associated with the development of ductal carcinoma.

Historical Perspective

Ductal carcinoma was first described by MacCarthy in 1893.^[1]

Classification

Ductal carcinoma may be classified according to the Armed Forces Institute of Pathology (AFIP) into 2 groups:

Large cell

More aggressive form
Also referred to as comedocarcinoma

Small cell

Less aggressive
Subtypes include cribriform, micropapillary, papillary, and solid in situ.

Other variants of ductal carcinoma include, non-DCIS entities.

Pathophysiology

The pathogenesis of ductal carcinoma is characterized by the microinvasion of cancer cells limited to the ducts with no extension beyond the basement membrane.
The mutation on HER2/neu has been associated with the development of ductal carcinoma.
On gross pathology, characteristic findings of ductal carcinoma, include:

White
Firm stellate lesion

On microscopic histopathological analysis, characteristic findings of ductal carcinoma, include:

Equal spacing of cells - "cookie cutter" look.
Cells line-up along lumen/glandular spaces - form "Roman briges".
Nuclear enlargement (key feature)

Causes

Common causes of ductal carcinoma, may include:

Mutations in BRCA1/BRCA2 genes

Differentiating ductal carcinoma from other Diseases

Ductal carcinoma must be differentiated from other diseases that cause nipple discharge, breast skin color change, and palpable mass such as:

Periductal mastitis
Breast lipoma
Inflammatory carcinoma of breast
Phyllodes tumour

Epidemiology and Demographics

The prevalence of ductal carcinoma is approximately 32.5 per 100,000 women worldwide.

Age

Ductal carcinoma is commonly observed among females between 40 to 80 years old
Ductal carcinoma is rarely observed among males between 60 and 70 years of age
Ductal carcinoma is more commonly observed among postmenopausal women

Gender

Females are significantly more commonly affected with ductal carcinoma than males.

Race

There is no racial predilection for ductal carcinoma.

Risk Factors

Common risk factors in the development of ductal carcinoma, include:

Family history of breast cancer
Mutations in BRCA1/BRCA2 genes
Previous exposure to radiation therapy
Increased breast density
Hormonal therapy
Nulliparity
Obesity

Natural History, Complications and Prognosis

The majority of patients with ductal carcinoma remain asymptomatic for years.
Early clinical features include skin color change or nipple discharge.
If left untreated, the majority of patients with ductal carcinoma may progress to develop lymph node invasion, and metastasis.
The most common complication of ductal carcinoma is lymphedema.
Prognosis generally depends on the histological subtype.

In general, the 20-year mortality rate among patients with ductal carcinoma is approximately 3.3%.
Factors related with worse prognosis, include: young age at diagnosis, black ethnicity, and high grade cancer.

Diagnosis

Symptoms

Ductal carcinoma is usually asymptomatic.
Symptoms of ductal carcinoma may include the following:

Nipple discharge

Skin color changes
Warm and thickened

Skin of an orange appearance
Nipple retraction

Physical Examination

Patients with ductal carcinoma usually are well-appearing.

Physical examination may show no specific physical findings.

In some cases, it may be remarkable for:

Palpable mass

Laboratory Findings

Laboratory findings consistent with the diagnosis of ductal carcinoma, include:

Positive/negative estrogen receptor (ER) and progesterone receptor (PR) expression

Imaging Findings

Mammography is the imaging modality of choice for ductal carcinoma.
On mammography, findings of ductal carcinoma, include:

Calcifications (most common)
Simple mass
Soft-tissue opacity
Asymmetry without calcification

The image below demonstrates findings compatible with ductal carcinoma.

Normal (left) versus cancerous (right) mammography image.

On ultrasound, findings of ductal carcinoma, include:

Microlobulated mild hypoechoic mass

Other Diagnostic Studies

Ductal carcinoma may also be diagnosed using biopsy.
Indications for biopsy, include:

Lesion limited to one quadrant or section of the breast

Treatment

Medical Therapy

The mainstay of therapies for ductal carcinoma are divided into 2 groups: hormonal therapy and targeted therapy.

Hormonal Therapy

Selective estrogen receptor modulators, such as:
Tamoxifen
Raloxifene

Targeted Therapy

HER2-directed therapy
Trastuzumab

The primary goal of medical therapy is to reduce the risk of ipsilateral or contralateral breast invasion and also decreases the risk of recurrence.

Surgery

Surgery is the mainstay of therapy for ductal carcinoma.
Surgical approaches for ductal carcinoma, include: mastectomy or breast-conserving therapy
Lumpectomy in conjunction with adjuvant chemotherapy or radiation is the most common approach to the treatment of ductal carcinoma (with negative margins)
Mastectomy is recommended for patients with extensive margins of ductal carcinoma.

Prevention

Effective measures for the secondary prevention of ductal carcinoma include: screening mammography for women between 50-74 years (or earlier if identified risk factors) and periodical breast self-examination (BSE).^[2]
Once diagnosed and successfully treated, patients with ductal carcinoma are followed-up every 3, 6, or 12 months depending on individual assessment.

References

↑ MacCarty WC. The histogenesis of cancer (carcinoma) of the breast and its clinical significance. Surg Gynecol Obstet 1913;17:441–59.
↑ US Task Preventive Force. http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/breast-cancer-screening Accessed on April 19, 2016

Template:WikiDoc Sources

[name-1] MacCarty WC. The histogenesis of cancer (carcinoma) of the breast and its clinical significance. Surg Gynecol Obstet 1913;17:441–59.

[preventive-2] US Task Preventive Force. http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/breast-cancer-screening Accessed on April 19, 2016

[1]

[2]

@@ Line 1: / Line 1: @@
 '''For patient information, click [[Breast cancer (patient information)|here]]'''
-{{Infobox_Disease |
+__NOTOC__
-  Name           = {{PAGENAME}} |
+{{SI}}
-  Image          = Breast DCIS histopathology (1).jpg |
+{{CMG}} {{AE}} {{MV}}
-  Caption        = Histopathologic image from ductal cell carcinoma in situ (DCIS) of breast. Hematoxylin-eosin stain. |
-  DiseasesDB     = |
+{{SK}} Intraductal hyperplasia; IDH; Atypical ductal hyperplasia; Comedocarcinoma; Duct cell carcinoma; Duct carcinoma
-  ICD10          = {{ICD10|C|50||c|50}}, {{ICD10|D|05||d|00}} |
-  ICD9           = {{ICD9|174}}-{{ICD9|175}}, {{ICD9|233.0}} |
+==Overview==
-  ICDO           = 8500  |
-  OMIM           = |
-  MedlinePlus    = |
-  MeshID         = D018270 |
-}}
-{{Breast cancer}}
-{{CMG}}
-{{SK}} Comedocarcinoma; Duct cell carcinoma; Duct carcinoma
+'''Ductal carcinoma''' is the most common type of breast cancer in women. Ductal carcinoma may be classified according to the Armed Forces Institute of Pathology (AFIP) into 2 groups: large cell carcinoma in situ and small cell carcinoma in situ. The pathogenesis of ductal carcinoma is characterized by the microinvasion of cancer cells limited to the ducts with no extension beyond the basement membrane. The mutation on HER2/neu has been associated with the development of ductal carcinoma.
-==Overview==
+==Historical Perspective==
-'''Ductal carcinoma''' is the most common type of [[breast cancer]] in [[women]]. It comes in two forms: '''invasive ductal carcinoma''' (IDC), an infilitrating, [[malignant]] abnormal proliferation of cells in tissue known as [[neoplasm]], and '''ductal carcinoma in situ''' (DCIS), a noninvasive neoplasm.
+Ductal carcinoma was first described by MacCarthy in 1893.<ref name="name"> MacCarty WC. The histogenesis of cancer (carcinoma) of the breast and its clinical significance. Surg Gynecol Obstet 1913;17:441–59.</ref>
 ==Classification==
-===Invasive Ductal Carcinoma===
+*Ductal carcinoma may be classified according to the Armed Forces Institute of Pathology (AFIP) into 2 groups:
-'''Invasive Ductal Carcinoma''' (IDC) is the most common form of invasive breast cancer. It accounts for 80% of all types of breast cancer.
+:*'''Large cell'''
+::*More aggressive form
+::*Also referred to as comedocarcinoma
+:*'''Small cell'''
+::*Less aggressive
+::*Subtypes include cribriform, micropapillary, papillary, and solid in situ.
-===Intraductal Carcinoma===
+*Other variants of ductal carcinoma include, non-DCIS entities.
-'''Intraductal carcinoma of the breast''' (Ductal Carcinoma In Situ, DCIS) is the most common type of noninvasive breast cancer in women. Ductal carcinoma refers to the development of [[cancer cells]] within the [[mammary gland|milk ducts]] of the breast. ''[[In situ]]'' means "in place" and refers to the fact that the cancer has not moved out of the duct and into any surrounding tissue. <p>
 ==Pathophysiology==
-===Microscopic Pathology===
+*The pathogenesis of ductal carcinoma is characterized by the microinvasion of cancer cells limited to the ducts with no extension beyond the basement membrane.
-====IDC====
+*The mutation on HER2/neu has been associated with the development of ductal carcinoma.
-On [[microscopic examination]], the cancerous cells invade and replace the surrounding normal tissues. IDC is divided in several [[histology|histological]] subtypes.
+*On gross pathology, characteristic findings of ductal carcinoma, include:
-====DCIS====
+:*White
-Ductal carcinoma refers to the development of [[cancer cells]] within the [[mammary gland|milk ducts]] of the breast.  ''[[In situ]]'' means "in place" and refers to the fact that the cancer has not moved out of the duct and into any surrounding tissue.  This cancer presents upon mammograms as small white specks of calcium.
+:*Firm stellate lesion
+*On microscopic histopathological analysis, characteristic findings of ductal carcinoma, include:
-==Natural History, Complications, and Prognosis==
+:*Equal spacing of cells - "cookie cutter" look.
-===Prognosis===
+:*Cells line-up along lumen/glandular spaces - form "Roman briges".
-====IDC====
+:*Nuclear enlargement (key feature)
-The [[prognosis]] of IDC depends, in part, on its histological subtype. Mucinous, papillary, cribriform, and tubular carcinomas have longer survival, and lower recurrence rates. The prognosis of the most common form of IDC, called "IDC Not Otherwise Specified", is intermediate. Finally, some rare forms of breast cancer (e.g. sarcomatoid carcinoma, inflammatory carcinoma) have a poor prognosis.
-Regardless of the histological subtype, the prognosis of IDC depends also on its [[Cancer staging|staging]], [[Grading (tumors)|histological grade]], expression of [[hormone receptor]]s and of [[oncogenes]] like [[HER2/neu]].
+==Causes==
+* Common causes of ductal carcinoma,  may include:
+:*Mutations in BRCA1/BRCA2 genes
+:*
+:*
+:*
+==Differentiating ductal carcinoma from other Diseases==
+*Ductal carcinoma must be differentiated from other diseases that cause nipple discharge, breast skin color change, and palpable mass such as:
+:*Periductal mastitis
+:*Breast lipoma
+:*Inflammatory carcinoma of breast
+:*Phyllodes tumour
-==Physical Examination==
+==Epidemiology and Demographics==
-===Breast===
+* The prevalence of ductal carcinoma is approximately 32.5 per 100,000 women worldwide.
-* A breast lump that usually feels much harder or firmer than benign breast lesions.
+===Age===
+*Ductal carcinoma is commonly observed among females between 40 to 80 years old
+*Ductal carcinoma is rarely observed among males between 60 and 70 years of age
+*Ductal carcinoma is more commonly observed among postmenopausal women
-==Laboratory Findings==
+===Gender===
-===Other Imaging Findings===
+*Females are significantly more commonly affected with ductal carcinoma than males.
-====Mammogram====
-=====IDC=====
-On [[mammography]], IDC is usually visualized as a mass with fine spikes radiating from the edges.
-=====DCIS=====
+===Race===
-As screening mammography has become more widespread, DCIS has become one of the most commonly diagnosed breast conditions. It is often referred to as "stage zero breast cancer." In countries where screening mammography is uncommon, DCIS is sometimes diagnosed at a later stage, but in countries where screening mammography is widespread, it is usually diagnosed on a mammogram when it is so small that it has not formed a lump. DCIS is not painful or dangerous, and it does not metastasize unless it first develops into invasive cancer. <p>
+*There is no racial predilection for ductal carcinoma.
-DCIS is usually discovered through a [[mammogram]] as very small specks of calcium known as [[microcalcification]]s. However, not all microcalcifications indicate the presence of DCIS, which must be confirmed by biopsy. DCIS may be multifocal, and treatment is aimed at excising all of the abnormal duct elements, leaving "clear margins", an area of much debate. After excision treatment often includes local radiation therapy. With appropriate treatment, DCIS is unlikely to develop into invasive cancer. Surgical excision with radiation lowers the risk that the DCIS will recur or that invasive breast cancer will develop.<p>
+==Risk Factors==
+*Common risk factors in the development of ductal carcinoma, include:
+:*Family history of breast cancer
+:*Mutations in BRCA1/BRCA2 genes
+:*Previous exposure to radiation therapy
+:*Increased breast density
+:*Hormonal therapy
+:*Nulliparity
+:*Obesity
-==Medical Therapy==
+== Natural History, Complications and Prognosis==
-===Surgery and Device Based Therapy===
+*The majority of patients with ductal carcinoma remain asymptomatic for years.
-====IDC====
+*Early clinical features include skin color change or nipple discharge.
-Treatment of IDC usually starts with surgery to remove the main tumor mass and to sample the [[lymph nodes]] in the axilla. The [[cancer staging|stage]] of the tumor is ascertained after this first surgery.
+*If left untreated, the majority of patients with ductal carcinoma may progress to develop lymph node invasion, and metastasis.
-====DCIS====
+*The most common complication of ductal carcinoma is lymphedema.
-DCIS patients have two surgery strategy choices. They are lumpectomy (most commonly followed by radiation therapy) or mastectomy.
+*Prognosis generally depends on the histological subtype.
+:*In general, the 20-year mortality rate among patients with ductal carcinoma is approximately 3.3%.
+:*Factors related with worse prognosis, include: young age at diagnosis, black ethnicity, and high grade cancer.
-[[Lumpectomy]] is surgery that removes only the cancer and a rim of normal breast tissue around it. For women with only one area of cancer in their breast, and a tumor under 4 centimeters that was removed with clear margins, lumpectomy followed by radiation is often equivalent to mastectomy for mortality related to their cancer, albeit at the higher risk of local disease recurrence on the breast/chest wall. The addition of radiation therapy to lumpectomy in DCIS reduces the risk of local recurrence by about 58% as compared to excision alone. Lumpectomy with radiation is estimated to carry between a 12-19% chance at 15 years for local recurrence of breast cancer (approximately a 0.5% to 1.0% risk per year), which would require a "salvage mastectomy".
+== Diagnosis ==
+=== Symptoms ===
+*Ductal carcinoma is usually asymptomatic.
+*Symptoms of ductal carcinoma may include the following:
+:*Nipple discharge
+::*Skin color changes
+::*Warm and thickened
+:*Skin of an orange appearance
+:*Nipple retraction
-Patients with family history of breast cancer and those presenting with breast cancer who are less than 40 years old face higher risks of local recurrence with breast conservation techniques. Extensive DCIS of high grade, large size, and resected with minimal surgical margins, even with radiotherapy, results in recurrence rates of at least 50% and would be better served with a mastectomy procedure.
+=== Physical Examination ===
+*Patients with ductal carcinoma usually are well-appearing.
+:*Physical examination may show no specific physical findings.
+*In some cases, it may be remarkable for:
+:*Palpable mass
-[[Mastectomy]] may also  be the preferred treatment in certain instances:
+=== Laboratory Findings ===
-* Two or more tumors exist in different areas of the breast (a "multifocal" cancer).
+*Laboratory findings consistent with the diagnosis of ductal carcinoma, include:
-* Failure to achieve adequate margins on attempted lumpectomy.
+:*Positive/negative estrogen receptor (ER) and progesterone receptor (PR) expression
-* The breast has previously received [[radiation]] (XRT) treatment.
-* The tumor is large relative to the size of the breast.
-* The patient has had [[scleroderma]] or another disease of the connective tissue, which can complicate XRT treatment.
-* The patient lives in an area where XRT is inaccessible
-* The patient is apprehensive about their risk of local recurrence
-* The patient is less than 40 or has a strong family history of breast cancer
-The system for analysing the suitability of DCIS patients for the options of breast conservation without radiation, breast conservation with radiation, or mastectomy is called the VanNuys Prognostic Scoring Index (VNPI). This VNPI analyzes DCIS features in terms of size, grade, surgical margins, and patient age and assigns "scores" to favourable features.
+===Imaging Findings===
+*Mammography is the imaging modality of choice for ductal carcinoma.
+*On mammography, findings of ductal carcinoma,  include:
+:*Calcifications (most common)
+:*Simple mass
+:*Soft-tissue opacity
+:*Asymmetry without calcification
+*The image below demonstrates findings compatible with  ductal carcinoma.
+<gallery>
+Image:Mammo breast cancer.jpg|Normal (left) versus cancerous (right) mammography image.
+</gallery>
+*On ultrasound, findings of ductal carcinoma,  include:
+:*Microlobulated mild hypoechoic mass
-===Pharmacotherapy===
+=== Other Diagnostic Studies ===
-===IDC===
+*Ductal carcinoma may also be diagnosed using biopsy.
-[[Adjuvant therapy]] (i.e. treatment after surgery) usually includes [[chemotherapy]], [[radiotherapy]], hormonal therapy (e.g. [[Tamoxifen]]) and targeted therapy (e.g. [[Trastuzumab]]). More surgery is occasionally needed to complete the removal of the initial tumor or to remove recurrences.
+*Indications for biopsy, include:
+:*Lesion limited to one quadrant or section of the breast
+:*
+== Treatment ==
+=== Medical Therapy ===
+*The mainstay of therapies for ductal carcinoma are divided into 2 groups: hormonal therapy and targeted therapy.
+'''Hormonal Therapy'''
+:*Selective estrogen receptor modulators, such as:
+:*Tamoxifen
+:*Raloxifene
+'''Targeted Therapy'''
+:*HER2-directed therapy
+:*Trastuzumab
+*The primary goal of medical therapy is to reduce the risk of ipsilateral or contralateral breast invasion and also decreases the risk of recurrence.
-The treatment options offered to a given patient are determined by the form, stage and location of the cancer, and also by the age, history of prior disease and general health of the patient. Not all patients are treated the same way.
+=== Surgery ===
-====DCIS====
+*Surgery is the mainstay of therapy for ductal carcinoma.
-Tamoxifen or another hormonal therapy is recommended for some women with DCIS to help prevent breast cancer. Hormonal therapy further decreases the risk of recurrence of DCIS or the development of invasive breast cancer. However, they have potentially dangerous side effects, such as increased risk of endometrial cancer, severe circulatory problems, or stroke. In addition, hot flashes, vaginal dryness, abnormal vaginal bleeding, and a possibility of premature menopause are common for women who were not yet menopausal when they started treatment.
+*Surgical approaches for ductal carcinoma, include: mastectomy or breast-conserving therapy
+*Lumpectomy in conjunction with adjuvant chemotherapy or radiation is the most common approach to the treatment of ductal carcinoma (with negative margins)
+*Mastectomy is recommended for patients with extensive margins of ductal carcinoma.
-Unlike women with invasive breast cancer, women with DCIS do not undergo chemotherapy and have traditionally not been advised to have their lymph nodes tested or removed. Some institutional series reporting significant rates of recurrent invasive cancers after mastectomy for DCIS, have recently endorsed routine sentinal node biopsy (SNB) in these patients. <ref> Tan JC, McCready DR, Easson AM, Leong WL. Role of Sentinel Lymph Node Biopsy in Ductal Carcinoma-in-situ Treated by Mastectomy. Ann Surg Oncol. 2007 Feb;14(2):638-45.[PMID 17103256]</ref>, while other have concluded it be reserved for selected patients. Most agree that SNB should be considered with tissue diagnosis of high risk DCIS (grade III with palpable mass or larger size on imaging) as well as in patients undergoing mastectomy after a core or excisional biopsy diagnosis of DCIS. <ref> van Deurzen CH, et al. Is there an indication for sentinel node biopsy in patients with ductal carcinoma in situ of the breast? A review. Eur J Cancer. 2007 Feb 12. [PMID 17300928]</ref> <ref> Yen TW, et al. Predictors of invasive breast cancer in patients with an initial diagnosis of ductal carcinoma in situ: a guide to selective use of sentinel lymph node biopsy in management of ductal carcinoma in situ. J Am Coll Surg. 2005 Apr;200(4):516-26. [PMID 15804465]</ref> Experts are not sure whether all women with DCIS would eventually develop invasive breast cancer if they live for a long time and are not treated.
+=== Prevention ===
+*Effective measures for the secondary prevention of ductal carcinoma include: screening mammography for women between 50-74 years (or earlier if identified risk factors)  and periodical breast self-examination (BSE).<ref name="preventive> US Task Preventive Force. http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/breast-cancer-screening Accessed on April 19, 2016</ref>
+*Once diagnosed and successfully treated, patients with ductal carcinoma are followed-up every 3, 6, or 12 months depending on individual assessment.
 ==References==
-{{reflist|2}}
+{{Reflist|2}}
-{{Epithelial neoplasms}}
 [[Category:Oncology]]
 [[Category:Types of cancer]]