Surgical Pathology Criteria–

Ductal Carcinoma in Situ of the Breast

Differential Diagnosis

Low Grade DCIS vs. Atypical Ductal Hyperplasia (ADH)

Ductal vs. Lobular may be a problem in pagetoid or complete involvement of ducts by LCIS, in solid low grade DCIS, or in lobular involvement by DCIS cells (cancerization of lobules)

DCIS LCIS
Cohesive Non-cohesive
May show moderate to marked pleomorphism Mild to moderate pleomorphism
No pagetoid involvement of ducts May show pagetoid pattern in ducts
May show irregular or partial involvement of acini Uniform involvment of acini
Frequent cribriform or micropapillary pattern No cribriform spaces or micropapillae
Frequently amphophilic cytoplasm Cytoplasm usually clear to eosinophilic
E-cadherin positive E-cadherin negative
Indeterminate cases will be encountered and should be treated as DCIS (excision with clear margins)

Papillary DCIS Intraductal Papilloma
Thin, delicate fibrovascular stalks Broad, hyalinized stalks
Myoepithelial cells restricted to stalk lining Myoepithelial cells integral part of lesion
No proliferation in stalk stroma Adenosis-like ductal proliferation in hyalinized stroma
Necrosis may be present Necrosis rare over age 40
Mitotic figures may be present Mitotic figures rare over age 40

DCIS vs. Invasive Carcinoma

Marker Sensitivity Specificity
Calponin Excellent Very good
p63 Excellent Excellent
Smooth muscle myosin heavy chain Good Excellent
CD10 (CALLA) Good Good
High molecular weight cytokeratin Very good Poor
Maspin Good Poor
S100 Good Very poor
Actin Good Very poor

Cribriform Ductal Carcinoma In Situ Collagenous Spherulosis
May have intralumenal mucin but lacks fibrillar or laminated appearance Frequently fibrillar or laminated spherules
Myoepithelial component restricted to peripheral layer of duct Myoepithelial cells surround spherules
Nuclei slightly enlarged compared to normal (2-3 times larger than RBC) Nuclei identical in size and appearance to normal

A number of low grade or benign lesions are characterized by pools of mucin

Mucinous DCIS Extracellular, intralumenal mucin in a duct lined by DCIS, no mucin in contact with stroma
DCIS with mucocele-like lesion Typical DCIS with discrete areas of rupture resulting in mucin pools in stroma, no groups of cells floating in mucin
ADH with mucocele-like lesion Some but not all features required for diagnosis of DCIS with discrete areas of rupture resulting in mucin pools in stroma, no groups of cells floating in mucin
Mucocele-like lesion Pools of mucin in stroma variably lined by bland epithelium, usually no groups of cells floating in mucin (if present they are normal ductal cells and are not complex), almost always a microscopic lesion
Mucinous carcinoma Mucin in contact with stroma, neoplastic cells floating in mucin
Nodular mucinosis Nodules of stromal mucin, no epithelial component, subareolar

Micropapillary Ductal Carcinoma In Situ Gynecomastia-like Lesion of Female Breast
Micropapillae have bulbous, expanded ends Micropapillae have thin tips, wider base
Uniform cells throughout Smaller cells at top
Hyperchromatic throughout Hyperchromatic at top, not base
Often associated with other DCIS patterns Often associated with other hyperplastic patterns

Low Grade Ductal Carcinoma In Situ and Atypical Ductal Hyperplasia Columnar Cell Change / Hyperplasia
Architectural complexity manifested by a) partial or complete filling of ducts or b) arcades or micropapillary formations Essentially a flat lesion, lacks architectural complexity
Low grade nuclear atypia present (except some cases of ADH that have architectural complexity) Cytologically bland

Low Grade Ductal Carcinoma In Situ and Atypical Ductal Hyperplasia Flat Epithelial Atypia
Architectural complexity manifested by a) partial or complete filling of ducts or b) arcades or micropapillary formations Lacks architectural complexity
All three have low grade nuclear atypia, except for some cases of ADH, which must have architectural complexity

High Grade Ductal Carcinoma In Situ Flat Epithelial Atypia
Grade III nuclear atypia Low grade nuclear atypia
Frequent comedonecrosis Lacks comedonecrosis

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