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| '''For patient information, click [[Breast cancer (patient information)|here]]'''
| | #REDIRECT [[Breast cancer]] |
| __NOTOC__
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| {{SI}}
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| {{CMG}} {{AE}} {{MV}}
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| {{SK}} Intraductal hyperplasia; IDH; Atypical ductal hyperplasia; Comedocarcinoma; Duct cell carcinoma; Duct carcinoma
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| ==Overview==
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| '''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. The most important cause of ductal carcinoma is mutations in the BRCA1/BRCA2 genes. On microscopic histopathological analysis, characteristic findings of ductal carcinoma, include:
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| equal spacing of cells - "cookie cutter" look, cells line-up along lumen, and nuclear enlargement (key feature). Common risk factors in the development of ductal carcinoma, include: family history of breast cancer, mutations in BRCA1/BRCA2 gene, previous exposure to radiation therapy, increased breast density, and [[hormonal therapy]]. 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). On the other hand, [[mastectomy]] is recommended for patients with extensive margins of ductal carcinoma. 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>
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| ==Historical Perspective==
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| 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>
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| ==Classification==
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| *Ductal carcinoma may be classified according to the Armed Forces Institute of Pathology (AFIP) into 2 groups:<ref name="pmid20071685">{{cite journal |vauthors=Virnig BA, Tuttle TM, Shamliyan T, Kane RL |title=Ductal carcinoma in situ of the breast: a systematic review of incidence, treatment, and outcomes |journal=J. Natl. Cancer Inst. |volume=102 |issue=3 |pages=170–8 |year=2010 |pmid=20071685 |doi=10.1093/jnci/djp482 |url=}}</ref>
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| :*'''Large cell'''
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| ::*More aggressive form
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| ::*Also referred to as comedocarcinoma
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| :*'''Small cell'''
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| ::*Less aggressive
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| ::*Subtypes include cribriform, micropapillary, papillary, and solid in situ.
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| *Other variants of ductal carcinoma include, non-DCIS entities.
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| ==Pathophysiology==
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| *The pathogenesis of ductal carcinoma is characterized by the microinvasion of cancer cells limited to the ducts with no extension beyond the basement membrane.
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| *The mutation on HER2/neu has been associated with the development of ductal carcinoma.
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| *On gross pathology, characteristic findings of ductal carcinoma, include:<ref name="pmid20071685">{{cite journal |vauthors=Virnig BA, Tuttle TM, Shamliyan T, Kane RL |title=Ductal carcinoma in situ of the breast: a systematic review of incidence, treatment, and outcomes |journal=J. Natl. Cancer Inst. |volume=102 |issue=3 |pages=170–8 |year=2010 |pmid=20071685 |doi=10.1093/jnci/djp482 |url=}}</ref>
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| :*White
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| :*Firm stellate lesion
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| *On microscopic histopathological analysis, characteristic findings of ductal carcinoma, include:
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| :*Equal spacing of cells - "cookie cutter" look.
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| :*Cells line-up along lumen/glandular spaces - form "Roman briges".
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| :*Nuclear enlargement (key feature)
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| :*The image below demonstrates histopathological findings of ductal carcinoma.
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| <gallery>
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| Image: Breast DCIS histopathology (1).jpg|Ductal carcinoma: cells line-up along lumen (form "Roman briges")
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| </gallery>
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| ==Causes==
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| *The most important cause of ductal carcinoma is mutations in the [[BRCA1|BRCA1/BRCA2]] genes.
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| ==Differentiating ductal carcinoma from other Diseases==
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| *Ductal carcinoma must be differentiated from other diseases that cause [[nipple discharge]], breast skin color change, and palpable mass such as:<ref name="pmid16319971">{{cite journal |vauthors=Erbas B, Provenzano E, Armes J, Gertig D |title=The natural history of ductal carcinoma in situ of the breast: a review |journal=Breast Cancer Res. Treat. |volume=97 |issue=2 |pages=135–44 |year=2006 |pmid=16319971 |doi=10.1007/s10549-005-9101-z |url=}}</ref>
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| :*[[Mastitis|Periductal mastitis]]
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| :*[[Lipoma|Breast lipoma]]
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| :*[[Inflammatory breast cancer|Inflammatory carcinoma of breast]]
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| :*[[Phyllodes tumor]]
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| ==Epidemiology and Demographics==
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| * The prevalence of ductal carcinoma is approximately 32.5 per 100,000 women worldwide.<ref name="pmid20071685">{{cite journal |vauthors=Virnig BA, Tuttle TM, Shamliyan T, Kane RL |title=Ductal carcinoma in situ of the breast: a systematic review of incidence, treatment, and outcomes |journal=J. Natl. Cancer Inst. |volume=102 |issue=3 |pages=170–8 |year=2010 |pmid=20071685 |doi=10.1093/jnci/djp482 |url=}}</ref>
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| ===Age===
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| *Ductal carcinoma is commonly observed among females between 40 to 80 years old
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| *Ductal carcinoma is rarely observed among males between 60 and 70 years of age
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| *Ductal carcinoma is more commonly observed among postmenopausal women<ref name="radiopedia">Ductal Carcinoma. Frank Galliard. Radiopedia http://radiopaedia.org/articles/ductal-carcinoma-in-situ Accessed on April 19, 2016 </ref>
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| ===Gender===
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| *Females are significantly more commonly affected with ductal carcinoma than males.
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| ===Race===
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| *There is no racial predilection for ductal carcinoma.
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| ==Risk Factors==
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| *Common risk factors in the development of ductal carcinoma, include:<ref name="pmid16319971">{{cite journal |vauthors=Erbas B, Provenzano E, Armes J, Gertig D |title=The natural history of ductal carcinoma in situ of the breast: a review |journal=Breast Cancer Res. Treat. |volume=97 |issue=2 |pages=135–44 |year=2006 |pmid=16319971 |doi=10.1007/s10549-005-9101-z |url=}}</ref>
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| :*Family history of breast cancer
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| :*Mutations in BRCA1/BRCA2 genes
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| :*Previous exposure to radiation therapy
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| :*Increased breast density
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| :*[[Hormonal therapy]]
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| :*Nulliparity
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| :*Genetic syndromes (eg. [[Li-Fraumeni syndrome|Li-Fraumeni]], [[Cowden syndrome]])
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| :*[[Obesity]]
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| == Natural History, Complications and Prognosis==
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| *The majority of patients with ductal carcinoma remain asymptomatic for years.<ref name="pmid20071685">{{cite journal |vauthors=Virnig BA, Tuttle TM, Shamliyan T, Kane RL |title=Ductal carcinoma in situ of the breast: a systematic review of incidence, treatment, and outcomes |journal=J. Natl. Cancer Inst. |volume=102 |issue=3 |pages=170–8 |year=2010 |pmid=20071685 |doi=10.1093/jnci/djp482 |url=}}</ref>
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| *Early clinical features include skin color change or nipple discharge.
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| *If left untreated, the majority of patients with ductal carcinoma may progress to develop lymph node invasion, and metastasis.
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| *The most common complication of ductal carcinoma is lymphedema.
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| *Prognosis generally depends on the histological subtype.<ref name="pmid16319971">{{cite journal |vauthors=Erbas B, Provenzano E, Armes J, Gertig D |title=The natural history of ductal carcinoma in situ of the breast: a review |journal=Breast Cancer Res. Treat. |volume=97 |issue=2 |pages=135–44 |year=2006 |pmid=16319971 |doi=10.1007/s10549-005-9101-z |url=}}</ref>
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| :*In general, the 20-year mortality rate among patients with ductal carcinoma is approximately 3.3%.<ref name="pmid20071685">{{cite journal |vauthors=Virnig BA, Tuttle TM, Shamliyan T, Kane RL |title=Ductal carcinoma in situ of the breast: a systematic review of incidence, treatment, and outcomes |journal=J. Natl. Cancer Inst. |volume=102 |issue=3 |pages=170–8 |year=2010 |pmid=20071685 |doi=10.1093/jnci/djp482 |url=}}</ref>
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| :*Factors related with worse prognosis, include: young age at diagnosis, black ethnicity, and high grade cancer.<ref name="pmid20071685">{{cite journal |vauthors=Virnig BA, Tuttle TM, Shamliyan T, Kane RL |title=Ductal carcinoma in situ of the breast: a systematic review of incidence, treatment, and outcomes |journal=J. Natl. Cancer Inst. |volume=102 |issue=3 |pages=170–8 |year=2010 |pmid=20071685 |doi=10.1093/jnci/djp482 |url=}}</ref>
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| == Diagnosis ==
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| === Symptoms ===
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| *Ductal carcinoma is usually asymptomatic.
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| *Symptoms of ductal carcinoma may include the following:<ref name="radiopedia">Ductal Carcinoma. Frank Galliard. Radiopedia http://radiopaedia.org/articles/ductal-carcinoma-in-situ Accessed on April 19, 2016 </ref>
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| :*[[Nipple discharge]]
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| ::*Skin color changes
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| ::*Warm and thickened
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| :*Skin of an orange appearance
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| :*Nipple retraction
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| === Physical Examination ===
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| *Patients with ductal carcinoma usually are well-appearing.
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| :*Physical examination may show no specific physical findings.
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| *In some cases, it may be remarkable for:<ref name="radiopedia">Ductal Carcinoma. Frank Galliard. Radiopedia http://radiopaedia.org/articles/ductal-carcinoma-in-situ Accessed on April 19, 2016 </ref>
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| :*Palpable mass
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| === Laboratory Findings ===
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| *Laboratory findings consistent with the diagnosis of ductal carcinoma, include:<ref name="pmid20071685">{{cite journal |vauthors=Virnig BA, Tuttle TM, Shamliyan T, Kane RL |title=Ductal carcinoma in situ of the breast: a systematic review of incidence, treatment, and outcomes |journal=J. Natl. Cancer Inst. |volume=102 |issue=3 |pages=170–8 |year=2010 |pmid=20071685 |doi=10.1093/jnci/djp482 |url=}}</ref>
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| :*Positive/negative estrogen receptor (ER) and progesterone receptor (PR) expression
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| ===Imaging Findings===
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| *Mammography is the imaging modality of choice for ductal carcinoma.<ref name="pmid16319971">{{cite journal |vauthors=Erbas B, Provenzano E, Armes J, Gertig D |title=The natural history of ductal carcinoma in situ of the breast: a review |journal=Breast Cancer Res. Treat. |volume=97 |issue=2 |pages=135–44 |year=2006 |pmid=16319971 |doi=10.1007/s10549-005-9101-z |url=}}</ref>
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| *On mammography, findings of ductal carcinoma, include:<ref name="pmid16319971">{{cite journal |vauthors=Erbas B, Provenzano E, Armes J, Gertig D |title=The natural history of ductal carcinoma in situ of the breast: a review |journal=Breast Cancer Res. Treat. |volume=97 |issue=2 |pages=135–44 |year=2006 |pmid=16319971 |doi=10.1007/s10549-005-9101-z |url=}}</ref><ref name="radiopedia">Ductal Carcinoma. Frank Galliard. Radiopedia http://radiopaedia.org/articles/ductal-carcinoma-in-situ Accessed on April 19, 2016 </ref>
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| :*Calcifications (most common)
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| :*Simple mass
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| :*Soft-tissue opacity
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| :*Asymmetry without calcification
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| *The image below demonstrates findings compatible with ductal carcinoma.
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| <gallery>
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| Image:Mammo breast cancer.jpg|Normal (left) versus cancerous (right) mammography image.
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| </gallery>
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| *On ultrasound, findings of ductal carcinoma, include:<ref name="radiopedia">Ductal Carcinoma. Frank Galliard. Radiopedia http://radiopaedia.org/articles/ductal-carcinoma-in-situ Accessed on April 19, 2016 </ref>
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| :*Microlobulated mild hypoechoic mass
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| === Other Diagnostic Studies ===
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| *Ductal carcinoma may also be diagnosed using biopsy.
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| *Indications for biopsy, include:
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| :*Lesion limited to one quadrant or section of the breast
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| == Treatment ==
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| === Medical Therapy ===
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| *The mainstay of therapies for ductal carcinoma are divided into 2 groups: hormonal therapy and targeted therapy.<ref name="pmid20071685">{{cite journal |vauthors=Virnig BA, Tuttle TM, Shamliyan T, Kane RL |title=Ductal carcinoma in situ of the breast: a systematic review of incidence, treatment, and outcomes |journal=J. Natl. Cancer Inst. |volume=102 |issue=3 |pages=170–8 |year=2010 |pmid=20071685 |doi=10.1093/jnci/djp482 |url=}}</ref>
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| '''Hormonal Therapy'''
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| :*Selective estrogen receptor modulators, such as:
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| :*[[Tamoxifen]]
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| :*[[Raloxifene]]
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| '''Targeted Therapy'''
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| :*HER2-directed therapy
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| :*[[Trastuzumab]]
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| *The primary goal of medical therapy is to reduce the risk of ipsilateral or contralateral breast invasion and also decreases the risk of recurrence.<ref name="pmid20071685">{{cite journal |vauthors=Virnig BA, Tuttle TM, Shamliyan T, Kane RL |title=Ductal carcinoma in situ of the breast: a systematic review of incidence, treatment, and outcomes |journal=J. Natl. Cancer Inst. |volume=102 |issue=3 |pages=170–8 |year=2010 |pmid=20071685 |doi=10.1093/jnci/djp482 |url=}}</ref>
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| === Surgery ===
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| *Surgery is the mainstay of therapy for ductal carcinoma.<ref name="radiopedia">Ductal Carcinoma. Frank Galliard. Radiopedia http://radiopaedia.org/articles/ductal-carcinoma-in-situ Accessed on April 19, 2016 </ref>
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| *Surgical approaches for ductal carcinoma, include: mastectomy or breast-conserving therapy
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| *Lumpectomy in conjunction with adjuvant chemotherapy or radiation is the most common approach to the treatment of ductal carcinoma (with negative margins)
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| *Mastectomy is recommended for patients with extensive margins of ductal carcinoma.
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| === Prevention ===
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| *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><ref name="radiopedia">Ductal Carcinoma. Frank Galliard. Radiopedia http://radiopaedia.org/articles/ductal-carcinoma-in-situ Accessed on April 19, 2016 </ref>
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| *Once diagnosed and successfully treated, patients with ductal carcinoma are followed-up every 3, 6, or 12 months depending on individual assessment.<ref name="radiopedia">Ductal Carcinoma. Frank Galliard. Radiopedia http://radiopaedia.org/articles/ductal-carcinoma-in-situ Accessed on April 19, 2016 </ref>
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| ==References==
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| {{Reflist|2}}
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