13.3.09

Measuring size of DCIS

Measuring Size (Extent) of DCIS


Although not required for pT classification or stage assignment, the size (extent) of DCIS is an important factor in patient management. Although a precise measurement is often not possible, an estimate of the extent of DCIS is clinically important.

Size /Extent of Ductal Carcinoma In Situ (DCIS) and Clinical Significance
DCIS Size/ Extent
Up to 2 cm:
Breast conservation with wide negative margins can be achieved in most women.
>2-4 cmWide negative margins may be difficult to achieve in some women with breast-conserving surgery.

>4 cm
Breast conservation with wide negative margins may be impossible to achieve in some women.
There is a possibility of undetected areas of invasion if the area involved by DCIS is not completely examined. Lymph node sampling may be recommended.

Methods to measure DCIS:
DCIS in One Block:
The area involved by DCIS can be measured from a single slide, if DCIS is present in only one block. If separate foci are present on the same slide, the largest distance between foci should be reported. This method will underestimate the extent of DCIS when multiple blocks are involved, and should not be used in such cases.
DCIS in multiple blocks in case of Serial Sequential Sampling:

The entire specimen is blocked out in such a way that the location of each block can be determined. The extent of the DCIS can be calculated by using a diagram of the specimen, the thickness of the slices, and the location of the involved blocks. This method is recommended for all excisions likely to harbor DCIS or with previously diagnosed DCIS (eg, by diagnosis on a prior core needle biopsy).

DCIS in case of Nonsequential Sampling:

Multiplying the number of blocks involved by DCIS by the approximate width of a tissue section gives an estimate of the extent. ( multiplying by 0.4 cm is recommended,which is size of tissue thickness)

Specimen sampling to measure size of DCIS:

For specimens with a known diagnosis of DCIS (eg, by prior core needle biopsy) it is highly recommended that the entire specimen is examined using serial sequential sampling to exclude the possibility of invasion, to completely evaluate the margins, and to aid in determining extent.If an entire excisional specimen or grossly evident lesion is not examined microscopically, it is helpful to note the approximate percentage of the specimen or lesion that has been examined.


References:


1. Silverstein MJ, Poller D, Craig P, et al. A prognostic index for ductal carcinoma in situ of the breast. Cancer. 1996;77:2267-2274.
2. Grin A, Horne G, Ennis M, O’Malley FP. Measuring extent of DCIS in breast excision specimens: a comparison of four methods. Arch Pathol Lab Med. 2009;133:31-37.
3. Dadmanesh F, Fan X, Dastane A, Amin MB, Bose S. Comparative analysis of size estimation by mapping and counting number of blocks with DCIS in breast excision specimens. Arch Pathol Lab Med. 2009;133:26-30.

4. ww.cap.org

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Interesting Case

Clinical History:

53 years male,History of hypertension and tachycardia,MRI abdomen:-Left adrenal mass:- size 5.8 cm Right renal mass:- size-3.0cm Microscopic examination of the renal mass showed vascular tumor with diffuse sheets of clear cells having Fuhrman grade III nuclei. There was no evidence of necrosis within the tumor. There was no evidence of extraparenchymal invasion.
Gross examination of the left adrenal gland revealed cortically centered, solid and multinodular mass measuring 6.5 x 6.0 x 5.0 cm and weighing 122 grams. The tumor was encapsulated but showed evidence of extraparenchymal penetration. The tumor had golden brown cut surface with areas of hemorrhage and necrosis. The partial nephrectomy showed 3.0cm x 3.0cm x 3.0 cm yellow solid mass which did not invade into the perinephric adipose tissue.
Microscopically, the adrenal mass had predominant diffuse sheets and focal trabecular arrangements. The former pattern was present in about third of tumor. The cells had clear cytoplasm and round to ovoid nuclei with conspicuous nucleoli. Mitotic rate was 9/50 HPF and included atypical forms. Gross necrosis and capsular invasion were documented microscopically. There was no evidence of lymphovascular invasion. Considering the above mentioned features, a Weiss histopathologic score2 of 7/9 was applied.



Discussion:

The differential diagnosis included Renal Cell Carcinoma (RCC) with contralateral adrenal metastasis, Adrenocortical carcinoma (ACC) with contralateral renal metastasis, synchronous RCC and ACC or synchronous RCC and adrenocortical adenoma. A panel of immunohistochemical stains was performed to sort out the diagnosis. Adrenal tumor demonstrated strong Vimentin positivity and is negative for CK7, CK20, E1/AE3, EMA, Synaptophysin and S100.Renal cell carcinoma was positive for CK7, AE1/AE3, EMA (weak) and Vimentin. It was negative for CK20, Synaptophysin and S100. The difference of immunoprofile between the two tumors documented that they originated from two different primaries.

Final Diagnosis:

The diagnosis of synchronous RCC and ACC rather than metastasis influences the prognosis.

Prognosis:

The longest disease free interval after removal of contralateral adrenal metastasis was 12.1 years8 and the longest crude survival was 14.3 years. In contrast non metastazing RCC has an excellent prognosis if no metastasis developed.