Group 1A: Example 2.2

10.1055/b-0034-80355

Group 1A: Example 2.2

A 70-year-old asymptomatic woman, screening examination. The faint cluster of crushed stone-like calcifications was not perceived. At her next screening examination 18 months later she was still asymptomatic and was called back for further assessment of the cluster of calcifications.

Ex. **2.2**-1 & 2 Detail of the MLO projection in two consecutive screenings with an interval of 18 months. The barely perceptible cluster of discernible, crushed stone-like calcifications (within the circle) has evolved to a mixture of crushed stone-like and casting type calcifications, occupying a much larger volume.

Ex. **2.2**-3 & 4 Stereoscopic images of one extremely distended TDLU (22 mm in diameter!). There are a few atrophic TDLUs in the surrounding tissue for comparison of size. The individual cancerous acini measure up to 2-3 mm in diameter, much larger than one entire normal sized TDLU. The central necrotic contents and the intraluminal calcification of some of the acini have fallen out during specimen preparation.

Ex. **2.2**-5 & 6 Large-section histological images of the solitary TDLU at two different slice levels. The TDLU is extremely distended by in situ carcinoma, central necrosis, and amorphous calcifications.

Histological diagnosis: 18 mm ⊠ 11 mm ⊠ 8 mm Grade 3 in-situ carcinoma with solid and cribriform cell architecture, containing multiple foci of microinvasion.

Ex. **2.2**-7 & 8 Intermediate magnification of the extremely distended acini containing solid cell proliferation, extensive central necrosis, and large intraluminal, amorphous calcifications.

Ex. **2.2**-9 & 10 Stereoscopic images of atrophic breast tissue for comparison with the individual acini, which are greatly distended by in situ carcinoma.

Ex. **2.2**-11 Medium-power histological image (H & E) of an acinus with solid cell proliferation, central necrosis, and amorphous calcification.

Ex. **2.2**-12 & 13 Higher-magnification **stereoscopic subgross, thick-section (3D) images** of the acini that have been greatly distended by the in situ carcinoma, necrosis, and amorphous calcifications. Some of the acini measure 2-3 mm, which is two to three times larger than an entire normal TDLU.

Ex. **2.2**-14 Medium-power histological image (illumination with polarized light) of one acinus distended by solid cell proliferation (1), central necrosis (2), and amorphous calcification (3).

Ex. **2.2**-15 & 16 Stereoscopic image pair of the surrounding normal breast tissue with pleated ducts and atrophic TDLUs.

Treatment and follow-up: Sector resection was performed. No postoperative radiotherapy or other adjuvant treatment was given. The patient had no evidence of breast cancer at the most recent follow-up, 12 years after operation.

Comment

The large-section histological image and the subgross 3D images clearly show that the disease was limited to a single, extremely distended TDLU. The malignant cells were confined to I the acini of the lobule and no ductal involvement was found. These observations are at odds with the conventional term “ductal” carcinoma in situ. Sefton R. Wellings and his co-workers pointed out that pathologists, viewing traditional, small histological sections, might have mistaken the extremely distended acini for ducts.1 The fact that the disease is restricted to a single, isolated TDLU should be a justification for less radical treatment, such as surgical excision alone without adjunctive therapy.

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