Misleading images of ductal carcinoma in situ: 4 lymph nodes with metastasis / Imágenes equívocas de carcinoma ductal in situ: 4 ganglios linfáticos con metástasis

Since sentinel lymph node examination became routine, findings of benign ectopic breast tissue in lymph nodes have increased. We report images of ductal carcinoma in situ (DCIS) in four lymph nodes in a 76-year-old woman with bilateral breast carcinoma. The right lumpectomy showed intermixed invasive lobular and ductal carcinoma, plus DCIS. 19 nodes were isolated in the axillary lymphadenectomy, 4 of which displayed solid and cribriform DCIS. Myosin and p63 immunohistochemical techniques were positive, suggesting an erroneous diagnosis of “metastatic DCIS”. A further three cases of DCIS in lymph nodes have been previously reported, all with a distinct layer of myoepithelial cells with actin, myosin or p63. Biologically, these images of DCIS in lymph nodes are not credible and three major hypotheses have been proposed to explain these findings: Iatrogenic Mechanical Transport, Revertant DCIS, and primary DCIS of lymph nodes. We consider the first one the most plausible explanation. Our case is unique as several, rare findings are simultaneously observed. More new cases, together with additional immunohistochemical techniques and molecular testing on previous cases, are needed to find a definitive explanation of this histologic finding.(AU)

A partir del uso rutinario del examen del ganglio centinela, los hallazgos de tejido mamario ectópico son frecuentes. Presentamos los hallazgos de carcinoma ductal in situ (CDIS) en 4 ganglios linfáticos en una mujer de 76 años con carcinoma de mama bilateral. La lumpectomía derecha mostró una mezcla de patrones de carcinomas ductal y lobular infiltrante, además de CDIS. De los 19 ganglios aislados, 4 mostraron patrones cribiformes y sólidos de CDIS. La miosina y la p63 fueron positivas, sugiriendo un diagnóstico erróneo de «CDIS metastático». En la literatura se han comunicado 3 casos adicionales de patrones de CDIS en ganglios linfáticos, mostrando capa periférica de células mioepiteliales positivas para actina, miosina o p63. Desde un punto de vista biológico, estos hallazgos de CDIS en ganglios linfáticos son discutibles, proponiéndose 3 hipótesis para explicarlo: transporte mecánico yatrogénico, CDIS revertido y CDIS primario de ganglio linfático. Creemos que la primera alternativa es la más plausible. Nuestro caso es único al mostrar, de modo conjunto, diversos hallazgos infrecuentes. El estudio de nuevos casos, así como la aplicación de técnicas inmunohistoquímicas y moleculares a casos de archivo, arrojarían datos que permitirían llegar a una explicación definitiva de este hallazgo histológico.(AU)

Misleading images of ductal carcinoma in situ: 4 lymph nodes with metastasis.

Since sentinel lymph node examination became routine, findings of benign ectopic breast tissue in lymph nodes have increased. We report images of ductal carcinoma in situ (DCIS) in four lymph nodes in a 76-year-old woman with bilateral breast carcinoma. The right lumpectomy showed intermixed invasive lobular and ductal carcinoma, plus DCIS. 19 nodes were isolated in the axillary lymphadenectomy, 4 of which displayed solid and cribriform DCIS. Myosin and p63 immunohistochemical techniques were positive, suggesting an erroneous diagnosis of "metastatic DCIS". A further three cases of DCIS in lymph nodes have been previously reported, all with a distinct layer of myoepithelial cells with actin, myosin or p63. Biologically, these images of DCIS in lymph nodes are not credible and three major hypotheses have been proposed to explain these findings: Iatrogenic Mechanical Transport, Revertant DCIS, and primary DCIS of lymph nodes. We consider the first one the most plausible explanation. Our case is unique as several, rare findings are simultaneously observed. More new cases, together with additional immunohistochemical techniques and molecular testing on previous cases, are needed to find a definitive explanation of this histologic finding.

Predictors and effectiveness of different biopsy techniques in spotting invasion in the clinically diagnosed breast ductal carcinoma in situ / Factores predictivos y efectividad de diferentes técnicas de biopsia en la detección de focos infiltrantes en carcinomas in situ diagnosticados clínicamente

Objectives: To study the management of patients with ductal carcinoma in situ (DCIS) and detect the predictors of recurrence and of missing an invasive component in the preoperative biopsy, aiming at guiding tailored treatment of these cases.Materials and methods: A total of 123 cases of DCIS, pure/with invasion, were retrieved from the database of a tertiary cancer hospital in the period from February 2007 to February 2018. Clinical, radiologic & pathologic characteristics and its impact on the surgical management were analyzed.Results: The mean age of the patients was 50.5±12.4 years. The commonest presentation was a palpable mass in 82.9% of the cases. Conservative breast surgery was successfully performed in 15 cases and mastectomy in 108 cases. Recurrence was reported in 11 cases. The underestimation rate in core needle biopsy was 48.9% missing invasive component within diagnosed malignant lesions and 19.6% missing the diagnosis of malignancy. On the other hand, overtreatment was noted as regard surgical procedure and adjuvant therapies.Conclusions: Mastectomy still the most common surgical treatment of DCIS and unfortunately sentinel lymph node biopsy is still underused. Underestimation of invasive component can occur in at least 1/4 of the patients, complexing the treatment plan. Overtreatment with axillary surgery, chemotherapy or radiotherapy needs governance. (AU)

Objetivos: Estudiar el manejo de pacientes con carcinoma ductal in situ (CDIS) y detectar los predictores de recaída y de ausencia de un componente invasivo en la biopsia preoperatoria, con el objetivo de orientar el tratamiento a medida de estos casos.Materiales y métodos: Se recuperó un total de 123 casos de CDIS, puro/con invasión de la base de datos de un hospital de cáncer terciario en el período de febrero de 2007 a febrero de 2018. Se analizaron las características clínicas, radiológicas y patológicas, así como su impacto en el manejo quirúrgico.Resultados: La edad media fue de 50,5 ± 12,4 años. La presentación más común fue masa palpable en el 82,9% de los casos. Se realizó cirugía de mama conservadora con éxito en 15 casos y mastectomía en 108 casos. Se informó de recaída en 11 casos. La tasa de subestimación en la biopsia con aguja fue de 48,9% sin componente invasivo en lesiones malignas diagnosticadas y 19,6% sin diagnóstico de malignidad. Por otra parte, se observó un exceso de tratamiento con relación al procedimiento quirúrgico y las terapias adyuvantes.Conclusiones: La mastectomía sigue siendo el tratamiento quirúrgico más común del CDIS y desafortunadamente no se utiliza aún la biopsia de ganglio linfático centinela. La subestimación del componente invasivo puede ocurrir en al menos el 25% de los pacientes, complejizando el plan de tratamiento. Debe gestionarse el sobretratamiento con cirugía axilar, quimioterapia o radioterapia. (AU)

Predictive factors of invasion in ductal carcinoma in situ diagnosed by core-needle biopsy.

OBJECTIVE: To identify clinical, radiological, and histopathological characteristics that could be predictive factors of microinvasive/invasive breast carcinoma in patients with diagnosis of ductal carcinoma in situ (DCIS) by core-needle biopsy. MATERIAL AND METHODS: This is a retrospective study conducted from 2006-2017, which included women ≥18 years of age with initial DCIS, and who were treated with surgery. Final diagnosis was divided in DCIS and microinvasive/invasive carcinoma. RESULTS: 334 patients were included: 193 (57.8%) with DCIS and 141 (42.2%) with microinvasive/invasive carcinoma (microinvasive 5.1%, invasive 37.1%). Lymph node metastasis occurred in 16.3%. Differences between DCIS and microinvasive/invasive groups included the presence of palpable nodule (36.7% vs. 63.2%), radiological nodule (29% vs. 51%), bigger radiological-tumor size (1.2 cm vs. 1.7 cm), and larger microcalcification extension (2.5 cm vs. 3.1 cm), all of these variables p ≤0.05. Hormonal receptors and HER2 expression were similar. After logistic regression analysis, predictive factor of invasion was the presence of palpable nodule (OR = 4.072, 95%CI = 2.520-6.582, p <0.001) and radiological multicentric disease (OR = 1.677, 95%CI = 1.036-2.716, p = 0.035). CONCLUSIONS: In patients with DCIS, palpable nodule, and radiological multicentric disease, upgrade to microinvasive/invasive is high, and sentinel lymph node is recommended.

OBJETIVO: Identificar características clínicas, radiológicas e histopatológicas como factores predictivos de carcinoma mamario microinvasor/invasor en pacientes con Carcinoma Ductal In Situ (CDIS) diagnosticado mediante aguja de corte. MATERIAL Y MÉTODOS: Estudio retrospectivo de 2006­2017, en mujeres ≥18 años con CDIS diagnosticado con aguja de corte y tratadas con cirugía. Los diagnósticos finales fueron CDIS y carcinoma microinvasor/invasor. RESULTADOS: Se incluyeron 334 pacientes, 193 (57.8%) con CDIS y 141 (42.2%) con carcinoma microinvasor/invasor (microinvasor 5.1%, invasor 37.1%). Hubo 16.3% casos con afección ganglionar. Las diferencias entre el grupo de CDIS y carcinoma microinvasor/invasor fue la presencia de tumor palpable (36.7% vs. 63.2%), nódulo visto por imagen (29% vs. 51%), tumores más grandes (1.2 cm vs. 1.7 cm), y mayor extensión de microcalcificaciones (2.5 cm vs. 3.1 cm), estas variables con p ≤0.05. Los receptores hormonales y HER2 fueron similares. En el análisis de regresión logística, los factores predictivos de invasión fueron tumor palpable (OR = 4.072, IC95% = 2.520­6.582, p <0.001) y multicentricidad radiológica (OR = 1.677, IC95% = 1.036­2.716, p = 0.035). CONCLUSIONES: En CDIS, tumor palpable y enfermedad multicéntrica radiológica, el escalamiento a carcinoma microinvasor/invasor es alto y es recomendable realizar ganglio centinela.

Underestimation of invasive breast carcinoma in patients with initial diagnosis of ductal carcinoma in situ: Size matters.

BACKGROUND: The aim of our study was to identify those patients with preoperative diagnosis of ductal carcinoma in situ (DCIS) and high risk of upstaging to invasive breast carcinoma (IBC), in whom sentinel lymph node biopsy (SLNB) should be considered. MATERIALS AND METHODS: One-hundred and five DCIS patients treated with breast-conserving surgery (BCS) or mastectomy were studied. Preoperative features of the tumours were analyzed to investigate its association with underestimation of IBC on final pathology. RESULTS: Overall, the underestimation rate of IBC was 16.2%. The underestimation rate was highest in lesions with initial size >2 cm compared with those with size ≤2 cm (26.8% vs. 4.1%, respectively; p < 0.003). Eighty-eight patients (83.8%) underwent concurrent SLNB and only one case had lymph node involvement (1.1%). CONCLUSIONS: SLNB should be considered in DCIS patients receiving BCS with lesions greater than 2 cm since approximately one in four will harbour an IBC.

Infraestimación de carcinoma infiltrante de mama en pacientes con diagnóstico inicial de carcinoma ductal in situ: el tamaño importa / Underestimation of invasive breast carcinoma in patients with initial diagnosis of ductal carcinoma in situ: Size matters

Introducción: El objetivo de nuestro estudio consistió en identificar aquellas pacientes con diagnóstico preoperatorio de carcinoma ductal in situ (CDIS) y alto riesgo de presentar un carcinoma infiltrante en la lesión, en las que se debería considerar realizar una biopsia selectiva de ganglio centinela (BSGC). Métodos: Se estudiaron 105 pacientes con CDIS tratadas mediante cirugía conservadora o mastectomía. Se analizaron las características preoperatorias de los tumores para investigar su asociación con la infraestimación de carcinoma infiltrante. Resultados: El porcentaje global de infraestimación de carcinoma infiltrante fue del 16,2%. El porcentaje de infraestimación fue mayor en las lesiones con un tamaño inicial superior a 2 cm en comparación con las lesiones con un tamaño igual o menor a 2 cm (26,8% vs. 4,1%, respectivamente; p < 0,003). Se realizó la BSGC en 88 pacientes (83,8%), encontrándose afectación ganglionar en un solo caso (1,1%). Conclusiones: En pacientes con diagnóstico inicial de CDIS tratadas mediante cirugía conservadora, se debería considerar realizar una BSGC cuando el tamaño de la lesión es superior a 2 cm, ya que uno de cada cuatro casos albergará la presencia de un carcinoma infiltrante. (AU)

Introduction: The aim of our study was to identify those patients with preoperative diagnosis of ductal carcinoma in situ (DCIS) and high risk of upstaging to invasive breast carcinoma (IBC), in whom sentinel lymph node biopsy (SLNB) should be considered. Methods: One-hundred and five DCIS patients treated with breast-conserving surgery (BCS) or mastectomy were studied. Preoperative features of the tumors were analyzed to investigate its association with underestimation of IBC on final pathology. Results: Overall, the underestimation rate of IBC was 16.2%. The underestimation rate was highest in lesions with initial size >2 cm compared with those with size ≤2 cm (26.8% vs. 4.1%, respectively; p < 0.003). Eighty-eight patients (83.8%) underwent concurrent SLNB and only one case had lymph node involvement (1.1%). Conclusions: SLNB should be considered in DCIS patients receiving BCS with lesions greater than 2 cm since approximately one in four will harbor an IBC. (AU)

Underestimation of invasive breast carcinoma in patients with initial diagnosis of ductal carcinoma in situ: Size matters. / Infraestimación de carcinoma infiltrante de mama en pacientes con diagnóstico inicial de carcinoma ductal in situ: el tamaño importa.

INTRODUCTION: The aim of our study was to identify those patients with preoperative diagnosis of ductal carcinoma in situ (DCIS) and high risk of upstaging to invasive breast carcinoma (IBC), in whom sentinel lymph node biopsy (SLNB) should be considered. METHODS: One-hundred and five DCIS patients treated with breast-conserving surgery (BCS) or mastectomy were studied. Preoperative features of the tumors were analyzed to investigate its association with underestimation of IBC on final pathology. RESULTS: Overall, the underestimation rate of IBC was 16.2%. The underestimation rate was highest in lesions with initial size >2 cm compared with those with size ≤2 cm (26.8% vs. 4.1%, respectively; p < 0.003). Eighty-eight patients (83.8%) underwent concurrent SLNB and only one case had lymph node involvement (1.1%). CONCLUSIONS: SLNB should be considered in DCIS patients receiving BCS with lesions greater than 2 cm since approximately one in four will harbor an IBC.

Carcinoma ductal in situ associado à fibroadenoma: relato de caso / Carcinoma ductal in situ arising in a fibroadenoma: report of a rare case

Apesar de fibroadenoma ser uma das lesões mais comuns da mama, sua correlação a alteração maligna é rara.1,2,3,5,7 Quando ocorre tem apresentação clínica similar a dos fibroadenomas típicos, diagnóstico anatomopatológico em geral pós-cirúrgico e tratamento conforme do carcinoma do mesmo tipo histológico isolado.1,2,3,4,6 Apresentamos caso de mulher de 52 anos, apresentando em propedêutica investigativa nódulo em mama direita. Core-biopsy sugeriu carcinoma ductal in situ desenvolvido dentro de fibroadenoma, confirmado em análise anatomopatológica pósoperatória. Tratamento e seguimento se deu conforme já estabelecido pela literatura para carcinoma in situ. Devido baixa incidência, há poucas evidências científicas quanto ao diagnóstico, tratamento e prognóstico desse tipo de lesão. Portanto, apresentar à comunidade científica casos de carcinoma inclusos a fibroadenoma se faz relevante.

Although fibroadenoma is one of the most common lesions of the breast, its correlation with malignant changes is rare. When it occurs, the clinical presentation is similar to typical fibroadenomas, anatomopathological diagnosis is after surgery and treatment goes according to the carcinoma histological type. A case of a 52-year-old woman is presented, with an impalpable nodule in the right breast, diagnosed from screening exams. Corebiopsy suggested carcinoma ductal in situ developed within fibroadenoma, confirmed in the postoperative anatomopathological analysis. Treatment and follow-up followed as established in the literature for carcinoma in situ. Due the low incidence, there are poor scientific evidence regarding the diagnosis, treatment and prognosis of this type of injury. Therefore, presenting cases of Carcinoma ductal in situ arising in a fibroadenoma to the scientific community is so relevant.

Adherencia a hormonoterapia en pacientes con carcinoma ductal in situ de mama / Adherence to hormonal therapy in patients with ductal carcinoma in situ of the breast

Introducción Las pacientes con Carcinoma Ductal in Situ de mama (cdis) tienen mayor riesgo de desarrollar carcinoma invasor. Aquellas con receptores hormonales positivos se beneficiarían con hormonoterapia. El largo período de tratamiento y los efectos adversos asociados al mismo hacen dificultosa la adherencia. Objetivos El objetivo del presente trabajo es analizar la adherencia a la hormonoterapia en pacientes operadas por Carcinoma Ductal in Situ en el Hospital Universitario Austral. Material y método Es un estudio observacional, analítico, de corte transversal. Se incluyeron pacientes con diagnóstico de Carcinoma Ductal in Situ que fueron intervenidas quirúrgicamente en el Hospital Universitario Austral en el período comprendido entre el 24 de julio de 2000 y el 5 de julio de 2017. Los datos fueron recopilados a través de una encuesta. Resultados Se obtuvieron 100 encuestas. La adherencia fue del 82%. La misma no se modificó según edad, conocimiento de riesgos y beneficios del tratamiento, tipo y número de cirugías, radioterapia y número de consultas. Las reacciones adversas a la medicación fueron la causa más frecuente de abandono al tratamiento. Conclusiones El tratamiento multidisciplinario podría asegurar un óptimo nivel de adherencia

Introduction Patients with Ductal Carcinoma in Situ of the breast (dcis) have a higher risk of developing invasive carcinoma. Those with hormone receptor-positive would benefit from hormonal therapy. The long period of treatment and the associated adverse events make adherence difficult. Objectives The aim of this study is to analyze the adherence of hormonal therapy in operated patients with Ductal Carcinoma in Situ at Hospital Universitario Austral. Materials and method It is an observational, analytical and cross-sectional study. Patients diagnosed with Ductal Carcinoma in Situ who underwent surgery at Hospital Universitario Austral in the period between 07/24/2000 and 07/05/2017 were included. The data was collected through a survey. Results 100 surveys were obtained. The adherence was 82%. It was not modified according to age, knowledge of risks and benefits of the treatment, type and number of surgeries, radiotherapy and number of consultations. Adverse events were the most frequent cause of discontinue of treatment. Conclusions Multidisciplinary treatment could ensure an optimal level of adherence

Carcinoma ductal in situ de la mama con características apocrinas: reporte de un caso / Ductal carcinoma in situ of the breast with apocrine characteristics: case report

Resumen Se presenta el caso de una femenina de 69 años con un carcinoma ductal in situ de la mama, el cual presentaba diferenciación apocrina y alto grado nuclear. La forma de presentación clínica se hizo patente en forma de microcalcificaciones detectadas en la mamografía, y corroboradas histológicamente como comedonecrosis. La diferenciación apocrina se comprobó por medio de tinciones de inmunohistoquímica. El diagnóstico se realizó en una biopsia excisional, pero dado a que uno de los márgenes se encontraba comprometido, la paciente se sometió posteriormente a una mastectomía.

Abstract We present the case of a 69 year old female diagnosed with a ductal in situ carcinoma of the breast. The tumor had apocrine differentiation and a high nuclear grade. The clinical presentation corresponded to microcalcifications detected on mammography, which were histologically patent in the form of comedo type necrosis. The aforementioned apocrine differentiation was reassured using the aid of immunohistochemistry. The biopsy was an excisional biopsy, but due to positive quirurgical margins, the patient was later reintervened for total mastectomy.

Radiotherapy in breast ductal carcinoma in situ / Radioterapia em carcinoma ductal in situ de mama

Breast ductal carcinoma in situ (DCIS) comprises a heterogeneous group of lesions with different forms of clinical and pathological presentation. Postoperative radiotherapy is usually performed in DCIS patients who underwent conservative breast surgery. The objective of the present study was to describe indications and clinical evidences of radiotherapy for breast DCIS patients

O carcinoma ductal in situ (CDIS) de mama compreende um grupo heterogêneo de lesões com diferentes formas de apresentação clínica e patológica. A radioterapia pós-operatória é normalmente realizada nas pacientes com CDIS submetidas à cirurgia conservadora de mama. O presente estudo teve o objetivo de apresentar as indicações e as evidências para a utilização da radioterapia na abordagem do CDIS de mama.

Actualidad para el diagnóstico del carcinoma ductal in situ: correlación radiopatológica / Current issues in the diagnosis of ductal carcinoma in situ: a radiopathological correlation

El carcinoma ductal in situ (CDIS) se encuentra en un grupo heterogéneo de tumores, cuyo diagnóstico se ha visto incrementado con el uso de la mamografía como método de cribado. El sistema de clasificación de Van Nuys, que se basa principalmente en el grado nuclear histológico y la presencia de necrosis, es el sistema más reproducible para la clasificación histopatológica. La anomalía más común que se observa en la mamografía son las microcalcificaciones, coexistiendo con otras lesiones como masas y distorsión arquitectural, que representan lesiones de bajo grado. El diagnóstico inicial debe realizarse mediante anamnesis y examen físico detallado que permita realizar una aproximación a las características morfoestructurales de la lesión, para posteriormente llegar a un acercamiento imagenológico y dinámico mediante resonancia magnética (RM), complementada con técnicas de inmunohistoquímica que caractericen el tumor. La presencia de distribución segmentaria morfológica es típico de malignidad (CDIS). La cinética de las lesiones en el estudio dinámico de la RM varía, siendo patognomónico de CDIS el patrón de washout en la fase de reforzamiento tardío. Sin embargo, el patrón dinámico parece estar correlacionado con los hallazgos mamográficos. Los hallazgos de RM y TC multidetector pueden ser útiles en combinación con la RM de mama para el mapeo preoperatorio. Sin embargo, existen técnicas complementarias como la espectroscopía y la difusión ponderada que mejoran la especificidad de la RM y tienen utilidad en la predicción de respuesta a la quimioterapia adyuvante. Estas aplicaciones futuras podrán mejorar la capacidad de diagnóstico oportuno y opciones de tratamiento.

Ductal carcinoma in situ (DCIS) falls into a heterogeneous group of tumors, whose diagnosis has increased with the use of mammography as screening method. The Van Nuys Prognostic Index, mainly based on histological nuclear grade and presence of necrosis, is the most reproducible histopathological classification system. The most common abnormality observed during a mammography are microcalcifications, which coexist with other lesions such as masses and architectural distortion, and represent low-grade lesions. The initial diagnosis should be performed by anamnesis and a detailed physical examination to help determine the morphostructural characteristics of the lesion. Then an imaging and dynamic approach should be achieved by magnetic resonance imaging (MRI) complemented by immunohistochemistry to characterize the tumor. The presence of morphological segmental distribution is typical of malignancy (DCIS). The kinetics of the lesions using a dynamic MRI varies, with the washout and late enhancement pattern being pathognomonic for DCIS. However, the dynamic pattern seems to be correlated with mammographic findings. Multidetector CT and MRI findings may be useful in combination with breast MRI for preoperative mapping. Nevertheless, there are complementary techniques such as spectroscopy and weighted diffusion that improve the specificity of the MRI and are useful in predicting response to adjuvant chemotherapy. These future applications will improve the ability for early diagnosis and treatment options.

Can positron emission mammography help to identify clinically significant breast cancer in women with suspicious calcifications on mammography?

OBJECTIVE: To evaluate the diagnostic accuracy of positron emission mammography (PEM) for identifying malignant lesions in patients with suspicious microcalcifications detected on mammography. METHODS: A prospective, single-centre study that evaluated 40 patients with suspicious calcifications at mammography and indication for percutaneous or surgical biopsy, with mean age of 56.4 years (range: 28-81 years). Patients who agreed to participate in the study underwent PEM with 18F-fluorodeoxyglucose before the final histological evaluation. PEM findings were compared with mammography and histological findings. RESULTS: Most calcifications (n = 34; 85.0 %) were classified as BIRADS 4. On histology, there were 25 (62.5 %) benign and 15 (37.5 %) malignant lesions, including 11 (27.5 %) ductal carcinoma in situ (DCIS) and 4 (10 %) invasive carcinomas. On subjective analysis, PEM was positive in 15 cases (37.5 %) and most of these cases (n = 14; 93.3 %) were confirmed as malignant on histology. There was one false-positive result, which corresponded to a fibroadenoma, and one false negative, which corresponded to an intermediate-grade DCIS. PEM had a sensitivity of 93.3 %, specificity of 96.0 % and accuracy of 95 %. CONCLUSION: PEM was able to identify all invasive carcinomas and high-grade DCIS (nuclear grade 3) in the presented sample, suggesting that this method may be useful for further evaluation of patients with suspected microcalcifications. KEY POINTS: • Many patients with suspicious microcalcifications at mammography have benign results at biopsy. • PEM may help to identify invasive carcinomas and high-grade DCIS. • Management of patients with suspicious calcifications can be improved.

Enfermedad de Paget mamaria: Presentacion de dos casos / Mammary Paget's disease: Report of two cases

La Enfermedad de Paget Mamaria (EPM), es una neoplasia infrecuente del complejo pezón/areola, que se presenta como expresión de un carcinoma intraductal adyacente. Presentamos dos casos de pacientes atendidas en nuestro servicio.

Mammary Paget's disease is a rare neoplasm of the nipple/areola area, which is presented as an expression of an adjacent intraductal carcinoma. We report two cases of patients treated in our service.

Cancerização de lóbulos: correlação de achados mamográficos e histológicos / Cancerization of lobules: correlation between mammography and histological findings

OBJETIVO: Caracterizar os aspectos mamográficos de cancerização de lóbulos associados a carcinoma ductal in situ (CDIS), por meio de correlação entre achados de imagem e histológicos. MATERIAIS E MÉTODOS: O presente estudo retrospectivo foi baseado em uma revisão de laudos histopatológicos de 135 pacientes submetidas a biópsia de mama. O diagnóstico de cancerização de lóbulos associada a CDIS foi confirmado em 12 das pacientes. Dois casos foram excluídos porque os cortes histopatológicos não estavam disponíveis para correlação da patologia com a mamografia. Todas as imagens mamográficas foram retrospectivamente analisadas às cegas quanto aos resultados histológicos e classificados por dois experientes radiologistas especializados em mama. RESULTADOS: Nove casos (90 por cento) apresentavam microcalcificações redondas agrupadas e um (10 por cento) apresentava calcificações lineares. A distribuição das calcificações foi definida como lobular em todos os casos. A análise histopatológica demonstrou quatro casos de CDIS cribriforme, dois casos de comedocarcinoma, um caso de CDIS sólido, um caso de CDIS cribriforme associado com sólido e um caso de CDIS cribriforme associado com sólido e comedocarcinoma. No caso em que havia calcificações redondas e lineares, o subtipo histológico era de CDIS cribriforme. Com relação ao número de microcalcificações, nove casos apresentavam mais do que 20 e apenas um caso apresentava menos do que 10 microcalcificações. CONCLUSÃO: Na presente coorte, a avaliação mamográfica de pacientes com CDIS apresentando cancerização de lóbulos demonstrou agrupamentos de microcalcificações redondas com distribuição lobular. Embora agrupamentos de calcificações redondas sejam normalmente associados a um processo benigno, a cancerização de lóbulos por CDIS pode produzir um padrão similar, mimetizando, assim, uma condição benigna.

OBJECTIVE: To characterize the mammographic appearance of cancerization of lobules by ductal carcinoma in situ (DCIS), by correlating imaging and histological findings. MATERIALS AND METHODS: This retrospective study was based on a review of the histopathological reports of 135 patients who underwent breast biopsy. A diagnosis of cancerization of lobules by DCIS was confirmed in 12 patients. Two cases were excluded because the histopathological sections were not available to correlate pathological and mammographic findings. All mammograms were retrospectively reviewed and categorized by two experienced breast radiologists, with no knowledge of the histological findings. RESULTS: Nine cases (90 percent) presented clusters of round microcalcifications, and one (10 percent) had round and linear calcifications. The distribution of the calcifications was defined as lobular in all the cases. Histopathological study showed four cases of cribriform DCIS, two cases of comedo DCIS, one case of solid DCIS, one case of cribriform associated with solid DCIS, and one case of cribriform associated with solid and comedo DCIS. In the case showing round and linear calcifications, the histological subtype was cribriform DCIS. With respect to the number of microcalcifications, nine cases presented more than 20, and only one case showed less than 10 microcalcifications. CONCLUSION: In our cohort, the mammographic evaluation of patients with DCIS presenting cancerization of lobules demonstrated clusters of microcalcifications in a lobular distribution. Although clusters of round calcifications are typically associated with a benign process, cancerization of lobules by DCIS may produce a similar pattern, thus mimicking a benign condition.

Carcinoma in situ dentro de un fibroadenoma de mama: tres casos clínicos / Carcinoma within a fibroadenoma of the breast: report of three cases

El fibroadenoma (FA) es un tumor frecuente de la mama que se presenta usualmente en la segunda y tercera década de la vida. Los carcinomas de la mama raramente se desarrollan dentro de un FA, existiendo alrededor de 200 casos descritos en la literatura. Nosotros reportamos la presencia de carcinoma ductal in s/fu(CDIS) al interior de un FA en tres pacientes mujeres de 31, 45 y 47 años. La presencia de microcalcificaciones en dos pacientes y la sospecha de un papiloma intraductal en la tercera, determinaron la necesidad de mastectomía parcial y el consiguiente hallazgo de CDIS al interior de un FA. En dos casos hubo presencia de CDIS extenso en el parénquima mamario adyacente y fueron sometidas finalmente a una mastectomía total. Recomendamos un seguimiento estricto en mujeres con FA a partir de la cuarta década de la vida. En pacientes con lesiones mamarias pro I iterativas o con CDIS que presentan además un FA, se recomienda vigilancia del FA o resección de éste al momento de extirpar el CDIS.

The fibroadenoma (FA) is a common tumor of the breast that usually occurs in the second or third decade of Ufe. The carcinomas of the breast rarely arising within a FA, with around 200 cases reported in the literature. We report the presence of DCIS within a FA on three female patients of 31, 45 and 47 years old. Due to the presence of microcalcifications in two patients and the suspicion of an intraductal papilloma in the third, they underwent a partial mastectomy with the consequent finding of DCIS inside a FA. In two cases there were extensive DCIS in the adjacent breast parenchyma and finally they underwent a total mastectomy. We recommend a strict follow up in women with FA from the fourth decade of life. In patients with proliferatives breast lesions or DCIS that simultaneously presenting a FA, we recommend surveillance of FA or remove it at the same time of the resection of DCIS.

Carcinoma ductal in situ: classificação e recomendações ao patologista cirúrugico / In situ ductal carcinoma: classification and guidelines for the surgical pathologist

Com o advento da mamografia preventiva de rotina, o diagnóstico de lesões precoces e de carcinoma ductal in situ da mama tem aumentado progressivamente nos últimos 10 anos. A classificação do carcinoma ductal in situ obedece basicamente parâmetros morfológicos como atipia e presença de necrose. No entanto, várias classificações diferentes foram propostas ao longo dos anos, com abordagens nem sempre equivalentes. Neste trabalho, abordamos criticamente as diferentes classificações disponíveis em ordem cronológica de aparecimento e sua aplicabilidade na rotina diagnóstica e terapêutica destas lesões.

In the past ten years, the introduction of screening mammography in breast cancer detection progressively increased the rate of diagnosis of premalignant lesions, such as in situ ductal carcinoma of the breast. Classification of in situ ductal carcinoma basically obeys morphological parameters, such as presence of atypia or necrosis. However, multiple different classifications have been proposed by distinct groups, with not always comparable approaches. In this review, we enlist the main working classifications available chronologically disposed along with diagnosis and therapeutic remarks, their applicability and reproducibility.