Rosen's Breast Pathology, 4e

365

Ductal Carcinoma In Situ

A

B

FIG. 11.44.  DCIS in a radial sclerosing lesion. A: DCIS of cribriform type ( arrows ) and ductal hyper- plasia in a radial sclerosing lesion. B: Magnified view of DCIS shown in (A) .

high- and low-grade components may coexist in a patient or even in one duct (Figs. 11.10 and 11.53). Some high-grade DCIS exhibit the basal-like immu- nophenotype (no reactivity for ER and progesterone re- ceptors [PRs] and for HER2). This form of DCIS is the putative precursor to invasive basal-like ductal carcinoma. Bryan et al. 152 found the basal-like immunophenotype in 4 (6%) of 66 DCIS with high nuclear grade. These DCIS expressed basal cytokeratins and/or epidermal growth factor receptor (EGFR) significantly more often than did high-grade DCIS, which did not have the basal-like immunophenotype. Silverstein et al. 153 proposed a classification of DCIS based on nuclear grade (high or nonhigh) and the presence or absence of necrosis as part of a prognostic index. Three prognostic categories resulting from consideration of these

variables were as follows: Group 1, nonhigh nuclear grade without necrosis; Group 2, nonhigh nuclear grade with necrosis; and Group 3, high nuclear grade with or without necrosis. The Van Nuys Prognostic Index (VNPI, discussed in greater detail below) includes margin status and tumor size as well as these histologic groups. 154 Follow-up revealed a significant correlation between the VNPI and the risk of recurrence in the breast after conservation therapy. VNPI should be used only if margin status and tumor size can be reliably assessed. Grading has been a component of other classification schemes for assessing the effectiveness of breast conserva- tion therapy in the treatment of DCIS. Including those cited previously, at least six classifications have been proposed. 155 These have been based on some or all of the following fea- tures: architecture, nuclear grade, presence or absence of

FIG. 11.45.  DCIS, radial configuration. A: Stellate lesion with a scleroelastotic center. B: Cribriform DCIS shown here is present throughout the tumor.