Invasive ductal carcinoma

Last revised by Dr Mohammad Taghi Niknejad on 28 Jun 2021

Invasive ductal carcinoma not otherwise specified, also known as invasive carcinoma of no special type, is the most common type of breast cancer (70-80%) 5. It is an infiltrating, malignant and abnormal proliferation of neoplastic cells in the breast tissues.

The latest (4th) edition of the World Health Organization classification of tumors of the breast changed the preferred terminology from invasive ductal carcinoma, not otherwise specified (NOS) to invasive (breast) carcinoma of no special type (NST) 4. The rationale is that the use of 'ductal' relies on unproven histogenetic assumptions for this heterogeneous group of cancers. Invasive ductal carcinoma or ductal NOS remains acceptable and commonly used terms. 

The peak age of presentation is about 50 to 60 years. African Americans have a higher predisposition to grade 3 cancer and also present a higher death rate.

Large palpable, immobile mass.

  • irregular mass with or without calcifications
  • spiculated hyperdense lesion (usually grade 1 41% vs 26% in grade 3)
  • circumscribed lesions more common grade 3 (36%) 
  • microcalcifications are present in 34% of grade 1 and 37% of grade 3 Invasive ductal carcinoma 5
    • amorphous (associated with low grade Invasive ductal carcinoma)
    • pleomorphic (associated with high grade Invasive ductal carcinoma) 
  • ill-defined lesion
  • hypoechoic mass
  • hyperechoic angular margins
  • posterior acoustic shadowing (71% grade 1)
  • posterior enhancement (45% grade 3)
  • a ductal extension may be seen which is the extension of the lesion into the surrounding parenchyma
  • branched or spiculated pattern
  • microcalcifications

Depicts increased stiffness of the mass and the tissue that surrounds it. This feature correlates with the tumor grade 5.

  • T1
    • isointense to parenchyma
    • hypointense to fat
  • T1 C+ (Gd)
    • irregular or spiculated lesion
    • ring enhancement with centripetal progression
    • dilated veins draining the tumor
    • non-mass enhancement
    • early wash-in (higher initial enhancement ratio IER)
    • 76-91% show wash-out or plateau kinetic curves
  • T2
    • iso to hypointense to parenchyma
    • hyperintense edematous zone

The Nottingham combined histologic grade system, also called the modified Scarff-Bloom-Richardson grading system is recommended by The College of American Pathologists (CAP).´This grading system is based on the following criteria: 

  • tubule formation 
    • 1 point: >75% of the tumor "majority of tumor"
    • 2 points: 10-75% of tubular formation
    • 3 points:  <10% of tubular formation
  • nuclear pleomorphism
    • 1 point: nuclei with minimal or mild variation in size and shape
    • 2 points: nuclei with moderate variation in size and shape
    • 3 points: marked variation in size and shape
  • mitotic activity
    • 1 point: 0-5 per 10 high power fields (HPFs)
    • 2 points: 5-10 per 10 HPFs
    • 3 points: >10 per 10 HPFs
  • Overall score:
    • 3-5 points: Grade 1 or well-differentiated tumor.
    • 6-7 points: Grade 2 or moderately differentiated tumor
    • 8-9 points: Grade 3 or poorly differentiated tumor 6

The Nottingham prognostic index (NPI) is used to determine the prognosis for Invasive Carcinoma of the Breast after surgery 7.

NPI = [0.2 x S] + N + G

Where:

  • S: size of the lesion in centimeters
  • N: node status: 0 nodes = 1, 1-3 nodes = 2, >3 nodes = 3
  • G: grade of tumor: Grade I =1, Grade II =2, Grade III =3

NPI ≤2.4 Excellent: 96% Cancer-specific ten-year survival

NPI >2.4 but ≤3.4 Good: 93% Cancer-specific ten-year survival

NPI >3.4 but ≤5.4 Moderate: 78% Cancer-specific ten-year survival

NPI >5.4 Poor: 44% Cancer-specific ten-year survival

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Cases and figures

  • Figure 1: histology
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  • Case 1
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  • Case 2
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  • Case 3
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  • Case 4
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  • Case 5
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  • Case 6
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  • Case 7: recurrence at mastectomy site
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  • Case 8: CT
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  • Case 9
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  • Case 10: incidental finding on CT
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