00:01
Classification: In situ,
ductal and lobular.
00:05
Stop here for one second.
00:07
What does in situ mean to you?
Malignancy.
00:11
What’s the difference
between this and invasive?
In situ, the basement
membrane is intact
and if it’s ductal,
can you picture it?
Major terminal duct and
the membrane’s intact.
00:25
I’d walk you through
comedocarcinoma already.
00:28
Lobular carcinoma in situ,
the lobule and its
membrane will be intact.
00:32
What happens now?
There’s every possibility that
the basement membrane is
then going to rupture.
00:37
Welcome to invasive.
00:39
Would you please tell me as
to what is the most common
invasive breast cancer?
It’s this one.
00:46
Invasive ductal cancer.
00:48
Lobular carninoma,
invasive type.
00:51
Upon histology,
it would show you those cells
that would be all marching
one behind the other.
00:59
And this is the one
that loves to spread.
01:01
This is the one that loves to
spread to the other breast
in fact, contralateral.
01:07
Non-invasive with in situ:
Malignant population of cells
that lack the capacity to invade.
01:13
Acini are distorted,
unfolded and take
appearance of small ducts.
01:17
Non-invasive in situ.
01:20
With in situ, special subtype,
we’ll walk you through
comedocarcinoma.
01:23
What does that mean to you?
This means that inside
the actual tumor,
you’d find areas
that are necrotic,
characterized by solid sheets
of high-grade malignant cells
and central necrosis.
01:34
Comedo-, comedocarcinoma.
01:37
There’s another subtype here,
punctate area of necrotic material
with comedone-like appearance.
01:44
The other subtype,
I’m not going to spend
so much time with,
but you pay attention
to the comedo,
which to you should mean
central, necrotic areas.
01:54
Now what’s interesting about
this one is the following:
First, take a look at the histologic
picture and you find Paget cells.
02:01
The Paget cells are
filled with mucin
and it would stain for
positive periodic acid-Schiff.
02:07
"So why in the world, Dr. Raj, are
you talking about ductal carcinoma
in situ and show me a
picture of Paget’s?
Before we begin,
can you picture the patient with
Paget’s disease in the nipple
and how she’s presenting.
02:19
Either by picture or
through description.
02:22
There’s an eczematous --
eczematous -- rash on the nipple.
02:26
Eczematous, not like
skin of an orange.
02:29
And when I briefly walk you
through Paget’s disease,
I told you that there would
have been underlying disease.
02:37
This is what I’m referring to.
02:39
Ductal carcninoma in situ,
the one subtype we talked about
earlier was comedocarcinoma.
02:46
Keep that separate.
02:47
Paget’s disease of the nipple which
looks like eczema on the nipple.
02:50
Picture that first.
02:52
Histology shows you Paget cells.
02:55
The other time that I’ve
shown you Paget cells was
extramammary with vulva.
03:01
Ductal carcinoma in situ that
extends from the nipple duct
into the contiguous skin
of the nipple and areola,
the underlying cancer that
you’re worried about here
most of the time with
Paget’s would be DCIS.
03:15
The nipple and areola are
frequently fissured, ulcerated
and oozing because of extreme
involvement of the nipple itself.
03:24
So you want to be really careful
and organize your thought here,
ductal carcinoma in situ,
comedocarcinoma,
ductal carcinoma in situ
being the underlying
malignancy for Paget’s
disease of the nipple.
03:36
With the duct being involved,
thus you would find there
to be nipple and areola
that are often involved with
fissures, ulcerations and oozing.
03:48
Now, let’s move on to
lobular carcinoma in situ.
03:51
First, think about the lobule.
03:54
Back deep by the
stroma, the lobule.
03:57
Manifested by proliferation in one
or more terminal duct or ductule
along with the lobule.
04:02
Here, you’d find more or
less your Signet ring cells.
04:05
Stop here for one second.
04:07
Doesn’t that sound
awfully familiar?
Signet ring? I know
that, I know that.
04:12
I know you do.
04:13
The last time we talked about this was
gastric adenocarcinoma, diffuse type.
04:19
And also we talked about
this in ovarian cancer.
04:23
Do you remember how you can
find the Signet ring cells
in an ovary or histologic
picture of an ovary.
04:29
Krukenberg.
04:30
Exactly, very good.
04:31
So why is Signet-ring cell
here and what kind of –
"Dr. Raj, I know you’re
going bring in parallel."
Of course, I am.
04:39
And this is more
molecular in nature.
04:42
Molecularly speaking, your diffuse
type of gastric adenocarcinoma
and the lobular carcinoma,
they love to spread.
04:51
They’re both
E-cadherin negative.
04:53
Keep that in mind,
especially as we get into
invasive lobular cancer.
04:58
So therefore, interesting
enough, two major cancers
that are E-cadherin negative
contain Signet ring cells,
which are filled with mucin.
05:09
Distends glandular acini.
05:12
Invasive cancer.
05:14
So what does invasive
cancer mean to you?
Invasive carcinoma
will be one in which
marked by increased and
dense fibrous stroma
giving a stoney hard
– feel your chin.
05:26
It feels like this, gritty.
05:28
Really gritty.
05:31
Corresponds to
histologic desmoplasia.
05:33
Stop here for one second.
05:35
Big time important.
05:36
Invasive pathology.
05:37
You’ve learned
about a phenomenon
that takes place
with adenocarcinoma
in which the surrounding tissues
undergo a fibrous change.
05:46
Some pathologist will
call it fibroplasia.
05:49
Some pathologist and
on your boards,
they most likely will
call it desmoplasia.
05:53
So it’s a non-neoplastic
but it’s fibrous.
05:56
Trying to wall off the invasion is
what the response is trying to do,
but in the process,
it actually makes it difficult for
chemotherapy to reach the cancer.
06:07
So where is their research?
Guaranteed in your practice,
oncology especially,
that you would be giving –
or you were thinking about when
to give desmoplasia inhibitors.
06:20
If you remove the wall,
it makes it easier to reach the
cancer cell, chemotherapy.
06:24
Big time important in
every way shape or form.
06:28
You may have
infiltrative attachment
to the surrounding
structure with fixation,
the dimpling of the skin,
retraction of the nipple.
06:35
All of these is then known
part of your invasive cancer.
06:39
Invasive lobular cancer
is where we are.
06:41
These tend to be bilateral.
06:44
Remember,
the most common
invasive would be your?
Good.
06:48
Ductal.
06:49
You definitely want to know about
lobular invasive, however.
06:52
This is the one that
loves to spread.
06:55
Bilateral.
06:56
Multicentric.
06:57
E-cadherin negative.
06:59
Diffusely invasive pattern.
07:01
Frequently metastasize to where?
Cerebrospinal fluid, ovary,
uterus, bone marrow.
07:07
All over the place.
07:09
The parallel that you want
to bring here once again,
remember we’re talking
about Signet ring cells.
07:14
We talked about
E-cadherin negative.
07:16
This one loves to
spread as well.
07:18
Look at the places
it loves to spread.
07:19
Everywhere.
07:21
CSF, ovary, uterus, bone
marrow, so on and so forth.
07:24
This is medullary cancer.
07:26
BRCA1 is the gene here.
07:28
Soft, fleshy consistency.
07:30
Well-circumscribed is what you
would expect upon morphology.
07:34
Good prognosis.
07:35
Not a whole lot to
say about medullary,
but you want to be familiar
or know that it exists.
07:41
Poor prognostic factors, however,
include high nuclear grade,
aneuploidy,
absence of hormone receptors,
p53 expression,
high proliferative rates.
07:54
So this would then make your
medullary cancer to be then
poor prognostically.
07:59
Our topic here very importantly is
prognostic factors for breast cancer.
08:03
I’ve mentioned a
few times now that
the most important prognostic
indicator would be
axillary lymph node spread.
08:09
Tumor size will then influence
your prognostication.
08:14
Estrogen and progesterone
receptor expression
would then help you
with prognosis
and if you find this
to be positive,
then you have drugs at
your disposal such as
your partial agonist, tamoxifen.
08:27
If there is increased
proliferative rate,
this then affects
your prognosis.
08:31
And over expression
or hyperexpression
of HER-2/neu has
worse prognosis.
08:37
However, we have a drug
that we are quite familiar
with,
trastuzumab.