Comedo necrosis vs. necrosis

Jordymom

Comedo necrosis vs. necrosis

Jordymom

Does anyone know if all necrosis on a path report is 'comedo' necrosis?  Can you have true comedo necrosis and not have a high nuclear grade?  This term 'comedo' gets thrown out alot, but there is relatively little about it's true definition.  Do people have path reports using the actual word comedo or is this more of an institutional or regional term used by some pathologists?

I did learn that 'comedo' essentially means something you can squeeze, like an acne lesion. 

Thanks for any help for the resident experts. 

Beesie

Most of the breast cancer sites I went to use the terms "necrosis" and "comedonecrosis" interchangeably.  I believe that "necrosis" is a generic term referring to dead cells, whereas "comedonecrosis" is a specific subtype of DCIS that includes necrosis. 

Here are definitions from http://www.dcis.info/dictionary.html:

Necrosis - The death of living cells or tissues caused by a lack of blood flow.

Comedo (kuh-ME-do) - A subtype of DCIS indicating a high grade of disease, which translates to higher risk for development of invasive breast cancer. Comedo looks and acts differently from other in situ subtypes. The center of the duct is plugged with dead cellular debris, known as "necrosis". This is a sign of rapid and aggressive growth. Also called Comedocarcinoma when it is in an invasive form.

BC.org also explains this well: http://www.breastcancer.org/symptoms/dcis/type_grade.jsp

As for your question, "Can you have true comedo necrosis and not have a high nuclear grade?", from the following site, I think the answer is yes.  http://www.breastdiseases.com/dcispath.htm   If I understand this correctly, comedo is a type of DCIS architecture.  It's usually associated with high nuclear grade, but not always. 

To your other question, my pathology report specifically said "comedonecrosis".

Anonymous

YUP so did mine. Good explanation Beesie.

mbordo

My path report said "single focus of necrosis".  I had a large amount of grade 2 intermixed with some ADH/grade 1.  Amazingly, that single focus was all that showed up on the mammogram...

Good question, as I had heard the term comedonecrosis, as well, and wondered why my path report only said "necrosis".  It makes sense, now!

Mary

Blundin2005

Me too...comodonecrosis 10%. 

It was 10 months from my previous mammogram when I found the lump not seen before.

Thanks for posting this.  

motheroffoursons

Mine was different.   The initial biopsy report has said comedocarcinoma with necrosis.  Probably just all the different versions meaning the same thing.  It was large, something like a 4.5 cm DCIS tumor at lumpectomy.  However, it was still grade 2 when all factors were considered.  Grade also depends on the number of cell divisions (mitoses) seen and other things I do not remember.

Jordymom

Thanks Beesie, although it does all seem to still be a little unclear.  If my path report shows intermediate grade with solid architecture and mentions finding necrosis, is this an oblique way of calling this comedo-necrosis?

From reading the links it appears that 'comedonecrosis' may have special characteristics beyond just a focus of necrosis in a solid looking DCIS tumor.  If this is not true and pathologists don't all use the same terminology to mean the same thing our jobs as informed patients just got harder.

jamiehop

I know this thread is a little older, but I came across it when looking for an answer recently.  I asked for an explanation on this as well as it seems the ole internet lacks clarification.  Here is what the leading breast pathologist at my hospital network says:

__________________________

The term "comedo necrosis" means a large central area of necrosis that is confluent and expansive on microscopic review - i.e. this extends along and expands the ducts involved by DCIS. This type of necrosis is usually only seen with high grade DCIS (nuclear grade 3) , which is most frequently comedo type DCIS.

Focal necrosis is a descriptor for very small areas of necrosis within a duct involved in DCIS. Focal necrosis is very common, and can be seen in all types of DCIS. When focal necrosis is present, the DCIS is at least nuclear grade 2 (and would not be generally classified as a nuclear grade 1).

I view comedo DCIS (which always has "comedo type necrosis") as a specific type of DCIS with a higher incidence of being associated with an invasive tumor. I don't equate any specific clinical connotations with focal necrosis (other than when I see it, I know I am dealing with at least grade 2 DCIS). Again, focal necrosis is just a common finding. When we view these cases under the microscope we are looking for "comedo type" necrosis, because if we see it, we know we are dealing with a higher grade and need to search for a comedo type of DCIS.

AlohaGirl

Thanks for this thread.  My pathology said "central necrosis" so not sure what that means, but since the necrosis was found in my biopsy and my DCIS was grade 2 at that time (pathology after lumpectomy showed no additional necrosis and was grade 2/3), my guess is that it was focal necrosis not comedo.  Since I've already had lumpectomy and rads and am in my second year of taking tamoxifen, I guess it doesn't really matter that much at this point.  If I think of it I will ask my oncologist next time I see him though.  I am curious.  

JulieH

I've been poking around the different discussion topics this morning and the one on Comedonecrosis & Necrosis in this forum has some information that you might find useful:  http://community.breastcancer.org/forum/68/topic/701836

While it can be overwhelming in volume at times,  the information at this site is really useful. 

KimD

This was very helpful.  Thank you jamiehop.

"The term "comedo necrosis" means a large central area of necrosis that is confluent and expansive on microscopic review - i.e. this extends along and expands the ducts involved by DCIS. This type of necrosis is usually only seen with high grade DCIS (nuclear grade 3) , which is most frequently comedo type DCIS.

Focal necrosis is a descriptor for very small areas of necrosis within a duct involved in DCIS. Focal necrosis is very common, and can be seen in all types of DCIS. When focal necrosis is present, the DCIS is at least nuclear grade 2 (and would not be generally classified as a nuclear grade 1).

I view comedo DCIS (which always has "comedo type necrosis") as a specific type of DCIS with a higher incidence of being associated with an invasive tumor. I don't equate any specific clinical connotations with focal necrosis (other than when I see it, I know I am dealing with at least grade 2 DCIS). Again, focal necrosis is just a common finding. When we view these cases under the microscope we are looking for "comedo type" necrosis, because if we see it, we know we are dealing with a higher grade and need to search for a comedo type of DCIS."

Annette47

Interesting.   I had what was called grade 2 DCIS but also had "central comedo necrosis" and a microinvasion of IDC.   All in a very small area (described to me as the size of a grain of rice).   Who knew there could be so much going on at the cellular level in such a small area!

denilynne

This is my diagnosis. Would someone explain to me, in layman's terms what this means?

Diagnosis:
A. Right breast, core biopsy: Intermediate nuclear grade ductal carcinoma
in situ (DCIS) with papillary and mucinous
features, focal comedonecrosis and associated microcalcifications. No
definite microinvasion identified. Please see
comment.

Comment:
Histologic sections show DCIS with a focus suspicious for microinvasion.
However, no definite microinvasion is
identified via immunohistochemical stains for myoepithelial markers p63 and
muscle specific actin. Additional
immunostains show the DCIS cells to be estrogen and progesterone receptor
(>95%) positive. Controls are
appropriate.

History:
Source: Right breast. Suspicious 1 cm grouping microcalcification right

voraciousreader

Briefly, you have non-invasive, grade 2, DCIS. However, it appears to have special histologies such as papillary and mucinous features. Although it appeared that it might include some invasion, it was ruled out with the help of the p63 marker.



You should do well! Good luck!

denilynne

Thank you so much! My pre-op appt is next Tuesday, then the blue dye for the sentinel biopsy, then the wire, then finally lumpectomy and sentinel biopsy on Sept 4.

Voracious reader, I can't thank you enough for explaining my diagnosis to me. In a few sentences, you have calmed my nerves. God bless you!

voraciousreader

Keep in mind, the final surgical pathology report should confirm the initial path report.

denilynne

I realize that they may find more or something different during surgery & the path report but now, I feel calmer and more comfortable about going on. Really, I felt so ín the dark and now, I see light!! Again, thank you.

voraciousreader

I am glad you are feeling better! Going forward, feel free to ask your team as many questions as you like. Bring a family member or friend with you to your appointments. Bring a recorder and/ or take notes. Come here too... to the discussion boards as well. You will find lots of support! You even taught me something new! I had mucinous invasive breast cancer and I never knew of mucinous or papillary DCIS until you posted. Mucious and papillary tumors are rare types of disease. That also explains why your pathologist went the distance in explaining how s/he arrived at the diagnosis. In the invasive form, they usually come with a favorable prognosis. Since you have DCIS with mucinous and papillary features and are ER positive, you should do very well. Keep in touch. I would appreciate your sharing the final path report and your treatment plan.

denilynne

I will share as I go through treatment.

You have explained more than anyone else to me and for that I am forever grateful.

denilynne

Dear Voraciousreader,

This addendum came in after the report I showed you above. Has anything changed as far as you can see?

ADDENDUM BREAST IMAGING DATED Aug 06, 2013 01:07:56 PM.

INDICATION: Right breast core biopsy pathology results available.

IMPRESSION:

1. The results are " intermediate nuclear grade ductal carcinoma in
situ with papillary and mucinous features, focal comedonecrosis and
associated microcalcifications. No definite microinvasion identified.
Histologic sections show DCIS with a focus suspicious for
microinvasion. However, no definite microinvasion is identified via
immunohistochemical stains for myoepithelial markers..." This is a
concordant malignant diagnosis.

2. Recommend referral to BCC.

voraciousreader

No changes... Except that the pathologist is recommending a breast surgeon. Basically, the pathologist forgot that info on the first report and is now covering their behind!

denilynne

Dumbheads!

Thanks!