The two models respectively predict a hierarchy of subclones arranged by phenotype, or multiple subclones with shared phenotypes. Alternatively, ITH could represent branching evolution with invasion of multiple subclones. Intra-tumoral heterogeneity (ITH) could represent clonal evolution where subclones with greater fitness confer more malignant phenotypes and invasion constitutes an evolutionary bottleneck. The findings illustrate how digital image analysis comprises a supplemental tool for pathologists to objectively classify DCIS and in the future, may provide a method to predict patient outcome through analysis of nuclear heterogeneity. Digital image analysis further revealed increasing heterogeneity within ducts or between ducts in tissues of worsening DCIS grade. A whole-tissue cell nuclear morphological analysis, that classified tumors by the worst ten percent in a duct-by-duct manner, identified nuclear size ranges associated with each DCIS grade. We developed a nuclear heterogeneity image index to objectively, and quantitatively grade DCIS. We asked whether cell nuclear morphology heterogeneity could be incorporated into a metric to classify DCIS. Aggressive cancers are highly heterogeneous. Objective methods that allow standardization and reproducibility of cell nuclear morphology assessment have potential to improve the criteria needed to predict DCIS progression and recurrence. Histological assessment of cell nuclear morphology is frequently used by pathologists to grade ductal carcinoma in situ (DCIS). Abnormalities in cell nuclear morphology are a hallmark of cancer.
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