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Topic review

Topic reviewDuctal carcinoma in situ; radiologic review2010-06-29R3

IntroductionMammography (MMG) as an adjunct in breast screening detection of ductal carcinoma in situ (DCIS)Noninvasive nature and favorable prognosis of DCIS

Diagnosis and management of DCIS : important


Definition of DCISProliferation of abnormal epithelial cells within basement membrane of mammary ductal system without stromal invasion ; precursor of invasive carcinomaThe pastThe presentRate of all breast cancer0.8-5.0%30%Palpable mass75%2 cm : sensitivity reaches as high as 92%

In the subgroup ofbreast tumors >2 cm in diameter, sensitivity reaches ashigh as 92%21

* Density of DCIS: how densely gathered the malignant ducts appeared in a low-power fieldRadiat Med (2008) 26:488493* Tumor maximum SUV/background maximum SUV = TBCDR (> 1.5 : threshold for detection of intraductal carcinoma)

Tumor cell density of intraductal carcinomaappears strongly correlated to detection byFDG-PET/CT.22

Fig. 2. Pure ductal carcinoma in situ (DCIS) of the right breast inan 85-year-old woman (case 4). a Maximum intensity projection(MIP) image of fl uorodeoxyglucose positron emission tomography(FDG-PET) shows abnormal FDG uptake in the right breast.b Pathological mapping shows the area of the DCIS (dots). Extensionof DCIS was 73 mm. The discrepancy in size between theFDG-PET/CT image and pathology was marked. Specimens weresliced into 10-mm contiguous sections. c Low power fi eld pathologicalspecimen shows the most densely packed intraductal componentarea judged as category C. (H&E, 40) d Low power fi eldpathological specimen shows peripheral low cell density area ofintraductal component judged as category A (arrow). (H&E,40)23

DUIH case

54/F Abnormal finding in screening MMG


At MMGParenchymal pattern 2Clustered microcalcification, Lt. LIQ - C0( )25



DiagnosticC0 microcalcification, left breast.

At Breast USLeft breast 7 , nipple 2 cm 1.5 cm gently lobulated, well circumscribed, and iso echoic nodule . microcalcifications hyperechoic dots . skin marker left magnification view marker microcalcification . Suspicious abnormality US guided core biopsy 5 . specimen mammography microcalcification .Left breast 2 right breast 7 0.5 cm 3 cyst . Both axilla .

At left magnfication viewLeft breast lower inner quadrant clustered pleomorphic microcalcifications .

US guided core biopsy wa done for suspicious abnormality in left breast, 7 o'clock direction.

BI-RADS category 4b.


DIAGNOSIS: Breast, left, needle biopsy: A few small foci of atypical ducts with focal necrosis & microcalcification, Suggestive of ductal carcinoma in-situ

USG-guided Hook-wire localization Bx : Breast, left, lumpectomyDuctal carcinoma in-situ Size of tumor: 0.7x0.4cm Nuclear grade: high Necrosis: present Van Nuys group 3 Surgical margins: free from tumor Venous invasion: absent Lymphatic invasion: absent Microcalcification: present

48/F Abnormal finding in screening mammography

48/F Abnormal finding in screening mammography Diagnostic2009-11-06 MMG New development of suspicious malignant microcalcifications in right breast, upper outer quadrant since 2007-10-12.

At USGLeft breast: Negative

Right breast:Nipple 10 5cm 0.9x0.6x1cm irregular shape indistinct margin microcalcified mass . Doppler peripheral portion mild vascularity . mass USG guided core biopsy 5 . Immediate complication specimen MMG calcification specimen .

Both axilla abnormal lymph node abnormal SCLN and IMLN.

At Rt magnification view Rt UOQ USG MMG clustered linear brainching pattern pleomorphic microcalcification . Suspicious malignant microcalcification.

USG guided core biopsy was done for suspicious malignant microcalcified mass in right 10 o'clock.

BI-RADS category 5.




DIAGNOSIS: Breast, right, needle biopsy: Ductal carcinoma in-situ (see note) with Microcalcification Necrosis Note) Biopsy invasive carcinoma .


History2009-11-06 MMG newly developed suspicious malignant microcalcifications in Rt breast UOQ US suspicious malignant microcalcified mass . mass USG guided core biopsy pathology ductal carcinoma in-situ .

TechniqueAxila T2 fat saturated image, SPAIR technique T1 axila dynamic study, lymph node evaluation delayed contrast image, dynamic study subtraction and reverse subtraction image .

FindingDynamic study right breast upper outer quadrant malignant microcalcified mass lesion 9.8x7.5x7.5mm irregular shape heterogeneous enhancement mass . Kinetic curve early enhancement and delayed wash out pattern . abnormal satellite nodule . Left breast . Scan image both axilla, internal mammary lymphatic chain supraclavicular area abnormal lymphadenopathy .

Known malignant mass in right UOQ(size: 9.8x7.5x7.5mm).

BI-RADS category 6. 36

DIAGNOSIS for frozen and permanent section: Breast, right, conserving operation: Ductal carcinoma in-situ Nuclear grade: 3/3 Necrosis present Van nuys classification group: 3/3 Architectural pattern: comedo, cribriform, solid Total size: 0.9x0.8cm Surgical margin: free from tumor, but very close to anterior margin(safety margin: 0.2mm) 7) Microcalcification present