Topic reviewDuctal carcinoma in situ

; radiologic review

2010-06-29R3 이진영

Introduction• Mammography (MMG) as an adjunct in breast screening detection of ductal carcinoma in situ (DCIS)• Noninvasive nature and favorable prog-

nosis of DCIS

• Diagnosis and management of DCIS : important

Definition of DCIS• Proliferation of abnormal epithelial

cells within basement membrane of

mammary ductal system without stromal inva-

sion ; precursor of invasive carcinoma

The past The present

Rate of all breast can-cer

0.8-5.0% 30%

Palpable mass 75% <10%

Location in breast 52% 44%

central UOQ

Progression of breast can-cer• Normal/ Nonprolifer-ative

changes• Proliferative dis-

ease• Atypical hyperpla-

sia• Ca in Situ• Invasive carcinoma

DCIS classification• Classification but not widely accept-

able

Nuclear grade High, intermediate, low

Architecture ComedocarcinomaSolidCribriformMicropapillaryPapillary

Rare types Clear cell, hypersecretory, mucinous

Evolution of DCIS

Imaging finding of DCIS

MMG of DCIS• M/C mammographic presentation–Microcalcifications(62%–98%)• Typically pleomorphic, varying in size, form,

density • Grouped in a cluster, frequently manifesting

linear or segmental arrangements

Benign calcifications- More rounded, more uniform in density- Scattered Or diffuse distributed in groups

MMG of DCIS• Pathogenesis calcification in DCIS– Proliferating malignant ductal cells lim-

ited to existing ductal and lobular units tumor cell central necrosis calcifications

MMG of DCIS• 6%–23% of DCIS lesions – Not visible at mammography

• Atypical mammographic findings –Mass or asymmetry(2-23%)– Prominent ducts – Other soft tissue changes

MMG of DCISScattered and pheomorphie calci-

fleations. Many casting calcifleations

Histologic diagnosis: high nuclear grade

(comedo) DCIS.

MMG of DCIS

Single cluster and pleo-morphic microcalcification. Intermediate nuclear grade DCIS.

Multiple clusters and fine granular microcalcification. Low nuclear grade (cribriform) DCIS.

Ductal Carcinoma In Situ of theBreast: Correlation BetweenMammographic Calcification

and Tumor SubtypeAJR 159:483-485, September 1992

5

US of DCIS• Not alternative of MMG but adjunctive tool• Advantage of US– Use of US to guide interventional procedures (eg,

needle biopsy, needle localization)– Helpful in detecting DCIS without calcifications – Evaluating disease extent in women with dense

breasts

• M/C US finding – Microlobulated mass w/ mild hypoechogenicity, ductal extension, normal acoustic transmission RadioGraphics 2002; 22:269–281

Spiculated margins, marked hypoechogenic-ity, a thick echogenic rim, post. acoustic shadowing suggested presence of invasion

US of DCISRadioGraphics 2002; 22:269–281

MRI of DCIS• Role of MRI in DCIS: not established in DCIS. – Contrast-enhanced MRI very sensitive for invasive cancers but DCIS has nonspecific app. and kinetic curves mimic fibrocystic changes & other benign finding

• Potential role of MRI for Dx of DCIS– Improved mapping of local DCIS extent and intraductal components around invasive cancers avoid re-excisions to obtain free margins

MRI of DCIS• Common DCIS finding : Nonmass cobblestone like enhancement, occasional confluent areas enhancement with variable enhancement kinetics

– Differential diagnosis Diffusely infiltrating (lobular) cancer or Adenosis / fibrocystic disease• DCIS: following milk duct

Segmental or ductal

• Other benign lesion: not following milk duct diffuse or multifocal or linear

Ductal carcinoma in situ, solid and comedo types, high nuclear grade, with central necrosis

ductal carcinoma in situ, cribriform and papillary types, inter-mediate grade

PET CT of DCIS• Sensitivity for the detection of DCIS : 25%–76.9% in a small number of ar-

ticles

• In the subgroup of breast tumors >2 cm : sensitivity reaches as high as 92%

* Density of DCIS: how densely gathered the malignant ducts appeared in a low-power field

Radiat Med (2008) 26:488–493

* Tumor maximum SUV/background maximum SUV = TBCDR (> 1.5 : threshold for detection of intraductal car-cinoma)

DUIH case

54/F Abnormal find-ing in screening MMG

CC MLO

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 1) Size of tumor: 0.7x0.4cm 2) Nuclear grade: high 3) Necrosis: present 4) Van Nuys group 3 5) Surgical margins: free from

tumor 6) Venous invasion: absent 7) Lymphatic invasion: absent 8) Microcalcification: present

48/F Abnor-mal finding in screening mammogra-phy

CC MLO

DIAGNOSIS: Breast, right, needle biopsy: Ductal carcinoma in-situ (see note) with 1) Microcalcification 2) Necrosis Note) Biopsy 되지

않은 부분에 invasive carcinoma 존재 가능성은 배제할 수 없습니다 .

DIAGNOSIS for frozen and permanent section: Breast, right, conserving operation: Ductal carcinoma in-situ 1) Nuclear grade: 3/3 2) Necrosis present 3) Van nuys classification

group: 3/3 4) Architectural pattern:

comedo, cribriform, solid

5) Total size: 0.9x0.8cm 6) Surgical margin: free

from tumor, but very close to anterior margin(safety margin: 0.2mm) 7) Microcalcification present