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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