Most DCIS Presents as Mammographic Calcifications

  • Fine linear or branching calcifications:
    • In a group or segmental distribution:
      • Are often associated with high-grade DCIS
  • Amorphous calcifications:
    • Are often associated with low-grade DCIS
  • Mammography relies on the presence of calcifications for the detection of DCIS:
    • Thus, lesions without calcifications are generally occult on mammography
  • Extensive DCIS:
    • Can present as a palpable mass
  • Nipple discharge:
    • Can also be a sign of either DCIS or invasive breast cancer
  • Paget disease;
    • Is a rare presentation:
      • Occurring in only 1% to 4% of women with breast cancer
    • It is characterized histologically by:
      • Intraepithelial tumor cells
      • It presents as a chronic ulceration or eczema of the nipple:
        • That can involve the surrounding areolar skin
    • It may be associated with invasion but, in the absence of invasion:
      • Is treated as DCIS
The form of the calcifications is the most important factor in the differentiation between benign and malignant.
If calcifications cannot be readily identified as typically benign or as ‘high probability of malignancy’, they are termed of ‘intermediate concern or suspicious’.
If a specific etiology cannot be given, a description of the calcifications should include their morphology and distribution using the descriptions given in the BI-RADS atlas.
In the BI-RADS atlas the following descriptions are given for the distribution of calcifications:
Diffuse or Scattered: diffuse calcifications may be scattered calcifications or multiple similar appearing clusters of calcifications throughout the whole breast.
Regional: scattered in a larger volume (> 2 cc) of breast tissue and not in the expected ductal distribution.
Clustered : at least 5 calcifications occupy a small volume of tissue.
Linear: calcifications arrayed in a line, which suggests deposits in a duct.
Segmental: calcium deposits in ducts and branches of a segment or lobe.
Diffuse or scattered distribution is typically seen in benign entities.
Even when clusters of calcifications are scattered throughout the breast, this favors a benign entity.
Regional distribution according to the BI-RADS atlas would favor a non-ductal distribution (i.e. benignity)

Segmental distribution would favor a ductal distribution (i.e. malignancy).
Sometimes this differentiation can be made, but in many cases the differentiation between ‘regional’ and ‘segmental’ is problematic, because it is not clear on a mammogram or MRI where the bounderies of a segment (or a lobe) exactly are.

Clustered calcifications are both seen in benign and malignant disease and are of intermediate concern.
When clusters are scattered througout the breast, this favors a benign entity.
A single cluster of calcification favors a malignant entity.
Linear distribution is typically seen when DCIS fills the entire duct and its branches with calcifications

#Arrangoiz #CancerSurgeon #BreastSurgeon #SurgicalOncologist #BreastCancer #LCIS #DCIS #DuctalCarcinomaInsitu #LobularNeoplasia #LobularCarcinomaInsitu #Surgeon #Teacher #Miami #Mexico #MSMC #MountSinaiMedicalCenter

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