Diagnosis of Ductal Carcinoma In Situ (DCIS)

• Clinical Presentation:
  • Before the implementation of routine screening mammography:
    • Most patients with DCIS presented with a:
      • Palpable mass
      • Nipple thickening
      • Nipple discharge
      • Paget disease of the nipple
    • Occasionally, DCIS was an incidental finding:
      • In an otherwise benign breast biopsy specimen
    • In patients with palpable lesions:
      • Up to 25% demonstrated foci of invasive disease
  • Now that screening mammography is more prevalent:
    • The incidence of DCIS has increased dramatically and currently comprises:
      • Approximately 20% of all breast cancers
    • Most cases of DCIS are diagnosed:
      • When the tumor is still clinically occult
    • Patients with abnormalities detected by screening mammography:
      • Should always undergo diagnostic imaging of the contralateral breast:
        • Because 0.5% to 3.0% of patients have:
          • Synchronous occult abnormalities or
          • Cancers in the contralateral breast
      • Mammographic images should be compared with previous images, if available, to establish interval changes
• Mammographic Features:
  • On a mammogram, DCIS can present as:
    • Microcalcifications:
      • 80% to 90% of mammographic manifestations
    • A soft-tissue density
    • Both
  • Microcalcifications are the most common (80% to 90%) mammographic manifestation of DCIS:
    • Which, in turn, accounts for 80% of all breast carcinomas:
      • Presenting with calcifications
  • Any interval change from a previous mammogram:
    • Is associated with malignancy in 15% to 20% of cases:
      • Most often indicates in situ disease
  • Holland et al. (1990):
    • Described two different classes of microcalcifications:
      • Linear branching-type microcalcifications:
        • Which are more often associated with:
          • High–nuclear-grade lesions
          • Comedo-type lesions
      • Fine, granular calcifications:
        • Which are primarily associated with:
          • Micropapillary or cribriform lesions:
            • Of lower nuclear grade and that do not show necrosis
    • Although the morphology of microcalcifications:
      • Suggests the architectural type of DCIS
        • It is not always reliable
  • Holland et al:
    • Also demonstrated that the mammographic findings:
      • Significantly underestimated the pathologic extent of disease:
        • Particularly in cases of:
          • Micropapillary DCIS:
            • Lesions were more than 2 cm larger by histologic examination than by mammographic estimation:
              • In 44% of cases of micropapillary lesions, compared with only 12% of cases of the pure comedo subtype
      • However, when magnification views were used in diagnostic mammographic examination:
        • The extent of disease was underestimated in only 14% of cases of micropapillary tumors
      • Hence, magnification views increase the image resolution and are better able to delineate the shape, number, and extent of microcalcifications when compared with mammography alone:
        • And should be used routinely in the evaluation of suspicious mammographic findings

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