Advances in Breast MRI in the Setting of Ductal Carcinoma In Situ

Abstract

Ductal carcinoma in situ (DCIS) of the breast is a pre-invasive breast malignancy with controversial clinical relevance and management. These lesions have increased in incidence with breast cancer screening programs and are associated with increasingly recognized clinical issues of overdiagnosis and overtreatment. This article discusses the imaging presentation of these lesions with emphasis on advances in breast MRI and its role in the management of DCIS.

Figure. 1 –

Traditional Pathologic Classification of DCIS. This includes 5 types (comedo, solid, cribriform, papillary, and micropapillary) based on architectural pattern.

Figure. 2 –

Van Nuys Pathologic Classification. This system stratifies DCIS into two major groups – non-high and high nuclear grade, with the non-high grade divided based based on the presense of comedonecrosis. (color image)

Figure 3.

Different morphologies of DCIS presenting as calcifications. Group of punctate (a) and group of amorphous (b) calcifications. Biopsy revealed low grade DCIS. Group of coarse heterogeneous (c) and pleomorphic (d) calcifications. Biopsy revealed high grade DCIS.

Figure 4.

Segmental fine pleomorphic and fine linear branching calcifications. Biopsy revealed high grade DCIS. Fine linear and fine linear-branching calcifications are often seen in high nuclear grade lesions with comedonecrosis.

Figure 5.

Sonographic appearances of DCIS. Oval, hypoechoic mass with circumscribed margins with no specific posterior acoustic features (a). Biopsy revealed intermediate grade DCIS. Irregular mass with indistinct margins and echogenic foci consistent with calcifications (b). Biopsy revealed DCIS with microinvasion. Dilated ducts with debris and echogenic foci consistent with calcifications in a 39 year old women with suspicious nipple discharge (c). Biopsy revealed high grade DCIS.

Figure 6.

MRI appearances of DCIS. Axial T1-weighted fat-suppressed subtraction image (a) shows segmental non-mass enhancement with clumped internal enhancement. Pathology confirmed extensive high grade DCIS. Axial post-contrast T1 fat suppressed MRI image (b) shows an irregular mass with spiculated margins with a biopsy marker clip within the mass (arrow). Pathology confirmed high grade DCIS. Axial maximum intensity projection (c) shows a focus of enhancement (arrow) in a patient who had a breast MRI for recently diagnosed contralateral breast cancer. This was biopsied under MRI guidance and shown to represent low grade DCIS.