Lars Grimm, MD, MHS , FSBI Associate Professor Department of Radiology Duke University Medical Center Multimodality Imaging of DCIS
Lars Grimm, MD, MHS, FSBI
Associate Professor
Department of Radiology
Duke University Medical Center
Multimodality Imaging
of DCIS
• Discuss classic and variant imaging appearances of DCIS on
mammography, US, and MRI
• Common mistakes and pitfalls in diagnosis
• Special case scenarios
Objectives
1. Average-risk screening
2. Symptomatic patient
3. High-risk screening
4. Upstaging of DCIS to invasive disease
5. Active surveillance
DCIS Scenarios
Average-Risk Screening
0
10
20
30
40
50
60
70
80
90In
cid
en
ce p
er
10
0,0
00
Invasive DCIS
+23%
+581%
DCIS Epidemiology
Data from SEER
Organized screening
• 909 consecutive cases of DCIS, 1980-1999
• 75% calcifications
• 27% associated soft-tissue abnormalities
• 12% palpable
• 12% nipple discharge
Barreau EJR 2005
Classic Mammographic Appearance
DCIS Calcifications
Rauch Ann Surg Oncol 2016
• DCIS reader study
• 10 readers, 150 cases of calcifications
• Interobserver variability
• Morphology: κ = 0.271
• Distribution: κ = 0.371
Limitations of BI-RADS
Grimm Unpublished Data
1. Mixed morphology
2. Coexisting benign pathologies
3. Incompatible distribution
4. Soft tissue density
5. Slow rate of growth
6. Failure to sufficiently evaluate morphology
Missed DCIS
Missed DCIS
BI-RADS: Coarse or ‘Popcorn-Like’
Multiple bilateral palpable masses, presumed FA
Missed DCIS
• Mixed morphology
• Coexisting benign pathologies
3.3 cm of DCIS
• Incompatible
distribution
• Soft tissue density
Missed DCIS
IDC
DCIS
Screening
• Coexisting benign pathologies
• Slow rate of growth
Missed DCIS
2007 2008 2011 2013
Missed DCIS
Synthetic Mammogram 2D Mammogram
• Failure to sufficiently evaluate morphology
Symptomatic DCIS
• Clinical symptoms: palpable, nipple discharge
• Imaging appearance: larger, non-calcified
• Histopathology: higher nuclear grade, ER negative, upstaged
to invasive disease
• Worse survival
Symptomatic DCIS
Koh Breast Cancer Res Treat 2015Shin AJR 2008
• Hypoechoic, irregular shaped, indistinct/microlobulated
margins
• Distended duct or invasive component
• Guide biopsy planning
Ultrasound of Calcified DCIS
• 58%-82% of non-calcified DCIS was symptomatic
• US only DCIS more likely low grade and small (<1 cm)
• Highly variable appearance
Ultrasound of Non-Calcified DCIS
Wang Radiographics 2013, Ikeda Radiology 1989, Kim J US Med 2009
DCIS + papillary lesionDCIS “Pseudomicrocystic” DCIS
• Periductal stiffness due to desmoplastic reaction
Elastography
Wang Radiographics 2013
• 105 women with pathologic nipple discharge
MRI for Nipple Discharge
Bahl AJR 2017
• Filling defects, obstruction, or
surface irregularity
• Association with suspicious
calcifications
Ductography for Nipple Discharge
Slawson Radiographics 2001
High-Risk Screening
• Higher sensitivity for DCIS than mammography (92% vs 56%)
• Dependent on grade: 98% for high, 91% for intermediate, and 80%
for low grade
MRI
Kuhl Lancet 2007
• Clumped non-mass enhancement
Classic MRI Appearance of DCIS
Linear Segmental Regional
• Enhancement of periductal stroma and duct wall
• Low/lowest frequency (<20%) of NME descriptors
• Highest PPV (65%) of NME descriptors
• High rate of DCIS (~40%)
Clustered Ring
Uematsu AJR 2012, Chikarmane AJR 2017
• Initial phase typically rapid
• Delayed phase variable
Kinetics
Jansen Radiology 2007
• Best means of defining extent
• Within 5 mm on MRI (60%) vs mammography (38%)
• Can identify both calcified and non-calcified
• Nipple extension
Extent of Disease
Marcotte-Bloch EJR 2011
“2 cm of amorphous calcifications” “6.3 cm of clumped NME”
Upstaging to Invasive Disease
Palpable
7 cm
Mass
DCIS Upstaged to Invasive Disease
Brennan Radiology 2011
All Upstaged to IDC
Active Surveillance
Active Surveillance Trials
LORETTA
Untreated DCIS
10 years
Untreated DCIS
4 years
5.4 cm
ER/PR+, high grade DCIS
6.8 cm
ER/PR/HER2+, high grade IDC
Untreated DCIS
ER/PR+, high grade DCIS
ER/PR+, HER2-, high grade IDC
3 years
Untreated DCIS
ER/PR+, high grade DCIS
ER/PR+, HER2-, high grade IDC
3 years
Thank You