Figure 1
Teaching Case
SectionBreast imaging
Case TypeClinical Cases
AuthorsDr.Teena Sleeba, Dr. Michelle Aline Antony, Dr. Krishna Prasad, Dr. Binu Joy
Connected authors
56 years, female
A 53-year-old post-menopausal lady presented for a mammogram due to occasional sensation of fullness in her right breast and a probable size difference she had noticed over a few months’ duration. No masses were felt clinically.
Multicentric high grade DCIS with invasion.
Lobular breast malignancy
Mastitis
Global asymmetry was seen on mammogram with no masses or microcalcifications.
Multiple subcentimetric ill-marginated nodules were seen in all quadrants of the right breast on US.
In view of suspicious morphology, US-guided core needle biopsy was taken from the most prominent lesions in two different quadrants. Histopathology revealed atypical cells and areas of DCIS.
MRI was then performed to evaluate the extent of the disease. Areas of nodular and linear non-mass areas of enhancement were seen. Disease activity was seen extending posteriorly till the pectoral with no involvement of the latter.
She underwent modified radical mastectomy with level 1 axillary nodal clearance. Due to lack of frozen section facility at the time the surgery was undertaken and given the diffuse extent of the disease, the decision to sample at least level 1 nodes was made. Gross specimen revealed extensive multicentric high grade DCIS with comedonecrosis and areas of invasive ductal carcinoma. All eleven nodes were negative.
Multiple subcentimetric ill-marginated nodules were seen in all quadrants of the right breast on US.
In view of suspicious morphology, US-guided core needle biopsy was taken from the most prominent lesions in two different quadrants. Histopathology revealed atypical cells and areas of DCIS.
MRI was then performed to evaluate the extent of the disease. Areas of nodular and linear non-mass areas of enhancement were seen. Disease activity was seen extending posteriorly till the pectoral with no involvement of the latter.
She underwent modified radical mastectomy with level 1 axillary nodal clearance. Due to lack of frozen section facility at the time the surgery was undertaken and given the diffuse extent of the disease, the decision to sample at least level 1 nodes was made. Gross specimen revealed extensive multicentric high grade DCIS with comedonecrosis and areas of invasive ductal carcinoma. All eleven nodes were negative.
Ductal carcinoma in situ (DCIS) is a heterogeneous spectrum of intraductal epithelial proliferations which have not breached the basement membrane [1]. It is a known precursor for invasive disease [2]. There has been a dramatic increase in the incidence of DCIS after screening mammograms got implemented into health care services [3].
DCIS typically present as microcalcifications on mammograms, however, approximately 10 - 20% of DCIS may be of the non-calcific variety [4].
Calcified DCIS tend to have more aggressive histological features than non-calcified DCIS with nuclear pleomorphism, more nucleoli and mitosis [5].
Comedonecrosis, though not mandatory, is a usual histological finding on calcified DCIS. This is due to rapid cell apoptosis and oncosis or passive cell death that is occurring within the tubulo-lobular unit. High grade DCIS is usually associated with the linear and branching type of microcalcification on mammogram [6].
In most cases DCIS usually involves the breast in a unicentric segmental fashion and true multicentric disease is unusual occurring in an estimated 10% of cases. Moreover, it is a known factor that patients who have both DCIS and invasion are clinically symptomatic [7].
Hence it was interesting that our patient was rather asymptomatic with no clinical findings while harboring multicentric high-grade DCIS with invasion. Mammogram too was conspicuous by lack of microcalcifcations.
Dedicated MRI techniques with high spatial resolution are capable of detecting as much as 98% of DCIS. A study done by Kuhl et al exclusively on patients with pure DCIS showed that MRI sensitivity was 98% compared with only 52% for mammography in women with high-grade DCIS [8].
To conclude, non–calcified DCIS may not always be associated with a lower histopathological grade. A multimodality approach with valuable information from MRI could play a vital role in diagnosing the entire extent of the disease and may eventually change the course of treatment for a given patient [9].
DCIS typically present as microcalcifications on mammograms, however, approximately 10 - 20% of DCIS may be of the non-calcific variety [4].
Calcified DCIS tend to have more aggressive histological features than non-calcified DCIS with nuclear pleomorphism, more nucleoli and mitosis [5].
Comedonecrosis, though not mandatory, is a usual histological finding on calcified DCIS. This is due to rapid cell apoptosis and oncosis or passive cell death that is occurring within the tubulo-lobular unit. High grade DCIS is usually associated with the linear and branching type of microcalcification on mammogram [6].
In most cases DCIS usually involves the breast in a unicentric segmental fashion and true multicentric disease is unusual occurring in an estimated 10% of cases. Moreover, it is a known factor that patients who have both DCIS and invasion are clinically symptomatic [7].
Hence it was interesting that our patient was rather asymptomatic with no clinical findings while harboring multicentric high-grade DCIS with invasion. Mammogram too was conspicuous by lack of microcalcifcations.
Dedicated MRI techniques with high spatial resolution are capable of detecting as much as 98% of DCIS. A study done by Kuhl et al exclusively on patients with pure DCIS showed that MRI sensitivity was 98% compared with only 52% for mammography in women with high-grade DCIS [8].
To conclude, non–calcified DCIS may not always be associated with a lower histopathological grade. A multimodality approach with valuable information from MRI could play a vital role in diagnosing the entire extent of the disease and may eventually change the course of treatment for a given patient [9].
References
[1] van Diest PJ (1999) Ductal carcinoma in situ in breast carcinogenesis. J Pathol 187: 383-4. (PMID: 10398095)
[2] ] Allred, C (2010) Ductal carcinoma in situ: terminology, classification, and natural history. J Natl Cancer Inst Monogr 41, 134-138. (PMID: 20956817)
[3] Joslyn SA (2006) : Ductal carcinoma in situ: trends in geographic, temporal, and demographic patterns of care and survival. Breast J 12: 20-7. (PMID: 16409583)
[4] Stomper, P.C., Connolly, J.L., Meyer, J.E. and Harris, J.R. (1989) Clinically Occult Ductal Carcinoma in Situ Detected with Mammography: Analysis of 100 Cases with Radiologic-Pathologic Correlation. Radiology 172, 235-241. (PMID: 2544922)
[5] Tani, H., Murakami, R., Kuwako, T., Kumita, S. and Matsubara, M. (2017) Calcified and Non-Calcified Ductal Carcinoma in Situ: Contrast Enhanced MRI Features and Pathological Correlation. Open Journal of Radiology 7, 151-163 (PMID: 23319110)
[6] Barnes, N.L.P., Dimopoulos, N., Williams, K.E., Howe, M., & Bundred, N.J. (2014) ). The frequency of presentation and clinico-pathological characteristics of symptomatic versus screen detected ductal carcinoma in situ of the breast. Eur J Surg Oncol 40, 249-252. (PMID: 24433818)
[7] Zunzunegui RG, Chung MA, Oruwari J, et al (2003) Casting-type calcifications with invasion and high-grade ductal carcinoma in situ: a more aggressive disease?. Arch Surg 138: 537-40. (PMID: 12742959)
[8] Kuhl CK, Schrading S, Bieling HB, et al. (2007) MRI for diagnosis of pure ductal carcinoma in situ: a prospective observational study. Lancet 370(9586):485–492. (PMID: 17693177)
[9] Marcotte-Bloch C, Balu-Maestro C, Chamorey E, et al. (2011) MRI for the size assessment of pure ductal carcinoma in situ (DCIS): a prospective study of 33 patients. Eur J Radiol 77(3):462–467 (PMID: 19896789)
Case information
| URL: | https://eurorad.org/case/15106 |
| DOI: | 10.1594/EURORAD/CASE.15106 |
| ISSN: | 1563-4086 |
License
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
Figure 2
Figure 3
Figure 4
Figure 5
Figure 6
Figure 7
Figure 8
Figure 1
Department of Radiology Rajagiri Hospital,Cochin,India
Figure 2
Department of Radiology Rajagiri Hospital,Cochin,India
Figure 3
Department of Radiology Rajagiri Hospital,Cochin,India
Figure 4
Department of Radiology Rajagiri hospital,Cochin,India
Figure 5
Department of Radiology,Rajagiri Hospital
Figure 6
Dept of Radiology Rajagiri hospital
Figure 7
Dept of Radiology Rajagiri hospital
Figure 8
Depatment of Radiology Rajagiri Hospital