Ductal carcinoma in situ
Ductal carcinoma in situ (DCIS) refers to a breast carcinoma limited to the ducts with no extension beyond the basement membrane, as a result of which the disease has not infiltrated the parenchyma of the breast and the lymphatics and cannot therefore metastasise.
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Epidemiology
The detection of DCIS has increased markedly in recent years secondary to the widespread use of screening mammography, and it now accounts for 25-40% of mammographically detected breast cancers 1,3. It also accounts for approximately 15-20% of all detected breast cancers
Risk factors for DCIS are similar to those for invasive carcinoma and include:
- increasing age
- family history of breast cancer
- nulliparity
- age of 30 years or older at the birth of the first child
Clinical presentation
Although most patients are asymptomatic, some present with nipple-related disease (nipple discharge or Paget disease of the breast) or have palpable abnormalities.
Pathology
DCIS is the non-obligate precursor of infiltrating ductal carcinoma (IDC). In the context of "over diagnosis" the low grade DCIS cases found on screening mammography are likely to cause to the number of cases where the diagnosis of breast malignancy has been made but could conceivably not have been fatal to the patient. Remember that to try and guess the grade of DCIS on the mammogram images is not plausible or reproducible. Low grade DCIS is not a dangerous disease and there is actually some thought on following the disease with MRI after a histological diagnosis has been made.
DCIS is not a single entity, but rather a spectrum of disease 3. In essence, it refers to breast epithelial cells that have become "cancerous" but still reside in their normal place in the ducts and lobules 10.
Markers
In some situations immunohistochemical staining for E-cadherin may help to differentiate from lobular carcinoma in situ.
Sub types
The traditional classification broadly divided DICS lesions into two types mainly based on central necrosis, grade, and cell type:
- comedo - large cell: more aggressive form; also referred to as comedocarcinoma
-
non-comedo - small cell: less aggressive; can be further divided into
- cribriform
- micropapillary
- papillary
- solid
New pathologic classification of DCIS is based on nuclear atypia and degree of necrosis.
Associations
- up to 11% of predetermined DCIS on imaging may have an invasive component at the time a biopsy is done 2
- 20-25% of DCIS revealed on core biopsy may have invasive ductal carcinoma following surgical excision
Radiographic features
Mammography
There are varied mammographic manifestations of DCIS, with casting-type calcifications being the most common (present in 50-75% of cases 3). Other manifestations include a soft-tissue opacity either with or without associated calcifications.
Although DCIS calcifications may assume varied appearances, linear calcifications are more likely to be associated with comedo-type DCIS, while granular calcifications are more often correlated with non-comedo DCIS.
Occasionally DCIS appears as a simple mass or asymmetry without calcification (~8% of cases) 12.
There may be a significant discrepancy between the distribution of the disease as seen on the mammogram and the distribution of the disease on the pathology specimen of the breast as examined by the pathologist. In general, the calcification underestimates the distribution of DCIS in the breast, i.e. not all the DCIS calcifies.
Breast ultrasound
One of the benefits of identifying a corresponding sonographic abnormality in women with mammographically detected DCIS is to use ultrasound to guide interventional (e.g. biopsy/hookwire) procedures. A microlobulated mild hypoechoic mass with ductal extension and normal acoustic transmission is considered the most common feature in sonographically detected DCIS.
With good quality ultrasound and enough effort, it is possible in everyday practice to identify the DCIS process as it grows in the ductal system of the breast. It is quite possible to identify those minute wild and crazy calcifications of DCIS in the ducts itself and ultrasound guided biopsy of DCIS is now an everyday procedure.
Breast MRI
DCISs can present as "no mass enhancement", "clustered ring enhancement", or a " mass or focus" on a contrast MRI. When enhanced, DCIS does not show a specific pattern and instead may be seen as a segmental or regional enhancement, branching and linear or mass enhancement with or without an irregular shape.
Treatment and prognosis
Treatment options for DCIS include mastectomy, lumpectomy with breast irradiation, or, for patients with small lesions (<1-2 cm) of low-grade DCIS, lumpectomy alone.
This disease is likely the precursor of IDC at a stage of the disease when the therapy is potentially curable. The advantage of diagnosis DCIS is that the chances of encountering metastatic disease are in theory zero when compared with IDC. With the introduction of screening mammography, the decreased mortality of breast carcinoma is in some part due to the identification of DCIS and effective therapy. In large screening programmes DCIS make up to 30% of malignancies diagnosed.
History and etymology
With the widespread use of screening mammography this disease is now commonly found before infiltrating ductal carcinoma (IDC) develops 15.
The historical background and current perspectives of DCIS need to acknowledge the role Roland Holland played in the process in the Netherlands 14.
Related articles
Breast imaging and pathology
- breast screening
-
mammography
- breast imaging and the technologist
- forbidden (check) areas in mammography
-
mammography views
- craniocaudal view
- mediolateral oblique view
- additional (supplementary) views
- true lateral view
- lateromedial oblique view
- late mediolateral view
- step oblique views
- spot view
- double spot compression view
- magnification view
- exaggerated craniocaudal (axillary) view
- cleavage view
- tangential views
- caudocranial view
- bullseye CC view
- rolled CC view
- elevated craniocaudal projection
- caudal cranial projection
- 20° oblique projection
- inferomedial superolateral oblique projection
- Eklund technique
- normal breast imaging examples
- digital breast tomosynthesis
- breast ultrasound
- breast ductography
- breast MRI
- breast morphology
- breast pathology
- malignant lesions
-
breast cancer
- breast adenocacrinoma
- ductal breast carcinoma
- ductal carcinoma in situ (DCIS)
- invasive ductal carcinoma
- lobular breast carcinoma
- ductal breast carcinoma
- adenoid cystic carcinoma of the breast
- apocrine carcinoma of the breast
- breast cancer metastases
- breast lymphoma
- breast sarcoma
- inflammatory carcinoma of breast
- intracystic breast cancer
- male breast cancer
- malignant phyllodes tumour
- metastases to the breast
- metaplastic carcinoma the breast
- gamuts
- breast adenocacrinoma
-
breast cancer
- borderline breast disease / high risk breast lesion
- benign lesions
- adenosis of the breast
- benign papillary lesions of the breast
- breast cyst
- breast haematoma
- breast hamartoma
- breast lipoma
- ductal adenoma of the breast
- epidermal inclusion cysts of the breast
- fat necrosis of the breast
- fibroadenoma
- granular cell tumour of the breast
- gynaecomastia
- lymphocytic mastitis
- mammary fibromatosis
- oil cyst
- phyllodes tumour
- post surgical breast scar
- post traumatic fibrosis
- pseudoangiomatous stromal hyperplasia (PASH)
- pseudogynaecomastia
- tubular adenoma
-
breast calcifications (approach)
- morphology
- distribution
- location
- lobular calcification within breast tissue
- intraductal calcification within breast tissue
- milk of calcium within a breast cyst
- vascular calcification in breast tissue
- skin (dermal) calcification in / around breast tissue
- suture calcification within breast tissue
- stromal calcification within breast tissue
- artifactual calcification from outside the breast
- suspicious breast calcifications
- infection/inflammation
- vascular lesions
- systemic disease
- gamuts
- classification systems
- malignant lesions
- breast cancer staging