High grade ductal carcinoma in situ

Case contributed by Dr Valerio Giacalone


The patient presented with a hard mass on palpation of the outer quadrants of the left breast.

Patient Data

Age: 45 years
Gender: Female

Mammographic examination shows a coarse calcification that may be an expression of calcific fibroadenoma.
There are also multiple foci of irregular, amorphous microcalcifications, almost all of which are of the crushed stone type and some of which are mold-like, distributed in the super outer quadrant.
The characteristics of the calcifications are suspicious of malignancy.

MRI shows:

Fibroglandular Tissue (FTG): marked
Breast parenchymal enhancement (BPE): mild, more evident on the right.
In the context of the left breast after administration of paramagnetic contrast medium, there is an area of hypervascular parenchymal thickening extending craniocaudal for about 40 mm, with an anteroposterior diameter of about 26 mm and a transverse diameter of about 27 mm, whose intensity-time curve shows suspicious dynamic characteristics (wash-out dynamics). Another area with the same characteristics is found near the axillary extension (15 mm x 13 mm).
The larger area of enhancement shows close relationships with the pectoral fascia, in the absence of any appreciable signs of MRI infiltration.
Limited to the above findings there is a hypointense lesion in all sequences, with peripheral enhancement after administration of contrast medium to be referred to as a known calcific fibroadenoma.
Bilaterally appreciable multiple millimetric hypervascular foci in the phases after contrast, compatible with foci of hormonal activation.
There are no hypervascular lesions in the contralateral breast suspected to be foci of neovascularization.
Some lymph nodes with clear hilum coexist bilaterally in both axillary cavities.

The patient had undergone a tomosynthesis mammogram only 6 months previously, for initial hormone therapy, where the calcific nodule was appreciated, and some small calcifications were found adjacent to the nodule but were labeled as benign, and not investigated further.

Case Discussion

The patient underwent a mammographic examination that showed multiple suspicious microcalcifications and then a breast MRI examination that revealed an area of enhancement with suspicious dynamic features.
A biopsy examination was performed and revealed "foci of high-grade ductal carcinoma in situ (consistent P63+)".
The patient had undergone a tomosynthesis examination less than a year previously, performed to undertake a course of hormonal stimulation. On the previous tomosynthesis, the large calcific fibroadenoma was appreciable, but some small surrounding calcifications may warrant further evaluation. The patient will undergo mastectomy and the diagnostic process will continue.

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