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Pure Ductal Carcinoma in Situ: A Range of MRI Features

¹ All authors: Department of Radiology, Brigham and Women's Hospital, 75 Francis St., Boston, MA 02115.

View larger version (121K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A —70-year-old woman with recent (< 6 months previously) diagnosis of atypical lobular hyperplasia by stereotactic biopsy of right breast calcifications. Bilateral MRI was performed to rule out occult malignancy. In this and all subsequent figures, sagittal image is from first run of dynamic contrast-enhanced series, and axial image is from delayed contrast-enhanced series. Sagittal (A) and axial (B) T1-weighted fat-suppressed 3D fast spoiled gradient-recalled echo images after contrast injection show 1.5-cm area of ductal and clumped enhancement (arrows) in contralateral breast, with persistent enhancement kinetics and no mammographic correlate. MRI-directed core biopsy followed by excision revealed ductal carcinoma in situ, cribriform and solid types, intermediate nuclear grade, with central necrosis.

View larger version (103K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B —70-year-old woman with recent (< 6 months previously) diagnosis of atypical lobular hyperplasia by stereotactic biopsy of right breast calcifications. Bilateral MRI was performed to rule out occult malignancy. In this and all subsequent figures, sagittal image is from first run of dynamic contrast-enhanced series, and axial image is from delayed contrast-enhanced series. Sagittal (A) and axial (B) T1-weighted fat-suppressed 3D fast spoiled gradient-recalled echo images after contrast injection show 1.5-cm area of ductal and clumped enhancement (arrows) in contralateral breast, with persistent enhancement kinetics and no mammographic correlate. MRI-directed core biopsy followed by excision revealed ductal carcinoma in situ, cribriform and solid types, intermediate nuclear grade, with central necrosis.

View larger version (124K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A —62-year-old woman with recently diagnosed right breast cancer underwent bilateral MRI to evaluate extent of disease. Sagittal (A) and axial (B) T1-weighted fat-suppressed 3D fast spoiled gradient-recalled echo dynamic images show known cancer (arrows) in right breast.

View larger version (125K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B —62-year-old woman with recently diagnosed right breast cancer underwent bilateral MRI to evaluate extent of disease. Sagittal (A) and axial (B) T1-weighted fat-suppressed 3D fast spoiled gradient-recalled echo dynamic images show known cancer (arrows) in right breast.

View larger version (130K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2C —62-year-old woman with recently diagnosed right breast cancer underwent bilateral MRI to evaluate extent of disease. In contralateral lower, outer breast, area of ductal clumped enhancement (arrows) with washout kinetics is seen. No sonographic or mammographic correlates were found. MRI-guided core biopsy followed by surgical excision reveals ductal carcinoma in situ (DCIS)—solid, cribriform, and micropapillary types, intermediate grade—with central necrosis.

View larger version (133K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2D —62-year-old woman with recently diagnosed right breast cancer underwent bilateral MRI to evaluate extent of disease. In contralateral lower, outer breast, area of ductal clumped enhancement (arrows) with washout kinetics is seen. No sonographic or mammographic correlates were found. MRI-guided core biopsy followed by surgical excision reveals ductal carcinoma in situ (DCIS)—solid, cribriform, and micropapillary types, intermediate grade—with central necrosis.

View larger version (137K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2E —62-year-old woman with recently diagnosed right breast cancer underwent bilateral MRI to evaluate extent of disease. Pathology images (E, low magnification; F, high magnification) of estrogen receptor– and progesterone receptor–positive, HER2/neu-negative DCIS show involved ducts in linear array and little periductal fibrosis (arrows).

View larger version (151K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2F —62-year-old woman with recently diagnosed right breast cancer underwent bilateral MRI to evaluate extent of disease. Pathology images (E, low magnification; F, high magnification) of estrogen receptor– and progesterone receptor–positive, HER2/neu-negative DCIS show involved ducts in linear array and little periductal fibrosis (arrows).

View larger version (113K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A —48-year-old woman with history of low-to intermediate-grade ductal carcinoma in situ (DCIS) in left breast who was treated with lumpectomy and radiation therapy 6 years previously. Routine mammogram (not shown) revealed equivocal increase in 5-mm area of calcifications in treated left upper breast. Sagittal (A) and axial (B) bilateral MR images show area of linear clumped persistent enhancement in left upper outer quadrant (arrows) that did not definitely correlate with mammographic calcifications. MRI-guided core needle biopsy revealed DCIS, cribriform and solid types, intermediate nuclear grade, associated microcalcifications, and necrosis. Surgical excision found DCIS only.

View larger version (148K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B —48-year-old woman with history of low-to intermediate-grade ductal carcinoma in situ (DCIS) in left breast who was treated with lumpectomy and radiation therapy 6 years previously. Routine mammogram (not shown) revealed equivocal increase in 5-mm area of calcifications in treated left upper breast. Sagittal (A) and axial (B) bilateral MR images show area of linear clumped persistent enhancement in left upper outer quadrant (arrows) that did not definitely correlate with mammographic calcifications. MRI-guided core needle biopsy revealed DCIS, cribriform and solid types, intermediate nuclear grade, associated microcalcifications, and necrosis. Surgical excision found DCIS only.

View larger version (139K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4A —49-year-old woman with recent diagnosis of invasive ductal carcinoma (thin arrow, A) of left breast. Sagittal (A) and axial (B) MR images obtained to determine extent of disease shows additional area of rapid ductal homogeneous enhancement (thick arrows) and washout kinetics in upper outer quadrant 3 cm posterior to primary mass (thin arrow, A). Pathology (not shown) revealed ductal carcinoma in situ, cribriform type, high nuclear grade, without necrosis.

View larger version (130K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4B —49-year-old woman with recent diagnosis of invasive ductal carcinoma (thin arrow, A) of left breast. Sagittal (A) and axial (B) MR images obtained to determine extent of disease shows additional area of rapid ductal homogeneous enhancement (thick arrows) and washout kinetics in upper outer quadrant 3 cm posterior to primary mass (thin arrow, A). Pathology (not shown) revealed ductal carcinoma in situ, cribriform type, high nuclear grade, without necrosis.

View larger version (84K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5A —29–year-old woman with strong family history of breast cancer who presented with palpable right upper outer quadrant lump that was seen on sonography as a 1-cm solid mass. Biopsy revealed invasive ductal carcinoma. Sagittal (A) and axial (B) bilateral MR images obtained to evaluate extent of disease show rapidly enhancing mass (arrows) in axillary tail that corresponds to known cancer.

View larger version (86K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5B —29–year-old woman with strong family history of breast cancer who presented with palpable right upper outer quadrant lump that was seen on sonography as a 1-cm solid mass. Biopsy revealed invasive ductal carcinoma. Sagittal (A) and axial (B) bilateral MR images obtained to evaluate extent of disease show rapidly enhancing mass (arrows) in axillary tail that corresponds to known cancer.

View larger version (69K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5C —29–year-old woman with strong family history of breast cancer who presented with palpable right upper outer quadrant lump that was seen on sonography as a 1-cm solid mass. Biopsy revealed invasive ductal carcinoma. In addition, sagittal (C) and axial (D) images show 3 x 3 x 2 cm area of clumped persistent enhancement in segmental distribution in right lower central breast (arrows) without mammographic or sonographic correlates. MRI-directed core biopsy followed by surgical excision revealed extensive ductal carcinoma in situ, solid, cribriform, and clinging types, intermediate grade, with central necrosis.

View larger version (67K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5D —29–year-old woman with strong family history of breast cancer who presented with palpable right upper outer quadrant lump that was seen on sonography as a 1-cm solid mass. Biopsy revealed invasive ductal carcinoma. In addition, sagittal (C) and axial (D) images show 3 x 3 x 2 cm area of clumped persistent enhancement in segmental distribution in right lower central breast (arrows) without mammographic or sonographic correlates. MRI-directed core biopsy followed by surgical excision revealed extensive ductal carcinoma in situ, solid, cribriform, and clinging types, intermediate grade, with central necrosis.

View larger version (112K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6A —55-year-old woman with BRCA1 gene mutation and history of breast-conserving therapy, including radiation therapy, for solid and cribriform intermediate-grade ductal carcinoma in situ (DCIS) without necrosis in upper outer right breast 1 year previously. Contrast-enhanced T1-weighted fat-suppressed 3D fast spoiled gradient-recalled echo sagittal (A) and axial (B) images from routine surveillance MRI show focal area of clumped enhancement (arrows) with plateau kinetics in lower inner contralateral left breast. MRI-directed biopsy revealed DCIS, solid and cribriform types, intermediate grade, with necrosis.

View larger version (108K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6B —55-year-old woman with BRCA1 gene mutation and history of breast-conserving therapy, including radiation therapy, for solid and cribriform intermediate-grade ductal carcinoma in situ (DCIS) without necrosis in upper outer right breast 1 year previously. Contrast-enhanced T1-weighted fat-suppressed 3D fast spoiled gradient-recalled echo sagittal (A) and axial (B) images from routine surveillance MRI show focal area of clumped enhancement (arrows) with plateau kinetics in lower inner contralateral left breast. MRI-directed biopsy revealed DCIS, solid and cribriform types, intermediate grade, with necrosis.

View larger version (126K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7A —69-year-old woman with family history (sister) of breast cancer and recent negative mammogram. Sagittal (A) and axial (B) screening MR images obtained for surveillance show area of nonmass segmental clumped enhancement (arrows) with plateau kinetics in upper inner left breast. Pathology revealed ductal carcinoma in situ, solid and comedo types, high nuclear grade, with central necrosis.

View larger version (95K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7B —69-year-old woman with family history (sister) of breast cancer and recent negative mammogram. Sagittal (A) and axial (B) screening MR images obtained for surveillance show area of nonmass segmental clumped enhancement (arrows) with plateau kinetics in upper inner left breast. Pathology revealed ductal carcinoma in situ, solid and comedo types, high nuclear grade, with central necrosis.

View larger version (158K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8A —32-year-old woman with palpable right upper outer quadrant nodularity and negative mammography and sonography. Sagittal (A) and axial (B) MR images show nonmass regional heterogeneous persistent enhancement (arrows) in right lower outer quadrant, and no abnormality in upper breast. MRI-guided core biopsy and subsequent mastectomy (neither shown) revealed extensive ductal carcinoma in situ (DCIS) in region of MRI enhancement. DCIS was of solid, cribriform, and clinging types, high nuclear grade, without necrosis.

View larger version (151K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8B —32-year-old woman with palpable right upper outer quadrant nodularity and negative mammography and sonography. Sagittal (A) and axial (B) MR images show nonmass regional heterogeneous persistent enhancement (arrows) in right lower outer quadrant, and no abnormality in upper breast. MRI-guided core biopsy and subsequent mastectomy (neither shown) revealed extensive ductal carcinoma in situ (DCIS) in region of MRI enhancement. DCIS was of solid, cribriform, and clinging types, high nuclear grade, without necrosis.

View larger version (125K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9A —50-year-old woman with strong family history of breast and ovarian cancer (maternal aunts, grandmother, and great aunts). Mammography (not shown) showed group of faint heterogeneous calcifications at 12-o'clock position in right breast. Sagittal (A) and axial (B) MR images show 6 x 3 x 2 cm nonmass with regional rapid contrast uptake (arrows) in right upper inner quadrant, heterogeneous internal enhancement, and persistent kinetics separate from area of calcifications. Pathology of MRI-directed excision (not shown) revealed ductal carcinoma in situ, cribriform and papillary types, intermediate grade. Surgical biopsy (not shown) of mammographically detected calcifications in superior central breast revealed lobular carcinoma in situ.

View larger version (120K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9B —50-year-old woman with strong family history of breast and ovarian cancer (maternal aunts, grandmother, and great aunts). Mammography (not shown) showed group of faint heterogeneous calcifications at 12-o'clock position in right breast. Sagittal (A) and axial (B) MR images show 6 x 3 x 2 cm nonmass with regional rapid contrast uptake (arrows) in right upper inner quadrant, heterogeneous internal enhancement, and persistent kinetics separate from area of calcifications. Pathology of MRI-directed excision (not shown) revealed ductal carcinoma in situ, cribriform and papillary types, intermediate grade. Surgical biopsy (not shown) of mammographically detected calcifications in superior central breast revealed lobular carcinoma in situ.

View larger version (94K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10A —43-year-old woman who presented with palpable firmness in outer upper quadrant of her left breast while breast-feeding. Bilateral mammogram (not shown) showed suspicious pleomorphic calcifications in corresponding region. Stereotactically guided core biopsy (not shown) revealed cribriform and solid types of ductal carcinoma in situ, intermediate nuclear grade. Sagittal MR images obtained to evaluate extent of disease show segmental area of rapid homogeneous enhancement and washout kinetics (arrows) encompassing most of upper outer quadrant.

View larger version (96K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10B —43-year-old woman who presented with palpable firmness in outer upper quadrant of her left breast while breast-feeding. Bilateral mammogram (not shown) showed suspicious pleomorphic calcifications in corresponding region. Stereotactically guided core biopsy (not shown) revealed cribriform and solid types of ductal carcinoma in situ, intermediate nuclear grade. Sagittal MR images obtained to evaluate extent of disease show segmental area of rapid homogeneous enhancement and washout kinetics (arrows) encompassing most of upper outer quadrant.

View larger version (85K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10C —43-year-old woman who presented with palpable firmness in outer upper quadrant of her left breast while breast-feeding. Bilateral mammogram (not shown) showed suspicious pleomorphic calcifications in corresponding region. Stereotactically guided core biopsy (not shown) revealed cribriform and solid types of ductal carcinoma in situ, intermediate nuclear grade. Sagittal MR images obtained to evaluate extent of disease show segmental area of rapid homogeneous enhancement and washout kinetics (arrows) encompassing most of upper outer quadrant.

View larger version (147K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10D —43-year-old woman who presented with palpable firmness in outer upper quadrant of her left breast while breast-feeding. Bilateral mammogram (not shown) showed suspicious pleomorphic calcifications in corresponding region. Stereotactically guided core biopsy (not shown) revealed cribriform and solid types of ductal carcinoma in situ, intermediate nuclear grade. Extent of involvement is well visualized on 3D maximum intensity projections (arrows).

View larger version (132K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10E —43-year-old woman who presented with palpable firmness in outer upper quadrant of her left breast while breast-feeding. Bilateral mammogram (not shown) showed suspicious pleomorphic calcifications in corresponding region. Stereotactically guided core biopsy (not shown) revealed cribriform and solid types of ductal carcinoma in situ, intermediate nuclear grade. Extent of involvement is well visualized on 3D maximum intensity projections (arrows).

View larger version (138K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11A —70-year-old woman with history of grade 2 invasive, mixed ductal and lobular carcinoma in left breast and associated ductal carcinoma in situ (DCIS) 2 years previously. Patient was treated with lumpectomy and radiation therapy. On routine follow-up mammography (not shown), new 0.8-cm right upper outer quadrant mass was seen. Sagittal (A) and axial (B and C) MR images identify this mammographically detected lesion as rim-enhancing round mass (thick arrow, A) with irregular margins and heterogeneous internal enhancement. In addition, MR images show 0.5 x 0.7 cm nonmass ductal clumped enhancement (thin arrow) with persistent kinetics 4 cm anterior and inferior to mass. Sonographically guided core biopsy of mass (not shown) revealed invasive ductal carcinoma, but area of clumped enhancement was visible only on MRI. Subsequent MRI-guided core biopsy and surgical excision (neither shown) of this nonmass enhancement revealed DCIS, solid type, intermediate to high nuclear grade.

View larger version (118K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11B —70-year-old woman with history of grade 2 invasive, mixed ductal and lobular carcinoma in left breast and associated ductal carcinoma in situ (DCIS) 2 years previously. Patient was treated with lumpectomy and radiation therapy. On routine follow-up mammography (not shown), new 0.8-cm right upper outer quadrant mass was seen. Sagittal (A) and axial (B and C) MR images identify this mammographically detected lesion as rim-enhancing round mass (thick arrow, A) with irregular margins and heterogeneous internal enhancement. In addition, MR images show 0.5 x 0.7 cm nonmass ductal clumped enhancement (thin arrow) with persistent kinetics 4 cm anterior and inferior to mass. Sonographically guided core biopsy of mass (not shown) revealed invasive ductal carcinoma, but area of clumped enhancement was visible only on MRI. Subsequent MRI-guided core biopsy and surgical excision (neither shown) of this nonmass enhancement revealed DCIS, solid type, intermediate to high nuclear grade.

View larger version (124K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11C —70-year-old woman with history of grade 2 invasive, mixed ductal and lobular carcinoma in left breast and associated ductal carcinoma in situ (DCIS) 2 years previously. Patient was treated with lumpectomy and radiation therapy. On routine follow-up mammography (not shown), new 0.8-cm right upper outer quadrant mass was seen. Sagittal (A) and axial (B and C) MR images identify this mammographically detected lesion as rim-enhancing round mass (thick arrow, A) with irregular margins and heterogeneous internal enhancement. In addition, MR images show 0.5 x 0.7 cm nonmass ductal clumped enhancement (thin arrow) with persistent kinetics 4 cm anterior and inferior to mass. Sonographically guided core biopsy of mass (not shown) revealed invasive ductal carcinoma, but area of clumped enhancement was visible only on MRI. Subsequent MRI-guided core biopsy and surgical excision (neither shown) of this nonmass enhancement revealed DCIS, solid type, intermediate to high nuclear grade.

View larger version (135K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12A —47-year-old woman with strong family history (mother) of breast cancer. Developing density on screening mammography with no sonographic correlate led to bilateral breast MRI. Contrast-enhanced sagittal (A) and axial (B) images show 2-cm irregular mass (arrows) with rapid homogeneous enhancement and plateau kinetics in inferior central right breast. Pathology (not shown) revealed ductal carcinoma in situ (DCIS), comedo and cribriform types, high nuclear grade, with central necrosis.

View larger version (121K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12B —47-year-old woman with strong family history (mother) of breast cancer. Developing density on screening mammography with no sonographic correlate led to bilateral breast MRI. Contrast-enhanced sagittal (A) and axial (B) images show 2-cm irregular mass (arrows) with rapid homogeneous enhancement and plateau kinetics in inferior central right breast. Pathology (not shown) revealed ductal carcinoma in situ (DCIS), comedo and cribriform types, high nuclear grade, with central necrosis.

View larger version (159K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12C —47-year-old woman with strong family history (mother) of breast cancer. Developing density on screening mammography with no sonographic correlate led to bilateral breast MRI. Pathology images (C, low magnification; D, high magnification) show estrogen receptor– and progesterone receptor–positive, HER2/neu-positive DCIS with marked periductal fibrosis (arrows) in contrast to adipose tissue in upper right corner of both images. Involved ducts are clustered, markedly distended, and enlarged.

View larger version (135K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12D —47-year-old woman with strong family history (mother) of breast cancer. Developing density on screening mammography with no sonographic correlate led to bilateral breast MRI. Pathology images (C, low magnification; D, high magnification) show estrogen receptor– and progesterone receptor–positive, HER2/neu-positive DCIS with marked periductal fibrosis (arrows) in contrast to adipose tissue in upper right corner of both images. Involved ducts are clustered, markedly distended, and enlarged.

View larger version (8K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 13A —Kinetic curve characteristics of pure ductal carcinoma in situ. Graphs were drawn by CADstream computer-aided evaluation system (CADstream, version 4.1, Confirma). Typical dynamic time–intensity curves show initial rapid uptake followed by either persistent increase in signal intensity (type I), associated with 6% risk of malignancy (A); signal intensity not increasing after initial rise, reaching plateau (type II), 64% probability of malignancy (B); or rapid washout in delayed phase (type III), 87% probability of malignancy (C) [10].

View larger version (8K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 13B —Kinetic curve characteristics of pure ductal carcinoma in situ. Graphs were drawn by CADstream computer-aided evaluation system (CADstream, version 4.1, Confirma). Typical dynamic time–intensity curves show initial rapid uptake followed by either persistent increase in signal intensity (type I), associated with 6% risk of malignancy (A); signal intensity not increasing after initial rise, reaching plateau (type II), 64% probability of malignancy (B); or rapid washout in delayed phase (type III), 87% probability of malignancy (C) [10].

View larger version (9K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 13C —Kinetic curve characteristics of pure ductal carcinoma in situ. Graphs were drawn by CADstream computer-aided evaluation system (CADstream, version 4.1, Confirma). Typical dynamic time–intensity curves show initial rapid uptake followed by either persistent increase in signal intensity (type I), associated with 6% risk of malignancy (A); signal intensity not increasing after initial rise, reaching plateau (type II), 64% probability of malignancy (B); or rapid washout in delayed phase (type III), 87% probability of malignancy (C) [10].

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