DOI:10.2214/AJR.07.2206
AJR 2008; 190:516-525
© American Roentgen Ray Society
Screening-Detected and Symptomatic Ductal Carcinoma in Situ: Differences in the Sonographic and Pathologic Features
Hee Jung Shin1,
Hak Hee Kim1,
Sun Mi Kim1,
Gui Young Kwon2,
Gyungyub Gong2 and
On Koo Cho3
1 Department of Radiology and Research Institute of Radiology, Asan Medical
Center, University of Ulsan, College of Medicine, 388-1 Pungnap-dong,
Songpa-Gu, Seoul 138-376, Korea.
2 Department of Pathology, Asan Medical Center, University of Ulsan, College of
Medicine, Seoul, Korea.
3 Department of Radiology, Hanyang University Hospital, College of Medicine,
Seoul, Korea.
Received March 9, 2007;
accepted after revision September 9, 2007.
Address correspondence to H. H. Kim
(hhkim{at}amc.seoul.kr).
Abstract
OBJECTIVE. The purpose of our study was to retrospectively compare
the sonographic and pathologic features of screening-detected and symptomatic
ductal carcinoma in situ (DCIS).
MATERIALS AND METHODS. Of 5,790 cases diagnosed as breast cancer at
our institution between January 1998 and December 2005, 528 (9.1%) cases were
DCIS. We found 106 screening-detected and 125 symptomatic DCIS lesions in 226
patients (age range, 20–77 years; mean age, 47.8 years) who underwent
preoperative whole-breast sonography and mammography. Three radiologists
reviewed the sonographic features of these 231 cases of DCIS by consensus
according to Breast Imaging Reporting and Data System (BI-RADS). The
pathologic features were also reviewed. Statistical comparisons were performed
using the chi-square test, the Fisher's exact test, and the Mann-Whitney
U test.
RESULTS. On sonography, masses (p < 0.001) and
associated ductal change (p = 0.019) were more common in symptomatic
than in asymptomatic patients. Associated microcalcifications and posterior
shadowing were more frequently found in screening-detected than in symptomatic
DCIS (p < 0.001). On mammography, microcalcifications were more
common in screening-detected than in symptomatic DCIS, and masses were more
common in symptomatic than in screening-detected DCIS (p < 0.001).
No significant differences were seen in the pathologic features of the two
groups.
CONCLUSION. Our results showed that differences exist in the
sonographic features of screening-detected and symptomatic DCIS. Recognition
of the many and varied sonographic appearances of DCIS might be helpful to
decrease the false-negative rate of bilateral whole-breast sonography and to
detect symptomatic mammographically occult DCIS when we use sonography to
supplement mammography.
Keywords: breast • breast neoplasm • ductal carcinoma in situ • mammography • pathology • screening • sonograph
Introduction
Ductal carcinoma in situ (DCIS) represents a spectrum of noninvasive breast
cancers composed of malignant epithelial cells still surrounded by the normal
basement membrane of the duct
[1]. Before the use of
widespread mammographic screening, DCIS was rarely detected and accounted for
only 0.8–5.0% of all breast cancers
[1]. In recent years, DCIS has
been encountered more frequently because of the widespread use of mammographic
screening in asymptomatic women. DCIS now accounts for as much as 30% of
breast cancers in screened populations and approximately 5% of breast
carcinomas in symptomatic women
[2–4].
Generally, DCIS is clinically silent but can manifest as a palpable mass,
nipple discharge, or Paget's disease
[1,
5]. DCIS represents a broad
biologic spectrum of disease and has become increasingly important due to both
a dramatic rise in the detection rate and an ongoing controversy regarding its
clinical significance and optimal treatment
[6,
7]. Treatment ranges from
simple excision to various forms of wider excision (segmental resection,
quadrant resection, and so forth), all of which may or may not be followed by
radiation therapy [7]. Because
DCIS is a heterogeneous group of lesions rather than a single entity, and
because patients have a wide variety of personal needs that must be considered
during treatment selection, it is obvious that no single approach will be
appropriate for all forms of the disease or for all patients
[7]. Therefore, treatment
decisions are based on a variety of measurable parameters (tumor extent,
margin width, nuclear grade, comedo-type architecture, and so forth)
[7].
The mammographic features of DCIS have been well described in the
literature, with microcalcifications being the dominant feature
[4,
8,
9]. Other findings, such as
masses, architectural distortions, dilated retroareolar ducts, and developing
densities, have also been reported
[10,
11]. Although most cases of
DCIS are diagnosed mammographically, 6–23% of DCIS lesions are not
visible on mammography [3,
4,
10]. Several studies have
examined the role of sonography in the evaluation of mammographically detected
microcalcifications and the sonographic findings of DCIS
[12–16].
Yang and Tse [17] described
the sonographic and mammographic features of symptomatic DCIS. To our
knowledge, little is known about the differences in the sonographic features
of screening-detected and symptomatic DCIS. The purpose of this study was to
retrospectively compare the sonographic and pathologic features of
screening-detected and symptomatic DCIS.
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Fig. 1B —41-year-old woman with painless palpable mass in left breast.
Orthogonal sonograms show irregularly shaped, mixed hyper- and hypoechoic
lesion (arrows) in left breast. Surgery confirmed intermediate grade
papillary ductal carcinoma in situ.
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Fig. 1C —41-year-old woman with painless palpable mass in left breast.
Orthogonal sonograms show irregularly shaped, mixed hyper- and hypoechoic
lesion (arrows) in left breast. Surgery confirmed intermediate grade
papillary ductal carcinoma in situ.
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Materials and Methods
Patient Selection
This retrospective study of images and data was approved by the
institutional review board of our institution. The requirement for individual
patient informed consent was waived. From January 1998 to December 2005, 5,790
cases of breast cancer were diagnosed at our institution. Of these cases, 528
patients (9.1%) had DCIS. We found 226 patients who underwent bilateral
whole-breast sonography preoperatively.
We classified a lesion detected on screening mammography or screening
whole-breast sonography in the women without any symptoms as
screening-detected DCIS, and a lesion detected on mammography or sonography in
symptomatic patients with a palpable abnormality, nipple discharge, or Paget's
disease as symptomatic DCIS. Of 226 patients, 18 had bilateral cancers.
Thirteen patients had invasive carcinoma in the contralateral breast. The
remaining five patients had bilateral DCIS. Therefore, we included 231 lesions
from 226 women who underwent whole-breast sonography preoperatively; and the
remaining 302 cases were excluded from this study because the patients did not
undergo preoperative sonography.
In our institution, screening whole-breast sonography was performed in
women with dense breast tissue, in high-risk women younger than 40 years with
a family history of breast cancer, and in women who themselves wanted to
undergo screening. Diagnostic sonography was performed in women with newly
diagnosed cancer to assess the extent of disease (multifocality,
multicentricity, or bilaterality) and in symptomatic women with a palpable
abnormality or nipple discharge.
Clinical Features
The following clinical features were obtained from the medical records.
These were whether DCIS was detected on screening mammography or screening
whole-breast sonography, and include the presence of symptoms such as a
palpable abnormality, nipple discharge, or Paget's disease. One hundred one
women were asymptomatic, and 125 women exhibited symptoms. Of the 125 women
with symptomatic DCIS lesions, 86 (69%) had a palpable mass, 25 (20%) had
spontaneous nipple discharge, 13 (10%) had both a palpable abnormality and
nipple discharge, and only one woman (1%) had Paget's disease of the nipple.
Therefore, 38 patients had spontaneous and uniorificial nipple discharge,
which was bloody in 16 and serous in 22.
Sonography
Three radiologists performed whole-breast sonography of all 226 study
patients. Sonography was performed with 5–12-MHz transducers on an
HDI-3000, HDI-5000, or IU-22 (Philips Medical Systems) sonography unit. We
usually performed whole-breast sonography, not targeted sonography, to
evaluate mammographic or clinical findings. The usual time to complete a
bilateral whole-breast sonographic examination was 15–30 minutes.
Lesions that did not fulfill the criteria of benignity as defined by Stavros
et al. [18] were evaluated
using sonographically guided biopsies such as core-needle or fine-needle
aspiration biopsies. Sonograms were retrospectively reviewed independently by
three breast radiologists with 3, 6, and 15 years of clinical experience, and
the sonographic features were recorded with reference to the mammographic and
clinical findings. A consensus interpretation was reached in cases of
disagreement. Whole-breast sonography was performed in the transverse and
longitudinal planes, and scanning was begun in the right breast with woman's
arm raised above her head. Investigators documented each lesion with an image
of its largest horizontal diameter and an image perpendicular to that with its
respective diameter. For each lesion, investigators recorded the location
according to positions on the clock face, and estimated the distance from the
nipple in centimeters. If there was uncertainty in correlation of mammographic
findings with sonographic abnormalities, a small radiopaque marker was placed
on the skin over the lesion. The area was reevaluated with mammography, and
finding the marker in the expected location confirmed that the same lesion was
being imaged.
The sonographic findings were classified as negative, mass, or nonmass
lesion. As in the MRI lexicon of BI-RADS
[19], in our study we defined
a nonmass lesion as a lesion with minimal or no mass effect, a focal
heterogeneity distinguished from the adjacent normal breast parenchyma, or
calcifications not associated with a mass. Nonmass lesions could have areas or
spots of normal glandular tissue or fat interspersed with these lesions (Fig.
1A,
1B,
1C). When a mass was present,
the sonographic findings were evaluated according to sonographic BI-RADS
[20] lexicon—that is,
the shape (oval, round, or irregular), its orientation (parallel to the skin
surface or not), the margin (circumscribed or not circumscribed), lesion
boundary (abrupt interface or echogenic halo), echo pattern (isoechoic,
hypoechoic, complex cystic, mixed hyper- and hypoechoic), posterior acoustic
features (none, enhancement, or shadowing), associated ductal change, the
presence of microcalcifications (none, microcalcifications in mass, or
microcalcifications outside of mass), and size. Distribution of calcifications
seen on sonography was subsequently classified as clustered or nonclustered.
Calcifications in a mass or calcifications that were not associated with a
mass and smaller than 1 cm3 in volume on sonography were defined as
clustered calcifications. Scattered calcifications within and outside of a
mass or calcifications that were scattered over more than 1 cm3 in
volume were defined as nonclustered calcifications.
Mammography
Mammograms were available in 220 DCIS cases from 215 patients. Mammograms
in two of another 11 patients were not available because of lost films, and
nine other patients had not undergone mammography because of their young age;
these patients were excluded from the analysis of mammographic findings.
Mammography in two standard imaging planes—the mediolateral oblique
(MLO) and craniocaudal (CC)—was performed with a Senographe DMR scanner
(GE Healthcare) or with a Performa scanner (Instrumentarium), with additional
views being obtained as necessary. Mammograms were retrospectively reviewed by
three breast radiologists for masses, calcifications, masses with
calcifications, and architectural distortions according to the BI-RADS lexicon
[21]. The mammographic
features were recorded, and any discrepancy in opinion was also resolved by
consensus.
We also reviewed mammograms in 528 patients. Six patients had bilateral
DCIS. Thirty-seven mammograms were not available for this retrospective
review.
Galactography
Galactography was performed in 17 (45%) of the 38 patients with nipple
discharge, which was bloody in 16 and serous in 22. Galactography was
performed by cannulation of the ductal opening using a 30-gauge Jabczenski
cannula (Cook). Nonionic iodinated contrast material (Iopamiron 300
[iopamidol], Bracco) was injected until the patient felt discomfort or pain.
Two mammographic views (CC and MLO) were then obtained. The procedure was not
attempted in the eight patients in whom no discharge was expressible at the
time of examination. Sonography with biopsy was done before galactography
because of associated palpable abnormalities (n = 13) that resulted
in a diagnosis of DCIS, and galactography was not performed in these patients.
Three radiologists also retrospectively reviewed the galactograms by
consensus.
Histopathology
Histopathologic findings in excisional biopsy, breast-conserving surgery,
or mastectomy specimens served as the gold standard. Two pathologists analyzed
the following histologic parameters: nuclear grade, comedo necrosis,
microinvasion, hormonal receptor, P53 tumor suppressor gene, C-erbB-2
oncogene, and size. Lesions were also classified using the Van Nuys
classification system [22,
23]. Lesions with pure DCIS
and DCIS with microinvasion (invasive focus of 
1 mm) as defined by
previously published criteria
[24] were included in this
study. Available long-term follow-up data on patients with microinvasive
carcinoma suggest that the prognosis after surgery is excellent, and that
there is no difference in local recurrence and overall survival rates when
compared with those of patients with pure DCIS
[25]. In general, the
therapeutic algorithm is similar for patients with pure DCIS and those with
DCIS with microinvasion [26].
However, for pure DCIS, sentinel node imaging is not indicated at excision,
whereas it is performed for DCIS with microinvasion. Patients with DCIS
associated with minimal invasion and infiltrative ductal cancer were excluded
from our study.
Statistical Analysis
To determine whether there are differences in the sonographic,
mammographic, and pathologic findings between screening-detected and
symptomatic DCIS, statistical analysis was performed using a statistical
software system (SPSS for Windows, 2002, version 11.0; Microsoft Institute).
The Fisher's exact test and chi-square test were used for the nonparametric
independent variables, and the Mann-Whitney U test was used for the
variables such as age, sonographic size, and pathologic size with abnormal
distributions. Findings with a p value of less than 0.05 were
considered to be statistically significant.
Results
Two hundred twenty-six women (age range, 20–77 years; mean, 47.8
years) with 231 DCIS lesions were included in the study group. Of these 231
cases, 106 lesions in 101 women (age range, 33–73 years; mean, 50.5
years) constituted the screening-detected group, and 125 lesions in 125 women
(age range, 20–77 years; mean, 45.5 years) constituted the symptomatic
group. The mean age of the screening-detected group was significantly greater
than that of the symptomatic group (p < 0.001).
Sonography
There were 12 false-negative cases on sonography, which included 11
screening-detected DCIS cases and one symptomatic case. Of 11 false-negative
cases in the screening-detected group, 10 showed microcalcifications and only
one showed architectural distortion on mammography. The one false-negative
case in the symptomatic group showed a mass with microcalcifications on
mammography, and this patient presented with a palpable abnormality.
False-negative cases and nonmass lesions were more frequently found in
screening-detected patients than in the symptomatic group, whereas masses were
more common in the symptomatic than in the screening-detected group
(p < 0.001) (Table
1). Although false-negative mammographic results were more
frequently found in symptomatic than in screening-detected DCIS, 124 (99%) of
125 symptomatic DCIS lesions were detected on whole-breast sonography.
A total of 193 masses were detected on sonography for both
screening-detected (asymptomatic) and symptomatic DCIS. The sonographic
findings of these masses were as follows
(Table 2): The shape of a mass
was irregular in 124 cases (124/193, 64%) (Fig.
2A,
2B,
2C,
2D) and oval in 70 cases
(70/193, 36%) (Fig. 3A,
3B,
3C). The margin of a mass was
indistinct in 98 cases (98/193, 51%) (Fig.
2A,
2B,
2C,
2D), microlobulated in 77 cases
(77/193, 40%) and circumscribed in 18 cases (18/193, 9%) (Fig.
3A,
3B,
3C). No significant difference
was seen in the shape (p = 0.377) and margin (p = 0.398) of
a mass between the symptomatic and the screening-detected groups. The
orientation of the mass was parallel in 185 cases (185/193, 96%) and not
parallel in eight cases (8/193, 4%). The lesion boundary of the mass showed an
echogenic halo in 138 cases (138/193, 72%) and an abrupt interface in 55 cases
(55/193, 28%). Also, no significant difference was seen in the orientation
(p = 0.194) and the lesion boundary (p = 0.565) of the mass
between the symptomatic and the screening-detected groups.
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TABLE 2: Comparison of Sonographic Findings of 193 Lesions with Mass in
Screening-Detected Ductal Carcinoma In Situ (DCIS) and Symptomatic
DCIS
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Fig. 2A —Asymptomatic 44-year-old woman with micropapillary ductal
carcinoma in situ (DCIS). Mammogram shows irregularly shaped, high-density
mass (arrows) in upper outer quadrant of right breast.
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Fig. 2B —Asymptomatic 44-year-old woman with micropapillary ductal
carcinoma in situ (DCIS). Orthogonal sonograms show irregularly shaped, mixed
hyper- and hypoechoic mass with indistinct margin (arrows) in right
breast.
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Fig. 2C —Asymptomatic 44-year-old woman with micropapillary ductal
carcinoma in situ (DCIS). Orthogonal sonograms show irregularly shaped, mixed
hyper- and hypoechoic mass with indistinct margin (arrows) in right
breast.
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Fig. 2D —Asymptomatic 44-year-old woman with micropapillary ductal
carcinoma in situ (DCIS). Sonogram shows associated duct dilatation and
nodular wall thickening (arrows) in subareolar area of right breast.
At surgery, these dilated ducts with intraductal nodules were also involved by
DCIS.
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Fig. 3B —Asymptomatic 58-year-old woman with intermediate-grade ductal
carcinoma in situ. Sonograms show relatively circumscribed, oval, hypoechoic
mass (arrows) with clustered microcalcifications and posterior
acoustic shadowing (arrowhead, C) in left breast. Power
Doppler study shows no increased vascularity in mass.
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Fig. 3C —Asymptomatic 58-year-old woman with intermediate-grade ductal
carcinoma in situ. Sonograms show relatively circumscribed, oval, hypoechoic
mass (arrows) with clustered microcalcifications and posterior
acoustic shadowing (arrowhead, C) in left breast. Power
Doppler study shows no increased vascularity in mass.
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In terms of echogenicity of the mass, we found a tendency for DCIS to be
isoechoic or hypoechoic in the screening-detected group and to be mixed hyper-
and hypoechoic or complex cystic in the symptomatic group; this factor was
statistically different for the two groups (p = 0.011). Although
normal posterior features was the most common finding in both
screening-detected and symptomatic groups (Fig.
1A,
1B,
1C), posterior acoustic
enhancement was more frequently found in the symptomatic than in the
screening-detected group, whereas posterior acoustic shadowing was more
frequently found in the screening-detected than in the symptomatic group
(Figs. 3A,
3B,
3C and
4A,
4B) (p < 0.001).
Associated ductal change, such as abnormal caliber or arborization, was more
likely to be found in symptomatic than in screening-detected DCIS (p
< 0.019) (Fig. 5A,
5B,
5C). Associated
microcalcifications were more often seen in screening-detected than in
symptomatic DCIS (p < 0.001). When there were associated
microcalcifications, clustered microcalcifications were more likely to be seen
in the screening-detected DCIS patients (Figs.
3A,
3B,
3C and
4A,
4B), and nonclustered
microcalcifications were more likely to be seen in the symptomatic DCIS cases
(Fig. 5A,
5B,
5C) (p <
0.001).
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Fig. 4A —Asymptomatic 45-year-old woman with cribriform and papillary
ductal carcinoma in situ. Screening mammogram shows multifocal clustered
microcalcifications (arrows) in upper outer quadrant of right
breast.
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Fig. 4B —Asymptomatic 45-year-old woman with cribriform and papillary
ductal carcinoma in situ. Sonogram shows hypoechoic mass (arrows)
with clustered microcalcifications and posterior shadowing
(arrowhead) in right breast.
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Fig. 5B —36-year-old woman with palpable lump in right breast.
Sonogram shows irregularly shaped, mixed hyper- and hypoechoic mass
(arrows) in left breast. Nonclustered microcalcifications were
detected within and outside mass.
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The mean diameter of a mass on sonography was 1.7 cm (range, 0.5–6.3
cm) in screening-detected DCIS and 2.7 cm (range, 0.4–9.0 cm) in
symptomatic DCIS. The mean diameter of the mass in patients with symptomatic
DCIS was significantly larger than that in patients with screening-detected
DCIS (p < 0.001).
Mammography and Galactography
Mammography was available in 104 screening-detected DCIS cases and in 116
symptomatic DCIS cases (Table
3). Microcalcifications were the most common finding and were
noted in 87 (40%) of the 220 cases, followed by the presence of a mass in 45
cases (20%) and the presence of a mass with microcalcifications in 42 cases
(19%). Architectural distortion was noted in only seven lesions (3%).
Microcalcifications were more frequently found in screening-detected DCIS, and
the presence of a mass was more frequently found in symptomatic DCIS
(p < 0.001). False-negative mammographic results were more likely
to be seen in the symptomatic than in the screening-detected group (Fig.
1A,
1B,
1C). The false-negative rate of
mammography was 28 (24%) for symptomatic DCIS and 11 (11%) for
screening-detected DCIS. Of 28 cases with false-negative mammographic results
in the symptomatic group, 23 had dense breast tissue on mammography, and the
remaining five were noncalcified lesions that were smaller than 2 cm in
diameter. Of these 28 cases, 14 patients presented with palpable abnormality,
11 with nipple discharge, and three with both palpable abnormality and nipple
discharge. Of 11 cases with false-negative mammographic results in the
screening-detected group, eight had dense breasts tissue on mammography and
the remaining three were small lesions with no calcifications smaller than 1
cm in diameter.
For the entire cohort of 528 cases, mammography was available in 257
screening-detected DCIS cases and in 240 symptomatic DCIS cases. The
false-negative rate of mammography was 41 (17%) for symptomatic DCIS and 11
(4%) for screening-detected DCIS, which were also significantly different
between the two groups (p < 0.001). Microcalcifications numbered
192 (75%) in the screening-detected group and 53 (22%) in the symptomatic
group. Masses with or without calcifications numbered 46 (18%) in the
screening-detected group and 139 (58%) in the symptomatic group. Architectural
distortion was found in eight (3%) of screening-detected DCIS cases and in
seven (3%) symptomatic DCIS cases. Microcalcifications were more frequently
found in the screening-detected than in the symptomatic group, and the
presence of masses with or without calcifications was more frequently found in
the symptomatic than in the screening-detected group (p <
0.001).
The findings of all 17 galactograms available for retrospective review were
positive and showed single or multiple intraductal filling defects with or
without duct dilatation.
Histopathology
Eighty-one lesions were classified as Van Nuys group 1, 101 as Van Nuys
group 2, and 49 as Van Nuys group 3. No statistically significant difference
was seen in the proportion of comedo necrosis between the symptomatic and the
screening-detected groups (p = 0.386). Also, no significant
difference was seen between the two groups in terms of the nuclear grade,
microinvasion, hormonal receptor status, and the presence of P53 tumor
suppressor gene and C-erbB-2 oncogene
(Table 4).
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TABLE 4: Comparison of Histopathologic Findings in Screening-Detected Ductal
Carcinoma In Situ (DCIS) and Symptomatic DCIS
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The mean diameter of the masses on pathology was 2.4 cm (range,
0.2–10.0 cm) in screening-detected DCIS and 3.4 cm (range,
0.3–11.0 cm) in symptomatic DCIS. The mean diameter of the masses in
patients with symptomatic DCIS was significantly larger than that in patients
with screening-detected DCIS (p < 0.001).
Discussion
On mammography, 62–98% of DCIS cases are detected because of the
presence of microcalcifications, with 2–23% manifesting as a mass or
asymmetric density only [3,
4,
10]. Mammographic
abnormalities were noted in 82% (181/220) of the cases in our study. These
consisted of microcalcifications (40%), masses (20%), masses with
microcalcifications (19%), and architectural distortions (3%). In our results,
frequency of microcalcifications with or without a mass on mammography was
59%, which is lower than the frequency in prior reports
[3,
4,
10]. This difference might be
due to the fact that our results included only patients who underwent
preoperative sonography, whereas many patients with DCIS underwent only
mammography at our institution. Of 497 mammograms for the entire cohort that
were available for the retrospective review, there were false-negative results
(10%), microcalcifications (49%), masses (23%), masses with
microcalcifications (15%), and architectural distortions (3%). For the entire
cohort, the differences were seen in the mammographic features of
screening-detected versus symptomatic DCIS in our study. Microcalcifications
were more frequently found in screening-detected DCIS, and masses were more
frequently found in symptomatic DCIS. Bellamy et al.
[27] also noted an increased
proportion of the comedocarcinoma subtype of mammographically detected lesions
compared with symptomatic lesions. Yang and Tse
[17] suggested that a lower
percentage of mammographically visible microcalcifications and a higher
percentage of dominant masses in symptomatic DCIS correspond to a lower
percentage of comedo necrosis or high-grade lesions in symptomatic DCIS.
However, in our study, pathologic findings, including comedo necrosis, nuclear
grade, Van Nuys classification, microinvasion, and hormonal receptor status,
did not show a significant difference between the screening-detected and
symptomatic groups.
Although most cases of DCIS are diagnosed with mammography, 6–23% of
DCIS lesions are not visible mammographically
[3,
4,
10]. Sonography generally has
not been considered a diagnostic technique for DCIS because it is less
sensitive than mammography for the identification of calcifications
[28]. Nonetheless, one
prospective study showed that the use of diagnostic sonography as an adjunct
to mammography resulted in an increase in sensitivity of 7.4% for the
detection of breast cancer, without a compromise in specificity
[29]. The emergence of
high-resolution transducers and the increasing experience of physicians in
breast sonography have resulted in improved sensitivity and specificity of
sonography and increased confidence in using this technique
[12,
13,
16,
18,
29,
30].
Tohno et al. [31] and
Stavros [32] reported the
sonographic features of DCIS to be architectural distortion, an intracystic
lesion, or a bulky hypoechoic vascular mass with ductal extension and
prominent microlobules. More recently, Moon et al.
[12] reported that the most
common sonographic findings of DCIS included microlobulated mass, mild
hypoechogenicity, ductal extension, and no posterior feature. Yang and Tse
[17] analyzed the sonographic
findings of 60 symptomatic patients with DCIS and reported that the most
common sonographic findings in DCIS were irregular masses with indistinct or
microlobulated margins and no posterior features, followed by ductal changes
and architectural distortions. The microcalcifications visible on sonography
and mammography were associated with a high Van Nuys classification. The
findings in our study concur with those of Moon et al.
[12] and Yang and Tse
[17] and confirm that, when
evident on sonography, DCIS appears most frequently as a solid, irregular mass
with indistinct margins and no posterior features. We found that the common
sonographic findings in symptomatic DCIS were irregular masses with no
calcifications or associated ductal change. It is important to recognize the
many and various sonographic appearances of DCIS in order to decrease the
false-negative rate of bilateral whole-breast sonography and to detect
symptomatic mammographically occult DCIS.
Another review of sonographic features of DCIS diagnosed with
sonographically guided large core needle biopsy reported that DCIS lesions
tended to show more malignant mammographic and sonographic features as
histologic grade and size increased
[14]. We found that the mean
size of the lesions in screening-detected DCIS was smaller than that in
symptomatic DCIS. However, we did not detect a trend toward a higher Van Nuys
classification in symptomatic than in screening-detected DCIS.
The ability to visualize microcalcifications using sonographic equipment
has been described elsewhere in the literature
[33]. Several reports have
further described the ability of sonography to depict mammographically
detected microcalcifications
[12,
13,
34]. Moon et al.
[16] reported that
calcifications associated with malignant tumors were more likely to be seen on
sonography than calcifications associated with benign lesions. In our study,
microcalcifications on sonography and posterior shadowing were more frequently
found in screening-detected than in symptomatic DCIS. Berg and Gilbreath
[35] reported that in their
prospective study of 40 patients with known breast cancer, whole-breast
sonography complemented mammography in the preoperative evaluation of patients
with breast cancer, particularly when breast conservation is contemplated.
They also reported that sonography can be helpful to diagnose DCIS; however,
it is not a good method to accurately delineate disease extent for DCIS that
presents primarily with calcifications.
The primary limitation of our study is that our study population consisted
only of patients who underwent preoperative sonography, so there might be a
selection bias. Because most DCIS cases were diagnosed mammographically, a
larger number of symptomatic patients underwent preoperative sonography, and
most asymptomatic patients did not undergo preoperative sonography. Further
investigation will be needed to evaluate the values of mammography and
sonography in the diagnosis of DCIS. The second limitation is the
retrospective nature of our study. Further study will be needed to
prospectively evaluate the role of sonography in the diagnosis of DCIS. The
third limitation is the relatively small number of study patients. At our
institution, a large number of patients were referred from other institutions.
Therefore, a relatively high percentage of advanced or invasive carcinoma and
a relatively low percentage of DCIS were seen. We think that this is the
reason for the relatively low percentage (9.1%) incidence of DCIS at our
institution.
In conclusion, our results show differences in the sonographic features of
screening-detected and symptomatic DCIS. That is, masses and associated ductal
change were more common in symptomatic than in asymptomatic patients, whereas
associated microcalcifications and posterior shadowing were more frequently
found in screening-detected than in symptomatic DCIS. The role of sonography
in the diagnosis of DCIS might be to evaluate clinical abnormalities in the
symptomatic patients when there are nonspecific mammographic soft-tissue
densities without calcifications. Recognition of the many and varied
sonographic appearances of DCIS might be helpful to decrease the
false-negative rate of bilateral whole-breast sonography, and also to detect
symptomatic mammographically occult DCIS when we use sonography to supplement
mammography.
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Abstract
Introduction
