DOI:10.2214/AJR.07.3779
AJR 2008; 191:689-699
© American Roentgen Ray Society
Pure Ductal Carcinoma in Situ: A Range of MRI Features
Sughra Raza1,
Monica Vallejo,
Sona A. Chikarmane and
Robyn L. Birdwell
1 All authors: Department of Radiology, Brigham and Women's Hospital, 75 Francis
St., Boston, MA 02115.
Received February 5, 2008;
accepted after revision March 18, 2008.
Address correspondence to S. Raza
(sraza1{at}partners.org).
CME
This article is available for CME credit.
See
www.arrs.org
for more information.
Abstract
OBJECTIVE. The purpose of this article is to describe and illustrate
the variety of common morphologic features, enhancement patterns, and kinetics
of pure ductal carcinoma in situ (DCIS) on dynamic contrast-enhanced MRI of
the breast, using the American College of Radiology BI-RADS lexicon.
CONCLUSION. Breast MRI plays an important role in the detection of
DCIS, which most often appears as nonmass clumped enhancement, in a ductal or
segmental distribution, with variable enhancement kinetics.
Keywords: breast • ductal carcinoma in situ • MRI • pure ductal carcinoma in situ • women's imaging
Introduction
Ductal carcinoma in situ (DCIS) or intraductal carcinoma is a noninvasive
malignancy characterized by the clonal proliferation of malignant epithelial
cells originating in the terminal ductal lobular unit, with no histologic
evidence of invasion of the basement membrane. It is most often asymptomatic
and may involve multiple sites separated by normal tissue in the same ductal
system or in different ductal systems. Typically, part of the natural
pathophysiology of DCIS is calcification in the affected ducts. These
calcifications are visible in up to 90% of DCIS cases diagnosed on mammography
alone [1], most commonly in
clustered, linear, or segmental distributions. Approximately 10–20% of
DCIS may present as a mass or other parenchymal lesion such as architectural
distortion with or without calcifications
[2]. With the widespread use of
mammographic screening, DCIS now accounts for 20–30% of breast cancers
detected at screening mammography
[3], and evidence suggests that
approximately 14–75% of cases may progress to invasive carcinoma
[4]. When intraductal carcinoma
is treated with surgery achieving negative margins and no radiation therapy,
the recurrence rate is 22.5%
[4]. The recurrence rate is
higher if close or positive margins are present at the time of surgery.
Regardless of treatment method (mastectomy, lumpectomy with radiation
therapy, or wide surgical excision alone), half the recurrences are invasive
(
20% with distant metastases at 10 years)
[5]. Whole-breast radiation
therapy reduces the recurrence rate by 50%, and treatment of estrogen
receptor–positive cases with tamoxifen reduces this risk by another 50%
[4]. Therefore, early detection
and accurate assessment of the extent of disease are important for thorough
breast-conserving treatment and to achieve the best possible prognosis.
Because calcifications are not present in all cases of DCIS, such lesions
are mammographically occult, contributing to a mammographic sensitivity of
70–80% [3]. Similarly,
because all involved areas may not calcify equally, the extent of disease is
often underestimated on mammography. Therefore, alternative means of detecting
DCIS have been explored, including the use of contrast-enhanced MRI. Breast
MRI has emerged as an important tool in the detection and characterization of
breast cancer, showing sensitivity ranging from 90–100% for invasive
carcinoma [6,
7]. In contrast, the reported
sensitivity of MRI for detection of DCIS is lower, ranging from 77% to 96%
[8], perhaps because of
differences in tumor size, degree of angiogenesis and histology, and
differences in imaging protocols
[9]. Despite these limitations,
the distinct advantage of MRI in the detection of carcinoma is that, based on
tumor vascularity, vessel density, and permeability, even noncalcified
mammographically occult areas of DCIS can be seen because of abnormal contrast
uptake.
Imaging Technique
During the study period, May 2004 to December 2007, breast MRI examinations
were performed at our facility with the patient prone in either a Signa 1.5-T
or HDX 3-T commercially available system (both from GE Healthcare) using a
dedicated breast surface coil. Our routine protocol included a three-plane
localizing sequence followed by a sagittal fat-suppressed T2-weighted sequence
and axial fast spoiled gradient-recalled echo T1-weighted
non–fat-saturated sequences for each breast before the administration of
contrast material. Dynamic sagittal VIBRANT (volume imaging for breast
assessment) T1-weighted fat-suppressed 3D fast spoiled gradient-recalled echo
(3D FSPGR) sequences were then performed before and four times after the IV
administration of 20 mL of contrast material (Magnevist [gadopentetate
dimeglumine], Bayer Healthcare) at 2 mL/s. The first contrast-enhanced dynamic
sequence was obtained at approximately 2 minutes, followed by three more
consecutive sequences. Finally, an axial T1-weighted fat-suppressed 3D FSPGR
delayed sequence was performed. Postprocessed subtracted images,
maximum-intensity-projection (MIP) images, and Angiogenesis Maps (CADstream,
version 4.1, Confirma) were processed by a computeraided evaluation system
(CADstream).
MRI Characteristics of DCIS
Enhancement Patterns
The BI-RADS lexicon [10]
describes three types of enhancing lesions seen on breast MRI: first, focus,
defined as a spot of enhancement that is too small (< 5 mm) to allow
further morphologic characterization; second, mass, or "a 3D
space-occupying lesions, usually round, oval, or irregular in shape;"
and third, nonmasslike enhancement, which is "enhancement of an area
that is not a mass" and is characterized by distribution and internal
enhancement patterns. Previous studies
[11,
12] have shown that pure DCIS
most often presents as nonmasslike enhancement (Figs.
1A,
1B,
2A,
2B,
2C,
2D,
2E,
2F,
3A,
3B,
4A,
4B,
5A,
5B,
5C,
5D,
6A,
6B,
7A,
7B,
8A,
8B,
9A,
9B,
10A,
10B,
10C,
10D,
10E,
11A,
11B,
11C) and less commonly as a
mass (Fig. 12A,
12B,
12C,
12D).
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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.
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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.
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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.
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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.
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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.
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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.
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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).
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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).
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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).
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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).
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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Nonmasslike Enhancement Distribution Patterns
BI-RADS descriptors demonstrate variability in their use as well as their
specificity and positive predictive value for DCIS. Furthermore, the older
literature was hampered by the lack of an existing lexicon, leading to great
variability in the frequency of reported distributions. Since 2003, when the
first edition of the BI-RADS MRI lexicon was published, some authors have
chosen to group linear, ductal, and segmental distributions
[13,
14], whereas others
distinguish segmental from ductal and linear
[11,
12]. Segmental distribution is
defined as "a triangular area of enhancement, apex pointing to the
nipple, suggesting a duct or its branches" (Figs.
5A,
5B,
5C,
5D,
7A,
7B, and
10A,
10B,
10C,
10D,
10E). The BI-RADS lexicon
defines linear as "a line that may not conform to a duct" (Fig.
3A,
3B) and ductal as "a
line that may have branching, conforming to a duct" (Figs.
1A,
1B,
2A,
2B,
2C,
2D,
2E,
2F, and
4A,
4B). Less common distributions
seen in pure DCIS are regional, "enhancement in a large volume of tissue
not conforming to a ductal distribution, geographic"
[10] (Figs.
8A,
8B,
9A,
9B, and
11A,
11B,
11C); and focal area,
"enhancement in a confined area, less than 25% of quadrant"
[10] (Fig.
6A,
6B).
Internal Enhancement Patterns
The most common internal enhancement pattern found in pure DCIS is clumped,
"cobblestone like enhancement, with occasional confluent areas"
[11,
12] (Figs.
1A,
1B,
2A,
2B,
2C,
2D,
2E,
2F,
3A,
3B,
5A,
5B,
5C,
5D,
6A,
6B,
7A,
7B, and
11A,
11B,
11C). Other enhancement
patterns include heterogeneous or "nonuniform enhancement in a random
pattern" (Figs. 8A,
8B and
9A,
9B).
Kinetic Patterns
The kinetic curve shape is created by perfusion and diffusion of contrast
material from the blood vessels to the extracellular space. Reports suggest
that perfusion rates increase as a lesion progresses from in situ to invasive
[15], and that microvessel
density plays a role as well
[16,
17]. With current MRI
techniques, as outlined earlier, a temporal resolution of 120 seconds will not
image lesion perfusion but rather capture the diffusion of the contrast
material [11]. On the basis of
the BI-RADS lexicon [10], the
initial phase of enhancement, within 2 minutes or when the shape of the
kinetic curve starts to change, is described as fast, medium, or slow. The
delayed phase (after 2 minutes or after the curve starts to change) is
described as either persistent (type I), continued increase in signal over
time; plateau (type II), signal intensity does not change over time after
initial rise; or washout (type III), signal intensity decreases from the
highest point after an initial rise
[10] (Fig.
13A,
13B,
13C).
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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].
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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].
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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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The pharmacokinetic time–signal intensity curves associated with pure
DCIS are variable. In the initial phase, rapid uptake is most commonly seen;
in the delayed phase, persistent, plateau, and washout kinetics are all seen
[11] (Fig.
13A,
13B,
13C). A recent article
[11] observed no significant
difference in the morphology or kinetic enhancement characteristics among the
different nuclear grades of pure DCIS.
Recognizing that breast MRI is evolving, both technically and with regard
to the lexicon, the degree to which morphologic and kinetic characteristics
play a role in interpretation and recommendations varies between masses and
nonmasslike enhancing lesions. Because as many as 30% of DCIS cases seen as
nonmasslike enhancement show the least worrisome pattern of persistent
enhancement, interpretation and final recommendations should be based on
morphology rather than on the kinetic curves
[18,
19].
In addition, DCIS is not usually visible on either non-fat-suppressed or
fat-suppressed T2-weighted sequences or unenhanced T1-weighted images because
it either mimics normal breast parenchyma or, less likely, appears relatively
hypointense [20].
Conclusion
Contrast-enhanced dynamic MRI of the breast is complementary to mammography
in the detection of DCIS because enhancement may be seen in areas of calcified
as well as noncalcified intraductal carcinoma. This allows detection of
noncalcified disease and more accurate assessment of the extent of disease,
improving treatment and prognosis. On MRI, DCIS can manifest in a range of
appearances, frequently as clumped nonmass-like enhancement, in a ductal or
segmental distribution, most commonly showing rapid initial contrast uptake
with plateau, persistent, or washout kinetics in the delayed phase.
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Abstract
Introduction
