Lars Grimm, MD, MHS, FSBI

Associate Professor

Department of Radiology

Duke University Medical Center

Multimodality Imaging

of DCIS

• Discuss classic and variant imaging appearances of DCIS on

mammography, US, and MRI

• Common mistakes and pitfalls in diagnosis

• Special case scenarios

Objectives

1. Average-risk screening

2. Symptomatic patient

3. High-risk screening

4. Upstaging of DCIS to invasive disease

5. Active surveillance

DCIS Scenarios

Average-Risk Screening

0

10

20

30

40

50

60

70

80

90In

cid

en

ce p

er

10

0,0

00

Invasive DCIS

+23%

+581%

DCIS Epidemiology

Data from SEER

Organized screening

• 909 consecutive cases of DCIS, 1980-1999

• 75% calcifications

• 27% associated soft-tissue abnormalities

• 12% palpable

• 12% nipple discharge

Barreau EJR 2005

Classic Mammographic Appearance

DCIS Calcifications

Rauch Ann Surg Oncol 2016

• DCIS reader study

• 10 readers, 150 cases of calcifications

• Interobserver variability

• Morphology: κ = 0.271

• Distribution: κ = 0.371

Limitations of BI-RADS

Grimm Unpublished Data

1. Mixed morphology

2. Coexisting benign pathologies

3. Incompatible distribution

4. Soft tissue density

5. Slow rate of growth

6. Failure to sufficiently evaluate morphology

Missed DCIS

Missed DCIS

BI-RADS: Coarse or ‘Popcorn-Like’

Multiple bilateral palpable masses, presumed FA

Missed DCIS

• Mixed morphology

• Coexisting benign pathologies

3.3 cm of DCIS

• Incompatible

distribution

• Soft tissue density

Missed DCIS

IDC

DCIS

Screening

• Coexisting benign pathologies

• Slow rate of growth

Missed DCIS

2007 2008 2011 2013

Missed DCIS

Synthetic Mammogram 2D Mammogram

• Failure to sufficiently evaluate morphology

Symptomatic DCIS

• Clinical symptoms: palpable, nipple discharge

• Imaging appearance: larger, non-calcified

• Histopathology: higher nuclear grade, ER negative, upstaged

to invasive disease

• Worse survival

Symptomatic DCIS

Koh Breast Cancer Res Treat 2015Shin AJR 2008

• Hypoechoic, irregular shaped, indistinct/microlobulated

margins

• Distended duct or invasive component

• Guide biopsy planning

Ultrasound of Calcified DCIS

• 58%-82% of non-calcified DCIS was symptomatic

• US only DCIS more likely low grade and small (<1 cm)

• Highly variable appearance

Ultrasound of Non-Calcified DCIS

Wang Radiographics 2013, Ikeda Radiology 1989, Kim J US Med 2009

DCIS + papillary lesionDCIS “Pseudomicrocystic” DCIS

• Periductal stiffness due to desmoplastic reaction

Elastography

Wang Radiographics 2013

• 105 women with pathologic nipple discharge

MRI for Nipple Discharge

Bahl AJR 2017

• Filling defects, obstruction, or

surface irregularity

• Association with suspicious

calcifications

Ductography for Nipple Discharge

Slawson Radiographics 2001

High-Risk Screening

• Higher sensitivity for DCIS than mammography (92% vs 56%)

• Dependent on grade: 98% for high, 91% for intermediate, and 80%

for low grade

MRI

Kuhl Lancet 2007

• Clumped non-mass enhancement

Classic MRI Appearance of DCIS

Linear Segmental Regional

• Enhancement of periductal stroma and duct wall

• Low/lowest frequency (<20%) of NME descriptors

• Highest PPV (65%) of NME descriptors

• High rate of DCIS (~40%)

Clustered Ring

Uematsu AJR 2012, Chikarmane AJR 2017

• Initial phase typically rapid

• Delayed phase variable

Kinetics

Jansen Radiology 2007

• Best means of defining extent

• Within 5 mm on MRI (60%) vs mammography (38%)

• Can identify both calcified and non-calcified

• Nipple extension

Extent of Disease

Marcotte-Bloch EJR 2011

“2 cm of amorphous calcifications” “6.3 cm of clumped NME”

Upstaging to Invasive Disease

Palpable

7 cm

Mass

DCIS Upstaged to Invasive Disease

Brennan Radiology 2011

All Upstaged to IDC

Active Surveillance

Active Surveillance Trials

LORETTA

Untreated DCIS

10 years

Untreated DCIS

4 years

5.4 cm

ER/PR+, high grade DCIS

6.8 cm

ER/PR/HER2+, high grade IDC

Untreated DCIS

ER/PR+, high grade DCIS

ER/PR+, HER2-, high grade IDC

3 years

Untreated DCIS

ER/PR+, high grade DCIS

ER/PR+, HER2-, high grade IDC

3 years

Thank You

lars.grimm@duke.edu