HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Figures Only Full Text (PDF) CME Test (opens in a new window) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Moon, W. K. Articles by Im, J.-G. Search for Related Content PubMed PubMed Citation Articles by Moon, W. K. Articles by Im, J.-G. Related Collections Breast (Imaging and Interventional) Ultrasound

US of Ductal Carcinoma In Situ¹

¹ From the Departments of Radiology (W.K.M., J.S.M., Y.J.L., J.G.I.), Pathology (I.A.P.), and Surgery (D.Y.N.), Clinical Research Institute, Seoul National University Hospital, 28 Yongon-Dong, Chongno-Gu, Seoul 110-744, Korea, and the Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Korea. Recipient of a Certificate of Merit award for an education exhibit at the 2000 RSNA scientific assembly. Received April 27, 2001; revision requested June 6 and received September 6; accepted September 24. Address correspondence to W.K.M. (e-mail: moonwk@radcom.snu.ac.kr).

	Abstract

Top Abstract LEARNING OBJECTIVES FOR TEST... Introduction Patient Selection US Examination Techniques US Findings Potential Role of US... Conclusions References

 
Little is known about the ultrasonographic (US) features of ductal carcinoma in situ (DCIS) of the breast because this entity usually manifests as pure mammographic calcifications and is rarely evaluated with US. US findings were recorded in 70 patients with DCIS and then analyzed and correlated with mammographic and histologic findings. A microlobulated mass with mild hypoechogenicity, ductal extension, and normal acoustic transmission was the most common US finding in DCIS. Spiculated margins, marked hypoechogenicity, a thick echogenic rim, and posterior acoustic shadowing at US often suggested the presence of invasion. US performed with a 10–13-MHz transducer and optimal technique can be used as a complement to mammography in detecting and evaluating DCIS of the breast, as it demonstrates breast lesions associated with malignant microcalcifications in most cases. The main benefit of identifying a US abnormality in women with mammographically detected DCIS is to allow the use of US to guide interventional procedures (eg, needle biopsy, needle localization). US may also be helpful in detecting DCIS without calcifications and in evaluating disease extent in women with dense breasts. Nevertheless, further research is needed to delineate the role of US in the evaluation of patients with DCIS.

© RSNA, 2002

Index Terms: Breast neoplasms, 00.32 • Breast neoplasms, calcifications, 00.812 • Breast neoplasms, diagnosis, 00.1298 • Breast neoplasms, US, 00.1298

	LEARNING OBJECTIVES FOR TEST 3

Top Abstract LEARNING OBJECTIVES FOR TEST... Introduction Patient Selection US Examination Techniques US Findings Potential Role of US... Conclusions References

 
After reading this article and taking the test, the reader will be able to:

• Identify the US features of DCIS.
  
• Describe the US examination technique in depicting DCIS.
  
• Discuss the potential role of US in the evaluation of DCIS.
  

	Introduction

Top Abstract LEARNING OBJECTIVES FOR TEST... Introduction Patient Selection US Examination Techniques US Findings Potential Role of US... Conclusions References

 
Before the advent of widespread mammographic screening, ductal carcinoma in situ (DCIS), or noninvasive ductal carcinoma, was rarely detected, accounting for only 0.8%–5.0% of all breast cancers (1). Most of these lesions manifested clinically as a palpable mass, nipple discharge, or Paget disease. However, in recent studies of women undergoing mammographic screening, DCIS has accounted for 15%–20% of all detected breast cancers and 25%–56% of clinically occult breast cancers detected at mammography (2,3). DCIS represents a broad biologic spectrum of disease and has become increasingly important due to both a dramatic rise in the detection rate and ongoing controversy surrounding its clinical significance and optimal treatment (4,5).

At mammography, 62%–98% of DCIS lesions are detected owing to the presence of calcifications, with 2%–23% manifesting as simply a mass or asymmetric density (2,3,6). Although most cases of DCIS are diagnosed mammographically, 6%–23% of DCIS lesions are not visible at mammography (2,3,6–8). Little is known about the ultrasonographic (US) features of DCIS because this entity usually manifests as pure mammographic calcifications, which, to our knowledge, have rarely been evaluated with US.

In this article, we discuss US examination techniques for evaluation of DCIS. We also discuss and illustrate the various US features of DCIS with correlation of mammographic and histologic findings. In addition, we discuss the potential role of US in this setting.

	Patient Selection

Top Abstract LEARNING OBJECTIVES FOR TEST... Introduction Patient Selection US Examination Techniques US Findings Potential Role of US... Conclusions References

 
Between September 1997 and March 2000, 1,821 consecutive women with a suspicious mammographic or clinical abnormality or with newly diagnosed breast cancer underwent US with 10–13-MHz transducers before undergoing excisional or percutaneous needle biopsy. Carcinoma was diagnosed at excisional biopsy in 594 women; 33 of these women had pure DCIS, 42 had DCIS with microinvasion, and 519 had invasive carcinoma. Microinvasion was defined as the extension of cancer cells beyond the basement membrane into the adjacent tissues with no focus more than 0.1 cm in diameter (9). US depicted DCIS lesions in 70 of the 75 patients with DCIS (93%); 31 patients had pure DCIS, and 39 patients had DCIS with microinvasion. These patients formed the study population (Table). At histologic analysis, these DCIS lesions proved to be comedocarcinoma in 36 cases and noncomedocarcinoma in 34 (18 cribriform, six micropapillary, six papillary, four solid). The nuclear grade was classified as low (n = 8), intermediate (n = 43), or high (n = 19).

	US Examination Techniques

Top Abstract LEARNING OBJECTIVES FOR TEST... Introduction Patient Selection US Examination Techniques US Findings Potential Role of US... Conclusions References

 
The quality of breast US is closely related to the performance of the equipment used for the examination and the skill of the examiner. Linear-array, broad-bandwidth transducers with maximum frequencies of 10–13 MHz and a center frequency of at least 7 or 7.5 MHz are required to depict DCIS in the breast (Fig 1). The adjustment of focal zones, system gain, and time gain compensation setting is also important. US should be performed in radial and antiradial planes as well as longitudinal and transverse planes (10,11). In patients with DCIS, radial US is particularly useful for depicting intraductal masses and evaluating the ductal extent of disease, whereas antiradial US is more helpful for evaluating the surface characteristics of the mass (Figs 2, 3).

View larger version (148K): [in this window] [in a new window] [Download PPT slide]   Figure 1a.  Comedo-type DCIS in a 41-year-old woman. (a) Mediolateral oblique spot magnification mammogram obtained during needle localization shows a 7-mm cluster of microcalcifications of variable size and shape adjacent to the localization needle (arrow). (b) Radial US image obtained with a 10-MHz transducer shows a microlobulated, hypoechoic mass 9 mm in diameter (large solid arrows) with ductal extension (open arrows) in the area corresponding to the microcalcifications seen at mammography. The punctate echogenic dots seen within the mass (small solid arrows) probably represent the calcifications. (c) Radial US image obtained with a 13-MHz transducer better shows the microlobulated margin (large solid arrows), ductal extension (open arrows), and calcifications (small solid arrows) of the mass. (d) Photomicrograph (original magnification, x100; hematoxylin-eosin [H-E] stain) shows high-grade DCIS with central necrosis and calcification (arrow) within an enlarged duct.

View larger version (155K): [in this window] [in a new window] [Download PPT slide]   Figure 1b.  Comedo-type DCIS in a 41-year-old woman. (a) Mediolateral oblique spot magnification mammogram obtained during needle localization shows a 7-mm cluster of microcalcifications of variable size and shape adjacent to the localization needle (arrow). (b) Radial US image obtained with a 10-MHz transducer shows a microlobulated, hypoechoic mass 9 mm in diameter (large solid arrows) with ductal extension (open arrows) in the area corresponding to the microcalcifications seen at mammography. The punctate echogenic dots seen within the mass (small solid arrows) probably represent the calcifications. (c) Radial US image obtained with a 13-MHz transducer better shows the microlobulated margin (large solid arrows), ductal extension (open arrows), and calcifications (small solid arrows) of the mass. (d) Photomicrograph (original magnification, x100; hematoxylin-eosin [H-E] stain) shows high-grade DCIS with central necrosis and calcification (arrow) within an enlarged duct.

View larger version (149K): [in this window] [in a new window] [Download PPT slide]   Figure 1c.  Comedo-type DCIS in a 41-year-old woman. (a) Mediolateral oblique spot magnification mammogram obtained during needle localization shows a 7-mm cluster of microcalcifications of variable size and shape adjacent to the localization needle (arrow). (b) Radial US image obtained with a 10-MHz transducer shows a microlobulated, hypoechoic mass 9 mm in diameter (large solid arrows) with ductal extension (open arrows) in the area corresponding to the microcalcifications seen at mammography. The punctate echogenic dots seen within the mass (small solid arrows) probably represent the calcifications. (c) Radial US image obtained with a 13-MHz transducer better shows the microlobulated margin (large solid arrows), ductal extension (open arrows), and calcifications (small solid arrows) of the mass. (d) Photomicrograph (original magnification, x100; hematoxylin-eosin [H-E] stain) shows high-grade DCIS with central necrosis and calcification (arrow) within an enlarged duct.

View larger version (180K): [in this window] [in a new window] [Download PPT slide]   Figure 1d.  Comedo-type DCIS in a 41-year-old woman. (a) Mediolateral oblique spot magnification mammogram obtained during needle localization shows a 7-mm cluster of microcalcifications of variable size and shape adjacent to the localization needle (arrow). (b) Radial US image obtained with a 10-MHz transducer shows a microlobulated, hypoechoic mass 9 mm in diameter (large solid arrows) with ductal extension (open arrows) in the area corresponding to the microcalcifications seen at mammography. The punctate echogenic dots seen within the mass (small solid arrows) probably represent the calcifications. (c) Radial US image obtained with a 13-MHz transducer better shows the microlobulated margin (large solid arrows), ductal extension (open arrows), and calcifications (small solid arrows) of the mass. (d) Photomicrograph (original magnification, x100; hematoxylin-eosin [H-E] stain) shows high-grade DCIS with central necrosis and calcification (arrow) within an enlarged duct.

View larger version (128K): [in this window] [in a new window] [Download PPT slide]   Figure 2a.  Comedo-type DCIS with microinvasion in a 53-year-old woman. (a) Craniocaudal spot magnification mammogram shows an ill-defined 9-mm mass (solid arrow) with adjacent linear microcalcifications (open arrow). (b) Antiradial US image shows an ill-defined hypoechoic mass (arrows) with heterogeneous echotexture and posterior acoustic shadowing. (c) Radial US image better shows the mass (large arrows) with ductal extension (small arrows) and posterior acoustic shadowing.

View larger version (177K): [in this window] [in a new window] [Download PPT slide]   Figure 2b.  Comedo-type DCIS with microinvasion in a 53-year-old woman. (a) Craniocaudal spot magnification mammogram shows an ill-defined 9-mm mass (solid arrow) with adjacent linear microcalcifications (open arrow). (b) Antiradial US image shows an ill-defined hypoechoic mass (arrows) with heterogeneous echotexture and posterior acoustic shadowing. (c) Radial US image better shows the mass (large arrows) with ductal extension (small arrows) and posterior acoustic shadowing.

View larger version (143K): [in this window] [in a new window] [Download PPT slide]   Figure 2c.  Comedo-type DCIS with microinvasion in a 53-year-old woman. (a) Craniocaudal spot magnification mammogram shows an ill-defined 9-mm mass (solid arrow) with adjacent linear microcalcifications (open arrow). (b) Antiradial US image shows an ill-defined hypoechoic mass (arrows) with heterogeneous echotexture and posterior acoustic shadowing. (c) Radial US image better shows the mass (large arrows) with ductal extension (small arrows) and posterior acoustic shadowing.

View larger version (154K): [in this window] [in a new window] [Download PPT slide]   Figure 3.  Comedo-type DCIS in a 53-year-old woman in whom clustered microcalcifications were identified at screening mammography. Antiradial US image shows a microlobulated, hypoechoic mass 13 mm in diameter (large arrow). The punctate echogenic dots seen within the mass (small arrows) probably represent the calcifications seen at mammography.

	US Findings

Top Abstract LEARNING OBJECTIVES FOR TEST... Introduction Patient Selection US Examination Techniques US Findings Potential Role of US... Conclusions References

 
At US, lesions are described in terms of shape, orientation, echogenicity, echotexture, margin, boundary echo, ductal extension, acoustic transmission, and evidence of calcifications (10). The US findings in the 70 patients with DCIS are summarized in the Table.

DCIS with Calcifications
US is less sensitive for the demonstration of microcalcifications than is mammography (13–15). The smaller the calcifications, the lower the sensitivity of US. However, the high-frequency transducers currently being used can yield a higher percentage of mammographically visible calcifications than could the lower-frequency transducers that were used previously (14–16). With use of high-frequency, correctly focused 10–13-MHz probes, tiny echogenic spots without acoustic shadowing that correspond to the mammographic findings can be seen (Figs 1–4). Calcifications associated with malignant tumors are more likely to be seen at US because most malignant calcifications occur within the mass, unlike most benign calcifications, which occur within echogenic breast parenchyma (17,18).

View larger version (131K): [in this window] [in a new window] [Download PPT slide]   Figure 4a.  Solid DCIS with microinvasion in a 45-year-old woman. (a) Craniocaudal spot magnification mammogram shows a partially obscured 10-mm mass (black arrow) with fine linear microcalcifications (white arrow). (b) Radial US image shows a hypoechoic mass with punctate calcifications (open arrows). The mass is partially circumscribed (large solid arrow) and partially ill-defined (small solid arrows). (c) Photomicrograph (original magnification, x40; H-E stain) shows low-grade DCIS with a solid pattern (arrows) but no evidence of necrosis.

View larger version (136K): [in this window] [in a new window] [Download PPT slide]   Figure 4b.  Solid DCIS with microinvasion in a 45-year-old woman. (a) Craniocaudal spot magnification mammogram shows a partially obscured 10-mm mass (black arrow) with fine linear microcalcifications (white arrow). (b) Radial US image shows a hypoechoic mass with punctate calcifications (open arrows). The mass is partially circumscribed (large solid arrow) and partially ill-defined (small solid arrows). (c) Photomicrograph (original magnification, x40; H-E stain) shows low-grade DCIS with a solid pattern (arrows) but no evidence of necrosis.

View larger version (209K): [in this window] [in a new window] [Download PPT slide]   Figure 4c.  Solid DCIS with microinvasion in a 45-year-old woman. (a) Craniocaudal spot magnification mammogram shows a partially obscured 10-mm mass (black arrow) with fine linear microcalcifications (white arrow). (b) Radial US image shows a hypoechoic mass with punctate calcifications (open arrows). The mass is partially circumscribed (large solid arrow) and partially ill-defined (small solid arrows). (c) Photomicrograph (original magnification, x40; H-E stain) shows low-grade DCIS with a solid pattern (arrows) but no evidence of necrosis.

At US, DCIS with mammographic calcification often manifests as a microlobulated, hypoechoic mass with ductal extension and punctate calcifications (Figs 1–4). Microlobulation is recognized by the presence of many small (1–2-mm) lobulations on the surface of solid breast nodules (Fig 3). At histologic analysis, microlobulation manifests as gross ductal distention by cancer cells or cancerized lobules. Ductal extension is seen as a projection that extends radially from the nodule into the duct (Figs 1, 2). This finding represents pagetoid or ductal spread of cancer cells. In patients with nipple discharge or eczema, US of the subareolar area can depict single or multiple distended ducts with punctate calcifications. Calcified DCIS lesions are usually mildly hypoechoic but can be isoechoic relative to fat or surrounding breast parenchyma, making them difficult to visualize. The echotexture of the lesions is heterogeneous, perhaps owing to the presence of punctate echogenic calcifications. No DCIS lesions have an echogenic pseudocapsule. Normal acoustic transmission is typical, but posterior shadowing may be seen in high-grade comedo-type DCIS lesions (Fig 2).

US findings in DCIS with calcifications seem to be nonspecific. Similar US findings may also be seen in some benign lesions such as sclerosing adenosis, atypical ductal hyperplasia, and radial scar (19,20).

DCIS without Calcifications
Mammographic detection of DCIS lesions without microcalcifications may be quite difficult, especially in dense breasts. About 10% of all DCIS lesions manifest as soft-tissue masses or asymmetric densities at mammography (3), whereas up to 16% can be mammographically occult (6,8). At pathologic analysis, they are non–comedo-type lesions (cribriform, micropapillary, papillary, or solid). The lesions tend to spread without tumor cell necrosis and calcification (21,22). Intracystic papillary carcinoma is a variant of papillary-type DCIS in which tumor cells are located primarily in a single cystically dilated space.

At US, most DCIS lesions without calcifications manifest as single or multiple hypoechoic masses without a pseudocapsule (Fig 5). Ductal extension is sometimes seen. It is easier to visualize noncalcified DCIS lesions than calcified DCIS lesions at US because of their hypoechogenicity, but they can also be misinterpreted as benign nodules due to their roundness and well-circumscribed margins. Posterior acoustic enhancement may be seen in large masses. DCIS lesions without calcifications may manifest as a solid and cystic mass.

View larger version (159K): [in this window] [in a new window] [Download PPT slide]   Figure 5a.  Cribriform DCIS in a 50-year-old woman with a 15-mm invasive cancer in the contralateral breast. (a) Radial US image shows a round, hypoechoic mass 6 mm in diameter (solid arrow) with ductal extension toward the nipple (open arrow). This finding shows disproportionate distention of the terminal duct lobular unit. However, the finding is nonspecific and may also be seen in fibrocystic change and atypical ductal hyperplasia (cf Fig 4). (b) Mediolateral oblique spot magnification mammogram obtained after US-guided needle localization shows no definite lesion. (c) Photomicrograph (original magnification, x100; H-E stain) shows low-grade DCIS with a fenestrated, sievelike pattern (arrows).

View larger version (124K): [in this window] [in a new window] [Download PPT slide]   Figure 5b.  Cribriform DCIS in a 50-year-old woman with a 15-mm invasive cancer in the contralateral breast. (a) Radial US image shows a round, hypoechoic mass 6 mm in diameter (solid arrow) with ductal extension toward the nipple (open arrow). This finding shows disproportionate distention of the terminal duct lobular unit. However, the finding is nonspecific and may also be seen in fibrocystic change and atypical ductal hyperplasia (cf Fig 4). (b) Mediolateral oblique spot magnification mammogram obtained after US-guided needle localization shows no definite lesion. (c) Photomicrograph (original magnification, x100; H-E stain) shows low-grade DCIS with a fenestrated, sievelike pattern (arrows).

View larger version (182K): [in this window] [in a new window] [Download PPT slide]   Figure 5c.  Cribriform DCIS in a 50-year-old woman with a 15-mm invasive cancer in the contralateral breast. (a) Radial US image shows a round, hypoechoic mass 6 mm in diameter (solid arrow) with ductal extension toward the nipple (open arrow). This finding shows disproportionate distention of the terminal duct lobular unit. However, the finding is nonspecific and may also be seen in fibrocystic change and atypical ductal hyperplasia (cf Fig 4). (b) Mediolateral oblique spot magnification mammogram obtained after US-guided needle localization shows no definite lesion. (c) Photomicrograph (original magnification, x100; H-E stain) shows low-grade DCIS with a fenestrated, sievelike pattern (arrows).

View larger version (135K): [in this window] [in a new window] [Download PPT slide]   Figure 6a.  Papillary DCIS in a 77-year-old woman with bloody nipple discharge. (a) Craniocaudal mammogram shows a suspicious density in the subareolar region (arrow). (b) Craniocaudal ductogram demonstrates multiple filling defects within distended ducts (arrows). (c) Radial US image shows irregularly distended ducts containing multiple echogenic nodules (arrows). N = nipple.

View larger version (108K): [in this window] [in a new window] [Download PPT slide]   Figure 6b.  Papillary DCIS in a 77-year-old woman with bloody nipple discharge. (a) Craniocaudal mammogram shows a suspicious density in the subareolar region (arrow). (b) Craniocaudal ductogram demonstrates multiple filling defects within distended ducts (arrows). (c) Radial US image shows irregularly distended ducts containing multiple echogenic nodules (arrows). N = nipple.

View larger version (153K): [in this window] [in a new window] [Download PPT slide]   Figure 6c.  Papillary DCIS in a 77-year-old woman with bloody nipple discharge. (a) Craniocaudal mammogram shows a suspicious density in the subareolar region (arrow). (b) Craniocaudal ductogram demonstrates multiple filling defects within distended ducts (arrows). (c) Radial US image shows irregularly distended ducts containing multiple echogenic nodules (arrows). N = nipple.

View larger version (136K): [in this window] [in a new window] [Download PPT slide]   Figure 7a.  Papillary DCIS with microinvasion in a 63-year-old woman with a palpable mass. (a) Craniocaudal spot magnification mammogram shows an ill-defined 20-mm mass without calcifications (arrows). (b) Antiradial US image shows diffuse ill-defined hypoechoic lesions (arrows) with posterior acoustic shadowing.

View larger version (131K): [in this window] [in a new window] [Download PPT slide]   Figure 7b.  Papillary DCIS with microinvasion in a 63-year-old woman with a palpable mass. (a) Craniocaudal spot magnification mammogram shows an ill-defined 20-mm mass without calcifications (arrows). (b) Antiradial US image shows diffuse ill-defined hypoechoic lesions (arrows) with posterior acoustic shadowing.

DCIS with Microinvasion and Invasive Cancer
A microlobulated mass with mild hypoechogenicity, ductal extension, and normal acoustic transmission is the most common US finding in pure DCIS. Lesions tend to demonstrate more malignant features at US as size and histologic grade increase (24). High-grade comedo-type DCIS often manifests as an ill-defined mass with heterogeneous echotexture. However, considerable overlap exists, and the histologic grade or predominant subtype of DCIS cannot be predicted on the basis of US features alone.

Spiculated margins, marked hypoechogenicity, a thick echogenic rim, and posterior acoustic shadowing at US often suggest the presence of microinvasion in DCIS (Figs 2, 7, 8) or of invasive carcinoma (Fig 9). Both pathologic conditions commonly manifest as a soft-tissue density with microcalcifications at mammography. It is difficult to differentiate pure DCIS from DCIS with microinvasion or invasive cancer. The US findings in invasive breast cancer have been well described in the literature (10,14).

View larger version (144K): [in this window] [in a new window] [Download PPT slide]   Figure 8a.  Comedo-type DCIS with microinvasion in a 53-year-old woman. (a) Craniocaudal spot magnification mammogram shows an irregular, spiculated mass 9 mm in diameter with granular microcalcifications (arrow). (b) Radial US image shows a spiculated hypoechoic mass (large arrow) with elongated ductal extension toward the nipple (small arrows). (c) Photomicrograph (original magnification, x100; H-E stain) shows extension of intermediate-grade cancer cells beyond the basement membrane (arrow) with associated comedo-type necrosis.

View larger version (176K): [in this window] [in a new window] [Download PPT slide]   Figure 8b.  Comedo-type DCIS with microinvasion in a 53-year-old woman. (a) Craniocaudal spot magnification mammogram shows an irregular, spiculated mass 9 mm in diameter with granular microcalcifications (arrow). (b) Radial US image shows a spiculated hypoechoic mass (large arrow) with elongated ductal extension toward the nipple (small arrows). (c) Photomicrograph (original magnification, x100; H-E stain) shows extension of intermediate-grade cancer cells beyond the basement membrane (arrow) with associated comedo-type necrosis.

View larger version (185K): [in this window] [in a new window] [Download PPT slide]   Figure 8c.  Comedo-type DCIS with microinvasion in a 53-year-old woman. (a) Craniocaudal spot magnification mammogram shows an irregular, spiculated mass 9 mm in diameter with granular microcalcifications (arrow). (b) Radial US image shows a spiculated hypoechoic mass (large arrow) with elongated ductal extension toward the nipple (small arrows). (c) Photomicrograph (original magnification, x100; H-E stain) shows extension of intermediate-grade cancer cells beyond the basement membrane (arrow) with associated comedo-type necrosis.

View larger version (153K): [in this window] [in a new window] [Download PPT slide]   Figure 9.  Invasive breast cancer in a 65-year-old woman in whom a spiculated mass was detected at screening mammography. Antiradial US image shows a spiculated, hypoechoic mass 11 mm in diameter (large arrow) with posterior acoustic shadowing and a thick echogenic rim that is best seen at the lateral margins of the mass (small arrows).

	Potential Role of US in the Evaluation of DCIS

Top Abstract LEARNING OBJECTIVES FOR TEST... Introduction Patient Selection US Examination Techniques US Findings Potential Role of US... Conclusions References

First, US can be used to visualize large (>10-mm) clusters of microcalcifications with a high suspicion for malignancy (ie, an estimated likelihood of malignancy of 75% or higher based on mammographic assessment criteria). The main benefit of identifying a US abnormality in women with mammographically detected microcalcifications is to allow the use of US to guide interventional procedures (eg, needle biopsy, needle localization). US-guided procedures are faster and less expensive than stereotactically guided procedures (25,26). In addition, at institutions that do not have stereotactic equipment, the use of US in selected cases would extend the role of percutaneous biopsy. US may also help guide biopsy of the invasive component of tumors in patients with mammographic microcalcifications.

Second, US can be used to increase the specificity of mammography and help reduce the number of surgical or core biopsies performed in women with microcalcifications. In one study, the presence of a mass at US served as the diagnostic criterion for malignancy in American College of Radiology Breast Imaging Reporting and Data System category 4 (n = 40) or 5 (n = 22) microcalcifications over 10 mm (18). The sensitivity, specificity, positive predictive value, and negative predictive value of US were 100% (31 of 31 lesions), 84% (31 of 37), 81% (25 of 31), and 100% (31 of 31), respectively (18). Power Doppler US and a US contrast agent may also be useful in differentiating nonpalpable breast cancers from benign tumors (27).

Third, US can be used to reveal occult DCIS in patients with dense breasts. In their study of 3,626 women with dense breasts, normal mammograms, and normal physical examinations, Kolb et al (28) found 11 cancers (0.3% of cases) with screening US. Of these 11 cancers, one (9%) proved to be DCIS. In a study of 6,113 women, Buchberger et al (29) found 28 cancers with screening US (0.5% of cases), three of which (11%) were DCIS. The ability to visualize mammographically occult cancer at US has recently led to the investigation of this modality as a tool for breast cancer staging. In their study of 40 women with known or strongly suspected breast cancer, Berg and Gilbreath (30) found nine mammographically occult multifocal and multicentric cancers with whole-breast US of the ipsilateral breast, two of which (22%) proved to be DCIS. US can also be used preoperatively to detect clinically and mammographically occult DCIS in the contralateral breast (Fig 5). US may play an important part in the evaluation of noncalcified DCIS, not only in detecting the lesion but also in evaluating its pathologic extent.

Fourth, US can be used to evaluate patients with nipple discharge when ductography is not possible or indeterminate. Ductography is generally the procedure of choice for the evaluation of nipple discharge (Fig 6). However, there are both absolute and relative contraindications to ductography (31), and US can be used in such cases.

	Conclusions

Top Abstract LEARNING OBJECTIVES FOR TEST... Introduction Patient Selection US Examination Techniques US Findings Potential Role of US... Conclusions References

 
US with a high-frequency transducer can be used as a complement to mammography in detecting and evaluating DCIS of the breast. Optimal US technique is critical for demonstrating DCIS. A microlobulated mass with mild hypoechogenicity, ductal extension, and normal acoustic transmission is the most common US finding in DCIS. Spiculated margins, marked hypoechogenicity, a thick echogenic rim, and posterior acoustic shadowing often suggest the presence of invasion. The main benefit of identifying a US abnormality in women with mammographically detected DCIS is to allow the use of US to guide interventional procedures (eg, needle biopsy, needle localization). US may be helpful in detecting DCIS without calcifications and in evaluating disease extent in women with dense breasts. Further research is needed to delineate the role of US in the evaluation of patients with DCIS.

	Footnotes

 
See the commentary by Birdwell following this article.

Abbreviations: DCIS = ductal carcinoma in situ, H-E = hematoxylin-eosin

	References

Top Abstract LEARNING OBJECTIVES FOR TEST... Introduction Patient Selection US Examination Techniques US Findings Potential Role of US... Conclusions References

 

1. Schnitt SJ, Silen W, Sadowsky NL, Connolly JL, Harris JR. Ductal carcinoma in situ (intraductal carcinoma) of the breast. N Engl J Med 1988; 318:898-903.[Medline]
2. Dershaw DD, Abramson A, Kinne DW. Ductal carcinoma in situ: mammographic findings and clinical implications. Radiology 1989; 170:411-415.[Abstract/Free Full Text]
3. Stomper PC, Connolly JL, Meyer JE, Harris JR. Clinically occult ductal carcinoma in situ detected with mammography: analysis of 100 cases with radiologic-pathologic correlation. Radiology 1989; 172:235-241.[Abstract/Free Full Text]
4. Silverstein MJ. Ductal carcinoma in situ (DCIS) of the breast: diagnostic and therapeutic controversies. J Am Coll Surg 2001; 192:196-214.[CrossRef][Medline]
5. Feig SA. Ductal carcinoma in situ: implications for screening mammography. Radiol Clin North Am 2000; 38:653-668.[CrossRef][Medline]
6. Ikeda DM, Andersson I. Ductal carcinoma in situ: atypical mammographic appearances. Radiology 1989; 172:661-666.[Abstract/Free Full Text]
7. Orel SG, Mendonca MH, Reynolds C, Schnall MD, Solin LJ, Sullivan DC. MR imaging of ductal carcinoma in situ. Radiology 1997; 202:413-420.[Abstract/Free Full Text]
8. Holland R, Peterse JL, Millis RR, et al. Ductal carcinoma in situ: a proposal for a new classification. Semin Diagn Pathol 1994; 11:167-180.[Medline]
9. American Joint Committee on Cancer. AJCC cancer staging manual Philadelphia, Pa: Lippincott-Raven, 1997; 172.
10. Stavros AT, Thickman D, Rapp CL, Dennis MA, Parker SH, Sisney GA. Solid breast nodules: use of sonography to distinguish between benign and malignant lesions. Radiology 1995; 196:123-134.[Abstract/Free Full Text]
11. Teboul M. Ductal echography. In: Madjar H, Teubner J, Hackeloer BJ, eds. Breast ultrasound update. Basel, Switzerland: Karger, 1994; 110-126.
12. Swann CA, Kopans DB, McCarthy KA, White G, Hall DA. Localization of occult breast lesions: practical solutions to problems of triangulation. Radiology 1987; 163:577-579.[Abstract/Free Full Text]
13. Sickles EA. Sonographic detectability of breast calcifications. Proc SPIE 1983; 419:51-52.
14. Rizzatto G, Chersevani R, Abbona M, Lombardo VL, Macorig D. High-resolution sonography of breast carcinoma. Eur J Radiol 1997; 24:11-19.[CrossRef][Medline]
15. Ranieri E, D’Andrea MR, D’Alessio A, et al. Ultrasound in the detection of breast cancer associated with isolated clustered microcalcifications, mammographically identified. Anticancer Res 1997; 17:2831-2835.[Medline]
16. Hashimoto BE, Kramer DJ, Picozzi VJ. High detection rate of breast ductal carcinoma in situ calcifications on mammographically directed high-resolution sonography. J Ultrasound Med 2001; 20:501-508.[Abstract]
17. Gufler H, Buitrago-Tellez CH, Madjar H, Allmann KH, Uhl M, Rohr-Reyes A. Ultrasound demonstration of mammographically detected microcalcifications. Acta Radiol 2000; 41:217-221.[CrossRef][Medline]
18. Moon WK, Im JG, Noh DY, Yeon KM, Han MC. US of mammographically detected clustered microcalcifications. Radiology 2000; 217:849-854.[Abstract/Free Full Text]
19. Kasumi F, Sakuma H. Ultrasonic image of noninvasive carcinomas. In: Madjar H, Teubner J, Hackeloer BJ, eds. Breast ultrasound update. Basel, Switzerland: Karger, 1994; 168-173.
20. Stavros AT. Ultrasound of ductal carcinoma in situ. In: Silverstein MJ, eds. Ductal carcinoma in situ of the breast. Baltimore, Md: Williams & Wilkins, 1997; 135-158.
21. Boyages J, Recht A, Connolly J, et al. Noninvasive ductal carcinoma of the breast: the relevance of histologic categorization. Hum Pathol 1993; 24:16-23.[CrossRef][Medline]
22. Holland R, Hendriks JHCL, Verbeek ALM, Mravunac M, Schuurmans Stekhoven JH. Extent, distribution, and mammographic/histological correlations of breast ductal carcinoma in situ. Lancet 1990; 335:519-522.[CrossRef][Medline]
23. Soo MS, Williford ME, Walsh R, Bentley RC, Kornguth PJ. Papillary carcinoma of the breast: imaging findings. AJR Am J Roentgenol 1995; 164:321-326.[Abstract/Free Full Text]
24. Schoonjans JM, Brem RF. Sonographic appearance of ductal carcinoma in situ diagnosed with ultrasonographically guided large core needle biopsy: correlation with mammographic and pathologic findings. J Ultrasound Med 2000; 19:449-457.[Abstract]
25. Liberman L, Feng TL, Dershaw DD, Morris EA, Abramson AF. US-guided core breast biopsy: use and cost-effectiveness. Radiology 1998; 208:717-723.[Abstract/Free Full Text]
26. Rubin E, Mennemeyer ST, Desmond RA, et al. Reducing the cost of diagnosis of breast carcinoma: impact of ultrasound and image-guided biopsies on a clinical breast practice. Cancer 2001; 91:324-332.[CrossRef][Medline]
27. Moon WK, Im JG, Noh DY, Yeon KM, Han MC. Nonpalpable breast lesions: evaluation with power Doppler US and a microbubble contrast agent. Radiology 2000; 217:240-246.[Abstract/Free Full Text]
28. Kolb TM, Lichy J, Newhouse JH. Occult cancer in women with dense breasts: detection with screening US—diagnostic yield and tumor characteristics. Radiology 1998; 207:191-199.[Abstract/Free Full Text]
29. Buchberger W, Dekoekkoek-Doll P, Springer P, Obrist P, Dunser M. Incidental findings on sonography of the breast: clinical significance and diagnostic workup. AJR Am J Roentgenol 1999; 173:921-927.[Abstract/Free Full Text]
30. Berg WA, Gilbreath PL. Multicentric and multifocal cancer: whole-breast US in preoperative evaluation. Radiology 2000; 214:59-66.[Abstract/Free Full Text]
31. Slawson SH, Johnson BA. Ductography: how to and what if. RadioGraphics 2001; 21:133-150.[Abstract/Free Full Text]

This article has been cited by other articles:

				H. J. Shin, H. H. Kim, S. M. Kim, G. Y. Kwon, G. Gong, and O. K. Cho Screening-Detected and Symptomatic Ductal Carcinoma in Situ: Differences in the Sonographic and Pathologic Features Am. J. Roentgenol., February 1, 2008; 190(2): 516 - 525. [Abstract] [Full Text] [PDF]

				D. K. Kang, G. S. Jeon, H. Yim, and Y. S. Jung Diagnosis of the Intraductal Component of Invasive Breast Cancer: Assessment With Mammography and Sonography J. Ultrasound Med., November 1, 2007; 26(11): 1587 - 1600. [Abstract] [Full Text] [PDF]

				J. H. Cha, W. K. Moon, N. Cho, S. M. Kim, S. H. Park, B.-K. Han, Y. H. Choe, J. M. Park, and J.-G. Im Characterization of Benign and Malignant Solid Breast Masses: Comparison of Conventional US and Tissue Harmonic Imaging Radiology, December 1, 2006; 242(1): 63 - 69. [Abstract] [Full Text] [PDF]

				N. Cho, W. K. Moon, J. H. Cha, S. M. Kim, B.-K. Han, E.-K. Kim, M. H. Kim, S. Y. Chung, H.-Y. Choi, and J.-G. Im Differentiating Benign from Malignant Solid Breast Masses: Comparison of Two-dimensional and Three-dimensional US Radiology, July 1, 2006; 240(1): 26 - 32. [Abstract] [Full Text] [PDF]

				B. Mesurolle, M. El-Khoury, D. Hori, J.-P. Phancao, S. Kary, E. Kao, and D. Fleiszer Sonography of postexcision specimens of nonpalpable breast lesions: value, limitations, and description of a method. Am. J. Roentgenol., April 1, 2006; 186(4): 1014 - 1024. [Abstract] [Full Text] [PDF]

				J. H. Cha, W. K. Moon, N. Cho, S. Y. Chung, S. H. Park, J. M. Park, B. K. Han, Y. H. Choe, G. Cho, and J.-G. Im Differentiation of Benign from Malignant Solid Breast Masses: Conventional US versus Spatial Compound Imaging Radiology, December 1, 2005; 237(3): 841 - 846. [Abstract] [Full Text] [PDF]

				W. T. Yang and G. M. K. Tse Sonographic, Mammographic, and Histopathologic Correlation of Symptomatic Ductal Carcinoma In Situ Am. J. Roentgenol., January 1, 2004; 182(1): 101 - 110. [Abstract] [Full Text] [PDF]

				W. K. Moon, D.-Y. Noh, and J.-G. Im Multifocal, Multicentric, and Contralateral Breast Cancers: Bilateral Whole-Breast US in the Preoperative Evaluation of Patients Radiology, August 1, 2002; 224(2): 569 - 576. [Abstract] [Full Text] [PDF]

This Article Abstract Figures Only Full Text (PDF) CME Test (opens in a new window) Submit a response Alert me when this article is cited Alert me when eLetters are posted