CASE 15106 Published on 12.11.2017
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High-grade DCIS: atypical clinico-imaging presentation

Section

Breast imaging

Case Type

Clinical Cases

Authors

Dr.Teena Sleeba, Dr. Michelle Aline Antony, Dr. Krishna Prasad, Dr. Binu Joy

Rajagiri Hospital,
Aluva;
Chunangamvely Cochin,
India;
Email:teenasleeba@gmail.com
Connected authors
Patient

56 years, female

Categories
Area of Interest Breast ; Imaging Technique Mammography, Ultrasound, MR, Catheter arteriography, Teleradiology, Image manipulation / Reconstruction
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Clinical History
A 53-year-old post-menopausal lady presented for a mammogram due to occasional sensation of fullness in her right breast and a probable size difference she had noticed over a few months’ duration. No masses were felt clinically.
Imaging Findings
Global asymmetry was seen on mammogram with no masses or microcalcifications.
Multiple subcentimetric ill-marginated nodules were seen in all quadrants of the right breast on US.
In view of suspicious morphology, US-guided core needle biopsy was taken from the most prominent lesions in two different quadrants. Histopathology revealed atypical cells and areas of DCIS.

MRI was then performed to evaluate the extent of the disease. Areas of nodular and linear non-mass areas of enhancement were seen. Disease activity was seen extending posteriorly till the pectoral with no involvement of the latter.
She underwent modified radical mastectomy with level 1 axillary nodal clearance. Due to lack of frozen section facility at the time the surgery was undertaken and given the diffuse extent of the disease, the decision to sample at least level 1 nodes was made. Gross specimen revealed extensive multicentric high grade DCIS with comedonecrosis and areas of invasive ductal carcinoma. All eleven nodes were negative.
Discussion
Ductal carcinoma in situ (DCIS) is a heterogeneous spectrum of intraductal epithelial proliferations which have not breached the basement membrane [1]. It is a known precursor for invasive disease [2]. There has been a dramatic increase in the incidence of DCIS after screening mammograms got implemented into health care services [3].

DCIS typically present as microcalcifications on mammograms, however, approximately 10 - 20% of DCIS may be of the non-calcific variety [4].

Calcified DCIS tend to have more aggressive histological features than non-calcified DCIS with nuclear pleomorphism, more nucleoli and mitosis [5].
Comedonecrosis, though not mandatory, is a usual histological finding on calcified DCIS. This is due to rapid cell apoptosis and oncosis or passive cell death that is occurring within the tubulo-lobular unit. High grade DCIS is usually associated with the linear and branching type of microcalcification on mammogram [6].

In most cases DCIS usually involves the breast in a unicentric segmental fashion and true multicentric disease is unusual occurring in an estimated 10% of cases. Moreover, it is a known factor that patients who have both DCIS and invasion are clinically symptomatic [7].

Hence it was interesting that our patient was rather asymptomatic with no clinical findings while harboring multicentric high-grade DCIS with invasion. Mammogram too was conspicuous by lack of microcalcifcations.


Dedicated MRI techniques with high spatial resolution are capable of detecting as much as 98% of DCIS. A study done by Kuhl et al exclusively on patients with pure DCIS showed that MRI sensitivity was 98% compared with only 52% for mammography in women with high-grade DCIS [8].


To conclude, non–calcified DCIS may not always be associated with a lower histopathological grade. A multimodality approach with valuable information from MRI could play a vital role in diagnosing the entire extent of the disease and may eventually change the course of treatment for a given patient [9].
Differential Diagnosis List
Multicentric high grade DCIS with invasion.
Lobular breast malignancy
Mastitis
Final Diagnosis
Multicentric high grade DCIS with invasion.
Case information
URL: https://www.eurorad.org/case/15106
DOI: 10.1594/EURORAD/CASE.15106
ISSN: 1563-4086
License

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.

Figure 1

Fat -uppressed T1W post-contrast image

Fat -uppressed T1W post-contrast image
Ill-defined nodular and linear non-mass-like areas of enhancement reaching till the pectoral. Skin and nipple was unremarkable.
Figure 2

Ultrasound

Ultrasound
US image showing ill-marginated hypoechoic lesions with perilesional echogenic halo.
Figure 3

Photomicrograph

Photomicrograph
High-grade DCIS with central comedo-type necrosis (small black arrow). The neoplastic cells demonstrate markedly enlarged nuclei, with significant pleomorphism, coarse chromatin, and lack of polarity (long black arrow).
Figure 4

Photomicrograph

Photomicrograph
Invasive component seen adjacent to DCIS with malignant cells seen in the stroma (black arrow).
Figure 5

Post-contrast Maximum Intensity Projection images

Post-contrast Maximum Intensity Projection images
MIP Images showing diffuse involvement of right breast.
Figure 6

Craniocaudal view

Craniocaudal view
CCview: Global asymmetry seen in right breast.
Figure 7

MLO Views

MLO Views
MLO views: Global asymmetry right breast with mild discrepancy in size better appreciated in MLO views.
Figure 8

DWI and ADC

DWI and ADC
Diffusion restriction seen involving most of right breast. Hypointensity seen on corresponding ADC images.