Initial presentation of DCIS on mammography
DCIS is usually discovered on breast cancer screening mammograms from the presence of microcalcifications within breast tissue.
Please note, this page is still good, but is getting a little old, whereas this new page on DCIS is up-to-date.
In the absence of clinically detectable evidence of breast cancer, these small white specs on the Xray give an indication to the radiologist that something unusual is happening within the breast. Many breast microcalcifications turn out to be benign, but certain shapes and patterns are more indicative of a very early breast cancer development.
The initial presenting mammographic features of microcalcifications in DCIS tend to vary between casting, crush stone, and powerish types, with the highest percentage being crushed stone microcalcifications. Asymmetrical density with architectural distortion is not found quite as often, but where it does occur, the DCIS tends to be of a higher nuclear grade.
It should be noted that not all cases of ductal carcinoma in situ will show microcalcifications. In these situations, high resolution ultrasound can be useful for detecting non-calcified DCIS. However, there would typically have to be some compelling reason to use ultrasound, such as a high risk patient or unusual clinical features. Approximately 10-20% of DCIS cases will not show calcifications at all, and about 16% of all breast DCIS is hidden from mammography altogether.
Presenting radiologic appearance of DCIS microcalcifications at breast cancer screening
|Common Presenting Radiologic features with DCIS|
|Casting microcalcifications||Crushed stone microcalcifications||Powederish microcalcifications||Asymmetrical density with architectural distortion||Dominant Mass||Galactographic Findings|
|high nuclear grade||80%||45%||11%||65%|
|low nuclear grade||20%||55%||89%||35%|
|overall relative frequency||23%||39%||13.5%||10%||7.5%||6%|
We can see from the chart above that overall, the most commonly occuring mammographic indication of DCIS are the crushed stone microcalcifications. However, it would appear that casting microcalcifications are more indicative of a higher grade ductal carcinoma, while powderish microcalcifications tend to be associated with a lower grade ductal carcinoma in situ. Asymmetrical density with architectural distortion also tends to be associated with a higher grade DCIS, along with casting microcalcifications.
Malignancy Ratio of All Stellate and Circular Masses
When a small DCIS mass is discovered within the breast via mammography, the shape of this mass can also give a clue as to its benign or malignant nature. Without a doubt, the presence of a somewhat stellate or star-shaped mass is far more indicative of an malignant breast cancer growth than an oval or circular shape. Of course, the relative ‘smoothness’ of the mass margin, if visible, is also a very strong indicator of malignancy, as malignant masses tend to have irregular margins, while benign masses due to various other breast changes generally have smooth borders.
|Malignancy Ratio of Stellate and Circular Masses|
|Mammographic Appearance of Masses||Histology||Relative Percentage|
Rate of DCIS discovery is increasing, due to screening mammograms
The rate of breast cancers discovered as DCIS is thought to be increasing, but this is partially a testament to the effectiveness of mammographic breast cancer screening programs. Ductal carcinoma in situ represents up to 30% of all new cases of breast cancer discovered by breast cancer screening. But remember, if breast cancer is caught while still ‘in situ’ (not yet penetrating the breast duct walls) there is very little risk of anything really bad happening. The 10 year survival rate following DCIS discovery is around 98%.
Can the type of microcalcifications predict invasive breast cancer potential?
Radiologists with long experience in breast cancer diagnosis do begin to get a feel for the subtle features in the presentation of microcalcifications which are more worrisome. But overall, calcifications which have a granular morphology, small size, and large numbers, and those occurring in clusters are general more indicative of a potentially invasive breast cancer. However, statistics and interpretations regarding DCIS calcifications are known to be rather erratic. At such an early stage, no one can really say what is going to happen. Also, the characteristic morphological features found in high-grade DCIS are not always present when the lesion is still very small. This is an important issue, because sometimes treatment decisions, including potential mastectomy, are made based on interpretation of microcalcifications, correlated by biopsy samples and other imaging methods. But generally, the size of the area affected by microcalcifications as seen on the mammogram X-ray can be used as an indicator of the size of the actual lesion, and this can influence thoughts and plans regarding possible excision. There really is no strict association of mammographic appearance of DCIS and the actual histopathological grade. But, DCIS lesions presenting as microcalcifications rather than just as a asymmetrical density are a little more easy to predict.
Other pathologic variables which correlate with DCIS
Other pathological variables that have been shown to have a significant relation to the mammographic appearance of DCIS. The architectural ‘pattern’ of cells certainly plays a role, as does cell size, necrosis, and certain hormonal abnormalities such as C-ebB-2 expression, P53 expression, MIB-1, and estrogen receptor and progesterone receptor expression. So, while there may be some doubt as to the prognostic indications of certain presentation of DCIS microcalcifications, a combination of mammographic information along with the pathological features suggested above does give a pretty good indication of the seriousness of the in situ breast cancer in question. However, studies have shown that there is still a relatively good correlation between the size of microcalcifications and pathological size of the tumor, irrespective of type of microcalcifications that are seen.
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