Initial presentation of Breast DCIS on mammography

Ductal carcinoma in-situ (DCIS) is usually discovered on breast cancer screening mammography 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 carcinoma in-situ (early-stage breast cancer), such as a palpable mass or lump, these small white specs on the X-ray 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 very early-stage breast cancer development.

microcalcification breast dcis xray

The initial presenting mammographic features of microcalcifications in breast DCIS tend to vary between casting, crush stone, and powderish 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 Breast 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 high grade breast 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 a 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
Stellate	malignant	55%
Stellate	benign	4%
Circular (oval)	malignant	28%
Circular (oval)	benign	16%

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 cancer potential?

Radiologists with a 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 carcinoma. However, statistics and interpretations regarding breast 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 treatment options regarding possible excision. There really is no strict association of mammographic appearance of breast DCIS and the actual histopathological grade. But, breast 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 ductal carcinoma insitu 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.

Here are a few Q & A’s with some links to other pages on ductal carcinoma in-situ.

I have just been diagnosed with ductal carcinoma in-situ – what is the treatment for dcis and will I be involved in the decision-making process? The standard treatment of DCIS is surgical removal of all the affected abnormal cells plus a margin of healthy tissue (this is known as a wide, local excision). How extensive the surgery needs to be generally depends on the amount of cancer cells within the breast ducts. If there are several areas or a large area of cancer cells than a mastectomy for dcis is sometimes indicated. Sometimes surgery will be combined with radiation therapy and hormonal therapy. You should be involved with the whole multidisciplinary team with any decision making process regarding your treatment. For an in-depth look at the treatment options for breast carcinoma in-situ please visit our most recent and up-to-date post HERE.
I have just finished treatment for DCIS and have had the all-clear. What are the chances of it coming back or spreading? There is plenty of information on the local recurrence rates of DCIS on our new up-to-date post with all the clinical trials HERE. By definition DCIS should be contained in the breast ducts so there is no lymph node involvement. Occasionally, a lymph node biopsy or sentinel lymph node biopsy may be requested. Statistics have shown that the local recurrence rate of simple DCIS at 5 years (for low or intermediate grade) is 6.1% and for high grade was 15.3%. For women who had a total mastectomy for DCIS the recurrence rate is only 1% in that breast.
My pathology report says ‘DCIS with microinvasion’ what does this mean? We have a full post on Microinvasive breast carcinoma. Microinvasive ductal breast cancer is a borderline condition between ductal carcinoma in situ and invasive ductal carcinoma. DCIS is at the non-invasive breast cancer stage. A very tiny amount of cancer cells have been found beyond the breast ducts – that is they have infiltrated through the basement membrane of the duct and into the surrounding breast tissue. However, the amount and effects are not sufficient to be labelled invasive ductal carcinoma (also known as infiltrating ductal carcinoma).

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