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Imaging Features of Micropapillary DCIS

Posted Jun 30, 2011 Updated Apr 10, 2023
By Yien Sien Lee MBBS FRCR , Jean Mathew DO , Basak E. Dogan MD , Erika Resetkova MD PhD , Lei Huo MD PhD , Wei Tse Yang MD
10 min read

Rationale and Objectives

The aim of this study was to describe the mammographic, sonographic, and magnetic resonance imaging (MRI) findings of micropapillary ductal carcinoma in situ.

Materials and Methods

Between May 2004 and April 2008, the pathology database of a single institution was reviewed for patients diagnosed with histologically proven DCIS with a predominant micropapillary component. Clinical data and preoperative imaging studies, including mammography, sonography, and/or MRI, were reviewed.

Results

Forty-one patients (mean age, 55 years; range, 33–82 years) with 42 tumors were included in this study. Most tumors ( n = 32 [76%]) were detected on screening mammography, with a mean tumor size of 4.7 cm (range, 0.5–13 cm). Of 42 tumors, seven (16%) were multicentric, and 23 (54%) were high nuclear grade. Calcifications were identified in 36 tumors (86%) on mammography, most frequently with pleomorphic morphology (15 tumors [42%]). Sonography was frequently normal (17 of 36 [47%]). When abnormal, irregular mass and angular margins were the most common sonographic features. All four tumors with MRI showed non-mass-like enhancement and showed the best correlation with pathologic size.

Conclusions

Micropapillary ductal carcinoma in situ is a unique subset of in situ cancer that is frequently clinically occult but has a large mean size at diagnosis and demonstrates highly suspicious features at imaging including pleomorphic calcifications on mammography and an irregular mass at sonography. MRI may be the imaging modality of choice for delineation of disease extent and warrants further validation.

Ductal carcinoma in situ (DCIS) is heterogeneous in histopathologic characteristics and biologic behavior . With the increased use of screening mammography, DCIS now accounts for 22% to 45% of breast cancers detected in patients undergoing biopsy for clinically occult lesions seen on mammography . Micropapillary DCIS is a subtype of DCIS characterized by the presence of papillary fronds that protrude into the ductal lumen in a regular distribution . This subtype of DCIS is frequently multifocal and multicentric, which may lead to underestimation of size by imaging modalities. Therefore, Scott et al proposed to separate pure cases of micropapillary DCIS to accrue prognostic information.

It is well documented that breast-conserving surgery followed by external-beam radiation is associated with a low rate of local recurrence, and survival is equivalent to treatment by mastectomy . Preoperative estimation of tumor size by mammography, sonography, and in some instances magnetic resonance imaging (MRI) is important in surgical planning to achieve histologic negative margins . Mammography has been shown to underestimate the histologic size of DCIS . The extent of size discrepancy was related to the histologic type of DCIS, the size of the micropapillary (cribriform) subtype of DCIS was more commonly underestimated on mammography compared to the comedo subtype, and frequently required one or more additional surgical procedures . To date, there are scant data in the literature describing the imaging characteristics of micropapillary DCIS. With this retrospective study, we aimed to describe the imaging features of micropapillary DCIS.

Materials and methods

Study Population

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Mammography

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Sonography

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MRI

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Image Evaluation

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Histopathologic Evaluation

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Results

Clinical Findings and Presentation

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Table 1

Clinical and Pathological Features in 41 Patients with 42 Micropapillary Ductal Carcinoma in Situ Tumors

Feature_n_ (%) Clinical presentation ( n = 41) Palpable mass 8 (20) Palpable mass with nipple discharge 1 (2) Nipple discharge 1 (2) Asymptomatic 31 (76) Tumor size (cm) ( n = 42) <2 7 (17) 2–5 17 (40) >5–10 13 (31) >10 5 (12) Nuclear grade ( n = 42) 1 and 2 19 (45) 3 23 (55) Estrogen receptor status (n = 42) Positive 35 (83) Negative 5 (12) Not available 2 (5) Progesterone receptor status (n = 42) Positive 28 (67) Negative 12 (29) Not available 2 (5) Human epidermal growth factor receptor 2 status ( n = 42) Positive 3 (7) Negative 5 (12) Not available 34 (81)

Percentages do not add up to 100%, because of rounding.

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Imaging Findings

Mammography

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Table 2

Mammographic, Sonographic, and MRI Findings in 42 Patients with Micropapillary Ductal Carcinoma in Situ

Imaging Finding_n_ (%) Mammography ( n = 42) Total calcifications 35 (83) Calcifications only 32 (76) Mass with calcifications 1 (2) Focal asymmetry with calcifications 1 (2) Architectural distortion with calcifications 1 (2) Mass only 3 (7) Focal asymmetry only 2 (5) Ductal dilatation 1 (2) Nipple skin thickening 1 (2) Sonography ( n = 36) Negative 17 (47) Architectural distortion 7 (19) Ductal dilatation 5 (14) Mass 7 (19) Mass characteristics (n = 7) Shape Irregular 5 (71) Oval 2 (19) Margins Indistinct 1 (14) Angular 4 (57) Microlobulated 2 (29) Echogenecity Hypoechoic 7 (100) MRI ( n = 4) Non-mass-like enhancement 4 (100) Distribution Segmental 2 (50) Regional 2 (50) Internal pattern Clumped 3 (75) Heterogeneous 1 (25) Type 1 kinetic curve 2 (50) Type 2 kinetic curve 1 (25) Type 3 kinetic curve 1 (25)

Percentages do not add up to 100%, because of rounding.

Figure 1, A 67-year-old woman who presented with a palpable left breast mass. (a) Magnification left mediolateral mammogram shows pleomorphic calcifications in segmental distribution ( arrow ). (b) Power Doppler sonogram shows moderate hypervascularity in solid hypoechoic mass with indistinct margins ( arrows ).

Table 3

Morphology and Distribution of Calcifications in 35 Patients with Micropapillary Ductal Carcinoma in Situ

Distribution Morphology Linear Heterogeneous Pleomorphic Amorphous Punctate Total Segmental 3 1 11 2 17 Grouped 3 4 1 8 Regional 1 4 3 8 Scattered 1 1 2 Total 3 5 15 10 2 35

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Sonography

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Figure 2, A 37-year-old woman who presented with a tender left breast mass and bloody nipple discharge. (a) Mediolateral left mammogram shows equal density mass with indistinct margins ( arrow ) in the superior breast corresponding to palpable abnormality, indicated with triangle marker. Curvilinear skin marker indicates postsurgical scar from incisional biopsy, which revealed ductal carcinoma in situ with positive margins on histology ( short arrow ). (b) Grayscale sonogram of the left breast shows irregular solid hypoechoic mass with indistinct margins ( arrows ) corresponding to mammography finding. (c) Sagittal dynamic contrast-enhanced subtraction magnetic resonance image shows multiple areas of clumped enhancement in the upper and central left breast spanning 9 cm ( arrows ). Pathology showed grade 2 micropapillary ductal carcinoma in situ measuring 8 cm.

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MRI

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Figure 3, (a) A 44-year-old woman who presented with a palpable mass in the upper outer right breast, status post incisional biopsy. Mediolateral mammogram shows postsurgical scar at the 10 o’clock position that showed with positive margins at surgery ( arrow ). No residual malignancy or calcifications were noted on mammography. (b) Sagittal dynamic contrast-enhanced magnetic resonance image of the right breast shows segmental heterogeneous non-mass-like enhancement occupying the central and superolateral breast, consistent with residual disease ( long arrow ). Ductal enhancement at retroareolar region suggests residual tumor ( short arrow ). Final histology showed extensive ductal carcinoma in situ (DCIS) and intraductal papilloma involvement by DCIS. (c) Full-volume maximal intensity projection image demonstrates ductal enhancement in the retroareolar region of the right breast ( arrows ).

Figure 4, (a) Craniocaudal mammogram of a 49-year-old patient with prepectoral saline implants who presented with right breast pain and nipple discharge. A postbiopsy scar in the lateral right breast indicates the site of partially excised grade 3 micropapillary ductal carcinoma in situ (DCIS) with positive margins ( arrow ). No evidence of residual disease was seen on mammography. (b) Bilateral axial contrast-enhanced delayed three-dimensional Volume Imaging for Breast Assessment (GE Healthcare, Milwaukee, WI) fat-suppressed magnetic resonance image shows regional heterogeneous non-mass-like enhancement occupying the lateral right breast ( arrows ) that was mammographically occult (not shown). Final histology showed extensive grade 2 micropapillary DCIS measuring 10 cm.

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Treatment and Histopathologic Findings

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Discussion

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Conclusions

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Academic Radiology, Volume 18, Issue 7
Journals General Radiology
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