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DCIS, High Grade
Vilert Loving, MD; Wei Tse Yang, MBBS
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KEY FACTS

  • Terminology

    • Imaging

      • Top Differential Diagnoses

        • Pathology

          • Clinical Issues

            TERMINOLOGY

            • Synonyms

              • Poorly differentiated DCIS
              • Nuclear grade 3 DCIS
            • Definitions

              • DCIS: Clonal proliferation of malignant epithelial cells within breast duct(s)
                • Myoepithelial cell layer remains intact around periphery of malignant cells
              • High nuclear grade: Enlarged, pleomorphic nuclei, 2.5-3.0x size of red blood cell (> 15 μm)
                • Central necrosis in duct lumen (comedonecrosis) almost always present; when present, termed comedocarcinoma or comedo DCIS

            IMAGING

            • General Features

              • Mammographic Findings

                • Ultrasonographic Findings

                  • MR Findings

                    • Nuclear Medicine Findings

                      • Image-Guided Biopsy

                        • Imaging Recommendations

                          DIFFERENTIAL DIAGNOSIS

                            PATHOLOGY

                            • General Features

                              • Staging, Grading, & Classification

                                • Gross Pathologic & Surgical Features

                                  • Microscopic Features

                                    CLINICAL ISSUES

                                    • Presentation

                                      • Demographics

                                        • Natural History & Prognosis

                                          • Treatment

                                            DIAGNOSTIC CHECKLIST

                                            • Consider

                                              • Image Interpretation Pearls

                                                Selected References

                                                1. Parikh U et al: Ductal carcinoma in situ: the whole truth. AJR Am J Roentgenol. 210(2):246-55, 2018
                                                2. Scott-Moncrieff A et al: MR imaging appearance of noncalcified and calcified DCIS. Breast J. 24(3):343-49, 2018
                                                3. Weigel S et al: Detection rates of ductal carcinoma in situ with biennial digital mammography screening: radiologic findings support pathologic model of tumor progression. Radiology. 286(2):424-32, 2018
                                                4. Kuhl CK et al: Impact of preoperative breast MR imaging and MR-guided surgery on diagnosis and surgical outcome of women with invasive breast cancer with and without DCIS component. Radiology. 161449, 2017
                                                5. Luiten JD et al: Trends in incidence and tumour grade in screen-detected ductal carcinoma in situ and invasive breast cancer. Breast Cancer Res Treat. 166(1):307-14, 2017
                                                6. Duffy SW et al: Screen detection of ductal carcinoma in situ and subsequent incidence of invasive interval breast cancers: a retrospective population-based study. Lancet Oncol. 17(1):109-14, 2016
                                                7. Morrow M et al: Society of Surgical Oncology-American Society for Radiation Oncology-American Society of Clinical Oncology Consensus Guideline on margins for breast-conserving surgery with whole-breast irradiation in ductal carcinoma in situ. Ann Surg Oncol. 23(12):3801-10, 2016
                                                8. Raj SD et al: Stereotactic biopsy of segmental breast calcifications: is sampling of anterior and posterior components necessary? Acad Radiol. 23(6):682-6, 2016
                                                9. Szynglarewicz B et al: Screen-detected ductal carcinoma in situ found on stereotactic vacuum-assisted biopsy of suspicious microcalcifications without mass: radiological-histological correlation. Radiol Oncol. 50(2):145-52, 2016
                                                10. van Roozendaal LM et al: Sentinel lymph node biopsy can be omitted in DCIS patients treated with breast conserving therapy. Breast Cancer Res Treat. 156(3):517-525, 2016
                                                11. Silverstein MJ et al: Treatment selection for patients with ductal carcinoma in situ (DCIS) of the breast using the University of Southern California/Van Nuys (USC/VNPI) prognostic index. Breast J. 21(2):127-32, 2015
                                                12. Chin-Lenn L et al: Predictors of treatment with mastectomy, use of sentinel lymph node biopsy and upstaging to invasive cancer in patients diagnosed with breast ductal carcinoma in situ (DCIS) on core biopsy. Ann Surg Oncol. 21(1):66-73, 2014
                                                13. Pilewskie M et al: Effect of MRI on the management of ductal carcinoma in situ of the breast. Ann Surg Oncol. 20(5):1522-9, 2013
                                                14. Rauch GM et al: Clinicopathologic, mammographic, and sonographic features in 1,187 patients with pure ductal carcinoma in situ of the breast by estrogen receptor status. Breast Cancer Res Treat. 139(3):639-47, 2013
                                                15. Deurloo EE et al: MRI of the breast in patients with DCIS to exclude the presence of invasive disease. Eur Radiol. 22(7):1504-11, 2012
                                                16. Gwak YJ et al: Ultrasonographic detection and characterization of asymptomatic ductal carcinoma in situ with histopathologic correlation. Acta Radiol. 52(4):364-71, 2011
                                                17. Hofvind S et al: Mammographic morphology and distribution of calcifications in ductal carcinoma in situ diagnosed in organized screening. Acta Radiol. 52(5):481-7, 2011
                                                18. Houssami N et al: Accuracy of a preoperative model for predicting invasive breast cancer in women with ductal carcinoma-in-situ on vacuum-assisted core needle biopsy. Ann Surg Oncol. 18(5):1364-71, 2011
                                                19. Kim JA et al: MRI findings of pure ductal carcinoma in situ: kinetic characteristics compared according to lesion type and histopathologic factors. AJR Am J Roentgenol. 196(6):1450-6, 2011
                                                20. Lari SA et al: Biological markers in DCIS and risk of breast recurrence: a systematic review. J Cancer. 2:232-61, 2011
                                                21. Early Breast Cancer Trialists' Collaborative Group (EBCTCG) et al: Overview of the randomized trials of radiotherapy in ductal carcinoma in situ of the breast. J Natl Cancer Inst Monogr. 2010(41):162-77, 2010
                                                22. Kurniawan ED et al: Risk factors for invasive breast cancer when core needle biopsy shows ductal carcinoma in situ. Arch Surg. 145(11):1098-104, 2010
                                                23. Park JS et al: Sonographic findings of high-grade and non-high-grade ductal carcinoma in situ of the breast. J Ultrasound Med. 29(12):1687-97, 2010
                                                24. Thomas J et al: Radiological and pathological size estimations of pure ductal carcinoma in situ of the breast, specimen handling and the influence on the success of breast conservation surgery: a review of 2564 cases from the Sloane Project. Br J Cancer. 102(2):285-93, 2010
                                                25. Virnig BA et al: Ductal carcinoma in situ of the breast: a systematic review of incidence, treatment, and outcomes. J Natl Cancer Inst. 102(3):170-8, 2010
                                                26. Virnig BA et al: Ductal carcinoma in situ: risk factors and impact of screening. J Natl Cancer Inst Monogr. 2010(41):113-6, 2010
                                                27. Shin HJ et al: Screening-detected and symptomatic ductal carcinoma in situ: differences in the sonographic and pathologic features. AJR Am J Roentgenol. 190(2):516-25, 2008
                                                28. Brem RF et al: Detection of ductal carcinoma in situ with mammography, breast specific gamma imaging, and magnetic resonance imaging: a comparative study. Acad Radiol. 14(8):945-50, 2007
                                                29. Kuhl CK et al: MRI for diagnosis of pure ductal carcinoma in situ: a prospective observational study. Lancet. 370(9586):485-92, 2007
                                                30. Lehman CD et al: MRI evaluation of the contralateral breast in women with recently diagnosed breast cancer. N Engl J Med. 356(13):1295-303, 2007
                                                31. Esserman LJ et al: Magnetic resonance imaging captures the biology of ductal carcinoma in situ. J Clin Oncol. 24(28):4603-10, 2006
                                                32. Collins LC et al: HER2 protein overexpression in estrogen receptor-positive ductal carcinoma in situ of the breast: frequency and implications for tamoxifen therapy. Mod Pathol. 18(5):615-20, 2005
                                                33. Collins LC et al: Outcome of patients with ductal carcinoma in situ untreated after diagnostic biopsy: results from the Nurses' Health Study. Cancer. 103(9):1778-84, 2005
                                                34. Groves AM et al: Characterization of pure high-grade DCIS on magnetic resonance imaging using the evolving breast MR lexicon terminology: can it be differentiated from pure invasive disease? Magn Reson Imaging. 23(6):733-8, 2005
                                                35. Bluemke DA et al: Magnetic resonance imaging of the breast prior to biopsy. JAMA. 292(22):2735-42, 2004
                                                36. Burstein HJ et al: Ductal carcinoma in situ of the breast. N Engl J Med. 350(14):1430-41, 2004
                                                37. De Roos MA et al: Correlation between imaging and pathology in ductal carcinoma in situ of the breast. World J Surg Oncol. 2(1):4, 2004
                                                38. Kricker A et al: Ductal carcinoma in situ of the breast, a population-based study of epidemiology and pathology. Br J Cancer. 90(7):1382-5, 2004
                                                39. Yang WT et al: Sonographic, mammographic, and histopathologic correlation of symptomatic ductal carcinoma in situ. AJR Am J Roentgenol. 182(1):101-10, 2004
                                                40. Neubauer H et al: High grade and non-high grade ductal carcinoma in situ on dynamic MR mammography: characteristic findings for signal increase and morphological pattern of enhancement. Br J Radiol. 76(901):3-12, 2003
                                                41. Silverstein MJ et al: Ductal carcinoma in situ: USC/Van Nuys Prognostic Index and the impact of margin status. Breast. 12(6):457-71, 2003
                                                42. Jaffer S et al: Histologic classification of ductal carcinoma in situ. Microsc Res Tech. 59(2):92-101, 2002
                                                43. Kessar P et al: How significant is detection of ductal carcinoma in situ in a breast screening programme? Clin Radiol. 57(9):807-14, 2002
                                                44. Kothari AS et al: Paget disease of the nipple: a multifocal manifestation of higher-risk disease. Cancer. 95(1):1-7, 2002
                                                45. Moon WK et al: Multifocal, multicentric, and contralateral breast cancers: bilateral whole-breast US in the preoperative evaluation of patients. Radiology. 224(2):569-76, 2002
                                                46. Moon WK et al: US of ductal carcinoma in situ. Radiographics. 22(2):269-80; discussion 280-1, 2002
                                                47. Bijker N et al: Histological type and marker expression of the primary tumour compared with its local recurrence after breast-conserving therapy for ductal carcinoma in situ. Br J Cancer. 84(4):539-44, 2001
                                                48. Evans AJ et al: Screen detected ductal carcinoma in situ (DCIS): overdiagnosis or an obligate precursor of invasive disease? J Med Screen. 8(3):149-51, 2001
                                                49. Viehweg P et al: In situ and minimally invasive breast cancer: morphologic and kinetic features on contrast-enhanced MR imaging. MAGMA. 11(3):129-37, 2000
                                                50. Hetelekidis S et al: Predictors of local recurrence following excision alone for ductal carcinoma in situ. Cancer. 85(2):427-31, 1999
                                                51. Lagios MD et al: Ductal carcinoma in situ. The success of breast conservation therapy: a shared experience of two single institutional nonrandomized prospective studies. Surg Oncol Clin N Am. 6(2):385-92, 1997
                                                52. Evans A et al: Ductal carcinoma in situ of the breast: correlation between mammographic and pathologic findings. AJR Am J Roentgenol. 162(6):1307-11, 1994
                                                53. Stomper PC et al: Ductal carcinoma in situ of the breast: correlation between mammographic calcification and tumor subtype. AJR. 159:483-5, 1992
                                                54. Holland R et al: Extent, distribution, and mammographic/histological correlations of breast ductal carcinoma in situ. Lancet. 335(8688):519-22, 1990
                                                55. Rosen PP et al: The clinical significance of pre-invasive breast carcinoma. Cancer. 46(4 Suppl):919-25, 1980
                                                Related Anatomy
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                                                Related Differential Diagnoses
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                                                References
                                                Tables

                                                Tables

                                                KEY FACTS

                                                • Terminology

                                                  • Imaging

                                                    • Top Differential Diagnoses

                                                      • Pathology

                                                        • Clinical Issues

                                                          TERMINOLOGY

                                                          • Synonyms

                                                            • Poorly differentiated DCIS
                                                            • Nuclear grade 3 DCIS
                                                          • Definitions

                                                            • DCIS: Clonal proliferation of malignant epithelial cells within breast duct(s)
                                                              • Myoepithelial cell layer remains intact around periphery of malignant cells
                                                            • High nuclear grade: Enlarged, pleomorphic nuclei, 2.5-3.0x size of red blood cell (> 15 μm)
                                                              • Central necrosis in duct lumen (comedonecrosis) almost always present; when present, termed comedocarcinoma or comedo DCIS

                                                          IMAGING

                                                          • General Features

                                                            • Mammographic Findings

                                                              • Ultrasonographic Findings

                                                                • MR Findings

                                                                  • Nuclear Medicine Findings

                                                                    • Image-Guided Biopsy

                                                                      • Imaging Recommendations

                                                                        DIFFERENTIAL DIAGNOSIS

                                                                          PATHOLOGY

                                                                          • General Features

                                                                            • Staging, Grading, & Classification

                                                                              • Gross Pathologic & Surgical Features

                                                                                • Microscopic Features

                                                                                  CLINICAL ISSUES

                                                                                  • Presentation

                                                                                    • Demographics

                                                                                      • Natural History & Prognosis

                                                                                        • Treatment

                                                                                          DIAGNOSTIC CHECKLIST

                                                                                          • Consider

                                                                                            • Image Interpretation Pearls

                                                                                              Selected References

                                                                                              1. Parikh U et al: Ductal carcinoma in situ: the whole truth. AJR Am J Roentgenol. 210(2):246-55, 2018
                                                                                              2. Scott-Moncrieff A et al: MR imaging appearance of noncalcified and calcified DCIS. Breast J. 24(3):343-49, 2018
                                                                                              3. Weigel S et al: Detection rates of ductal carcinoma in situ with biennial digital mammography screening: radiologic findings support pathologic model of tumor progression. Radiology. 286(2):424-32, 2018
                                                                                              4. Kuhl CK et al: Impact of preoperative breast MR imaging and MR-guided surgery on diagnosis and surgical outcome of women with invasive breast cancer with and without DCIS component. Radiology. 161449, 2017
                                                                                              5. Luiten JD et al: Trends in incidence and tumour grade in screen-detected ductal carcinoma in situ and invasive breast cancer. Breast Cancer Res Treat. 166(1):307-14, 2017
                                                                                              6. Duffy SW et al: Screen detection of ductal carcinoma in situ and subsequent incidence of invasive interval breast cancers: a retrospective population-based study. Lancet Oncol. 17(1):109-14, 2016
                                                                                              7. Morrow M et al: Society of Surgical Oncology-American Society for Radiation Oncology-American Society of Clinical Oncology Consensus Guideline on margins for breast-conserving surgery with whole-breast irradiation in ductal carcinoma in situ. Ann Surg Oncol. 23(12):3801-10, 2016
                                                                                              8. Raj SD et al: Stereotactic biopsy of segmental breast calcifications: is sampling of anterior and posterior components necessary? Acad Radiol. 23(6):682-6, 2016
                                                                                              9. Szynglarewicz B et al: Screen-detected ductal carcinoma in situ found on stereotactic vacuum-assisted biopsy of suspicious microcalcifications without mass: radiological-histological correlation. Radiol Oncol. 50(2):145-52, 2016
                                                                                              10. van Roozendaal LM et al: Sentinel lymph node biopsy can be omitted in DCIS patients treated with breast conserving therapy. Breast Cancer Res Treat. 156(3):517-525, 2016
                                                                                              11. Silverstein MJ et al: Treatment selection for patients with ductal carcinoma in situ (DCIS) of the breast using the University of Southern California/Van Nuys (USC/VNPI) prognostic index. Breast J. 21(2):127-32, 2015
                                                                                              12. Chin-Lenn L et al: Predictors of treatment with mastectomy, use of sentinel lymph node biopsy and upstaging to invasive cancer in patients diagnosed with breast ductal carcinoma in situ (DCIS) on core biopsy. Ann Surg Oncol. 21(1):66-73, 2014
                                                                                              13. Pilewskie M et al: Effect of MRI on the management of ductal carcinoma in situ of the breast. Ann Surg Oncol. 20(5):1522-9, 2013
                                                                                              14. Rauch GM et al: Clinicopathologic, mammographic, and sonographic features in 1,187 patients with pure ductal carcinoma in situ of the breast by estrogen receptor status. Breast Cancer Res Treat. 139(3):639-47, 2013
                                                                                              15. Deurloo EE et al: MRI of the breast in patients with DCIS to exclude the presence of invasive disease. Eur Radiol. 22(7):1504-11, 2012
                                                                                              16. Gwak YJ et al: Ultrasonographic detection and characterization of asymptomatic ductal carcinoma in situ with histopathologic correlation. Acta Radiol. 52(4):364-71, 2011
                                                                                              17. Hofvind S et al: Mammographic morphology and distribution of calcifications in ductal carcinoma in situ diagnosed in organized screening. Acta Radiol. 52(5):481-7, 2011
                                                                                              18. Houssami N et al: Accuracy of a preoperative model for predicting invasive breast cancer in women with ductal carcinoma-in-situ on vacuum-assisted core needle biopsy. Ann Surg Oncol. 18(5):1364-71, 2011
                                                                                              19. Kim JA et al: MRI findings of pure ductal carcinoma in situ: kinetic characteristics compared according to lesion type and histopathologic factors. AJR Am J Roentgenol. 196(6):1450-6, 2011
                                                                                              20. Lari SA et al: Biological markers in DCIS and risk of breast recurrence: a systematic review. J Cancer. 2:232-61, 2011
                                                                                              21. Early Breast Cancer Trialists' Collaborative Group (EBCTCG) et al: Overview of the randomized trials of radiotherapy in ductal carcinoma in situ of the breast. J Natl Cancer Inst Monogr. 2010(41):162-77, 2010
                                                                                              22. Kurniawan ED et al: Risk factors for invasive breast cancer when core needle biopsy shows ductal carcinoma in situ. Arch Surg. 145(11):1098-104, 2010
                                                                                              23. Park JS et al: Sonographic findings of high-grade and non-high-grade ductal carcinoma in situ of the breast. J Ultrasound Med. 29(12):1687-97, 2010
                                                                                              24. Thomas J et al: Radiological and pathological size estimations of pure ductal carcinoma in situ of the breast, specimen handling and the influence on the success of breast conservation surgery: a review of 2564 cases from the Sloane Project. Br J Cancer. 102(2):285-93, 2010
                                                                                              25. Virnig BA et al: Ductal carcinoma in situ of the breast: a systematic review of incidence, treatment, and outcomes. J Natl Cancer Inst. 102(3):170-8, 2010
                                                                                              26. Virnig BA et al: Ductal carcinoma in situ: risk factors and impact of screening. J Natl Cancer Inst Monogr. 2010(41):113-6, 2010
                                                                                              27. Shin HJ et al: Screening-detected and symptomatic ductal carcinoma in situ: differences in the sonographic and pathologic features. AJR Am J Roentgenol. 190(2):516-25, 2008
                                                                                              28. Brem RF et al: Detection of ductal carcinoma in situ with mammography, breast specific gamma imaging, and magnetic resonance imaging: a comparative study. Acad Radiol. 14(8):945-50, 2007
                                                                                              29. Kuhl CK et al: MRI for diagnosis of pure ductal carcinoma in situ: a prospective observational study. Lancet. 370(9586):485-92, 2007
                                                                                              30. Lehman CD et al: MRI evaluation of the contralateral breast in women with recently diagnosed breast cancer. N Engl J Med. 356(13):1295-303, 2007
                                                                                              31. Esserman LJ et al: Magnetic resonance imaging captures the biology of ductal carcinoma in situ. J Clin Oncol. 24(28):4603-10, 2006
                                                                                              32. Collins LC et al: HER2 protein overexpression in estrogen receptor-positive ductal carcinoma in situ of the breast: frequency and implications for tamoxifen therapy. Mod Pathol. 18(5):615-20, 2005
                                                                                              33. Collins LC et al: Outcome of patients with ductal carcinoma in situ untreated after diagnostic biopsy: results from the Nurses' Health Study. Cancer. 103(9):1778-84, 2005
                                                                                              34. Groves AM et al: Characterization of pure high-grade DCIS on magnetic resonance imaging using the evolving breast MR lexicon terminology: can it be differentiated from pure invasive disease? Magn Reson Imaging. 23(6):733-8, 2005
                                                                                              35. Bluemke DA et al: Magnetic resonance imaging of the breast prior to biopsy. JAMA. 292(22):2735-42, 2004
                                                                                              36. Burstein HJ et al: Ductal carcinoma in situ of the breast. N Engl J Med. 350(14):1430-41, 2004
                                                                                              37. De Roos MA et al: Correlation between imaging and pathology in ductal carcinoma in situ of the breast. World J Surg Oncol. 2(1):4, 2004
                                                                                              38. Kricker A et al: Ductal carcinoma in situ of the breast, a population-based study of epidemiology and pathology. Br J Cancer. 90(7):1382-5, 2004
                                                                                              39. Yang WT et al: Sonographic, mammographic, and histopathologic correlation of symptomatic ductal carcinoma in situ. AJR Am J Roentgenol. 182(1):101-10, 2004
                                                                                              40. Neubauer H et al: High grade and non-high grade ductal carcinoma in situ on dynamic MR mammography: characteristic findings for signal increase and morphological pattern of enhancement. Br J Radiol. 76(901):3-12, 2003
                                                                                              41. Silverstein MJ et al: Ductal carcinoma in situ: USC/Van Nuys Prognostic Index and the impact of margin status. Breast. 12(6):457-71, 2003
                                                                                              42. Jaffer S et al: Histologic classification of ductal carcinoma in situ. Microsc Res Tech. 59(2):92-101, 2002
                                                                                              43. Kessar P et al: How significant is detection of ductal carcinoma in situ in a breast screening programme? Clin Radiol. 57(9):807-14, 2002
                                                                                              44. Kothari AS et al: Paget disease of the nipple: a multifocal manifestation of higher-risk disease. Cancer. 95(1):1-7, 2002
                                                                                              45. Moon WK et al: Multifocal, multicentric, and contralateral breast cancers: bilateral whole-breast US in the preoperative evaluation of patients. Radiology. 224(2):569-76, 2002
                                                                                              46. Moon WK et al: US of ductal carcinoma in situ. Radiographics. 22(2):269-80; discussion 280-1, 2002
                                                                                              47. Bijker N et al: Histological type and marker expression of the primary tumour compared with its local recurrence after breast-conserving therapy for ductal carcinoma in situ. Br J Cancer. 84(4):539-44, 2001
                                                                                              48. Evans AJ et al: Screen detected ductal carcinoma in situ (DCIS): overdiagnosis or an obligate precursor of invasive disease? J Med Screen. 8(3):149-51, 2001
                                                                                              49. Viehweg P et al: In situ and minimally invasive breast cancer: morphologic and kinetic features on contrast-enhanced MR imaging. MAGMA. 11(3):129-37, 2000
                                                                                              50. Hetelekidis S et al: Predictors of local recurrence following excision alone for ductal carcinoma in situ. Cancer. 85(2):427-31, 1999
                                                                                              51. Lagios MD et al: Ductal carcinoma in situ. The success of breast conservation therapy: a shared experience of two single institutional nonrandomized prospective studies. Surg Oncol Clin N Am. 6(2):385-92, 1997
                                                                                              52. Evans A et al: Ductal carcinoma in situ of the breast: correlation between mammographic and pathologic findings. AJR Am J Roentgenol. 162(6):1307-11, 1994
                                                                                              53. Stomper PC et al: Ductal carcinoma in situ of the breast: correlation between mammographic calcification and tumor subtype. AJR. 159:483-5, 1992
                                                                                              54. Holland R et al: Extent, distribution, and mammographic/histological correlations of breast ductal carcinoma in situ. Lancet. 335(8688):519-22, 1990
                                                                                              55. Rosen PP et al: The clinical significance of pre-invasive breast carcinoma. Cancer. 46(4 Suppl):919-25, 1980