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

  • Terminology

    • Imaging

      • Top Differential Diagnoses

        • Pathology

          • Clinical Issues

            TERMINOLOGY

            • Abbreviations

              • Ductal carcinoma in situ (DCIS)
            • Synonyms

              • Nuclear grade 2 DCIS
            • Definitions

              • DCIS: Clonal proliferation of malignant epithelial cells within breast duct(s)
                • Myoepithelial cell layer remains intact surrounding malignant cells
              • Intermediate nuclear grade: Nuclei distinctly enlarged (1.5-2x normal); moderate variability in nuclear size, shape, and placement; pleomorphism intermediate between grade 1 (low grade) and grade 3 (high grade)

            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

                                • Microscopic Features

                                  CLINICAL ISSUES

                                  • Presentation

                                    • Demographics

                                      • Natural History & Prognosis

                                        • Treatment

                                          DIAGNOSTIC CHECKLIST

                                          • Consider

                                            • Image Interpretation Pearls

                                              Selected References

                                              1. Kim M et al: Microinvasive carcinoma versus ductal carcinoma in situ: a comparison of clinicopathological features and clinical outcomes. J Breast Cancer. 21(2):197-205, 2018
                                              2. Scott-Moncrieff A et al: MR imaging appearance of noncalcified and calcified DCIS. Breast J. 24(3):343-349, 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. Chavez de Paz Villanueva C et al: Factors associated with underestimation of invasive cancer in patients with ductal carcinoma in situ: precautions for active surveillance. JAMA Surg. 152(11):1007-14, 2017
                                              5. Kuerer HM et al: DCIS Margins and breast conservation: MD Anderson Cancer Center Multidisciplinary practice guidelines and outcomes. J Cancer. 8(14):2653-62, 2017
                                              6. 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
                                              7. Rudin AV et al: Flat epithelial atypia on core biopsy and upgrade to cancer: a systematic review and meta-analysis. Ann Surg Oncol. 24(12):3549-58, 2017
                                              8. 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
                                              9. 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. Pract Radiat Oncol. 6(5):287-95, 2016
                                              10. Park TS et al: Current trends in the management of ductal carcinoma in situ. Oncology (Williston Park). 30(9):823-31, 2016
                                              11. Esserman L et al: Rethinking the standard for ductal carcinoma in situ treatment. JAMA Oncol. 1(7):881-3, 2015
                                              12. Greenwood HI et al: Ductal carcinoma in situ of the breasts: review of MR imaging features. Radiographics. 33(6):1569-88, 2013
                                              13. Mun HS et al: Screening-detected calcified and non-calcified ductal carcinoma in situ: differences in the imaging and histopathological features. Clin Radiol. 68(1):e27-35, 2013
                                              14. Wang LC et al: US appearance of ductal carcinoma in situ. Radiographics. 33(1):213-28, 2013
                                              15. Alvarado R et al: Biology, treatment, and outcome in very young and older women with DCIS. Ann Surg Oncol. 19(12):3777-84, 2012
                                              16. 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
                                              17. Suh YJ et al: Comparison of the underestimation rate in cases with ductal carcinoma in situ at ultrasound-guided core biopsy: 14-gauge automated core-needle biopsy vs 8- or 11-gauge vacuum-assisted biopsy. Br J Radiol. 85(1016):e349-56, 2012
                                              18. Wallis MG et al: The effect of DCIS grade on rate, type and time to recurrence after 15 years of follow-up of screen-detected DCIS. Br J Cancer. 106(10):1611-7, 2012
                                              19. Brennan ME et al: Ductal carcinoma in situ at core-needle biopsy: meta-analysis of underestimation and predictors of invasive breast cancer. Radiology. 260(1):119-28, 2011
                                              20. 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
                                              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. 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
                                              23. Virnig BA et al: Ductal carcinoma in situ: risk factors and impact of screening. J Natl Cancer Inst Monogr. 2010(41):113-6, 2010
                                              24. 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
                                              25. 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
                                              26. Tozaki M et al: Breast MRI using the VIBE sequence: clustered ring enhancement in the differential diagnosis of lesions showing non-masslike enhancement. AJR Am J Roentgenol. 2006;187:313-21
                                              27. Barreau B et al: Mammography of ductal carcinoma in situ of the breast: review of 909 cases with radiographic-pathologic correlations. Eur J Radiol. 54(1):55-61, 2005
                                              28. 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
                                              29. Hwang ES et al: Patterns of chromosomal alterations in breast ductal carcinoma in situ. Clin Cancer Res. 10(15):5160-7, 2004
                                              30. 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
                                              31. Bonnett M et al: Histologic and radiographic analysis of ductal carcinoma in situ diagnosed using stereotactic incisional core breast biopsy. Mod Pathol. 15(2):95-101, 2002
                                              32. Cserni G: Sentinel lymph node biopsy as a tool for the staging of ductal carcinoma in situ in patients with breast carcinoma. Surg Today. 32(2):99-103, 2002
                                              33. Jaffer S et al: Histologic classification of ductal carcinoma in situ. Microsc Res Tech. 59(2):92-101, 2002
                                              34. 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
                                              35. Morrow M et al: Standard for the management of ductal carcinoma in situ of the breast (DCIS). CA Cancer J Clin. 52(5):256-76, 2002
                                              36. 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
                                              37. Farshid G et al: Spindle cell ductal carcinoma in situ. An unusual variant of ductal intra-epithelial neoplasia that simulates ductal hyperplasia or a myoepithelial proliferation. Virchows Arch. 439(1):70-7, 2001
                                              38. Leal C et al: Apocrine ductal carcinoma in situ of the breast: histologic classification and expression of biologic markers. Hum Pathol. 32(5):487-93, 2001
                                              39. Renshaw AA et al: Atypical ductal hyperplasia in breast core needle biopsies. Correlation of size of the lesion, complete removal of the lesion, and the incidence of carcinoma in follow-up biopsies. Am J Clin Pathol. 116(1):92-6, 2001
                                              40. Slanetz PJ et al: Mammographic appearance of ductal carcinoma in situ does not reliably predict histologic subtype. Breast J. 7(6):417-21, 2001
                                              41. Wahedna Y et al: Mammographic size of ductal carcinoma in situ does not predict the presence of an invasive focus. Eur J Cancer. 37(4):459-62, 2001
                                              42. Dinkel HP et al: Is the appearance of microcalcifications on mammography useful in predicting histological grade of malignancy in ductal cancer in situ? Br J Radiol. 73(873):938-44, 2000
                                              43. Goldstein NS et al: Differences in the pathologic features of ductal carcinoma in situ of the breast based on patient age. Cancer. 88(11):2553-60, 2000
                                              44. Stomper PC et al: Flow cytometric DNA analysis of specimen mammography-guided fine-needle aspirates of ductal carcinoma in situ. J Exp Clin Cancer Res. 19(3):309-15, 2000
                                              45. Page DL et al: Continued local recurrence of carcinoma 15-25 years after a diagnosis of low grade ductal carcinoma in situ of the breast treated only by biopsy. Cancer. 76(7):1197-200, 1995
                                              46. 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

                                                        • Abbreviations

                                                          • Ductal carcinoma in situ (DCIS)
                                                        • Synonyms

                                                          • Nuclear grade 2 DCIS
                                                        • Definitions

                                                          • DCIS: Clonal proliferation of malignant epithelial cells within breast duct(s)
                                                            • Myoepithelial cell layer remains intact surrounding malignant cells
                                                          • Intermediate nuclear grade: Nuclei distinctly enlarged (1.5-2x normal); moderate variability in nuclear size, shape, and placement; pleomorphism intermediate between grade 1 (low grade) and grade 3 (high grade)

                                                        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

                                                                            • Microscopic Features

                                                                              CLINICAL ISSUES

                                                                              • Presentation

                                                                                • Demographics

                                                                                  • Natural History & Prognosis

                                                                                    • Treatment

                                                                                      DIAGNOSTIC CHECKLIST

                                                                                      • Consider

                                                                                        • Image Interpretation Pearls

                                                                                          Selected References

                                                                                          1. Kim M et al: Microinvasive carcinoma versus ductal carcinoma in situ: a comparison of clinicopathological features and clinical outcomes. J Breast Cancer. 21(2):197-205, 2018
                                                                                          2. Scott-Moncrieff A et al: MR imaging appearance of noncalcified and calcified DCIS. Breast J. 24(3):343-349, 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. Chavez de Paz Villanueva C et al: Factors associated with underestimation of invasive cancer in patients with ductal carcinoma in situ: precautions for active surveillance. JAMA Surg. 152(11):1007-14, 2017
                                                                                          5. Kuerer HM et al: DCIS Margins and breast conservation: MD Anderson Cancer Center Multidisciplinary practice guidelines and outcomes. J Cancer. 8(14):2653-62, 2017
                                                                                          6. 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
                                                                                          7. Rudin AV et al: Flat epithelial atypia on core biopsy and upgrade to cancer: a systematic review and meta-analysis. Ann Surg Oncol. 24(12):3549-58, 2017
                                                                                          8. 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
                                                                                          9. 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. Pract Radiat Oncol. 6(5):287-95, 2016
                                                                                          10. Park TS et al: Current trends in the management of ductal carcinoma in situ. Oncology (Williston Park). 30(9):823-31, 2016
                                                                                          11. Esserman L et al: Rethinking the standard for ductal carcinoma in situ treatment. JAMA Oncol. 1(7):881-3, 2015
                                                                                          12. Greenwood HI et al: Ductal carcinoma in situ of the breasts: review of MR imaging features. Radiographics. 33(6):1569-88, 2013
                                                                                          13. Mun HS et al: Screening-detected calcified and non-calcified ductal carcinoma in situ: differences in the imaging and histopathological features. Clin Radiol. 68(1):e27-35, 2013
                                                                                          14. Wang LC et al: US appearance of ductal carcinoma in situ. Radiographics. 33(1):213-28, 2013
                                                                                          15. Alvarado R et al: Biology, treatment, and outcome in very young and older women with DCIS. Ann Surg Oncol. 19(12):3777-84, 2012
                                                                                          16. 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
                                                                                          17. Suh YJ et al: Comparison of the underestimation rate in cases with ductal carcinoma in situ at ultrasound-guided core biopsy: 14-gauge automated core-needle biopsy vs 8- or 11-gauge vacuum-assisted biopsy. Br J Radiol. 85(1016):e349-56, 2012
                                                                                          18. Wallis MG et al: The effect of DCIS grade on rate, type and time to recurrence after 15 years of follow-up of screen-detected DCIS. Br J Cancer. 106(10):1611-7, 2012
                                                                                          19. Brennan ME et al: Ductal carcinoma in situ at core-needle biopsy: meta-analysis of underestimation and predictors of invasive breast cancer. Radiology. 260(1):119-28, 2011
                                                                                          20. 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
                                                                                          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. 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
                                                                                          23. Virnig BA et al: Ductal carcinoma in situ: risk factors and impact of screening. J Natl Cancer Inst Monogr. 2010(41):113-6, 2010
                                                                                          24. 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
                                                                                          25. 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
                                                                                          26. Tozaki M et al: Breast MRI using the VIBE sequence: clustered ring enhancement in the differential diagnosis of lesions showing non-masslike enhancement. AJR Am J Roentgenol. 2006;187:313-21
                                                                                          27. Barreau B et al: Mammography of ductal carcinoma in situ of the breast: review of 909 cases with radiographic-pathologic correlations. Eur J Radiol. 54(1):55-61, 2005
                                                                                          28. 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
                                                                                          29. Hwang ES et al: Patterns of chromosomal alterations in breast ductal carcinoma in situ. Clin Cancer Res. 10(15):5160-7, 2004
                                                                                          30. 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
                                                                                          31. Bonnett M et al: Histologic and radiographic analysis of ductal carcinoma in situ diagnosed using stereotactic incisional core breast biopsy. Mod Pathol. 15(2):95-101, 2002
                                                                                          32. Cserni G: Sentinel lymph node biopsy as a tool for the staging of ductal carcinoma in situ in patients with breast carcinoma. Surg Today. 32(2):99-103, 2002
                                                                                          33. Jaffer S et al: Histologic classification of ductal carcinoma in situ. Microsc Res Tech. 59(2):92-101, 2002
                                                                                          34. 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
                                                                                          35. Morrow M et al: Standard for the management of ductal carcinoma in situ of the breast (DCIS). CA Cancer J Clin. 52(5):256-76, 2002
                                                                                          36. 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
                                                                                          37. Farshid G et al: Spindle cell ductal carcinoma in situ. An unusual variant of ductal intra-epithelial neoplasia that simulates ductal hyperplasia or a myoepithelial proliferation. Virchows Arch. 439(1):70-7, 2001
                                                                                          38. Leal C et al: Apocrine ductal carcinoma in situ of the breast: histologic classification and expression of biologic markers. Hum Pathol. 32(5):487-93, 2001
                                                                                          39. Renshaw AA et al: Atypical ductal hyperplasia in breast core needle biopsies. Correlation of size of the lesion, complete removal of the lesion, and the incidence of carcinoma in follow-up biopsies. Am J Clin Pathol. 116(1):92-6, 2001
                                                                                          40. Slanetz PJ et al: Mammographic appearance of ductal carcinoma in situ does not reliably predict histologic subtype. Breast J. 7(6):417-21, 2001
                                                                                          41. Wahedna Y et al: Mammographic size of ductal carcinoma in situ does not predict the presence of an invasive focus. Eur J Cancer. 37(4):459-62, 2001
                                                                                          42. Dinkel HP et al: Is the appearance of microcalcifications on mammography useful in predicting histological grade of malignancy in ductal cancer in situ? Br J Radiol. 73(873):938-44, 2000
                                                                                          43. Goldstein NS et al: Differences in the pathologic features of ductal carcinoma in situ of the breast based on patient age. Cancer. 88(11):2553-60, 2000
                                                                                          44. Stomper PC et al: Flow cytometric DNA analysis of specimen mammography-guided fine-needle aspirates of ductal carcinoma in situ. J Exp Clin Cancer Res. 19(3):309-15, 2000
                                                                                          45. Page DL et al: Continued local recurrence of carcinoma 15-25 years after a diagnosis of low grade ductal carcinoma in situ of the breast treated only by biopsy. Cancer. 76(7):1197-200, 1995
                                                                                          46. Rosen PP et al: The clinical significance of pre-invasive breast carcinoma. Cancer. 46(4 Suppl):919-25, 1980