Breast US in Patients with Breast Cancer Presenting as Microcalcifications Only on Mammography: Can US Differentiate DCIS from Invasive Cancer?

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1 Breast US in Patients with Breast Cancer Presenting as Microcalcifications Only on Mammography: Can US Differentiate DCIS from Invasive Cancer? Poster No.: C-1842 Congress: ECR 2012 Type: Scientific Exhibit Authors: J. Kang 1, J.-H. Lee 1, J.-Y. Han 1, J.-S. Park 1, Y.-M. Park 1, B.-H. Park 1, K.-J. Nam 2 ; 1 Busan/KR, 2 Seo-gu/KR Keywords: Neoplasia, Imaging sequences, Ultrasound, Breast DOI: /ecr2012/C-1842 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 11

2 Purpose To review US findings of breast cancers presenting as microcalcifications only on mammography and to evaluate helpful findings in differentiating DCIS from invasive cancer. In many recent studies, targeted ultrasonography (US) of mammographically depicted microcalcifications was performed to support the current role of sonography whether they can differentiate malignant microcalcifications from benign [1-5]. Knowledge of the risk of invasive carcinomas found in DCIS microcalcifications would be helpful in clinical management, such as selection of patients for axillary lymph node sampling. US manifestation in differentiating ductal carcinoma in situ (DCIS) and invasive cancer of mammographically depicted malignant microcalcifications was not studied before. Methods and Materials 1. Patients selection Page 2 of 11

3 Fig. 1 References: J. Kang; Busan, KOREA, Republic of 2. Imaging interpretation US examinations one experienced breast radiologist SONOLINE Antares (SiemensMedical System, Mountain view, CA, USA), 5-13 MHz linear array transducer Routine bilateral whole breast US and following targeted US examination for the areas of microcalcifications The US findings at the area of microcalcifications were retrospectively reviewed and classified as follows (Fig. 2 on page 4 ) : 1. negative (neither visible microcalcifications nor associated finding) 2. only microcalcifications without associated findings 3. microcalcifications within hypoechoic parenchymal thickening Page 3 of 11

4 4. microcalcifications within ductal changes (abnormal caliber or arborization of ducts) 5. microcalcifications within a mass 3. Establishment of final diagnosis Histopathologic diagnosis of the microcalcifications sonographically invisible lesion (n=18) -> by surgical excision after mammography-guided wire localization microcalcifications highly visible on US -> by US-guided core needle biopsy with a 14-gauge biopsy gun (n=38) or by surgical excision after US-guided wire localization (n=1) The final diagnosis of all cases was based on histopathologic result from surgery. Histologically we classified breast cancers as DCIS and invasive cancer. 4. Statistical Analysis Fisher's exact test p-value < 0.05 : statistically significant statistical soft ware system (SPSS for windows, version 19.0; Microsoft Institute, Chicago, IL, USA). Images for this section: Page 4 of 11

5 Fig. 2: US findings of breast cancer presenting as microcalcifications only on mammography. (A) Microcalcifications only (arrows). (B) Microcalcifications within hypoechoic parenchymal thickening (arrows). (C) Microcalcifications within ductal change (arrows). (D) Microcalcifications within mass (arrow). * Negative finding on US was not shown. Page 5 of 11

6 Results Histopathologic result of 64 lesions appeared as only microcalcifications on mammography DCIS, 27 (42.2%) Invasive cancer, 37 (57.8%) = 6 MIDC (9.4%) + 29 ICD (45.3%)+ 2 IDC with mucinous carcinoma (3.1%) US findings of 64 breast cancers presenting as microcalcifications only on mammography are summarized in Table 1. Associated finding US Invasive cancer Total Negative finding 15 (55.6) 3 (8.1) 18 (28.1) Only calcifications 3 (11.1) 2 (5.4) 5 (7.8) Hypoechoic thickening 6 (22.2) 11 (29.7) 17 (26.6) Ductal change 0 (0) 6 (16.2) 6 (9.4) Mass 3 (11.1) 15(40.5) 18 (28.1) Total 27(100) 37(100) 64 (100) * Numbers in parentheses are percentages. Table 1. US findings of 64 breast cancers presenting as microcalcifications only on mammography Among the 64 lesions, 46 (71.9%) were identified ultrasonographically. negative finding on US (n=18, 28.1%) calcifications within mass (n=18, 28.1%) calcifications within hypoechoic thickening (n=17, 26.6%) calcifications within ductal change (n=6, 9.4%) microcalcifications only (n=5, 7.8%) 1. Cases with negative findings in US were more frequently found in DCIS (n=15, 55.6%) than in invasive cancers (n=3, 8.1%) (p<0.001). 2. Cases with calcifications within ductal change (n=6, 16.2% of invasive cancer, n=0, 0% of DCIS, p=0.035) and mass (n=14, 37.8% of invasive Page 6 of 11

7 cancer, n=3, 11.1% of DCIS, p=0.022) were frequently found in invasive cancers than in DCIS. 3. Cases with hypoechoic thickening were more common in invasive cancer (n=12, 32.4%) than in DCIS (n=6, 22.2%), but this trend was not statistically significant (p=0.413). 4. Microcalcifications only did not show a significant difference between invasive cancer and DCIS (p=0.642). DCIS underestimation rates (i.e., DCIS at core biopsy and invasive cancer at surgery) : 7.9% 3 cases diagnosed as DCIS by US guided core needle biopsy => confirmed as 2 IDC and 1 MIDC Conclusion In conclusion, our results show differences in the sonographic findings of DCIS and invasive breast cancer when only microcalcifications showed on mammography. Targeted US is successful method depicting microcalcifications and might be helpful for predicting invasive breast cancers. For those who are at risk of invasion on the US findings, preoperative work up should be based upon the invasive cancer to avoid unnecessary second operation. Asian woman usually have dense background density and the dense breast tissue could obscure a microcalcification with associated density. There may be the possibility of showing microcalcifications only on mammography, even with the cases which contained associated density (Fig. 3 on page 8). Calcifications within ductal change (16.2% versus 0%; p<0.035) were more common in invasive cancer. Calcification within mass (37.8% versus 11.1%, p<0.012) were more frequent in invasive cancer regardless of the shape of the mass. The major limitations of this presentation 1. small number of patients and its retrospective nature Page 7 of 11

8 2. lacks precise pathologic correlation between the foci where invasion is suspicious in the US 3. lack of intra- and interobserver variability, as only one radiologist performed the US Images for this section: Fig. 2: US findings of breast cancer presenting as microcalcifications only on mammography. (A) Microcalcifications only (arrows). (B) Microcalcifications within hypoechoic parenchymal thickening (arrows). (C) Microcalcifications within ductal change (arrows). (D) Microcalcifications within mass (arrow). * Negative finding on US was not shown. Page 8 of 11

9 Fig. 3: IDC in a 51-year-old woman who presented with a palpable mass in left breast. (A) Left mediolateral oblique mammogram showed segmentally distributed fine pleomorphic microcalcifications in the palpable BB marker area (black arrows) of left inner breast. The overall breast composition is extremely dense. (B) Targeted US at the area of microcalcifications on mammography showed echogenic microcalcifications within hypoechoic parenchymal thickening (white arrows), which was obscured by extremely dense parenchyma on mammography. IDC with DCIS and microcalcifications were confirmed by mastectomy. Page 9 of 11

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11 14. Stomper PC, Winston JS, Proulx GM, Hurd TC, Edge SB. Mammographic detection and staging of ductal carcinoma in situ: mammographicpathological correlation. Semin in Breast Dis 2000;3: Moon WK, Myung JS, Lee UJ, Park IA, Noh DY, Im JG. US of ductal carcinoma In Situ. Radiographics 2002;22: Yang WT, Tse GM. Sonographic, mammographic, and histopathologic correlation of symptomatic ductal carcinoma in situ. AJR Am J Roentgenol 2004; 182: Park JS, Park YM, Kim EK, Kim SJ, Han SS, Lee SJ, In HS, Ryu JH. Sonographic findings of high-grade and non-high-grade ductal carcinoma in situ of the breast. J Ultrasound Med 2010;29: Zavagno G, Belardinelli V, Marconato R, et al. Sentinel lymph node metastasis from mammary ductal carcinoma in situ with microinvasion. Breast 2007;16: Guth AA, Mercado C, Roses DF, Darvishian F, Singh B, Cangiarella JF. Microinvasive breast cancer and the role of sentinel node biopsy: an institutional experience and review of the literature. Breast J 2008 [Epub]. 20. Van la Parra RFD, ErnstMF, Barneveld PC, Broekman JM, Rutten MJCM, Bosscha K. The value of sentinel lymph node biopsy in ductal carcinoma in situ (DCIS) and DCIS with microinvasion of the breast. ESJO 2008;34: Vieira CC. Mercado CL. Cangiarella JF. Moy L, Toth HK. Guth AA. Microinvasive ductal carcinoma in situ: clinical presentation, imaging features, pathologic findings, and outcome. EJR 2010;73: Personal Information J. Kang, J. H. Lee, J. Y. Han, B. H. Park, K. J. Nam, Departments of Radiology, Dong- A University College of Medicine, Busan, Korea. mail to: sthspecialjy@gmail.com J. S. Park, Y. M. Park; Department of Radiology, Inje University College of Medicine, Busan Paik Hospital, Busan, Korea Page 11 of 11