Pictorial Review of the Ultrasound Appearances of Ductal Carcinoma in Situ

Pictorial Review of the Ultrasound Appearances of Ductal Carcinoma in Situ Poster No.: R-0079 Congress: 2016 ASM Type: Educational Exhibit Authors: W. G. D. U. M. Wijesinghe, D. Gunawardena, D. B. Taylor ; 1 1 2 1 2 WA/AU, Perth, WA/AU Keywords: Biopsy, Screening, Ultrasound-Colour Doppler, Ultrasound, Mammography, Breast, Neoplasia DOI: 10.1594/ranzcr2016/R-0079 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 RANZCR's endorsement, sponsorship or recommendation of the third party, information, product or service. RANZCR 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 RANZCR 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,.doc documents and any other multimedia files are not available in the pdf version of presentations. Page 1 of 22

Learning objectives In this poster, we aim to discuss: The range of imaging appearances of sonographically visible ductal carcinoma in situ lesions (DCIS). The role of ultrasound (US) in the diagnosis and management of DCIS. Background Background Ductal carcinoma in situ (DCIS) is a malignant proliferation of ductal epithelial cells in the terminal ductal lobular unit confined by an intact basement membrane.[1] Being mostly an asymptomatic condition, DCIS accounted for less than 5% of breast cancers in the pre-breast cancer screening era.[2] At present up to 20% of breast cancers are DCIS, often picked up in community-based breast cancer screening programs.[3] DCIS has a much better prognosis than invasive breast cancer with a 10year mortality rate of 1.9%.[4] Microcalcifications are the most common manifestation on mammography, with a mass or asymmetric density being less common. Up to 16% of DCIS is mammographically occult.[5] Ultrasound is less sensitive than mammography for detection of microcalcifications. However, due to improvements in US technology, DCIS lesions are being increasingly detected with ultrasound. Histopathology: DCIS can have wide variety of appearances and is described in terms of: Architectural patterns: solid, comedo, cribriform, papillary, micropapillary, clinging or mixed. Nuclear appearance: graded as low, intermediate or high grade depending on the degree of pleomorphism, ranging from bland and monotonous in low nuclear grade, to pleomorphic in high nuclear grade. Presence or absence of necrosis. This may be present in any of architectural types, however, the comedo subtype is characterised by high nuclear grade with extensive central necrosis. Page 2 of 22

Presence or absence of calcifications, which may develop in either necrotic debris or secretory material.[6] Current trends: DCIS is a heterogeneous disease with not all types developing into invasive cancer, meaning that the current practice of surgical treatment of all screendetected cases may amount to overtreatment. There is an on-going phase III trial comparing surgery versus active monitoring in the management of screen detected or asymptomatic, low and intermediate grade DCIS (The LORIS Trial). The outcome of this study will help determine if low-risk DCIS can be safely monitored rather than surgically treated.[7] Imaging findings OR Procedure details Role of ultrasound in DCIS US can be used to further evaluate an abnormality detected on mammography. If visible on US, this modality should be used to guide biopsy. US is preferable to using stereotactic guidance for the following reasons: o Better patient comfort o No ionising radiation o Lower cost o Calcifications visible on ultrasound are three times more likely to be malignant[8] To improve the detection of mammographically occult DCIS in mammographically dense breasts. As a tool to further evaluate non-mass lesions detected on contrastenhanced MRI. [9] Ultrasound features of DCIS Mass Architectural distortion Ductal change Microcalcifications Pseudomicrocystic appearance Cystic-solid lesions Page 3 of 22

Vague area of altered echotexture Mass: According to Moon et al,[10] masses are often hypoechoic with a normal acoustic transmission(fig. 2 on page 7 ). Microlobulated margins are a common finding and sometimes ductal extension can be seen. Echotexture may be homogeneous( Fig. 12 on page 17) or heterogeneous(fig. 2 on page 7) and some lesions show increased vascularity( Fig. 3 on page 7).The shape of the mass lesions may be round, oval, lobular or irregular while the margin of the mass could be circumscribed, indistinct or microlobulated.[11] Architectural distortion: In a study of 31 pure DCIS lesions, Moon et al [10] found that none showed spiculated / angular margins or an echogenic halo, which are often considered as features of invasive disease. However, in a more recent study, Jae et al[12] reported these features in pure DCIS lesions that were non-high grade and non-comedo type and suggested that slow growth of non-high grade tumours allows time for host immune response and desmoplastic reaction causing architectural distortion. Ductal change: According to the BI-RADS system, ductal change is defined as abnormal calibre and arborization of ducts ( Fig. 8 on page 13).[13] Histologically, this appearance correlates with the presence of cancer cells within the duct with associated periductal inflammation.[14,15] Microcalcifications: Sonography is less sensitive than mammography for the detection of microcalcifications ( Fig. 2 on page 7 ) which appear as echogenic foci. Malignant microcalcifications are more likely to be seen on sonography due to the presence of an associated hypoechoic mass or ductal change( Fig. 8 on page 13 ) whereas benign, clinically insignificant microcalcifications within a background of echogenic normal breast parenchyma are often not detected. Studies have shown that sonographically detected microcalcifications are more often high grade than non-high grade.[14,15] Cystic / solid lesions and pseudomicrocystic appearance: Page 4 of 22

Complex masses may be either predominantly solid with multiple small cystic components or predominantly cystic with small solid components. Mesurolle et al reported that the predominantly solid masses with cystic components having a " pseudomicrocysic" appearance ( Fig. 5 on page 9 ) were caused by cancerization of the lobular component of the terminal duct lobular unit (TDLU).[11]These markedly hypoechoic lesions mimic a cluster of cysts which are known to represent dilated TDLUs. Vague area of altered echotexture Sometimes the only abnormality seen on ultrasound is a subtle area of altered echotexture. Accurate site correlation with mammographic abnormality helps in making a confident diagnosis and ultrasound can be used to guide biopsy. (Fig. 14 on page 18,Fig. 15 on page 20) Images for this section: Page 5 of 22

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Fig. 1: Case 1 Widespread calcifications detected on screening mammogram(arrows). Fig. 2: Case 1: Ultrasound of the area of the breast correlating to the mammographic abnormality shown in Fig. 1. Ill defined hypoecoich mass with irregular outline and microcalcifications. Ultrasound guided biopsy revealed high grade DCIS. Page 7 of 22

Fig. 3: Case 1: Increased vascularity seen with power Doppler ultrasound of the lesion shown on Fig.2. Page 8 of 22

Fig. 4: Case 2: Screening mammogram of a 55 y old woman shows a localized cluster of calcification(arrow).this was further evaluated with ultrasound(next image). Page 9 of 22

Fig. 5: Case 2: Pseudomicrocystic appearance seen on ultrasound, correlating to the mammographically detected localized cluster of calcification. Ultrasound guided biopsy was performed which showed intermediate grade DCIS. Page 10 of 22

Fig. 6: Case 2: The same lesion as fig 4 & 5. Vascularity seen with colour Doppler ultrasound. Page 11 of 22

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Fig. 7: Case 3: Screening mammogram of a 75y old woman. CC view of right breast mammogram showing widespread calcification.(arrows) Fig. 8: Case 3: Correlating to the mammographic abnormality of Fig. 7, area of ductal change with echogenic foci (arrow) suggestive of calcification are seen on ultrasound. Minimal posterior acoustic shadowing can also be appreciated. Ultrasound guided biopsy was performed which revealed high grade DCIS with significant calcification. Page 13 of 22

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Fig. 9: Case 4: A subtle area of architectural distortion picked up on screening mammography(arrow). This was further evaluated with ultrasound. Fig. 10: Case 4: Ultrasound appearance of the lesion from Fig.9. There is architectural distortion and dense posterior acoustic shadowing. Histology revealed intermediate grade DCIS with cribriform and pappilary architecture. Page 15 of 22

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Fig. 11: Case 5: Screening mammogram of a 69y old woman showing a localized cluster of calcification. Fig. 12: Case 5: Ultrasond of the same patient showing an iso to hypoechoic mass with ill-defined margin. Ultrasound guided biopsy of this lesion revealed high grade DCIS. Page 17 of 22

Fig. 13: Case 5: Slightly different plane through the lesion from Fig. 12 showing posterior acoustic shadowing. Page 18 of 22

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Fig. 14: Case 6: Screening mammogram of a 63y old woman showing widespread calcification. Fig. 15: Case 6: Subtle area of altered echotexture ( arrows) was seen on ultrasound correlating to the calcification shown on previous image. Histology revealed high grade DCIS with comedonecrosis and calcification. Page 20 of 22

Conclusion Ultrasound appearance of DCIS is heterogeneous, sometimes subtle and often non-specific. In spite of that, ultrasound has a valuable role in evaluating suspected DCIS lesions, particularly as a tool to aid biopsy. Radiologists' awareness and familiarity with the spectrum of likely appearance of DCIS is important to get the maximum use of this modality in breast cancer screening. Personal information References 1. Scoggins ME, Fox PS, Kuerer HM, Rauch GM, Benveniste AP, Park YM, et al. Correlation between sonographic findings and clinicopathologic and biologic features of pure ductal carcinoma in situ in 691 patients. AJR Am J Roentgenol. 2015;204(4):878-88. 2. Schnitt SJ, Silen W, Sadowsky NL, Connolly JL, Harris JR. Ductal carcinoma in situ (intraductal carcinoma) of the breast. New England Journal of Medicine. 1988;318(14):898-903. 3. Stomper PC, Connolly JL, Meyer JE, Harris JR. Clinically occult ductal carcinoma in situ detected with mammography: analysis of 100 cases with radiologic-pathologic correlation. Radiology. 1989;172(1):235-41. 4. Ernster VL, Barclay J, Kerlikowske K, Wilkie H, Ballard-Barbash R. Mortality among women with ductal carcinoma in situ of the breast in the population-based surveillance, epidemiology and end results program. Archives of internal medicine. 2000;160(7):953-8. 5. Ikeda DM, Andersson I. Ductal carcinoma in situ: atypical mammographic appearances. Radiology. 1989;172(3):661-6. 6. Kumar V, Abbas AK, Aster JC. Robbins basic pathology: Elsevier Health Sciences; 2012. 7. Francis A, Thomas J, Fallowfield L, Wallis M, Bartlett JM, Brookes C, et al. Addressing overtreatment of screen detected DCIS; the LORIS trial. European Journal of Cancer. 2015;51(16):2296-303. Page 21 of 22

8. Soo MS, Baker JA, Rosen EL. Sonographic detection and sonographically guided biopsy of breast microcalcifications. AJR Am J Roentgenol. 2003;180(4):941-8. 9. Wang LC, Sullivan M, Du H, Feldman MI, Mendelson EB. US appearance of ductal carcinoma in situ. Radiographics. 2013;33(1):213-28. 10. Moon WK, Myung JS, Lee YJ, Park IA, Noh DY, Im JG. US of ductal carcinoma in situ. Radiographics. 2002;22(2):269-80; discussion 80-1. 11. Mesurolle B, El-Khoury M, Khetani K, Abdullah N, Joseph L, Kao E. Mammographically non-calcified ductal carcinoma in situ: sonographic features with pathological correlation in 35 patients. Clin Radiol. 2009;64(6):628-36. 12. D'Orsi CJ. ACR BI-RADS Atlas: Breast Imaging Reporting and Data System2013. 13. Kim JH, Ko ES, Kim do Y, Han H, Sohn JH, Choe du H. Noncalcified ductal carcinoma in situ: imaging and histologic findings in 36 tumors. J Ultrasound Med. 2009;28(7):903-10. 14. Cho KR, Seo BK, Kim CH, Whang KW, Kim YH, Kim BH, et al. Non-calcified ductal carcinoma in situ: ultrasound and mammographic findings correlated with histological findings. Yonsei Med J. 2008;49(1):103-10. 15. Park JS, Park YM, Kim EK, Kim SJ, Han SS, Lee SJ, et al. Sonographic findings of high-grade and non-high-grade ductal carcinoma in situ of the breast. J Ultrasound Med. 2010;29(12):1687-97. Page 22 of 22