Ductal carcinoma in situ (DCIS) of the breast: diagnostic and therapeutic controversies

Comparison of mammography, ultrasound, and MRI in size assessment of ductal carcinoma in situ with histopathologic correlation

Background The ability to accurately assess tumor size in ductal carcinoma in situ (DCIS) is an important clinical issue when selecting the appropriate treatment plan. Purpose To compare the accuracy of using mammography, ultrasound (US), and magnetic resonance imaging (MRI) to assess DCIS tumor size based on imaging and histopathological findings. Material and Methods Fifty-six patients with DCIS were included. Mammography, US, and MRI were reviewed, and the accuracy of the measured tumor sizes were compared with the imaging and histopathological parameters. Results If visible, tumor measurements demonstrated high reliability with the pathologically determined size, with the best results obtained using US ( k = 0.851) followed by mammography ( k = 0.815) and MRI ( k = 0.738). Tumor size assessment was significantly more accurate when the lesion was shown as a mass on US ( P = 0.003) or MRI ( P < 0.001) with minimal and mild background parenchymal enhancement ( P = 0.016) on MRI. When mammography was used to assess tumor size, the tumors with positive estrogen receptor status and luminal A subtype demonstrated a significantly more accurate tumor size. Conclusion The combination of US and MRI, in addition to mammography, has an important role in assessing the exact tumor extent of DCIS.

Accuracy of an automated breast volume ultrasound system for assessment of the pre-operative extent of pure ductal carcinoma in situ: comparison with a conventional handheld ultrasound examination

The goal of the study described here was to compare the accuracy of an automated breast volume scanner (ABVS) with that of hand-held ultrasound (HHUS) in assessing the pre-operative extent of pure ductal carcinoma in situ (DCIS). This prospective study consisted of 33 patients with histopathologically proven pure DCIS who received conventional HHUS and ABVS examinations. The discrepancy and correlation coefficients were calculated to assess differences in sizes determined by imaging and histopathologic examination. Mean age was 51.8 y. Mean lesion size as assessed with the ABVS did not differ significantly from that determined by histopathology. Lesion size was adequately estimated, under-estimated or over-estimated with the ABVS in 64%, 15% and 21% of patients, and with HHUS in 42%, 15% and 42%, respectively (p < 0.05). The coefficient of correlation between histopathologic and ABVS measurements was higher than that between histopathologic and HHUS measurements. The ABVS appears to assess the extent of the lesion better than HHUS and can provide more accurate information pre-operatively.

Telomere length variation in normal epithelial cells adjacent to tumor: potential biomarker for breast cancer local recurrence

A better understanding of the risk of local recurrence (LR) will facilitate therapeutic decision making in the management of early breast cancers. In the present study, we investigated whether telomere length in the normal breast epithelial cells surrounding the tumor is predictive of breast cancer LR; 152 women who were diagnosed with breast cancer at the Lombardi Comprehensive Cancer Center were included in this nested case-control study. Cases (patients had LR) and controls (patients had no LR) were matched on year of surgery, age at diagnosis and type of surgery. Telomere fluorescent in situ hybridization was used to determine the telomere length using formalin fixed paraffin-embedded breast tissues. Small telomere length variation (TLV), defined as the coefficient variation of telomere lengths among examined cells, in normal epithelial cells adjacent to the tumor was significantly associated with a 5-fold (95% confidence interval = 1.2-22.2) increased risk of breast cancer LR. When the subjects were categorized into quartiles, a significant inverse dose-response relationship was observed with lowest versus highest quartile odds ratio of 15.3 (P(trend) = 0.012). Patients who had large TLV had significantly better 10 year recurrence free survival rate compared with patients who had small TLV (80 versus 33%). The present study revealed that TLV in normal epithelial cells adjacent to tumor is a strong predictor of breast cancer LR. If confirmed by future studies, TLV in normal epithelial cells adjacent to tumor has the potential to become a promising biomarker for predicting breast cancer LR after breast conserving surgery.

Noncalcified ductal carcinoma in situ: imaging and histologic findings in 36 tumors

OBJECTIVE

The purpose of this study was to evaluate imaging findings in noncalcified ductal carcinoma in situ (DCIS) and to compare histologic findings between noncalcified and calcified DCIS.

METHODS

From January 2005 to May 2008, 195 patients with pathologically confirmed DCIS were recruited. Among these, 36 patients (18%) had noncalcified DCIS. We retrospectively reviewed their imaging findings according to the American College of Radiology Breast Imaging Reporting and Data System. We also reviewed pathologic reports for all patients with DCIS to obtain information on the histologic type, nuclear grade, and biological markers.

RESULTS

Among the 36 patients with noncalcified DCIS, 21 (58%) were symptomatic. On mammography, 25 patients (69%) showed abnormal findings, and 11 patients showed false-negative findings. On sonography, 29 of 36 patients (81%) showed a mass, whereas the remaining 7 patients (19%) showed nonmass lesions. The sonographic findings for the masses were variable: 25 of 29 masses (86%) were irregular in shape; 14 of 29 (48%) showed indistinct margins; and 9 (31%) were angular or spiculated. The orientation of the mass was not parallel in 6 of 29 cases (21%). Two of 29 masses (7%) showed an echogenic halo at the lesion boundary. Noncalcified DCIS tended to have a nonhigh nuclear grade and was frequently the noncomedo type. In addition, c-erb-B2 was more commonly expressed in calcified DCIS.

CONCLUSIONS

Imaging findings for noncalcified DCIS are relatively nonspecific and are frequently similar to those of invasive malignancy. This knowledge may be useful for detecting noncalcified DCIS, planning treatment, and predicting the prognosis.

Recurrence after Mastectomy for Ductal Carcinoma in Situ

Mastectomy has long been a standard option for patients with ductal carcinoma in situ (DCIS). It is preferentially chosen by some women and may be suggested for individuals with recurrent, multifocal, or multicentric disease. We chose to evaluate our recent experience with mastectomy for DCIS. A retrospective review was conducted of 83 patients (87 breasts) from 1995 to 2006 who underwent mastectomy for DCIS. Mastectomy for DCIS was performed in 49 postmenopausal, 33 premenopausal, and one male patient. The average age was 53 years and the mean follow up was 4.5 years. Sentinel lymph node (SLN) biopsy was performed on 44 cases; positive nodes were identified in two. Intraoperative analyses of SLN were all negative. Only one patient had ipsilateral recurrence of the skin (1.1%). DCIS with microinvasion was noted in 32 per cent of the patients; none of these patients had ipsilateral recurrence. Three patients had positive microscopic margins; none have recurred to date. These results confirm the usefulness of mastectomy for patients with DCIS. We recommend SLN biopsy without intraoperative touch prep analysis. Additional treatment may not be required in patients with microinvasion, positive or close margins because our series shows no local recurrence in these patients.

Recent advances and current controversies in the management of DCIS of the breast

Ductal carcinoma in situ (DCIS) is commonly diagnosed today, mainly due to widespread use of screening mammography. Despite a better understanding of its biological behavior, many issues regarding its optimal management remain controversial. The biological behavior of DCIS has been associated with distinct molecular and histological features (such as expression of COX2, Ki67, c-erbB2, p53 mutation, presence or absence of comedonecrosis, nuclear grade, hormone receptor status, etc.). Recent advances in the diagnosis of DCIS include using magnetic resonance imaging, and the use of stereotactic-guided directional vacuum-assisted biopsy (DVAB). Ductoscopy and ductal lavage have a limited role in the management of DCIS. Surgical treatment of DCIS includes simple local excision to various forms of wider excision (segmental resection or quadrantectomy), or even mastectomy (either simple or skin-sparing). Radiotherapy following breast-conserving surgery significantly reduces local recurrence rates. Axillary lymph node dissection is not required for the management of DCIS; however, during the last decade, sentinel lymph node biopsy is increasingly used to exclude the presence of axillary metastases (when invasive disease is present within the DCIS). This approach has many advantages (including the avoidance of a second surgery if invasive disease is diagnosed within the DCIS) and should be considered when there is an increased probability for the presence of invasive breast cancer within the DCIS. The role of other minimally invasive methods (such as the "therapeutic" application of the DVAB technique, radiofrequency ablation, laser therapy, cryotherapy and brachytherapy) in the management of small DCIS remains unproven. Tamoxifen should be considered in the management of selected patients with DCIS, such as patients with hormone receptor positive DCIS, young patients, and patients without risk factors for potential side effects. Additionally, and controversial, there is evidence that aromatase inhibitors may be better than tamoxifen in the management of DCIS.

Screening-detected and symptomatic ductal carcinoma in situ: differences in the sonographic and pathologic features

OBJECTIVE

The purpose of our study was to retrospectively compare the sonographic and pathologic features of screening-detected and symptomatic ductal carcinoma in situ (DCIS).

MATERIALS AND METHODS

Of 5,790 cases diagnosed as breast cancer at our institution between January 1998 and December 2005, 528 (9.1%) cases were DCIS. We found 106 screening-detected and 125 symptomatic DCIS lesions in 226 patients (age range, 20-77 years; mean age, 47.8 years) who underwent preoperative whole-breast sonography and mammography. Three radiologists reviewed the sonographic features of these 231 cases of DCIS by consensus according to Breast Imaging Reporting and Data System (BI-RADS). The pathologic features were also reviewed. Statistical comparisons were performed using the chi-square test, the Fisher's exact test, and the Mann-Whitney U test.

RESULTS

On sonography, masses (p < 0.001) and associated ductal change (p = 0.019) were more common in symptomatic than in asymptomatic patients. Associated microcalcifications and posterior shadowing were more frequently found in screening-detected than in symptomatic DCIS (p < 0.001). On mammography, microcalcifications were more common in screening-detected than in symptomatic DCIS, and masses were more common in symptomatic than in screening-detected DCIS (p < 0.001). No significant differences were seen in the pathologic features of the two groups.

CONCLUSION

Our results showed that differences exist in the sonographic features of screening-detected and symptomatic DCIS. Recognition of the many and varied sonographic appearances of DCIS might be helpful to decrease the false-negative rate of bilateral whole-breast sonography and to detect symptomatic mammographically occult DCIS when we use sonography to supplement mammography.

MRI of the breast for the detection and assessment of the size of ductal carcinoma in situ

OBJECTIVE

The aim of the study was to compare the accuracy of magnetic resonance imaging (MRI) and mammography for the detection and assessment of the size of ductal carcinoma in situ (DCIS).

MATERIALS AND METHODS

The preoperative contrast-enhanced MRI and mammography were analyzed in respect of the detection and assessment of the size of DCIS in 72 patients (age range: 30-67 years, mean age: 47 years). The MRI and mammographic measurements were compared with the histopathologic size with using the Pearson's correlation coefficients and the Mann-Whitney u test. We evaluated whether the breast density, the tumor nuclear grade, the presence of comedo necrosis and microinvasion influenced the MRI and mammographic size estimates by using the chi-square test.

RESULTS

Of the 72 DCIS lesions, 68 (94%) were detected by MRI and 62 (86%) were detected by mammography. Overall, the Pearson's correlation of the size between MRI and histopathology was 0.786 versus 0.633 between mammography and histopathology (p < 0.001). MRI underestimated the size by more than 1 cm (including false negative examination) in 12 patients (17%), was accurate in 52 patients (72%) and overestimated the size by more than 1 cm in eight patients (11%) whereas mammography underestimated the size in 25 patients (35%), was accurate in 31 patients (43%) and overestimated the size in 16 patients (22%). The MRI, but not the mammography, showed significant correlation for the assessment of the size of tumor in noncomedo DCIS (p < 0.001 vs p = 0.060). The assessment of tumor size by MRI was affected by the nuclear grade (p = 0.008) and the presence of comedo necrosis (p = 0.029), but not by the breast density (p = 0.747) or microinvasion (p = 0.093).

CONCLUSION

MRI was more accurate for the detection and assessment of the size of DCIS than mammography.

National Breast Cancer Audit: ductal carcinoma in situ management in Australia and New Zealand

BACKGROUND

Ductal carcinoma in situ (DCIS) is a significant issue in Australia and New Zealand with rising incidence because of the implementation of mammographic screening. Current information on its natural history is unable to accurately predict progression to invasive cancer. In 2003, the National Breast Cancer Centre in Australia published recommendations for DCIS. In Australia and New Zealand, the National Breast Cancer Audit collects information on DCIS cases. This article will examine these recommendations and provide information from the audit on current DCIS management.

METHODS

Three thousand six hundred and twenty-nine cases of DCIS were entered by 274 breast surgeons between January 1998 and December 2004. Data items in the National Breast Cancer Audit database that were covered in the National Breast Cancer Centre recommendations were reviewed. Information was available on the following: diagnostic biopsy rates for all cases and mammographically positive cases and rates of breast conserving surgery (BCS), clear margins following BCS, postoperative radiotherapy following BCS for groups at high risk of recurrence as well as axillary procedures and tamoxifen prescription.

RESULTS

Close adherence was found in diagnostic biopsy, BCS and clear margin rates. Some high-risk groups received radiotherapy, although women with 'close' margins did not in 33% of cases. Axillary procedures were conducted in 23% of cases and most (81%) patients were not prescribed tamoxifen.

CONCLUSION

There was predominantly close adherence to recommendations with three possible areas of improvement: fewer axillary procedures, an appraisal of radiotherapy practice following BCS and more investigation into tamoxifen prescription practices for DCIS.

CHANGES IN THE MANAGEMENT OF DUCTAL CARCINOMA IN SITU BEFORE THE RELEASE OF CLINICAL PRACTICE RECOMMENDATIONS IN AUSTRALIA: THE CASE IN VICTORIA

BACKGROUND

This study examines changes in the management of ductal carcinoma in situ between 1995 and 1999 in the Australian State of Victoria. This period was before the release of Australian treatment recommendations.

METHODS

All new cases of ductal carcinoma in situ diagnosed between 1 April and 30 September in 1995 and 1999 were identified from the population cancer registry. Treating surgeons completed a questionnaire on the presentation and management of each case. In 1995, 64 out of 70 surgeons returned questionnaires for 137 cases (case response, 94%). In 1999, 68 surgeons treated 159 registered cases and 141 completed surveys were returned (case response, 89%).

RESULTS

More cases underwent an image-guided biopsy in 1999 (54%) than in 1995 (34%). Breast-conserving surgery (BCS) was used to treat 69% of cases in 1999 and 63% in 1995. The use of axillary procedures (clearance or sampling) for women treated by mastectomy decreased from 61% in 1995 to 30% in 1999. More patients treated with BCS had margins simply described as "clear" in 1995 (49%) than in 1999 (21%). In 1995, only 7% of cases treated with BCS had radiotherapy, and this was 25% in 1999.

CONCLUSION

In both 1999 and 1995, the majority of patients were treated by BCS, but only a minority received radiotherapy.

Repeat breast-conserving surgery for in-breast local breast carcinoma recurrence: the potential role of partial breast irradiation

Mastectomy is the current standard of care for in-breast local recurrence of breast carcinoma. The objective of the current study was to critically review the rationale for and the theoretic and actual risks and benefits of repeat breast-conserving surgery followed by partial breast irradiation (PBI) for in-breast local recurrence of breast carcinoma. The main outcomes of interest were local control and survival after in-breast local recurrence and side effects, complications, and cosmesis after reirradiation of the breast. The risk of local recurrence was not found to be eliminated with mastectomy; approximately 2-32% of patients treated with mastectomy develop a chest wall recurrence. The interpretation of local control rates in evaluating repeat breast-conserving surgery studies is difficult because of the lack of information regarding preoperative diagnostic mammography to rule out concurrent multicentric disease and microscopic margin status after surgery. Rates of subsequent local recurrence in these studies appeared to be between 19-50%, similar to reported rates of in-breast local recurrence in patients with a first diagnosis of breast carcinoma who were treated with conservative surgery without irradiation. Early follow-up studies of breast reirradiation suggest that catheter-based interstitial brachytherapy and standard external beam radiation therapy can be delivered to the breast more than once without significant side effects in most patients and with acceptable cosmesis in some patients. Mastectomy may not be necessary in all patients with an in-breast local recurrence of breast carcinoma. Recent advances in conformal radiation delivery and single-center published reports concerning repeat breast-conserving therapy support well designed prospective trials to formally test this hypothesis.

Trends in the Treatment of Ductal Carcinoma In Situ of the Breast

BACKGROUND

An increase in incidence of ductal carcinoma in situ (DCIS) of the breast has been documented, and concerns regarding overly aggressive treatment have been raised. This study was designed to evaluate the use of surgery and radiation therapy in treating DCIS.

METHODS

We used the National Cancer Institute's Surveillance, Epidemiology, and End Results database to assess treatment of patients with DCIS with no evidence of microinvasion who were diagnosed from January 1, 1992, through December 31, 1999. We assessed the rates of mastectomy, breast reconstruction, radiation therapy after lumpectomy, and axillary dissection. Associations were analyzed by logistic regression.

RESULTS

During the study period, 25 206 patients met selection criteria. The incidence of DCIS dramatically increased with time; however, the incidence of comedo lesions did not change. The rate of mastectomy decreased from 43% in 1992 to 28% in 1999, after controlling for age, race, tumor size, comedo histology, and geographic location. However, because of the increase in the diagnosis of DCIS, the age-adjusted incidence of mastectomy for DCIS in the population did not change (7.8 per 100 000 women in 1992 and 1999). Almost half the patients undergoing lumpectomy did not undergo radiation therapy (55% in 1992 and 46% in 1999); in those with comedo histology, 33% did not undergo radiation therapy after lumpectomy, even in 1999. Overall, patients were less likely to have axillary dissection over time (34% in 1992 versus 15% in 1999), yet the rate of axillary dissection was still high (30%) in patients undergoing mastectomy in 1999. Large, statistically and clinically significant variation by geographic location was found in treatment.

CONCLUSIONS

Treatment of DCIS changed in a clinically significant fashion between 1992 and 1999. Throughout this study, many patients were found to undergo aggressive surgical therapy, including mastectomy and axillary dissection, whereas others appeared to be undertreated, e.g., not receiving radiation therapy after lumpectomy, even in the presence of adverse histologic features. Variation in demographic and geographic factors indicates that at least some of these treatment differences reflect individual and institutional practice patterns that may be modifiable.

Optimal management of ductal carcinoma in situ of the breast

Ductal carcinoma in situ (DCIS) represents a breast lesion that is diagnosed with increasing frequency, mainly due to the wide use of screening mammography. Today, DCIS comprises 15-25% of all breast cancers detected at population screening programs. Consequently, the concepts of properly managing such patients assume a greater importance in everyday practice. Mammographically detected microcalcifications are the most common presentation of DCIS. Despite recent technological advances (including Stereotactic-guided directional vacuum-assisted biopsy), mammographically guided wire biopsy remains the "gold-standard" for obtaining a histological diagnosis in patients with non-palpable, mammographically detected DCIS. Management options include mastectomy, local excision combined with radiation therapy, and local excision alone. Given that DCIS is a heterogeneous group of lesions rather than a single entity, and because patients have a wide variety of personal needs that must be addressed during treatment selection, it is obvious that no single approach will be appropriate for all forms of DCIS or for all patients. Careful patient selection is of key importance in order to achieve the best results in the management of the individual patient with DCIS. Axillary lymph node dissection is unnecessary in the treatment of pure DCIS, but it is indicated when microinvasion is present. In these cases, sentinel lymph node biopsy may be an excellent alternative. In the NSABP B-24 trial, tamoxifen reduced both the invasive and non-invasive breast cancer events in either breast by 37%. Nearly all patients who develop a non-invasive recurrence following breast-sparing surgery are cured with mastectomy, and approximately 75% of those with an invasive recurrence are salvaged. Selected patients initially treated by lumpectomy alone may also undergo breast-conservation therapy at the time of relapse according to the same strict guidelines of tumor margin clearance required for the primary lesion; radiation therapy should be given following local excision. The use of systemic therapy in patients with invasive recurrence should be based on standard criteria for invasive breast cancer.

The relevance of occult axillary micrometastasis in ductal carcinoma in situ: a clinicopathologic study with long-term follow-up

BACKGROUND

Ductal carcinoma in situ (DCIS) represents 20% of newly diagnosed breast carcinoma cases. Historically, the incidence of axillary metastasis in DCIS has been small (1-2%) and its significance has been debated. It is widely known that serial sections of lymph nodes coupled with keratin immunohistochemistry (IHC) increases identification of micrometastasis. The advent of sentinel lymph node evaluation underscores the need to reevaluate the significance of occult micrometastases in DCIS.

METHODS

Patients with DCIS and negative axillary lymph nodes from 1974 to 1992 were selected from the Saint Barnabas Medical Center Tumor Registry. All diagnoses were confirmed, and paraffin blocks were retrieved after acceptance into the study. Seven serial sections were obtained from each block and evaluated with two cytokeratin IHC stains. Clinical follow-up ranged from 10 to 28 years.

RESULTS

One hundred two patients were included in the study. Micrometastases were identified in 13 patients (13%), mostly on 1 level and composed of microscopic clusters in the subcapsular sinus. Seven of these lymph node-positive patients (58%) had high-grade comedo DCIS, 4 (33%) had intermediate grades of various types of DCIS, and one had a low-grade micropapillary DCIS. The overall disease recurrence rate was 12%, but micrometasis was not detected in any of the patients who developed disease recurrence.

CONCLUSIONS

Serial IHC evaluation of lymph nodes dramatically increased the identification of occult micrometastasis. However, IHC detected micrometastasis has no apparent clinical significance in DCIS, based on the current long-term clinicopathologic study. Therefore, the authors questioned the significance of occult micrometastasis, identified by IHC, in DCIS of any type and extent. Further evaluation and follow-up of lymph node micrometastases in patients with invasive tumors of various sizes are needed. The current findings would not support altering the stage of patients with DCIS and micrometastasis detected by IHC only.

Value of the Van Nuys Prognostic Index in prediction of recurrence of ductal carcinoma in situ after breast-conserving surgery

BACKGROUND

The Van Nuys Prognostic Index (VNPI), an algorithm based on tumour size, tumour grade, presence of necrosis and excision margin width, is claimed to predict local recurrence after breast-conserving surgery for ductal carcinoma in situ (DCIS). The aim of this study was to examine the validity of the VNPI in a UK population.

METHODS

Clinicopathological data, including VNPI subgroups, for 237 patients who had breast-conserving operations for DCIS were examined. Multivariate data analysis was performed using a Cox regression model to examine the independence and relative importance of different variables in predicting recurrence, and to compare the data with those used in derivation of the VNPI.

RESULTS

The median follow-up was 47 months. There were 37 ipsilateral local recurrences. Excision margin width (P < 0.001) and tumour grade (by Van Nuys grading (P = 0.014) or simple nuclear grading (P = 0.004)) were the only independent risk factors for local recurrence. Excision margin width had three times more power than grade in predicting local recurrence. Subgrouping data by VNPI score predicted recurrence-free survival (P < 0.001), but stratified 78 per cent of patients into a group with a moderate risk of local recurrence.

CONCLUSION

Excision margin width is the most important predictor of local recurrence after breast-conserving surgery for DCIS. The VNPI lacked discriminatory power for guiding further patient management.

The clinical significance of cytokeratin-positive cells in lymph nodes at the time of mastectomy from patients with ductal carcinoma-in-situ

BACKGROUND

We determined the presence or absence of and clinical significance of cytokeratin-positive cells in the lymph nodes of patients who had had mastectomies for ductal carcinoma-in-situ.

METHODS

Two pathologists independently assessed the axillary lymph nodes found. All patients had either a core or open biopsy performed before the time of mastectomy. The lymph nodes were assessed with hematoxylin and eosin stain and immunohistochemistry for cytokeratin marker AE1/AE3. The slides were assessed for the presence or absence of epithelial cells. As a control, axillary lymph nodes found in prophylactic mastectomies were assessed. None of these had had a previous biopsy performed.

RESULTS

Lymph nodes from all patients demonstrated no obvious epithelial cells on hematoxylin and eosin stain. Peripheral sinuses of lymph nodes from six patients (23%) who had mastectomies for ductal carcinoma-in-situ contained a few cytokeratin-positive cells on immunohistochemistry. The lymph nodes of the control group demonstrated no cytokeratin-positive cells. The mean follow-up of patients was 5 years, and all patients were alive without recurrence at the time of the study.

CONCLUSIONS

Epithelial cells may be present in the lymph nodes draining a site of recent breast biopsy in the absence of invasive carcinoma, indicating that these are an artifact of recent surgery and not of micrometastatic disease.

The role of Tc99m-sestamibi scintimammography in combination with the triple assessment of primary breast cancer

AIM

The aim of this study was to evaluate if Tc99m-sestamibi scintimammography in addition to the triple assessment consisting of clinical examination, mammography, breast ultrasonography and fine needle aspiration cytology (FNA) enhances the diagnosis of breast cancer and helps in avoiding unnecessary operative biopsies.

METHODS

Pre-operational scintimammography was performed within 2 weeks of operation to 46 consecutive patients with abnormal findings in clinical breast examination, mammography or ultrasonography. Three patients had abnormalities in both breasts. Histological diagnosis was obtained in all 49 cases.

RESULTS

The histological diagnosis was benign in 18 (37%) cases and malignant in 31 (63%) cases. The overall sensitivity of scintimammography was 77% and the specificity was 61%. The sensitivity of scintimammography was 95% in invasive ductal carcinoma, 50% in invasive lobular carcinoma and 25% in ductal carcinoma in situ. Scintimammography showed 100% sensitivity in cases with invasive carcinoma, with highly suspicious findings for malignancy in the other examinations. The sensitivity was 63% in cases with indeterminate or contradictory findings in mammography, ultrasonography and FNA.

CONCLUSIONS

Adding scintimammography to the triple assessment does not seem to be helpful in the diagnosis of breast abnormalities because of low sensitivity in malignant cases with a challenging diagnosis by mammography, ultrasonography and FNA, and because of low overall specificity.

US of ductal carcinoma in situ

Little is known about the ultrasonographic (US) features of ductal carcinoma in situ (DCIS) of the breast because this entity usually manifests as pure mammographic calcifications and is rarely evaluated with US. US findings were recorded in 70 patients with DCIS and then analyzed and correlated with mammographic and histologic findings. A microlobulated mass with mild hypoechogenicity, ductal extension, and normal acoustic transmission was the most common US finding in DCIS. Spiculated margins, marked hypoechogenicity, a thick echogenic rim, and posterior acoustic shadowing at US often suggested the presence of invasion. US performed with a 10-13-MHz transducer and optimal technique can be used as a complement to mammography in detecting and evaluating DCIS of the breast, as it demonstrates breast lesions associated with malignant microcalcifications in most cases. The main benefit of identifying a US abnormality in women with mammographically detected DCIS is to allow the use of US to guide interventional procedures (eg, needle biopsy, needle localization). US may also be helpful in detecting DCIS without calcifications and in evaluating disease extent in women with dense breasts. Nevertheless, further research is needed to delineate the role of US in the evaluation of patients with DCIS.