Ductal carcinoma in situ with comedo necrosis

CLINICAL HISTORY

A 70-year-old woman with a history of microcalcification of the right breast, lumpectomy, and whole-breast x-ray therapy on right side for microinvasive cancer presented for annual digital mammogram.

FINDINGS

Right breast: Category 3, probably benign finding. Postsurgical changes in the right breast are stable from prior examination on Sept. 26, 2007. Inferiorly within the right breast are two linear calcifications that were present on the prior exam, only one of which was present on Dec. 19, 2006. Small calcifications are identified throughout the breast, stable from prior imaging. Thus, with the patient's history of breast carcinoma, very close follow-up examination of this area is recommended with a three-month follow-up. Alternatively, further evaluation given the patient's history of breast carcinoma and this area of microcalcifications within the breast, MRI examination may also be useful as clinically indicated. This MRI examination took place two weeks later.

ADDITIONAL FINDINGS

A segmental area of enhancement (both type I and type II) in the six o'clock position extends from the nipple posteriorly and inferiorly (Figures 1 and 2). Figure 3 shows rapid wash-in and wash-out areas in the 5.5 × 3-cm enhanced segment.

DIAGNOSIS

MR-guided biopsy was performed and core samples were obtained at the most posterior and anterior aspects of the ductal enhancement (Figure 4). Pathology showed ductal carcinoma in-situ, high grade with comedo necrosis in both locations.

DISCUSSION

This case clearly demonstrates the benefit of determining extent of disease preoperatively with MRI. Despite subtle changes at mammography, the patient actually had extensive disease that was detected only with MR mammography. Appropriate therapy and surgical management were only possible with the added benefit of breast MRI and the MRI-guided breast biopsy.

Case submitted by Paige Huber, M.D., with AnMed Health in Anderson, SC; Bernadette M. Kaufman, BSRS, RT(R)(MR), breast care product manager for Invivo in Pewaukee, WI; and Patricia MacDonald, a medical writer based in Garland, TX.

BIBLIOGRAPHY

Kinkel K, Helbich TH, Esserman LJ, et al. Dynamic high-spatial-resolution MR imaging of suspicious breast lesions: diagnostic criteria and interobserver variability. AJR 2000;175(1):35-43.
Kriege M, Brekelmans CTM, Boetes C, et al. Efficacy of MRI and mammography for breast cancer screening in women with familial or genetic predisposition. NEJM 2004;351(5):427-437.
Liberman L, Menell JH. Breast imaging reporting and data system (BI-RADS). Radiol Clin North Am 2002;40:409-430.
Tozaki M, Igarashi T, Matsushima S, Fukuda K. High-spatial-resolution MR imaging of focal breast masses: interpretation model based on kinetic and morphological parameters. Radiat Med 2005;23(1):43-50.