214 Journal of the National Cancer Institute Monographs, No. 41, 2010
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Ductal carcinoma in situ (DCIS) is a distinct lesion of the breast
that is a precursor to development of invasive carcinoma. Before the
widespread use of screening mammography, DCIS accounted for
less than 5% of breast cancers (1). Currently, this diagnosis is ren-
dered in about 30% of cases. Some of the cases diagnosed as DCIS
will not progress to invasive disease, and this has been offered as a
risk of screening mammography (2,3). This argument is cogent if
we had a means, at the detection phase, to determine which of these
in situ malignancies will progress to invasive disease. At this point,
it is not possible, with a high degree of certainty, to ascertain which
in situ malignancy will progress to invasive disease from those that
remain indolent. Certainly, studies aimed at which DCIS may
progress and those that may not should be one of the most active
areas for research, both at the detection and histology level. The
histology diagnosis of DCIS increased with routine use of mam-
mography (4), while the mortality from breast cancer, as verified by
many worldwide screening trials, has decreased by at least 30%, in
great part due to early nonclinical detection, almost entirely related
to mammography (5,6). Thus, it becomes quite clear that until we
possess the ability to assign different levels of concern for findings
suggestive of DCIS, at both the detection and histology phase, we
must continue searching and verifying the presence of in situ dis-
ease to help preserve the dramatic decrease in breast cancer mortal-
ity we see today.
Materials and Methods/Results
The detection of DCIS involves knowledge of the anatomy of the
terminal ductal lobular unit (TDLU) (Figure 1) and the types and
distributions of calcifications occurring in the terminal duct portion
of the TDLU, which significantly raise the potential for the pres-
ence of DCIS (Figures 2 and 3). The specific forms of calcifications
related to DCIS are amorphous, coarse and fine pleomorphic, and
fine linear. The suspicious distributions are linear and segmental.
The amorphous forms are small (2–300 µm) and hazy in appearance
(Figure 4). Their association with malignancy, especially DCIS, is
as high as 20% (7). Fine pleomorphic calcifications are more con-
spicuous than the amorphous forms but are also irregular in shape
with the same size range as amorphous calcifications (Figure 5, A
and B). Coarse pleomorphic calcifications are larger than the fine
pleomorphic or amorphous calcifications but do not exceed 1 mm
in size (Figure 6). A linear morphology is manifested as thin, irreg-
ular and discontinuous calcifications smaller than 0.5 mm (Figure 7).
These can be associated with DCIS in up to 80% of cases. The
linear and segmental distributions of calcifications are surrogate
markers for disease distributed in the duct or ducts of TDLUs. The
linear distribution represents calcifications arrayed in a line (Figure 8)
suggesting a ductal deposit, while a segmental distribution suggests
deposits in a duct and its branches. Distributions are equally as
important as the shapes of calcifications and may be also associated
with malignancy from 60% to 80% of the time (8).
To clearly understand the interplay of risk and benefit related
to detection of DCIS, some understanding of the receiver operat-
ing characteristic (ROC) curve is warranted. If we define a benefit
as detection of histologically proven DCIS and risk as a false-
positive benign event, the ROC curve allows us to see how the
true-positive and false-positive events interact. As is demonstrated
in Figure 9, the combination of sensitivity and specificity is defined
as accuracy of the examination and is represented by the area under
the curve. Most importantly, as the sensitivity of the examination
increases (the ability to identify DCIS in the population tested
from all DCIS in that population), the specificity of the examina-
tion (the ability of the examination to define those without DCIS
from all without DCIS in the population tested) decreases. Put
another way, as the false positives increase the false negatives or
missed DCIS decrease. As a test improves in accuracy, the apex of
the curve will move toward the left increasing both sensitivity and
specificity. However, one can maintain an identical accuracy but
either increase or decease sensitivity or specificity at the expense of
the other. This will indicate movement along an ROC curve but
Imaging for the Diagnosis and Management of Ductal
Carcinoma In Situ
Carl J. D’Orsi
Correspondence to: Carl J. D’Orsi, MD, Department of Radiology, Breast Imaging Center, Emory University Hospital, WCI Bldg, 1365-C Clifton Rd, Ste C1104,
Atlanta, GA 30322 (e-mail: firstname.lastname@example.org).
Diagnosis of ductal carcinoma in situ (DCIS) has increased dramatically in parallel with the increased use of screening mam-
mography. There are specific mammographic findings, most associated with shapes (amorphous, fine and coarse pleomorphic,
and fine linear) and distributions (linear and segmental) of calcifications that permit a reasonable sensitivity for detection of
DCIS without an unreasonable decrease in specificity, especially in view of the dramatic decrease in breast cancer mortality
associated with early detection. While some DCIS may never progress to invasive disease, at this time, we cannot make that
separation. This should be an active area for research.
J Natl Cancer Inst Monogr 2010;41:214–217
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Journal of the National Cancer Institute Monographs, No. 41, 2010 215
not displacement of that curve upward and to the left. As ones
accuracy increases to the 85%–90% level, it will become difficult
to further reasonably improve accuracy. If the goal of screening is
to detect early breast cancer (DCIS), the false negatives may be
decreased and sensitivity for detecting these events increased by
increasing the false positives and decreasing the specificity (more
benign workups and percutaneous biopsies). This is one definition
of the benefit to risk ratio. If we calculate this ratio, defining the
benefit of breast cancer detection by annual screening vs the risk
of producing a breast cancer by the screening process, that ratio is
about 55:1 (9,10). If ones accuracy is suboptimal, education con-
cerning the test (mammography) and features depicted by the test
can increase the accuracy and move the curve up and to the left.
This underlines the importance of Continuing Medical Education
for mammography as well as other breast imaging techniques.
Figure 1. Terminal ductal lobular unit. The basic subgross histological
unit in the breast is the terminal ductal lobular unit. There is a terminal
duct and a lobule. The lobule is subdivided into acini.
Figure 2. Spot magnification mammogram. The anatomy of the termi-
nal ductal lobular unit is demonstrated on this magnification spot view
with the lobule and acini filled with coarse heterogeneous calcifications
(large arrow) and the terminal duct filled with linear forms of calcifica-
tions (small arrow). Pathology: comedo ductal carcinoma in situ.
Figure 3. Histology of terminal ductal lobular unit.
Figure 4. Spot magnification mammogram. Cluster of amorphous cal-
cifications. Note the hazy appearance of these calcifications. Pathology:
cribiform ductal carcinoma in situ.
Figure 5. A) and B) Spot magnification mammograms. Two different
patients with a segmental arrangement of fine pleomorphic calcifica-
tions. Pathology: comedo ductal carcinoma in situ.
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216 Journal of the National Cancer Institute Monographs, No. 41, 2010
What are the facts related to detection and management of DCIS?
The detection of DCIS is a mammographic and almost always not a
clinical event. When rates of DCIS were compared from a pre-
mammography era with the one in which mammography was in
widespread use, the total number of DCIS was 200% higher than
expected when these eras were compared (11). The National Surgical
Adjuvant Breast and Bowel Project B24 trial (12) demonstrated a
7-year risk of recurrence of 11.1% for DCIS treated with radiation
therapy and lumpectomy. Untreated comedo DCIS may lead to inva-
sive disease in 1–5 years, and untreated non-comedo DCIS may lead
Figure 6. Spot magnification mammography. Cluster of coarse hetereo-
geneous calcifications. Note size of the individual particles approaching
1 mm (arrow). Pathology: benign fibroadenomatoid change.
Figure 7. Spot magnification mammogram. A segmental arrangement
of fine linear calcifications. Pathology: comedo ductal carcinoma in situ.
Figure 8. Spot magnification mammogram. Linear arrangement of
punctate calcifications. Pathology: cribiform ductal carcinoma in situ.
Figure 9. Receiver operating characteristic curve.
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Journal of the National Cancer Institute Monographs, No. 41, 2010 217
to invasive disease in 5–15 years. Approximately 25%–30% of DCIS
may never progress to invasive malignancy. However, at this point we
cannot determine, with any degree of significance, which will and
which will not progress. Breast cancer mortality relative risk for eight
world trials comparing populations using mammography with those
not utilizing mammography ranged from 0.68 to 1.02 (5,6). Breast
cancer mortality relative risk comparing the screening epoch with the
prescreening epoch ranged from 0.41 to 0.67 (13). There has been a
30% decrease in mortality in the United States beginning at the time
of widespread use of screening mammography. These facts compel us
to not trivialize DCIS and until there is information that allows one
to separate the progressive from nonprogressive DCIS, detection
must continue or we potentially place in jeopardy the historic strides
made in decreasing mortality from breast cancer.
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Affiliation of author: Department of Radiology, Breast Imaging Center,
Emory University Hospital, Atlanta, GA.
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