ARRS 2022 Abstracts


E1029. Interactive Case-Based Review of the Diagnostic and Therapeutic Controversies of Ductal Carcinoma In Situ
  1. Jasmine Gandhi; Beth Israel Deaconess Medical Center
  2. Tejas Mehta; Beth Israel Deaconess Medical Center; University of Massachusetts Medical Center
  3. Jordana Phillips; Beth Israel Deaconess Medical Center
Ductal carcinoma in situ (DCIS) is a relatively common, heterogeneous breast disease that is a non-obligate precursor to invasive breast cancer. Through multiple interactive cases, this exhibit will highlight the clinical and imaging presentations of DCIS, role of imaging in breast cancer staging, unique considerations for tissue diagnosis, immunohistochemistry, and its role in prognostic indices, as well as current and ongoing treatment controversies.

Educational Goals / Teaching Points
The clinical and imaging presentations of DCIS, role of imaging in staging, biopsy techniques including sampling lesions involving the nipple-areolar complex, immunohistochemistry, common risk assessment tools and active-surveillance only clinical trials will be reviewed.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
DCIS is often asymptomatic, usually presenting on mammography as calcifications, with mass, asymmetry, or architectural distortion being less common. On ultrasound, DCIS may be visualized as a mass or intraductal abnormality. On MRI, non-mass enhancement is most common. Clinical presentations include changes involving the nipple and nipple discharge. Histologic sampling is necessary to diagnose DCIS. Percutaneous core biopsy is most common, with skin punch biopsy or surgical biopsy being less common. Lesions in the nipple-areolar complex are best targeted with fine needle aspiration (FNA) or core needle device with no-throw technique. After diagnostic confirmation, breast MRI may be obtained to delineate the extent of disease. Axillary sentinel lymph node sampling is not routinely performed for DCIS but may be recommended for patients with extensive or high-grade DCIS, DCIS with microinvasion or those undergoing mastectomy given the increased likelihood of upgrade to invasive cancer. Hormone receptor status is determined in cases of invasive breast cancer and DCIS. Hormone receptor positive breast cancers have either estrogen (ER), progesterone (PR) or both (ER/PR) receptors in at least 1% of the cells which can be targeted with hormone therapy drugs. The presence of an additional protein marker, human epidermal growth factor receptor 2 (HER2), can provide another target for treatment. The Oncotype Dx Breast DCIS Score test is a prognostic index that determines risk of recurrence by evaluating tumor genetic markers. A complimentary approach is the Van Nuys Prognostic Index (VPNI), which also can predict risk of local recurrence after breast conservation therapy based on size, margin, and pathology. Controversies around overtreatment of low-risk DCIS have resulted in multiple trials to determine the efficacy of active surveillance, including the COMET trial in the U.S. and the LORD and LORIS trials in Europe.

Through an interactive case-based approach, this exhibit presents the various current diagnostic and therapeutic considerations of DCIS. At the completion of this series, participants will have reviewed the clinical and imaging presentations of DCIS, factors considered in breast staging and tissue sampling, targeted drug therapies, prognostic assessment tools, treatment options, and future research directions.