What is the most common presentation of ductal carcinoma in situ (DCIS)?

Most Common Presentation of Ductal Carcinoma In Situ (DCIS)

The most common presentation of ductal carcinoma in situ (DCIS) is microcalcifications detected on mammography, occurring in approximately 75-98% of cases, rather than breast pain, palpable mass, or nipple discharge. 1

Mammographic Presentations of DCIS

• Microcalcifications are the predominant presentation of DCIS (75-98% of cases), typically appearing pleomorphic and grouped in clusters, often with linear or segmental arrangements reflecting their presence within ducts 1
• The shape of calcification clusters is frequently irregular or triangular, suggesting a segmental or ductal distribution 1
• Soft tissue changes without calcifications occur in approximately 22% of cases 1
• Mass lesions account for only about 8% of DCIS presentations 1
• Nodules or prominent ducts represent approximately 8% of presentations 1
• Other soft tissue changes account for roughly 6% of presentations 1
• Negative mammograms (no visible findings) occur in about 16% of DCIS cases 1

Clinical Presentations of DCIS

• DCIS can present as a palpable mass, but this presentation is unusual 2
• Breast pain is not a common presentation of DCIS 1
• Nipple discharge can occur but is not the primary presentation 1
• About 10% of mammographically evident DCIS is an uncalcified mass 2
• Occasionally, DCIS is diagnosed without mammographic findings 2

Diagnostic Implications

• The high prevalence of microcalcifications as the presenting sign of DCIS underscores the importance of thorough mammographic evaluation with magnification views 1
• Mammography may underestimate the extent of DCIS, particularly for low and intermediate-grade lesions, by up to 2 cm in as many as 50% of cases 1
• For accurate assessment, both mediolateral oblique and craniocaudal views should be obtained, along with magnification views 1
• The definitive diagnosis of DCIS requires histopathologic examination, as imaging techniques cannot determine whether the basement membrane has been violated 2
• Stereotactic core-needle biopsy is the initial approach for sampling suspicious nonpalpable mammographic abnormalities 2

Recurrence Patterns

• When DCIS recurs after treatment, 75% of recurrences present as microcalcifications 1
• 80% of patients whose initial DCIS presented with microcalcifications will have recurrences that also manifest as microcalcifications 1
• In 94% of cases, recurrent tumor calcifications have morphology similar to the initial DCIS 1

Clinical Pearls and Pitfalls

• Despite recent technological advances, mammographically guided wire biopsy remains the "gold-standard" for obtaining a histological diagnosis in patients with non-palpable, mammographically detected DCIS 3
• If a presurgical diagnosis of DCIS is made by percutaneous core-needle biopsy, physicians should be aware that areas of invasive carcinoma are found in about 20% of cases at the time of surgical excision 2, 3
• Complete bilateral mammographic evaluation is essential before treatment planning, as bilateral DCIS has been reported in up to 19% of women 4