Extent of Disease

From 73% to 98% of DCIS evident mammographically is manifest as microcalcifications.84-86 The extent of calcifications on mammography can underestimate the area involved by DCIS, although Holland and Hendriks87 showed this dis crepancy was less than 2 cm in 80% to 85% of cases. When the original tumor is manifest as calcifications mammo-graphically, a postlumpectomy mammogram is advocated before radiation therapy, even when clear margins have been achieved.88 Residual calcifications on postoperative mammo-grams do predict residual tumor, with 10 (71%) of 14 patients having residual DCIS in the series of Gluck et al.89

Several series have demonstrated a detection benefit of sonography after mammography and clinical examination in evaluating the preoperative extent of breast cancer (Table 28.5), particularly in dense breasts.90 On average, 48% of breasts with cancer will have additional tumor foci not depicted on mammography or clinical examination.91 If US is being used to guide biopsy, there is an advantage to at least scanning the quadrant containing the cancer, because 93% of additional tumor foci are within the same quadrant as the index lesion,92 and more than 90% of malignant foci will be detected by combined mammography and US in this setting. When considering extent of disease, imaging of the contralateral breast should always be performed; 4% to 6% of patients are found to have unsuspected contralateral cancer on supplemental US or MRI.90,93-95

As with screening, MRI depicts additional tumor foci not seen on US, mammography, or clinical breast examination. Fischer et al.93 reported results in a series of 463 patients, including 405 cancers, where preoperative mammography, clinical breast examination, sonography, and MR imaging had been performed: multifocality in 30 of 42 patients, multicen-tricity in 24 of 50 patients, and additional contralateral carcinomas in 15 of 19 patients were depicted with MR imaging alone. As a result of the MR imaging findings, therapy was

TABLE 28.4. Results of evaluation of nipple discharge with galactography and ultrasound (US).

Detection of lesion at Detection of lesion Detection by combined

N galactography (%) at US (%) galactography and US (%)

TABLE 28.4. Results of evaluation of nipple discharge with galactography and ultrasound (US).

Detection of lesion at Detection of lesion Detection by combined

N galactography (%) at US (%) galactography and US (%)

Hild et al. 1998144

28 ducts with d/c with pathologic findings

19 (68)

26 (93)

28 (100)

Yang and Tse 2004145

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