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2 Table 1. Histopathologic Difference Between EIC Positive and EIC Negative Breast Cancer EIC positive (41) EIC negative (42) Total (83) Age (mean) Diagnosis Pure IDC IDC+DCIS DCIS with microinvasion ILC+LCIS Metaplastic carcinoma Mucinous carcinoma Operation method Radical or MRM Breast conserving surgery Location Rt Lt T statue T1a T1b T1c T T LN status N N Stage Stage I Stage IIA Stage IIB Histologic grade I 08* 6 14* II 13* 16 29* III 15* 20 35* Nucler grade I 15* 24 39* II 17* 15 32* III 04* 03 07* Type of DCIS Comedo Non-comedo Grade of DCIS High grade Low or intermediate Estrogen receptor positive negative Progesteron receptor positive negative C-erb positive negative IDC: Infiltrating ductal carcinoma, DCIS: Ductal carcinoma in situ ILC: Infiltrating lobular carcinoma, EIC: Extensive intraductal component *: except cases with ILC, or DCIS with microinvasion : cases with available pathologic examination 544

Accuracy (%) MMG 48.6 92.3 85.0 66.7 71.6 US 67.5 73.2 71.1 69.8 70.4 MRI 80.5 69.0 71.7 78.4 74.7 All combined 71.4 81.1 78.1 75.0 76.

Fig. 1. 47-year-old women with ductal carcinoma in situ with microinvasion. A.

3 Table 2. Comparison of Mammography, Ultrasonography and MRI For Detection of EIC in Cases with Invasive Breast Cancer Diagnostic method Sensitivity (%) Specificity (%) PPV (%) NPV (%) Accuracy (%) MMG US MRI All combined EIC: extensive intraductal component, MMG: mammography US: ultrasonography, MRI: magnetic resonance image PPV: positive predictive value, NPV: negative predictive value B A Fig year-old women with ductal carcinoma in situ with microinvasion. A. Mammogram shows regional distributed pleomorphic microcalcifications (arrow) without mass density at upper portion of the right breast. C B. Sonogram shows tubular and nodular hypoechoic structure (arrow) with numerous hyperechoic foci representing calcifications and architectural distortion. C. MR axial subtraction image using contrast-enhanced 3D-FMP-SPGR sequence shows clumped, regional enhancement at right breast. All three diagnostic methods reveal positive findings of EIC. 545

C A B Fig. 2. 48-year-old women with invasive ductal carcinoma with EIC A, B.

mass (arrow) with architectural distortion at right upper outer breast with

Microcalcifications are not present within or adjacent to the mass. D C.

4 C A B Fig year-old women with invasive ductal carcinoma with EIC A, B. Mediolateral and craniocaudal views of mammogram show spiculated hyperdense mass (arrow) with architectural distortion at right upper outer breast with enlarged axillary lymph node. Microcalcifications are not present within or adjacent to the mass. D C. Sonogram shows ill-defined and irregular shaped hypoechoic mass at right breast. D. Subtraction MRI image shows linear ductal enhancement extending from main tumor at right breast. Although mammography and sonography cannot reveal positive finding of EIC, MRI diagnoses EIC of the breast cancer. 546

A Fig. 3. 48-year-old woman with with invasive ductal carcinoma with EIC A.

calcifications (arrow) at right breast. B.

tumor, and reveals calcifications within the main tumor C.

5 A Fig year-old woman with with invasive ductal carcinoma with EIC A. Mammogram shows segmentally distributed irregular linear shaped calcifications (arrow) at right breast. B. Sonogram shows tubular hypoechoic structure (arrow) extending from the main tumor, and reveals calcifications within the main tumor C. Subtraction MRI image shows spiculated and round shaped enhancing mass at right breast. The mass doesn t have positive findings of EIC in MRI. B C 547

C A B Fig. 4. 43-year-old women with invasive ductal carcinoma with EIC negative. A, B.

architectural distortion at right upper outer breast. C.

Subtraction MRI image shows linear ductal enhancement extending from main tumor at right breast.

6 C A B Fig year-old women with invasive ductal carcinoma with EIC negative. A, B. Mediolateral and craniocaudal views of mammogram show spiculated hyperdense mass (arrow) with architectural distortion at right upper outer breast. C. Sonogram shows spiculated irregular shaped hypoechoic mass at right breast. D. Subtraction MRI image shows linear ductal enhancement extending from main tumor at right breast. Despite histopathologic finding reveals intraductal component adjacent the invasive tu- D mor, intraductal component within the invasive lesion is less than 10% in total tumor volume. 548

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8 Usefulness of Breast MRI for Diagnosing an Extensive Intraductal Component of Breast Cancer: Comparison with Mammography and Ultrasonography 1 Tae Hee Kim, M.D., Doo Kyung Kang, M.D.,Yong Sik Jung, M.D. 2, Hyunee Yim, M.D. 3 1 Department of Diagnostic Radiology, Ajou University, College of Medicine 2 Department of General Surgery, Ajou University, College of Medicine 3 Department of Pathology, Ajou University, College of Medicine Purpose: An extensive intraductal component of breast cancer is a principal risk factor for local recurrence, and this is difficult to diagnose with performing only mammography. We investigated the usefulness of breast MRI for evaluating an extensive intraductal component of breast cancer, and we compared this modality with mammography and ultrasonography (US). Materials and Methods: From March 2003 to July 2004, 90 patients underwent breast MRI among all the patients who were suffering with breast cancer and for whom an EIC was ultimately revealed to be present or not. A total 83 patients with stage I and II breast cancer were finally included in this study. EIC positivity was defined according to the imaging data as follows: 1) microcalcifications beyond the tumor shadow or malignant microcalcifications without a tumor mass on mammography, 2) tubular hypoechoic structures adjacent to the tumor or architectural distortion with calcifications beyond the tumor on US, and 3) linear or ductal enhancement, segmental or regional clumped enhancement, and spotty nodular or reticular enhancement adjacent to the tumor on MRI. EIC was present in 41 patients and this finding was negative in 42 patients. The results were then compared those results from mammography and US. Results: The sensitivities of detecting EIC by mammography, US and MRI were 48.6%, 67.5% and 80.5%, respectively, and the corresponding specificities were 92.3%, 73.2% and 69.0%, respectively. In the cases that were suspected to be EIC positive on more than two imaging modality, the positive predictive value (PPV) was 78.1%. In cases that were suspected of being EIC positive on just one imaging modality, the negative predictive value (NPV) was 75.0%. Conclusion: Breast MRI provides good information about an EIC of breast cancer and it is a more sensitive study than mammography and US, yet the specificity for the detection of EIC is highest on mammography. A combined evaluation by mammography, US and MRI is the most accurate way to diagnose an EIC of breast cancer. Index words : Breast Magnetic resonance (MR) Ultrasound (US) Mammography Address reprint requests to : Doo Kyung Kang, M.D., Department of Diagnostic Radiology, Ajou University, College of Medicine 5 Wonchon-dong, Youngtong-gu, Suwon , Korea. Tel Fax kdklsm@ajou.ac.kr 550

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