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DOI: 10.1148/radiol.2453062061
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(Radiology 2007;245:684-691.)
© RSNA, 2007

Breast Imaging

Pure Ductal Carcinoma in Situ: Kinetic and Morphologic MR Characteristics Compared with Mammographic Appearance and Nuclear Grade1

Sanaz A. Jansen, MSc, Gillian M. Newstead, MD, Hiroyuki Abe, MD, PhD, Akiko Shimauchi, MD, Robert A. Schmidt, MD, and Gregory S. Karczmar, PhD

1 From the Department of Radiology, University of Chicago, 5841 S Maryland Ave, MC 2026, Chicago, IL 60637. Received December 4, 2006; revision requested January 29, 2007; revision received March 1; accepted April 11; final version accepted June 1. Supported by the Segal Foundation, Biological Sciences Division at the University of Chicago, Department of Defense grant W81XWH-06-1-0329, and National Institutes of Health grants R21 CA104774-01A2 and 2 R01 CA078803-05A2. Address correspondence to G.M.N. (e-mail: gnewstead{at}radiology.bsd.uchicago.edu).


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 ADVANCES IN KNOWLEDGE
 IMPLICATION FOR PATIENT CARE
 References
 
Purpose: To retrospectively compare the kinetic and morphologic characteristics of pure ductal carcinoma in situ (DCIS) lesions depicted on dynamic contrast material–enhanced magnetic resonance (MR) images with the nuclear grade and conventional mammographic appearance of these lesions.

Materials and Methods: This HIPAA-compliant retrospective study was institutional review board approved, and informed patient consent was waived. Seventy-eight patients with 79 histologically proved pure DCIS lesions were selected. There were 17 low-nuclear-grade, 26 intermediate-nuclear-grade, 30 high-nuclear-grade, and six unclassified lesions. Sixty-five lesions were classified as fine pleomorphic, fine linear, or fine linear-branching calcifications (n = 31); amorphous or indistinct calcifications (n = 18); noncalcified mass (n = 10); or occult (n = 6) at conventional (x-ray) mammography. One experienced radiologist analyzed lesion morphology and kinetic curve shape according to the Breast Imaging Reporting and Data System lexicon. Initial enhancement percentage, time to peak enhancement (Tpeak), and signal enhancement ratio (a measure of washout) were calculated for each lesion.

Results: Of the 79 pure DCIS lesions, 20 (25%) exhibited enhancement plateau curves and 35 (44%) exhibited washout curves. The lesions with a masslike appearance on mammograms exhibited more suspicious kinetic characteristics (mean Tpeak ~ 2 minutes) than did the lesions with amorphous or indistinct calcifications (mean Tpeak = 4.4 minutes). There was no significant difference in enhancement kinetic properties across the nuclear grades. Lesion morphology was predominantly nonmass, with clumped or heterogeneous enhancement in a segmental or linear distribution.

Conclusion: The pure DCIS lesions exhibited washout, plateau, and persistent enhancement curves. Enhancement kinetic characteristics varied with mammographic appearance but not with nuclear grade.

Supplemental material: http://radiology.rsnajnls.org/cgi/content/full/245/3/684/DC1

© RSNA, 2007


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 ADVANCES IN KNOWLEDGE
 IMPLICATION FOR PATIENT CARE
 References
 
Ductal carcinoma in situ (DCIS) comprises a heterogeneous group of lesions with variable genetic, biologic, and histologic features. DCIS is generally considered a nonobligate precursor of invasive cancer; evidence suggests that in about 30%–50% of cases, the lesion will progress to become invasive (1). DCIS is typically depicted at conventional (x-ray) mammography as calcifications, although it may also appear masslike in its noncalcified form (2–5). Accurate depiction of the extent of DCIS is essential for successful breast conservation treatment.

Dynamic contrast material–enhanced magnetic resonance (MR) imaging (hereafter referred to as dynamic MR imaging) of the breast is being used with other conventional diagnostic techniques for several clinical purposes, including preoperative evaluation of the extent and multifocality of malignancy (6) and posttreatment follow-up (7). One advantage of dynamic MR imaging is high sensitivity (6,8,9). The contrast medium uptake (ie, kinetic) properties of invasive lesions typically involve a rapid increase and a washout over time, while benign lesions tend to enhance more slowly and persistently take up contrast medium over time (10,11).

There are relatively few prior reports of the appearance of pure DCIS at MR imaging, and the kinetic and morphologic properties of DCIS without evidence of microinvasion have not yet been well characterized (12–14). The reported sensitivity of MR imaging for detection of DCIS is 77%–96% (12,15–20). Pure DCIS lesions most often appear as nonmass clumped enhancement in a segmental or linear distribution (13,16), with mainly plateau or washout enhancement curves (12,13,16,17,21). These lesions are therefore thought to have less suspicious kinetic findings compared with invasive cancers (16,22). Various reports have indicated that the kinetic characteristics of low-grade pure DCIS lesions are different from those of intermediate- and high-grade lesions (13,22,23), whereas other studies have revealed no difference (15). The numbers of patients examined in these prior reports have been relatively small (n = 15–50), and these studies have mostly focused on morphologic and qualitative kinetic analyses. Thus, the purpose of our study was to retrospectively compare the kinetic and morphologic characteristics of pure DCIS lesions depicted on dynamic MR images with the nuclear grade and conventional mammographic appearance of these lesions.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 ADVANCES IN KNOWLEDGE
 IMPLICATION FOR PATIENT CARE
 References
 
Patients
At our institution, it is a routine protocol to perform breast MR examinations for diagnostic imaging, evaluation of disease extent, posttreatment evaluation, and screening for high cancer risk. We maintain a clinical database that includes the MR morphologic and kinetic data for all lesions found. The final diagnosis of the lesions is also entered into the database. The MR imaging and histologic findings for all patients are reviewed at a weekly interdisciplinary breast conference that includes radiologists, pathologists, and surgeons. The institutional review board of the University of Chicago approved our Health Insurance Portability and Accountability Act–compliant retrospective study, with waived informed patient consent. A review of 1770 records (for January 2002 through August 2005) revealed 78 women with 79 histologically proved pure DCIS lesions. The average patient age was 56 years (range, 31–86 years).

MR Imaging Analysis
Dynamic MR imaging protocol.—MR imaging was performed with a 1.5-T GE Signa unit (GE Healthcare, Milwaukee, Wis) by using a dedicated four-channel breast coil (Invivo, Orlando, Fla) with the patient in the prone position. Two protocols were used: In the first protocol, one precontrast image and five postcontrast images were acquired in the coronal plane by using a T1-weighted three-dimensional spoiled gradient-recalled acquisition in the steady state sequence (7.7/4.2 [repetition time msec/echo time msec], 30° flip angle, 3-mm section thickness, 1.4-mm in-plane spatial resolution) with no fat saturation. Acquisition of the first postcontrast image was started 20 seconds after the contrast medium injection, and the remaining images were acquired every 68 seconds thereafter. In the second dynamic protocol, there were four postcontrast acquisitions. The first, second, and fourth acquisitions were performed as described for the first protocol, and the third was a high-spatial-resolution coronal acquisition for 128 seconds. Gadodiamide (Omniscan; Nycomed-Amersham, Princeton, NJ) was injected intravenously at a dose of 0.1 mmol per kilogram of body weight and at a rate of 2.0 mL/sec and was followed by a 20-mL saline flush administered at the same rate. The following MR analyses were performed by using subtraction images, which were viewed at a workstation:

Morphologic MR analysis.—One radiologist (G.M.N.) with 14 years breast MR experience retrospectively reviewed the images and classified the lesion morphology. This analysis was not performed with the radiologist blinded to patient information and clinical history; rather, it was performed without knowledge of the lesion's nuclear grade and mammographic classification (discussed later in the text). Lesion morphology was classified by viewing coronal, sagittal, and transverse reconstructed MR images. The type, shape, distribution, margins, and internal enhancement pattern of the lesions were assessed according to the Breast Imaging Reporting and Data System (BI-RADS) lexicon. In addition, the maximal extent of the lesion in the sagittal plane was measured (Fig 1).


Figure 1A
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  		Figure 1a: (a) Sagittal T1-weighted three-dimensional spoiled gradient-recalled acquisition in the steady state subtraction MR image (7.7/4.2, 30° flip angle) of pure DCIS (arrows). (b) Corresponding enhancement kinetic curve generated by using in-house software.

 

Figure 1B
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  		Figure 1b: (a) Sagittal T1-weighted three-dimensional spoiled gradient-recalled acquisition in the steady state subtraction MR image (7.7/4.2, 30° flip angle) of pure DCIS (arrows). (b) Corresponding enhancement kinetic curve generated by using in-house software.

 
Enhancement kinetics MR analysis.—After classifying the lesion morphology, the same radiologist performed a retrospective kinetic analysis. By using institutional software, the radiologist generated enhancement kinetic curves by manually tracing a region of interest around the most enhancing part of the lesion as it appeared on the first postcontrast MR image in the coronal plane. The average region-of-interest size was 6.3 pixels. The radiologist performed a qualitative analysis of the enhancement curve shape according to the BI-RADS lexicon by assessing the initial contrast medium uptake (rapid, medium, or slow) and delayed-phase enhancement (persistent, plateau, or washout) characteristics of the curve. Quantitative kinetic parameters were also derived from the curves. For each curve, the initial enhancement percentage (E1), peak enhancement percentage (Epeak), and time to peak enhancement (Tpeak) were measured, as described by Szabo et al (24). The signal enhancement ratio (SER) was calculated as a measure of washout, as was done by Esserman et al (25) (Appendix E1, http://radiology.rsnajnls.org/cgi/content/full/245/3/684/DC1).

Histologic Classification
The histologic diagnosis of pure DCIS was based on the initial review of the lumpectomy or mastectomy specimens and was determined by means of consensus between two pathologists with 9 and 20 years of experience. There was no evidence of microinvasion, and no axillary involvement was found in this specimen population. Histologic classification of the nuclear grade was possible for 73 of the 79 lesions: 17 were low-grade, 26 were intermediate-grade, and 30 were high-grade pure DCIS lesions. Six lesions were unclassified.

Mammographic Classification
At our institution, conventional (x-ray) mammograms of 65 lesions were available and were retrospectively assessed by the same experienced radiologist (G.M.N.), who viewed the diagnostic mammograms on film approximately 4 months after performing the MR morphologic and kinetic analyses. For mammographic analysis, the radiologist was not blinded to the patient information and was aware of the diagnosis of pure DCIS but not the nuclear grade. In 49 of 65 lesions, calcifications were found and the morphology was classified according to the BI-RADS lexicon as fine pleomorphic, fine linear, fine linear branching, amorphous, or indistinct (Figs 2, 3). The mammographic findings were divided accordingly into four groups: (a) fine pleomorphic, fine linear, or fine linear-branching calcifications (n = 31); (b) amorphous or indistinct calcifications (n = 18); (c) noncalcified mass (n = 10); and (d) occult lesion (n = 6).


Figure 2
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  		Figure 2: Digital mammogram of right breast (mediolateral view with spot magnification) shows faint indistinct calcifications near clip.

 

Figure 3
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  		Figure 3: Digital mammogram of left breast (mediolateral view with spot magnification) shows linear-branching calcifications (arrows).

 
Statistical Analyses
The 73 lesions for which histologic classification was possible were classified according to nuclear grade (low, intermediate, or high), and the 65 lesions for which mammographic data were available were classified (fine pleomorphic, fine linear, or fine linear-branching calcifications; amorphous or indistinct calcifications; noncalcified mass; or occult lesion). The number of lesions with each kinetic and morphologic classification was determined for all 79 lesions and for each subpopulation. We compared the proportions of washout, plateau, and persistent (or rapid, medium, or slow) enhancement curves between lesions stratified according to either nuclear grade or mammographic appearance, and to test for significance, we used the pairwise Pearson {chi}2 test, with P < .05 indicating significance. We performed a similar analysis of the qualitative morphologic variables—for example, we compared the proportions of mass, nonmass, and focus-type enhancement between lesions stratified by either nuclear grade or mammographic appearance.

The mean values (with standard deviations) for each quantitative kinetic parameter (E1, Epeak, SER, and Tpeak) were calculated for all 79 lesions and for the nuclear grade– and mammographic classification–based subpopulations. We performed a pairwise comparison of the mean kinetic parameter values in each of these subpopulations by using the independent samples t test, with P < .05 indicating significance.

We also determined the discrepancies in the SER-based versus BI-RADS–based assessment of washout as follows: For an SER higher than 1.1, any enhancement curves classified as plateau or persistent were counted as inconsistent, and for an SER of between 0.9 and 1.1, any curves classified as persistent were counted as inconsistent (Appendix E1, http://radiology.rsnajnls.org/cgi/content/full/245/3/684/DC1).


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 ADVANCES IN KNOWLEDGE
 IMPLICATION FOR PATIENT CARE
 References
 
MR Findings
The dominant MR features of pure DCIS lesions were nonmass and clumped, heterogeneous, or homogeneous enhancement in a segmental or linear distribution (Table 1). Fifty-four (68%) of the 79 pure DCIS lesions showed rapid enhancement. The distribution of delayed-phase enhancement characteristics was more uniform, with 35 (44%) lesions showing washout-type curves (Fig 4).


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  		Table 1. Morphologic Distribution of Pure DCIS Lesions according to BI-RADS Lexicon

 

Figure 4A
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  		Figure 4a: Graphs illustrate distribution of qualitative BI-RADS–based (a) initial contrast medium uptake and (b) delayed-phase enhancement characteristics of 79 pure DCIS lesions.

 

Figure 4B
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  		Figure 4b: Graphs illustrate distribution of qualitative BI-RADS–based (a) initial contrast medium uptake and (b) delayed-phase enhancement characteristics of 79 pure DCIS lesions.

 
Mean kinetic parameter values were as follows: 188% ± 15 for E1, 242% ± 16 for Epeak, 212 seconds ± 13 for Tpeak, and 0.93 ± 0.04 for SER. On the basis of these quantitative measures of washout, the kinetic curves for pure DCIS lesions exhibited, on average, a plateau relative to the first postcontrast point. Overall, the quantitative and qualitative measures of washout were largely consistent. Of the 24 lesions with an SER higher than 1.1, one was classified as having a persistent enhancement curve and one was classified as having a plateau enhancement curve. Of the 17 lesions with an SER of between 0.9 and 1.1, one was classified as having a persistent curve.

MR Findings Compared with Nuclear Grades
MR morphology did not differ significantly among the low-, intermediate-, and high-nuclear-grade lesions (P > .24 for all comparisons, {chi}2 test). Neither the initial uptake and delayed-phase classifications nor the kinetic parameters (E1, Epeak, SER, Tpeak) differed significantly across the nuclear grades of pure DCIS (P > .06 for all comparisons, {chi}2 or independent samples t test).

MR Findings Compared with Mammographic Appearance
MR morphology did not differ significantly among the four mammographic classifications (P > .14 for all comparisons, {chi}2 test). Lesions with amorphous or indistinct calcifications were smaller at MR imaging (average size, 23 mm) than were lesions with fine pleomorphic, fine linear, or fine linear-branching calcifications (average size, 33 mm; P = .048). The distribution of initial uptake was significantly similar among all mammographic appearance groups (P > .42 for all comparisons, {chi}2 test). The {chi}2 test revealed significant differences in the distribution of delayed-phase curve types: Nine (90%) of the 10 lesions with a mass appearance on mammograms—compared with 14 (45%) of the 31 lesions with fine pleomorphic, fine linear, or fine linear-branching calcifications (P = .041, {chi}2 test) and four (22%) of the 18 lesions with amorphous or indistinct calcifications (P = .002, {chi}2 test)—exhibited washout-type curves (Fig 5).


Figure 5
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  		Figure 5: Graph illustrates distribution of qualitative BI-RADS–based enhancement characteristics of pure DCIS lesions assessed on the basis of mammographic appearance: amorphous or indistinct calcifications (n = 18); fine pleomorphic, fine linear, or fine linear-branching calcifications (n = 31); mass (n = 10); or occult lesion (n = 6).

 
There were also significant differences in some quantitative parameters (Table 2). The mean SER for the pure DCIS lesions with amorphous or indistinct calcifications was 0.77, whereas the corresponding values for the lesions with fine pleomorphic, fine linear, or fine linear-branching calcifications and those with a masslike appearance at mammography were 0.95 and 1.34, respectively. Thus, on the basis of these SER values, the enhancement kinetic curves for the mass lesions strongly wash out relative to the first postcontrast point, while the curves for lesions with fine pleomorphic, fine linear, or fine linear-branching calcifications reach a plateau and the curves for lesions with amorphous or indistinct calcifications continue to increase (P < .05). The mean Tpeak was 4.4 minutes for the amorphous or indistinct group; just under 3.5 minutes for the group with fine pleomorphic, fine linear, or fine linear-branching calcifications; and just under 2 minutes for the mass group (P < .05). The mean Tpeak for the mammographically occult lesions was 2.5 minutes, significantly shorter than that for the lesions with an amorphous or indistinct appearance (P = .025). However, the enhancement kinetic characteristics of the mammographically occult lesions did not differ significantly from those of the other lesion groups (P > .39 for all comparisons), although these lesions demonstrated the smallest enhancement percentages. Four of the six occult lesions were of high grade.


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  		Table 2. Kinetic Parameters of Pure DCIS Lesions Stratified according to Mammographic Appearance

 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
ADVANCES IN KNOWLEDGE
 IMPLICATION FOR PATIENT CARE
 References
 
In our study, pure DCIS lesions typically appeared as nonmass-like, clumped or heterogeneous enhancement at MR imaging. In addition, the lesions did not always exhibit the typical malignant washout kinetic curves and could show persistent and plateau curve types. Our findings were concordant with those reported in the literature (13,16).

We also established several quantitative kinetic parameters of 79 pure DCIS lesions. In a previous study in which similar acquisition timing was used, the reported mean E1 values for invasive and benign lesions were 273% and 163%, respectively (24). In our current study, the mean E1 for pure DCIS lesions was 188%; this implies that these lesions enhance less than invasive cancers and more than benign lesions. The reported mean Tpeak values for invasive and benign lesions were 173 and 430 seconds, respectively (24), whereas we calculated a mean Tpeak of 212 seconds—again a value intermediate between the values for benign and malignant lesions. In the study of Esserman et al (25), the average SER for invasive lesions was 1.35, indicating a strong washout relative to the first postcontrast point. We calculated a lower mean SER of 0.93, which indicates that pure DCIS lesions plateau relative to the first postcontrast point.

The kinetic curve shape is related to the perfusion and diffusion of contrast media from the blood vessels to the extracellular space; it is the unique physiologic features and vasculature of invasive, benign, and pure DCIS lesions that ultimately explain the described differences in kinetic curves (26–28). It has been reported that perfusion rates increase as the lesion progresses from benign focus to DCIS to invasive cancer (22) and are associated with microvessel density in DCIS lesions (23). Guidi et al (29) observed an increase in vessel density around the ducts with DCIS, although with variable patterns. Heffelfinger et al (30,31) found that the expression of angiogenic growth factors, such as vascular endothelial growth factor, increases with the progression of the lesion from hyperplasia to DCIS.

We observed no significant difference in enhancement kinetic characteristics among the different nuclear grades of pure DCIS. This supports the previous findings of Viehweg et al (15). On the other hand, a few groups have observed a difference between low-grade pure DCIS and intermediate- and high-grade pure DCIS lesions. In one study (13), the difference may have existed because five of the 12 low-grade lesions studied did not enhance at all; in our study, we only considered DCIS lesions that enhanced at MR imaging. In other studies (22,23), the numbers of lesions considered were perhaps too small (only three or four intermediate- and high-grade lesions) to yield significance.

To our knowledge, our study is the first investigation in which the conventional mammographic appearance of DCIS lesions was compared with the contrast medium uptake and washout in these lesions. There has been interest in the possibility that the conventional mammographic appearance of breast lesions may be a prognostic indicator (32–36). Tabar et al (34) reported that the survivals of women with masses or linear or linear-branching calcifications (ie, casting calcifications) are considerably worse than the survivals of women with other types of lesions, suggesting that the calcifications represent a duct-forming invasive cancer. In our study, lesions with fine pleomorphic, fine linear, or fine linear-branching calcifications—especially those that appeared as masses on conventional mammograms—were, according to conventional kinetic standards, more suspicious at MR imaging compared with lesions with amorphous or indistinct calcifications. In particular, DCIS lesions that appeared as masses at mammography exhibited, on average, typical malignant kinetic characteristics, with a short Tpeak and strong washout (ie, SER).

Esserman et al (25) studied the relationships between the SERs of invasive tumors and both tumor vascularity and histologic grade. They found that higher SER was associated with higher vascularity and higher Scarff-Bloom-Richardson grade. In our study, the SERs of pure DCIS lesions of various grades were statistically equivalent. On the other hand, SERs did vary according to mammographic appearance. This suggests that the conventional mammographic appearance of pure DCIS might be related to the underlying physiologic and biologic characteristics of the lesion in a way that nuclear grade is not.

There are several limitations to the dynamic MR imaging examinations described herein, including the placement and size of the region of interest and performing the quantitative analysis by using signal intensity rather than contrast medium concentration, which can lead to errors due to variability in the native T1 of the tissue. In addition, various institutions use different imaging protocols and pulse sequences, making comparisons of quantitative parameters across institutions problematic. Even at our institution, we used two protocols, and this may have compromised the reliability of the kinetic parameters used. We attempted to minimize this effect by considering parameters based on signal intensities measured at the initial and last postcontrast time points (which were at similar times in the two protocols).

There were further limitations of our study: The MR and mammographic analyses were performed by one experienced radiologist, and the images were reviewed retrospectively. Although the MR analysis was performed without knowledge of nuclear grade or mammographic classification, there was still the question of reproducibility. Although the radiologist who performed these evaluations had 14 years of breast MR experience, a larger number of readers and a fully controlled blinded study would have been desirable. In addition, we did not perform a detailed analysis of the relationship between the histologic and imaging findings—for example, to compare the lesion extent at histologic analysis with that at MR imaging, as has been done elsewhere (20,37,38). With some preliminary conclusions in hand, we may now be in a better position to pursue a more detailed study involving more lesions, more radiologists, and improved histologic analysis.

The distinctive morphology and variable kinetic pattern of DCIS may prompt some to suggest that MR image acquisitions that emphasize spatial rather than temporal resolution are more sensitive to DCIS. Although spatial resolution is important (39), sufficient temporal resolution is also needed to distinguish the more slowly and moderately enhancing nonmass-like morphology of pure DCIS from enhancing parenchyma. Although the diagnostic utility of kinetic descriptors may be compromised by the variable kinetic pattern of DCIS, understanding the kinetic features is important for improving the detection of these lesions. For example, the longer Tpeak and lower initial enhancement of pure DCIS lesions should be considered in some computer-aided detection schemes, in which the thresholds may be set too high and too early and thus run the risk of yielding a false-negative diagnosis. Conversely, setting thresholds too low may lead to more false-positive diagnoses and unnecessary biopsies; our results of enhancement kinetics quantification may help to balance these trade-offs.

In summary, we found that the variable enhancement kinetic characteristics of pure DCIS lesions were not associated with nuclear grade. Rather, lesions with a mammographic appearance of a soft-tissue mass or pleomorphic, linear, or linear-branching calcifications, as well as mammographically occult (ie, depicted at MR only) lesions, were more likely to exhibit plateau or washout enhancement characteristics than were lesions with amorphous or indistinct calcifications and might represent more aggressive disease. Recognition and understanding of the unique morphology and kinetic characteristics of pure DCIS at MR imaging might improve the detection of early-stage breast cancer.


   ADVANCES IN KNOWLEDGE
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 ADVANCES IN KNOWLEDGE
IMPLICATION FOR PATIENT CARE
 References
 


   IMPLICATION FOR PATIENT CARE
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 ADVANCES IN KNOWLEDGE
 IMPLICATION FOR PATIENT CARE
References
 


   FOOTNOTES
 

Abbreviations: BI-RADS = Breast Imaging Reporting and Data System • DCIS = ductal carcinoma in situ • E1 = initial enhancement percentage • Epeak = peak enhancement percentage • SER = signal enhancement ratio • Tpeak = time to peak enhancement

Guarantors of integrity of entire study, S.A.J., G.M.N.; study concepts/study design or data acquisition or data analysis/interpretation, all authors; manuscript drafting or manuscript revision for important intellectual content, all authors; manuscript final version approval, all authors; literature research, S.A.J., G.M.N.; clinical studies, S.A.J., G.M.N., H.A., A.S., R.A.S.; statistical analysis, S.A.J., G.S.K.; and manuscript editing, S.A.J., G.M.N., G.S.K.

Authors stated no financial relationship to disclose.


   References
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 ADVANCES IN KNOWLEDGE
 IMPLICATION FOR PATIENT CARE
 References
 

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S. Raza, M. Vallejo, S. A. Chikarmane, and R. L. Birdwell
Pure Ductal Carcinoma in Situ: A Range of MRI Features
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