REVIEW ARTICLE

Role of Breast MRI in the Evaluation

and Detection of DCIS: Opportunities
and Challenges
Heather I. Greenwood, MD,* Lisa J. Wilmes, PhD, Tatiana Kelil, MD, and
Bonnie N. Joe, MD, PhD

Historically, breast magnetic resonance imaging (MRI) was not considered an effective modality in the evaluation of ductal
carcinoma in situ (DCIS). Over the past decade this has changed, with studies demonstrating that MRI is the most sensitive
imaging tool for detection of all grades of DCIS. It has been suggested that not only is breast MRI the most sensitive imag-
ing tool for detection but it may also detect the most clinically relevant DCIS lesions. The role and outcomes of MRI in the
preoperative setting for patients with DCIS remains controversial; however, several studies have shown benefit in the pre-
operative evaluation of extent of disease as well as predicting an underlying invasive component. The most common pre-
sentation of DCIS on MRI is nonmass enhancement (NME) in a linear or segmental distribution pattern. Maximizing breast
MRI spatial resolution is therefore beneficial, given the frequent presentation of DCIS as NME on MRI. Emerging MRI tech-
niques, such as diffusion-weighted imaging (DWI), have shown promising potential to discriminate DCIS from benign and
invasive lesions. Future opportunities including advanced imaging visual techniques, radiomics/radiogenomics, and
machine learning / artificial intelligence may also be applicable to the detection and treatment of DCIS.
Level of Evidence: 3
Technical Efficacy Stage: 3
J. MAGN. RESON. IMAGING 2019.

Biology/Natural History prevalence of DCIS.14,15 Unfortunately, it is currently not

DUCTAL CARCINOMA IN SITU (DCIS) is a malignant
proliferation of ductal epithelial cells in which malignant cells
are confined to the duct of the terminal ductal lobular unit.1,2
It differs from invasive breast cancer in that DCIS has not
invaded beyond its intraductal origin. DCIS represents an
extremely heterogeneous group of lesions that differ in genetic
and molecular abnormalities, histopathologic features, and
biologic markers3 with variable potential for progression to
invasive disease.4,5 Some DCIS lesions will progress to an
aggressive invasive cancer.6,7 Evidence for progression of
DCIS to invasive carcinoma comes from prospective studies
evaluating the incidence of type of in-breast tumor recurrence
after breast conservation therapy, in which ~50% of ipsilateral
recurrences were invasive.8–13 However, not all DCIS will
progress to invasive cancer and autopsy series of women not
known to have breast cancer have shown up to a 14%
possible to determine which lesions will and will not pro-
gress.16 Therefore, treatment of this heterogeneous disease
can be controversial.
Prior to routine use of screening mammography, DCIS
accounted for only 1–2% of all breast cancers.17 With the
advent and wide acceptance of screening mammography over
the past several decades, the detection of DCIS has greatly
increased and it now accounts for 20% of screen-detected
breast cancers in the United States.18–21 Given the increased
detection along with the great heterogeneity and poor under-
standing of the natural history of DCIS, there has been
increased controversy over this disease process and potential
of overtreatment.22 Multiple studies and trials have aimed to
better understand DCIS lesions and their risk or progression
to invasion; however, there remains a lack of understanding
of this disease process.

View this article online at wileyonlinelibrary.com. DOI: 10.1002/jmri.26985

Received Jan 16, 2019, Accepted for publication Oct 16, 2019.

*Address reprint requests to: H.G., University of California San Francisco Department of Radiology and Biomedical Imaging, 1600 Divisadero St., Rm. C-250,
San Francisco, CA 94115. E-mail: Heather.greenwood@ucsf.edu

From the University of California San Francisco, Department of Radiology and Biomedical Imaging, San Francisco, California, USA

© 2019 International Society for Magnetic Resonance in Medicine 1

Journal of Magnetic Resonance Imaging

Imaging Appearance
The most common mammographic presentation of DCIS is
microcalcifications20,23,24; less frequently, it may present as a
mass or architectural distortion.20,23–25 Mammography is limited
in detecting noncalcified cases of DCIS, particularly in dense
breasts. Clinical breast magnetic resonance imaging (MRI) is not
limited by dense breast tissue as it relies on contrast enhancement
for the detection of breast cancer (Fig. 1). The most common
morphologic manifestation of DCIS on MRI is nonmass
enhancement (NME) (60–81% of cases), and less commonly
DCIS presents as a mass (14–41% of cases) or focus (1–12% of
cases) on MRI.26–28 When presenting as NME, the most com-
mon internal enhancement is clumped (41–64% of cases), and
the most common distribution patterns are linear or segmental
(14–77% of cases) (Fig. 2).20,26–28 There is great variety in the
kinetic pattern of DCIS, both in the initial and delayed phases.
The most common initial kinetic pattern is fast (49–68% of
cases), with all three types of delayed phases frequently
seen.26,28,29 A greater proportion of DCIS may have persistent or
plateau delayed curves than seen in invasive breast
carcinomas.26,27,29–31 The assessment of DCIS on MRI, thus,
heavily relies on morphologic features over kinetics.
Sensitivity/Specificity
Historically, MRI was considered a poor imaging modality
for the detection of DCIS. Early studies showed poor sensitiv-
ity and specificity for DCIS.32,33 The sensitivity of MRI for
invasive cancers was higher than for DCIS.32,34 This was
thought mostly to be related to technical issues, as early stud-
ies were done with higher temporal resolution at the cost of
lower spatial resolution. In addition, early studies evaluating
the sensitivity of MRI for DCIS were performed in women
with new diagnoses of DCIS detected on other modalities
such as mammography and ultrasound, and were evaluating

FIGURE 1: A 46-year-old female who presented with two left palpable breast lumps. Craniocaudal (CC) and mediolateral oblique
(MLO) mammograms (a) demonstrate heterogeneously dense breasts (BI-RADS C) with no abnormality to correlate with her lumps
(BB and triangular marker). Subsequent ultrasound (b) targeted to site of clinical concern in the left breast demonstrates an ill-
defined hypoechoic region. Subsequent ultrasound guided core biopsy revealed DCIS. Postcontrast fat-suppressed T1-weighted MR
image on 3T MRI (c) performed for extent of disease demonstrates segmental nonmass enhancement (NME) with a clustered ring
internal enhancement pattern spanning a much larger extent than on ultrasound and occult on mammography.

2

FIGURE 2: Subtracted postcontrast maximum intensity
projection (MIP) image demonstrates clumped nonmass
enhancement (arrow) in a segmental distribution in the lower
left breast.
for mass lesions as opposed to nonmass enhancement
(NME). However, now the higher performance of MRI sys-
tems with improved pulse sequences for breast imaging as
well as improved interpretation standards established in the
American College of Radiology (ACR) Breast Imaging and
Reporting and Data System (BI-RADS) for MRI have led to
more accurate MRI performance for DCIS.35 Recent studies
were performed with higher spatial resolution, started to look
for NME, and were performed for high-risk screening.20,32
These studies have shown higher sensitivity of MRI in the
detection of DCIS. Breast MRI now has been shown to be
more sensitive in the detection of DCIS than mammography
and ultrasound with a sensitivity of ~89–92% compared to
55–56% and 47%, respectively.32,36,37 For example, an
observational study by Kuhl et al found an overall sensitivity
of 92% (95% confidence interval [CI] 86–95%) for all DCIS
compared to 56% (95% CI 47–63%) for mammography.36
In addition, the sensitivity of MRI for detection of DCIS was
higher with high grade vs. low and intermediate grades, 98%
(95% CI 91–100%) vs. 85% (95% CI 74–91%), whereas
they found mammography to be less sensitive for high grade
than low grade 52% (95% CI 41–62%) vs. 60% (95% CI
48–71%). A more recent study by Baur et al retrospectively
Greenwood et al.: Breast MRI Evaluation and Detection of DCIS
analyzed the sensitivity of MRI for the detection of pure
DCIS in 58 patients who underwent surgery for DCIS and
had a preoperative breast MRI.38 They found a 79.3% sensi-
tivity for the detection of pure DCIS vs. 69% sensitivity of
mammography; however, this did not reach statistical signifi-
cance (P = 0.345). Their results were contradictory to Kuhl
et al,36 and found decreasing sensitivity with nuclear grade,
with the lowest sensitivity in high-grade DCIS of 66.7%
compared to 100% for low grade and 84.6% for intermediate
grade.
Despite contradictory reports in the literature, it has
been suggested that MRI may detect the more clinically rele-
vant cases of DCIS. Breast MRI may play a vital role in
detecting DCIS that will impact a patient’s outcome. This is
related to the fact that contrast enhancement is a biomarker
of angiogenic and protease activity. With increasing grades of
DCIS, vascularity increases. In addition, protease is required
to penetrate and invade beyond the ductal membrane.39
DCIS lesions that enhance on MRI are therefore more likely
to have potential to progress to invasive carcinoma with
higher likelihood than those detected on mammography.40
This is important to note, particularly in today’s environment
with criticism of overdiagnosis of biologically inert breast dis-
ease. Future research in this area is needed to clarify the
potential role of MRI in helping determine clinically
relevant DCIS.
Role of MRI in the Clinical Setting
The role of MRI in evaluating DCIS in the clinical setting is
focused both on early detection in screening high-risk patients
as well as preoperative evaluation of the extent of disease. In
addition, new research studies are using MRI for assessing
treatment response as well as for the purpose of active surveil-
lance in patients not undergoing surgical management of
DCIS.15,17,41
Preoperative Evaluation
Breast MRI is frequently ordered for the preoperative evalua-
tion of extent of disease in patients with newly diagnosed
breast cancer, with invasive or noninvasive disease. However,
its role and outcomes remain somewhat controversial. Large
prospective trials addressing this include the Comparative
effectiveness of MRI in breast cancer "COMICE" trial and
the MR mammography of nonpalpable breast tumors
"MONET" trial. The COMICE trial was the first prospective
multicenter randomized trial to assess use of preoperative
MRI in women with early-stage breast cancer. Over 1600
women were randomized to either receive preoperative MRI
or not. The primary endpoint was reoperation rate: wide local
excision or mastectomy within 6 months or pathological
avoidable mastectomy at initial operation. The COMICE
trial found no significant difference in reexcision rates
between patients who did and did not have a preoperative
3
Journal of Magnetic Resonance Imaging
MRI.42 However, there are criticisms that limit the conclu-
sions. The COMICE trial was performed in the UK, where
national health policy mandated reduction of reoperation
rates for positive margins to under 10% and therefore sur-
geons routinely take very wide excisions, which may have
negated the benefit of MRI. Also, the COMICE trial did not
use clearly defined localization techniques to translate the
imaging findings into surgical approaches. Not all sites per-
formed MRI biopsies after suspicious findings on MRI; many
women had mastectomies without pathologic confirmation of
disease. Now MRI biopsy is more widely available. A high
rate of mastectomy without pathological confirmation of dis-
ease should not happen at sites with high-quality MRI.43 The
MONET trial actually found higher reexcision rates in
patients undergoing preoperative MRI.44 However, there are
several criticisms of the MONET trial. It was not a multicen-
ter study and only included one surgeon who operated in all
of the cases. This trial, while having a higher reexcision rate
for the MRI group, had a very low sensitivity of MRI for the
detection of DCIS, which is in contraindication to the afore-
mentioned studies.32,36,37 In addition, critics have noted that
the volume of the excised tissue in the MRI group
(69.1 cm3) was much smaller than the volume in the no
MRI group (90.2 cm3), and even smaller in patients with
DCIS and negative MRI (40.3 cm3).
Current treatment for DCIS has involved mastectomy,
lumpectomy alone, or lumpectomy with radiation therapy.
Local recurrence rates after a DCIS diagnosis are 10–20% at
5 years, and half of all recurrences are invasive.45 A major risk
factor for recurrence is positive margins.46 In part, positive mar-
gins after surgery may be related to mammography not
detecting noncalcified DCIS, particularly in dense breasts.
While mammography may underestimate the extent of disease
of DCIS, most studies have shown that MRI either accurately
assesses or overestimates the extent of DCIS.35,47,48 In recent
years preoperative breast MRI has been used in women with
DCIS, with the goal of defining surgical treatment and reducing
need for additional surgical therapy following breast-conserving
surgery (BCS). A recent large meta-analysis of nine studies with
1077 women with and 2175 without preoperative MRI respec-
tively found no statistically significant difference between the
proportion of women with positive margins following BCS
between the groups.49 It did find that women with preoperative
MRI were significantly more likely to have initial mastectomy
than those without. However, several prior studies have not
used MR-guided biopsy or MR-guided localizations. Kuhl et al
evaluated surgical outcomes in women with breast cancer (with
and without DCIS components) undergoing not only preoper-
ative breast MRI but also MR-guided biopsy and/or MR-
guided preoperative localization.50 In these women, they found
a low positive margin rate, which did not differ between women
with DCIS components vs. women without DCIS components
(5.0% vs. 3.3%, respectively).
4
A study by Bae et al of 308 women with pure DCIS
who had undergone preoperative MRI evaluated the cancer
yield of preoperative bilateral breast MRI in women with
newly diagnosed DCIS.51 In addition, they evaluated if there
were certain subgroups of DCIS patients that MRI would be
more likely to find occult cancer. In 24 (8%) patients MRI
found additional sites of cancer—of those, 14 (58%) repre-
sented multifocal disease, 2 (8%) multicentric disease, and
8 (33%) contralateral disease. Twenty-two (92%) of the can-
cers were DCIS and 2 (8%) were invasive ductal cancers. Of
the invasive cancers, 1 was in the contralateral breast from the
known DCIS and the other was in a separate quadrant from
the known DCIS. Interestingly, they found that women less
than 50 years old had a significantly increased frequency of
additional cancer detection by MRI than women 50 years of
age or older. An index cancer size of greater than or equal to
2.5 cm was also associated with a higher frequency of addi-
tional cancer detection compared to index cancer size less
than 2.5 cm. The cancer yield in this study for preoperative
MRI in the setting of DCIS was 8%.
Underlying Invasive Disease
In addition to evaluating the extent of disease in patients with
biopsy-proven DCIS, MRI has been shown to be helpful in
predicting the presence of underlying invasive disease.
Promptly identifying the presence of invasive disease is
important, as it often changes surgical management. Wisner
et al performed a retrospective reader study evaluating
whether BI-RADS MRI criteria and/or radiologist perception
correlate with the presence of invasive cancer after an initial
core biopsy of pure DCIS.52 They found an upgrade rate of
25% (13/51) to invasive disease at surgery. The presence of a
mass on MRI was strongly associated with invasion for both
readers and highly correlated with invasion at surgery. Huang
et al also found that mass morphology on MRI was predictive
of an underlying invasive component.53 In addition, overall
size on MRI was moderately correlated with histopathology.
Therefore, features on MRI may be helpful in preoperatively
identifying an underlying invasive component in patients
with diagnosed DCIS.
Opportunities
As a response to several criticisms of overdiagnosis and over-
treatment of DCIS, several current trials are evaluating active
surveillance in patients with DCIS. For example, the
COMET trial, Comparison of Operative to Monitoring
Endocrine Therapy Trial for Low Risk DCIS, is a random-
ized prospective trial evaluating the risks and benefits of active
surveillance vs. guideline concordant care for low-risk DCIS.
The COMET trial is using mammography as the surveillance
imaging modality. The LORD study, Low Risk DCIS, is a
randomized international multicenter trial aiming to deter-
mine whether screen-detected low-grade DCIS can be safely

managed by active surveillance or whether traditional treat-
ment should remain standard of care. Like the COMET trial,
the LORD trial is also using mammography as its imaging
surveillance examination.
Given that MRI is the most sensitive imaging modality
for the detection of DCIS,32,36 MRI may be a useful tool for
imaging surveillance in patients electing for nonsurgical man-
agement at DCIS. A trial at our institution is evaluating post-
menopausal women with pure estrogen-receptor (ER)-positive
DCIS being treated with neoadjuvant endocrine therapy
(ET).41 Patients receive neoadjuvant letrozole and are moni-
tored with baseline and 3-month follow-up mammography
and MRI to determine which imaging modality is a better
tool for imaging surveillance in patients electing for non-
surgical management of DCIS. Preliminary results have dem-
onstrated MRI tumor volume decreased markedly in
3 months, while mammographic extent of disease was not sig-
nificantly altered.41 Early results are suggestive that MRI is
more accurate than mammography for evaluating treatment
response, and may be an effective modality for monitoring
treatment in response in patients treated with endocrine ther-
apy for ER-positive DCIS.
Technical Aspects
Field Strength
Breast MR image quality continues to improve with advances
in coil design and pulse sequences. Also, image quality has
benefited from the availability of increasing field strengths,
allowing radiologists to increase spatial resolution and/or tem-
poral resolution while potentially maintaining the signal-to-
noise ratio (SNR). Routine clinical breast MRI is currently
performed at 1.5T or increasingly at 3T.54,55
For routine clinical applications of screening or diagnos-
tic breast MRI, following the standards for American College
of Radiology accreditation,56 affords adequate spatial resolu-
tion for the detection and evaluation of DCIS. Higher SNRs
available with higher field strength of 3T compared with
1.5T can be utilized to maximize spatial resolution, which
has benefits in the evaluation of DCIS, as NME is a key fac-
tor in differentiating suspicious NME from benign back-
ground parenchymal enhancement. In a study using breast
MRI to evaluate the extent of DCIS preoperatively in the
same patient at 1.5T and 3T, 3T breast MRI showed higher
correlation with extent of DCIS at final pathology with mean
difference in maximum dimension between MRI and pathol-
ogy of 7.5 mm (range 0–35 mm) for 3T vs. a mean differ-
ence of 11.5 mm (range 0–50 mm) for 1.5T breast MRI57.
Standard Sequences
The primary diagnostic sequences used for breast MRI evalu-
ation of DCIS are the precontrast and dynamic postcontrast
T1-weighted 3D gradient echo sequences. To meet minimum
Greenwood et al.: Breast MRI Evaluation and Detection of DCIS
requirements for American College of Radiology accredita-
tion, these T1 sequences should cover bilateral breasts and
axillae, have in-plane spatial resolution of ≤1.0 mm, and slice
plane resolution of ≤3.0 mm with no gap.54,56 Use of fat sup-
pression is generally preferred and can be achieved on modern
scanners. Fat suppression is desirable to improve visualization
of enhancing lesions at breast MRI. Spectral fat suppression
techniques are most commonly used; however, achieving
homogeneous fat suppression is challenging, given the rela-
tively large fields of view and off-isocenter imaging involved
in bilateral breast MRI.58,59 If fat suppression is not used,
then image subtraction can be performed with the caveat that
there may be misregistration artifacts.60 T1-weighted dynamic
contrast-enhanced sequences are the primary means of identi-
fying mass and nonmass enhancement that may represent
potential cancer. A T2-weighted sequence through bilateral
breasts should also be included. Ideally, the plane and resolu-
tion should be as close as possible to the T1-weighted
sequence for ease of correlation with any enhancing lesions
on the T1-sequences. T2-weighted sequences are complemen-
tary to the T1-weighted sequences to provide further tissue
characterization and can also identify cysts. Maximizing spa-
tial resolution is beneficial when considering DCIS, which
often manifests as NME.20 Increased spatial resolution may
come at the expense of decreased temporal resolution. In a
retrospective analysis of dynamic contrast-enhanced MRI
using a 90-second vs. 180-second acquisition protocol, the
authors found no difference in delayed-phase kinetic informa-
tion for the 993 benign and malignant lesions, including
173 DCIS lesions.61 Although temporal resolution was lower,
spatial resolution improved by 45% using the 180-second
acquisition compared to the 90-second acquisition.
Emerging Techniques
Diffusion-Weighted Imaging
Diffusion-weighted imaging (DWI) is an emerging technol-
ogy in the breast, with potential to provide additional charac-
terization of tissue by measuring random motion or
diffusivity of water molecules.62,63 In fluid-filled structures,
such as simple cysts, water molecules can diffuse relatively
freely, whereas in tissue the diffusion path of water molecules
is restricted by cellular membranes and other structures. DWI
applies diffusion sensitizing gradients, typically in at least
three orthogonal directions, to a spin-echo-prepared sequence
to characterize the magnitude of water motion within tissue,
and thus indirectly provide information about tissue cellular-
ity and microstructure. In DWI the MR signal intensity is
dependent on the self-diffusion of water protons; tissues with
restricted water diffusion have higher signal intensity (appear
"brighter") on the diffusion-weighted image, while tissues
with higher water diffusion have lower signal intensity (and
appear "darker"). The relationship between the decay of the
5
Journal of Magnetic Resonance Imaging

MR signal and water mobility/free molecular diffusion can be
described by the monoexponential equation:
SðbÞ = S0 e −ADC=b
where S(b) is the signal intensity with diffusion weighting
gradient b, S0 is the signal intensity without diffusion
weighting, b is the b-value that reflects the strength and dura-
tion of the diffusion weighting gradient (s/mm2), and ADC
(mm2/s), is the apparent diffusion coefficient, a quantitative
measure of water mobility.64 ADC values are calculated from
the attenuation in signal intensity between at least two
diffusion-weighted images acquired at different b-values, and
are influenced by the choice of b-values. Parametric ADC
maps are generated from DWI images by calculating the
ADC value for each voxel. In general, water diffusivity will be
relatively higher in normal breast parenchyma, lower in solid
benign lesions, and lowest (most restricted diffusion) in
malignant lesions.62,65
Previous DWI studies have found that the ADC in
breast tumors was reduced relative to the ADC in normal
fibroglandular tissue and this difference was correlated with
an increase in cell density in tumors compared to normal tis-
sue.66,67 Additional details regarding DWI techniques and
clinical applications in the breast can be found in the review
article from Partridge et al.62
DWI of the breast is challenging given the large fields of
view (FOVs) required for bilateral breast coverage, off-isocenter
imaging, and the numerous fat–water interfaces inherent to
breast tissue. As a result, image quality is plagued by common
artifacts of chemical shift, ghosting in phase direction, inhomoge-
neous fat saturation, and image distortion.62 Incomplete fat
suppression can contribute to errors in calculated tumor
ADCs.68 Additionally, the effects of gradient nonlinearities,
inherent in all MRI scanners, are more pronounced for the larger
FOVs (larger offsets from magnet isocenter) needed for breast
MRI and can cause spatially dependent inaccuracies in the calcu-
lated ADC69 as a consequence of the systematic and spatially-
dependent bias of the diffusion-encoding b-value or b-matrix.70
Another limitation for breast DWI is that standard spin
echo single shot echo planar imaging (ss-EPI) sequences typi-
cally available on commercial scanners are prone to distortion
artifacts due to the relatively long readout durations, which
can make coregistration with other imaging sequences such as
T1-weighted DCE-MRI challenging.71
In spite of these challenges, numerous studies have
shown potential for DWI to improve specificity of breast
MRI in lesion characterization, neoadjuvant treatment moni-
toring, and even as a potential noncontrast screening exam in
patients with dense breasts.65,72–74
Similar to invasive breast cancer, DCIS has demonstrated
restricted diffusion on DWI at 1.5T75 (Fig. 3). DWI measure-
ments have also shown differences between high and low nuclear
grade DCIS lesions.76,77 Higher field strengths have demon-
strated an improved ability to evaluate differences in DWI signal
of lesions. A recent study explored the potential for DWI to dis-
tinguish DCIS from invasive cancer at 3T based on ADC values.
Using b values of 50 and 850 s/mm2, the investigators found the
mean ADC to be lower in invasive cancers compared to DCIS
(ADC mean [SD] of 0.9 [0.15] × 10 mm2/s vs. 1.24
[0.23] × 10 mm2/s, P < 0.001).78 Other work at 3T has shown
that the ADC values are lower in DCIS lesions that get upgraded
to invasive disease at surgical excision than in DCIS lesions that
do not get upgraded.79

FIGURE 3: Axial MR images of the left breast in a 42-year-old woman with newly diagnosed DCIS of the right breast who underwent
breast MRI for evaluation of extent of disease prior to surgery. Axial MR images are shown. DCE-MRI demonstrated a 4.0 cm
segmental area of nonmass-like enhancement (arrow) in the left breast that was assigned BI-RADS 5 (a). The lesion demonstrated
hyperintensity on b = 600 s/mm2 SDWI images (b) and low ADC (mean, 1.41 × 10-3 mm2/sec) and appeared darker (arrow) than
nonenhancing parenchyma on the ADC map (c). MRI-guided biopsy determined the lesion to be additional DCIS. From: Partridge
SC, Demartini WB, Kurland BF, Eby PR, White SW, Lehman CD. Differential diagnosis of mammographically and clinically occult
breast lesions on diffusion-weighted MRI. J Magn Reson Imaging 2010;31:562–570.

6

A study comparing DWI with b = 0 and 800 s/mm2 at
3T vs. 7T for characterizing breast lesions reported signifi-
cantly lower ADC values of normal breast tissue and malig-
nant lesions at 7T relative to 3T, with a larger difference seen
for malignant lesions.80 The diagnostic specificity using an
ADC threshold of 1.275 mm2/s was 90% at both field
strengths and the sensitivity was 94% and 100% at 3T and
7T, respectively. 7T DWI had 2.4-fold higher spatial resolu-
tion compared to 3T and similar SNR, so the differences in
ADC values, in particular for the lesions, may be due in part
to reduced partial volume effects for the 7T DWI. Although
this study only included one case of DCIS, the higher spatial
resolution DWI achieved may also have potential to improve
the detection and characterization of smaller cancer foci and
nonmass-like lesions such as DCIS. There is limited literature
on DWI of DCIS, but this may change as image quality and
spatial resolution of DWI in the breast improves.
Technical advances for breast DWI including correction
for gradient nonlinearity effects69 and eddy currents, as well
as advances in EPI DWI techniques such as reduced FOV
EPI DWI81 and multishot EPI DWI sequences, such as read-
out segmented DWI65 that have shorter echo spacing,
reduced distortion, and improved spatial resolution are being
evaluated and have shown promising initial results.
Gradient nonlinearity correction accounts for the spatial
nonlinearity of the gradient fields during calculation of ADC.
Gradient nonlinearity both shifts and artificially broadens the
corresponding ADC ROI histograms, and in turn increases
the variability of quantitative DWI metrics. A recent study of
multicenter DWI data found that gradient nonlinearity cor-
rection significantly reduced the overall mean ADC error in a
phantom of known ADC for all sites from 9.9% to 0.6%
(mean error range across different scanner configurations was
1.4–19.9%) and that the spatial dependence of GNC was
highest in the right–left (RL) and anterior–posterior
(AP) directions. In human subjects with invasive breast can-
cer, the mean tumor ADC at different imaging sites was sig-
nificantly reduced by gradient nonlinearity correction (range
–0.2% to –12%).69 Because the extent of gradient non-
linearity varies between MRI systems from the same vendor
and between systems from different vendors, the addition of
gradient nonlinearity correction will correct systematic ADC
map errors and is expected to have a positive effect on clinical
trials that use quantitative ADC, and in particular, for breast
DWI studies that have FOVs with large offsets from magnet
isocenter.
Advanced DWI sequences that have reduced readout
times compared to ss-EPI, resulting in reduced distortion and
improved spatial resolution, are also being investigated for
breast imaging. Examples of such sequences are reduced FOV
methods, which require fewer k-space lines to achieve higher
spatial resolution, and multishot EPI methods, in which k-
space sampling happens in a small number of "shots."
Greenwood et al.: Breast MRI Evaluation and Detection of DCIS
Evaluation of a high spatial resolution reduced FOV
DWI sequence, which uses a 2D spatially selective echo-
planar RF excitation pulse to reduce the FOV in the phase-
encode (PE) direction, in patients with locally advanced
breast cancer found that, qualitatively, the reduced FOV
DWI improved visualization of tumor morphologic detail,
heterogeneity, and conspicuity compared to a standard ss-
EPI. Quantitative measurements of the tumor ADC for both
sequences found no difference in mean tumor ADC; how-
ever, differences in the histogram distributions were found.
For example, for the lower range of tumor ADCs, the
reduced FOV DWI tumor ADCs were significantly lower.
This difference may reflect decreased partial volume averaging
of low-ADC tumor with higher-ADC normal tissue in the
reduced FOV DWI, which had a voxel size six times smaller
than the standard ss-EPI DWI.81
A study comparing a multishot readout segmented EPI
DWI sequence (RESOLVE) to ss-EPI in BI-RADS 4 and
5 lesions detected on breast MRI found that the multishot
technique increased lesion-to-background contrast and
improved separation of benign from malignant lesions by
RESOLVE compared to standard ss-EPI diffusion.65 These
advanced DWI techniques may have the potential to improve
DWI for visualization and evaluation of DCIS by increasing
spatial resolution and reducing image distortion.
Additionally, efforts to standardize DWI acquisitions
for breast and provide recommendations for best practices,
being undertaken by the Quantitative Imaging Biomarkers
Alliance (QIBA) and other working groups, may also improve
the specificity of DWI for DCIS. Recommendations for
breast DWI acquisitions can be found in the QIBA Profile:
Diffusion-Weighted Magnetic Resonance Imaging (DWI) on
the QIBA website.82
Diffusion Tensor Imaging
Diffusion tensor imaging (DTI), is an advanced diffusion
technique, which is sensitive to both the magnitude and
direction of water motion. In DTI, diffusion-weighed images
with a minimum of six noncollinear diffusion gradient direc-
tions are acquired to characterize the full diffusion tensor and
calculate the three eigenvalues of the diffusion tensor (λ1, λ2,
λ3), allowing for estimation of the directionality (anisotropy)
of water diffusion within tissue in addition to mean diffusiv-
ity (ADC). Fractional anisotropy (FA) is one commonly used
DTI-derived metric that reflects the degree of directionality
of water diffusion. In tissues where diffusion is isotropic, ie,
λ1 = λ2 = λ3, the theoretical value of FA is zero, whereas if
diffusion occurs principally along one direction and is highly
restricted in the other directions, FA will approach the maxi-
mal value of 1. The mean diffusivity (Davg), also referred to
as ADC (mm2/s), reflects the magnitude of water mobility,
and can be calculated from DTI data based on the methods
of Basser and Pierpaoli83 using Eq. 1:
7
Journal of Magnetic Resonance Imaging
λ1 + λ2 + λ3
ADC =
3 bility of mapping the breast ductal structure using these
FA is a unit-less measure that reflects the degree of direc-
tionality of diffusivity, and can be calculated using Eq. 2:
qffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
ðλ 1 − λ 2 Þ2 + ðλ 2 − λ 3 Þ2 + ðλ 3 − λ 1 Þ2
FA = pffiffiffiqffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi ffi ð2Þ
2 λ21 + λ22 + λ23
An initial study of breast cancer utilizing DTI found
that FA was lower in breast tumors than in normal breast
fibroglandular tissue, and that FA provided increased diagnos-
tic accuracy over ADC alone.84 It was hypothesized that the
lower FA in tumors might be attributable to a disruption of
the organized structure of normal breast parenchyma, charac-
terized by a network of ducts and lobules supported by
stroma, by the disorganized growth and increased cellularity
of tumors.84 That study found a significant difference in
tumor ADC, but not tumor FA, between malignant and
benign lesions, and no difference in either ADC or FA
between benign lesions and DCIS. Subsequent DTI studies
of breast have reproduced the finding of lower FA in
tumors85–87; however, other studies have found no difference
in FA between tumor and normal tissue,88,89 which suggests
further investigation is needed.
Recent studies that have evaluated DTI for discriminat-
ing DCIS from other breast lesions have also found mixed
results for DTI-derived metrics. A DTI study of 59 breast
cancers (14 DCIS) and 31 benign lesions found that
ADC(mean diffusivity (MD)) of invasive ductal carcinoma
(IDC) of grade III was significantly lower than that in DCIS
and IDC of grade I–II, while the FA was significantly higher
in benign lesions than in invasive cancer, with no significant
difference in FA between invasive cancer and DCIS. Lesion
cellularity measured by histology showed the malignant
lesions had higher cellularity than benign lesions, and lesion
cellularity had a negative association with ADC and a positive
association with FA.90 Similarly, a DTI study91 of 251 women
with breast cancer (21 in situ) found that MD was signifi-
cantly lower in invasive cancer than in both normal
fibroglandular tissue and DCIS. That study also found that
FA was lower in invasive cancer than in normal tissue; how-
ever, no significant difference between FA in invasive cancer
and DCIS was found. Additionally, multivariate analysis
showed that lower MD and FA were both associated with
larger lesion size, higher histologic grade, and lymph node
metastasis.91
In addition to evaluating ADC and FA, some breast
DTI studies have also looked at the primary eigenvector ori-
entation maps and found that the primary eigenvector was
generally oriented in the posterior to anterior direction, which
8
may reflect the ductal structures of the breast.85,92 The possi-
ð1Þ
eigenvectors in a manner analogous to DTI fiber tracking of
white matter in the brain is being explored. Similar to DWI,
advances in DTI techniques that result in higher spatial reso-
lution and reduced distortion may improve the ability to dis-
tinguish DCIS from other lesion types.
Advanced (Multiexponential) Diffusion Models:
IVIM and Kurtosis
The standard fitting model for DWI data in breast assumes a
monoexponential signal decay; however, there is increasing
interest in investigating multiexponential models that may
provide more insights into the biophysical properties of breast
tissue and lesions. Among these approaches are intravoxel
incoherent motion (IVIM), which aims to separate the contri-
butions of microvascular perfusion from diffusion, and diffu-
sion kurtosis imaging (DKI), which quantifies the deviation
of the diffusion distribution from a pure Gaussian distribu-
tion to characterize microstructural complexity.
The IVIM model, originally proposed by Le Bihan et al93
for brain imaging, requires the use of multiple low b values and
fits the signal decay using a biexponential model that calculates
perfusion fraction (fp), tissue diffusivity (Dt), and pseudo diffu-
sivity (Dp) in the microvasculature. In breast tumors, the
increased cellularity and resulting restricted water diffusion is
reflected in reduced Dt, and angiogenesis is reflected in higher
vascularity (increased fp), while blood velocity is reflected by Dp.
An initial study of IVIM in locally advanced breast cancer found
biexponential decay in breast tumors and monoexponential
decay in normal fibroglandular tissue. Measurable vascular frac-
tions were calculated for invasive lesions and DCIS, and the most
aggressive invasive ductal carcinoma group showed the highest
cellularity (lower Dt), highest vascularity (higher fp), and slowest
blood velocity (lower Dp). Additional IVIM studies of breast
lesions have found significant differences between malignant and
benign lesions, with malignant lesions having lower Dt and
higher fp.94–96
Kurtosis (K) is a dimensionless statistical metric used to
quantify the distribution of a probability function. Diffusion
in pure liquids has a Gaussian distribution (K = 0), while dif-
fusion in a tissue, which has barriers such as cell membranes
and compartments, will have a more peaked distribution,
with less weight on the "shoulders" of the distribution curve
(K > 0). DKI utilizes multiple imaging directions and higher
b values than standard breast DWI to calculate an apparent
diffusion coefficient (D) that is corrected for K.97 Recent
work evaluating DKI for diagnosing breast lesions showed
that malignant tumors had higher kurtosis than benign
tumors.95 These advanced diffusion approaches that quantify
the effects of perfusion and heterogeneity of the diffusion

environment on diffusion measurements may provide addi-
tional specificity for characterizing and differentiating breast
lesions such as DCIS.
Spectroscopy
Spectroscopy is a means of noninvasively probing the chemistry
of tissues based on the chemical shift phenomenon.98 In humans,
1H (proton) spectroscopy is most commonly performed as a
practical consideration, since clinical coils used for MRI are
tuned to the hydrogen proton. In addition to the static B0 mag-
netic field and applied B1 field, hydrogen protons experience
smaller magnetic fields from the electrons in their immediate
chemical environment. The degree of shielding or enhancement
of the magnetic field is based on a molecule’s chemical structure
surrounding the proton. Magnetic field homogeneity is critically
important in spectroscopic acquisitions. Water and lipid peaks
dominate most clinical breast MR spectra given their abundance
in breast tissue. Choline-containing compounds that resonate
around 3.2 ppm have shown promise as a biomarker of
malignancy,99 particularly in the area of neoadjuvant treatment
monitoring as an early predictor of treatment response.100 Unfor-
tunately, significant technical challenges limited quantitative
analysis in a multisite trial of in vivo MR spectroscopy for neo-
adjuvant treatment monitoring in locally advanced breast can-
cers.101 DCIS has been studied in the ex vivo setting using high-
resolution magic angle spinning (HR-MAS) 1H spectroscopy of
breast tissue samples using metabolic profiling to predict DCIS
associated with an invasive component vs. pure DCIS.102
Bartella et al103 evaluated proton MR spectroscopy of nonmass
enhancement in 32 patients at 1.5T. They identified choline in
all 12 malignant lesions for a sensitivity of 100%. The large aver-
age lesion size of 2.8 cm (range of 1.2–9 cm) likely contributed
to this study’s success, as the limit of spectroscopic resolution99
in the breast is currently around 1 cm. Given limitations of spa-
tial resolution and technical challenges, spectroscopy does not
currently have a substantial role to play in the evaluation of DCIS
in vivo.
Future Directions
Advanced Image Visualization Techniques
(3D Printing and Virtual/Augmented Reality)
3D printing is a process of manufacturing 3D objects from 2D
data, which allows better visualization of the spatial relation-
ship between different anatomical structures. In a similar man-
ner, virtual and augmented reality (VR/AR), which display 3D
images in an interactive computer-simulated environment,
enable superior depiction of anatomy compared to conven-
tional 2D images. The applications and benefits of 3D print-
ing and VR/AR have been demonstrated in essentially all
subspecialties of medicine.104–108 In the field of breast cancer
management, 3D printed models created from breast MRI
have been used for accurate tumor localization to guide breast-
Greenwood et al.: Breast MRI Evaluation and Detection of DCIS
conserving surgery.109 Preoperative planning and accurate vol-
ume analysis afforded by 3D printing and VR/AR have shown
promise to aid in achievement of better esthetic outcomes,
lower reoperation rates, and shorter operative times in breast-
conservation and reconstruction surgeries.110–116 A 3D printed
personalized biodegradable scaffold used for regeneration of
tissue has been a focus of current investigations and is poised
to overcome limitations of conventional breast reconstruction
techniques.117 Furthermore, 3D printing can be used to fabri-
cate customized intraoperative guides and patient-specific pros-
thesis, while both 3D printing and VR/AR can be used as
teaching tools for patients and trainees.107,118,119 Although
these advanced image visualization techniques are still in their
infancy and there is a paucity of literature that explore their
specific applications related to MRI of DCIS, opportunities
for further research are abundant.
Radiomics and Radiogenomics
There is significant variation in the presentation and outcome
of breast cancer among women. Currently available biological
biomarkers that are used to assess outcome and develop
targeted therapies tend to be invasive, costly, or not widely
available. In recent years there has been increased use of
radiomics, which studies specific features extracted from
radiological images through quantitative analysis and radio-
genomics, which correlates these quantitative imaging features
to gene expression profiles.120 Quantitative radiomics features
extracted from MRI can be used to identify molecular sub-
type of cancer, guide treatment decisions, provide prognostic
information about response to treatment, and predict risk of
recurrence.120–123
Machine Learning / Artificial Intelligence
In recent years there has been an increased use of radiomics,
which studies specific features extracted from radiological
images through quantitative analysis, and radiogenomics,
which correlates these quantitative imaging features to gene
expression profiles.120 Quantitative radiomics features
extracted from MRI have been used to identify molecular
subtypes of cancer, guide treatment decisions, provide prog-
nostic information about response to treatment, and predict
risk of recurrence.120–123 The recent advances in the field of
radiomics and radiogenomics can be largely attributed to
machine-learning techniques and accessibility to efficient
computing. Machine learning is the practice of using a dataset
to train a computer system to learn a specific task, progres-
sively improve performance, and make predictions in new set-
tings. In the case of breast MRI, machine-learning tools have
been shown to facilitate fully automated quantification of
fibroglandular tissue and background parenchymal enhance-
ment, tumor detection, localization, segmentation as well as
feature extraction for evaluation of treatment response and
9
Journal of Magnetic Resonance Imaging
prediction of recurrence.124–127 Machine-learning tools can
also use morphological and spatial information from the early
phases of breast MRI to extrapolate late-phase information
that might not be available in abbreviated protocols, thereby
allowing shorter scan times.125
Machine learning has a strong potential to revolutionize
the diagnosis and treatment of breast cancer and foster effi-
cient delivery of patient-specific care. Therefore, it is para-
mount for the radiologist to become familiar with this
promising emergent technology.
Conclusion
In conclusion, MRI now plays a significant role in screening
for DCIS, evaluating the extent of disease in patients with
new diagnoses of DCIS, and in predicting the presence of an
underlying invasive component. DWI has been shown to not
only be sensitive for the detection of DCIS but also has the
potential to differentiate DCIS from invasive disease. 3D
printing and augmented reality are promising to be supple-
mental tools for tumor localization and surgical planning.
Radiomics and machine learning are novel techniques with
great potential applications for the detection of DCIS, selec-
tion of patient-specific treatment, prognostication of response,
and prediction of recurrence.
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