AC Portal
Document Navigator

Imaging of Ductal Carcinoma in Situ (DCIS)

Variant: 1   Adult. Newly diagnosed DCIS. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
Digital breast tomosynthesis diagnostic Usually Appropriate ☢☢
Mammography diagnostic Usually Appropriate ☢☢
US breast May Be Appropriate O
MRI breast without and with IV contrast May Be Appropriate O
Mammography with IV contrast Usually Not Appropriate ☢☢
MRI breast without IV contrast Usually Not Appropriate O
CT chest with IV contrast Usually Not Appropriate ☢☢☢
CT chest without and with IV contrast Usually Not Appropriate ☢☢☢
CT chest without IV contrast Usually Not Appropriate ☢☢☢
FDG-PET breast dedicated Usually Not Appropriate ☢☢☢
Sestamibi MBI Usually Not Appropriate ☢☢☢

Variant: 2   Adult. Newly diagnosed DCIS. No surgical intervention. Active surveillance.
Procedure Appropriateness Category Relative Radiation Level
Digital breast tomosynthesis diagnostic Usually Appropriate ☢☢
Mammography diagnostic Usually Appropriate ☢☢
MRI breast without and with IV contrast May Be Appropriate O
US breast Usually Not Appropriate O
Mammography with IV contrast Usually Not Appropriate ☢☢
MRI breast without IV contrast Usually Not Appropriate O
CT chest with IV contrast Usually Not Appropriate ☢☢☢
CT chest without and with IV contrast Usually Not Appropriate ☢☢☢
CT chest without IV contrast Usually Not Appropriate ☢☢☢
FDG-PET breast dedicated Usually Not Appropriate ☢☢☢
Sestamibi MBI Usually Not Appropriate ☢☢☢

Variant: 3   Adult. Evaluation for local recurrence in patient with history of breast conservation therapy for DCIS. Routine surveillance.
Procedure Appropriateness Category Relative Radiation Level
Digital breast tomosynthesis diagnostic Usually Appropriate ☢☢
Digital breast tomosynthesis screening Usually Appropriate ☢☢
Mammography diagnostic Usually Appropriate ☢☢
Mammography screening Usually Appropriate ☢☢
MRI breast without and with IV contrast May Be Appropriate (Disagreement) O
US breast Usually Not Appropriate O
Mammography with IV contrast Usually Not Appropriate ☢☢
MRI breast without IV contrast Usually Not Appropriate O
CT chest with IV contrast Usually Not Appropriate ☢☢☢
CT chest without and with IV contrast Usually Not Appropriate ☢☢☢
CT chest without IV contrast Usually Not Appropriate ☢☢☢
FDG-PET breast dedicated Usually Not Appropriate ☢☢☢
Sestamibi MBI Usually Not Appropriate ☢☢☢

Variant: 4   Adult. Evaluation for ipsilateral local recurrence in a patient with history of mastectomy for DCIS. Routine surveillance.
Procedure Appropriateness Category Relative Radiation Level
US breast Usually Not Appropriate O
Digital breast tomosynthesis screening Usually Not Appropriate ☢☢
Mammography screening Usually Not Appropriate ☢☢
Mammography with IV contrast Usually Not Appropriate ☢☢
MRI breast without and with IV contrast Usually Not Appropriate O
MRI breast without IV contrast Usually Not Appropriate O
CT chest with IV contrast Usually Not Appropriate ☢☢☢
CT chest without and with IV contrast Usually Not Appropriate ☢☢☢
CT chest without IV contrast Usually Not Appropriate ☢☢☢
FDG-PET breast dedicated Usually Not Appropriate ☢☢☢
Sestamibi MBI Usually Not Appropriate ☢☢☢

Variant: 5   Adult. Suspected local recurrence based on symptoms, physical examination, or laboratory value in patient with history of breast conservation therapy for DCIS. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
US breast Usually Appropriate O
Digital breast tomosynthesis diagnostic Usually Appropriate ☢☢
Mammography diagnostic Usually Appropriate ☢☢
Mammography with IV contrast Usually Not Appropriate ☢☢
Image-guided core biopsy breast Usually Not Appropriate Varies
Image-guided fine needle aspiration breast Usually Not Appropriate Varies
MRI breast without and with IV contrast Usually Not Appropriate O
MRI breast without IV contrast Usually Not Appropriate O
CT chest with IV contrast Usually Not Appropriate ☢☢☢
CT chest without and with IV contrast Usually Not Appropriate ☢☢☢
CT chest without IV contrast Usually Not Appropriate ☢☢☢
FDG-PET breast dedicated Usually Not Appropriate ☢☢☢
Sestamibi MBI Usually Not Appropriate ☢☢☢

Variant: 6   Adult. Suspected local recurrence based on symptoms, physical examination, or laboratory value in patient with history of mastectomy for DCIS. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
US breast Usually Appropriate O
Digital breast tomosynthesis diagnostic Usually Not Appropriate ☢☢
Mammography diagnostic Usually Not Appropriate ☢☢
Mammography with IV contrast Usually Not Appropriate ☢☢
Image-guided biopsy chest Usually Not Appropriate Varies
Image-guided fine needle aspiration chest Usually Not Appropriate Varies
MRI breast without and with IV contrast Usually Not Appropriate O
MRI breast without IV contrast Usually Not Appropriate O
CT chest with IV contrast Usually Not Appropriate ☢☢☢
CT chest without and with IV contrast Usually Not Appropriate ☢☢☢
CT chest without IV contrast Usually Not Appropriate ☢☢☢
FDG-PET/CT skull base to mid-thigh Usually Not Appropriate ☢☢☢☢

Variant: 7   Adult. Known DCIS with microinvasion found on prior mammography, ultrasound, or MRI during initial evaluation. Axillary evaluation needed. Next imaging study.
Procedure Appropriateness Category Relative Radiation Level
US axilla Usually Not Appropriate O
US-guided core biopsy axillary node Usually Not Appropriate O
US-guided fine needle aspiration biopsy axillary node Usually Not Appropriate O
Digital breast tomosynthesis diagnostic Usually Not Appropriate ☢☢
Mammography with IV contrast Usually Not Appropriate ☢☢
MRI breast without and with IV contrast Usually Not Appropriate O
MRI breast without IV contrast Usually Not Appropriate O
Lymphoscintigraphy axilla Usually Not Appropriate ☢☢
CT chest with IV contrast Usually Not Appropriate ☢☢☢
CT chest without and with IV contrast Usually Not Appropriate ☢☢☢
CT chest without IV contrast Usually Not Appropriate ☢☢☢
FDG-PET/CT whole body Usually Not Appropriate ☢☢☢☢

Variant: 8   Adult. Known DCIS without microinvasion found on prior mammography, ultrasound, or MRI during initial evaluation. Axillary evaluation needed. Next imaging study.
Procedure Appropriateness Category Relative Radiation Level
US axilla Usually Not Appropriate O
US-guided core biopsy axillary node Usually Not Appropriate O
US-guided fine needle aspiration biopsy axillary node Usually Not Appropriate O
Digital breast tomosynthesis diagnostic Usually Not Appropriate ☢☢
Mammography with IV contrast Usually Not Appropriate ☢☢
MRI breast without and with IV contrast Usually Not Appropriate O
MRI breast without IV contrast Usually Not Appropriate O
Lymphoscintigraphy axilla Usually Not Appropriate ☢☢
CT chest with IV contrast Usually Not Appropriate ☢☢☢
CT chest without and with IV contrast Usually Not Appropriate ☢☢☢
CT chest without IV contrast Usually Not Appropriate ☢☢☢
FDG-PET/CT whole body Usually Not Appropriate ☢☢☢☢

Panel Members
Cherie M. Kuzmiak, DOa; Richard E. Sharpe Jr., MD, MBAb; Alana A. Lewin, MDc; Susan P. Weinstein, MDd; Victoria Blinder, MDe; Elizabeth H. Dibble, MDf; Katerina Dodelzon, MDg; Basak E. Dogan, MDh; Lisa V. Paulis, MDi; Jennifer Kay Plichta, MD, MSj; Lonie R. Salkowski, MD, PhD, MSk; Maryam Sattari, MD, MSl; John R. Scheel, MD, PhD, MPHm; Priscilla J. Slanetz, MD, MPHn.
Summary of Literature Review
Introduction/Background
Initial Imaging Definition
Discussion of Procedures by Variant
Variant 1: Adult. Newly diagnosed DCIS. Initial imaging.
Variant 1: Adult. Newly diagnosed DCIS. Initial imaging.
A. CT chest with IV contrast
Variant 1: Adult. Newly diagnosed DCIS. Initial imaging.
B. CT chest without and with IV contrast
Variant 1: Adult. Newly diagnosed DCIS. Initial imaging.
C. CT chest without IV contrast
Variant 1: Adult. Newly diagnosed DCIS. Initial imaging.
D. Digital breast tomosynthesis diagnostic
Variant 1: Adult. Newly diagnosed DCIS. Initial imaging.
E. FDG-PET breast dedicated
Variant 1: Adult. Newly diagnosed DCIS. Initial imaging.
F. Mammography diagnostic
Variant 1: Adult. Newly diagnosed DCIS. Initial imaging.
G. Mammography with IV contrast
Variant 1: Adult. Newly diagnosed DCIS. Initial imaging.
H. MRI breast without and with IV contrast
Variant 1: Adult. Newly diagnosed DCIS. Initial imaging.
I. MRI breast without IV contrast
Variant 1: Adult. Newly diagnosed DCIS. Initial imaging.
J. Sestamibi MBI
Variant 1: Adult. Newly diagnosed DCIS. Initial imaging.
K. US breast
Variant 2: Adult. Newly diagnosed DCIS. No surgical intervention. Active surveillance.
Variant 2: Adult. Newly diagnosed DCIS. No surgical intervention. Active surveillance.
A. CT chest with IV contrast
Variant 2: Adult. Newly diagnosed DCIS. No surgical intervention. Active surveillance.
B. CT chest without and with IV contrast
Variant 2: Adult. Newly diagnosed DCIS. No surgical intervention. Active surveillance.
C. CT chest without IV contrast
Variant 2: Adult. Newly diagnosed DCIS. No surgical intervention. Active surveillance.
D. Digital breast tomosynthesis diagnostic
Variant 2: Adult. Newly diagnosed DCIS. No surgical intervention. Active surveillance.
E. FDG-PET breast dedicated
Variant 2: Adult. Newly diagnosed DCIS. No surgical intervention. Active surveillance.
F. Mammography diagnostic
Variant 2: Adult. Newly diagnosed DCIS. No surgical intervention. Active surveillance.
G. Mammography with IV contrast
Variant 2: Adult. Newly diagnosed DCIS. No surgical intervention. Active surveillance.
H. MRI breast without and with IV contrast
Variant 2: Adult. Newly diagnosed DCIS. No surgical intervention. Active surveillance.
I. MRI breast without IV contrast
Variant 2: Adult. Newly diagnosed DCIS. No surgical intervention. Active surveillance.
J. Sestamibi MBI
Variant 2: Adult. Newly diagnosed DCIS. No surgical intervention. Active surveillance.
K. US breast
Variant 3: Adult. Evaluation for local recurrence in patient with history of breast conservation therapy for DCIS. Routine surveillance.
Variant 3: Adult. Evaluation for local recurrence in patient with history of breast conservation therapy for DCIS. Routine surveillance.
A. CT chest with IV contrast
Variant 3: Adult. Evaluation for local recurrence in patient with history of breast conservation therapy for DCIS. Routine surveillance.
B. CT chest without and with IV contrast
Variant 3: Adult. Evaluation for local recurrence in patient with history of breast conservation therapy for DCIS. Routine surveillance.
C. CT chest without IV contrast
Variant 3: Adult. Evaluation for local recurrence in patient with history of breast conservation therapy for DCIS. Routine surveillance.
D. Digital breast tomosynthesis diagnostic
Variant 3: Adult. Evaluation for local recurrence in patient with history of breast conservation therapy for DCIS. Routine surveillance.
E. Digital breast tomosynthesis screening
Variant 3: Adult. Evaluation for local recurrence in patient with history of breast conservation therapy for DCIS. Routine surveillance.
F. FDG-PET breast dedicated
Variant 3: Adult. Evaluation for local recurrence in patient with history of breast conservation therapy for DCIS. Routine surveillance.
G. Mammography diagnostic
Variant 3: Adult. Evaluation for local recurrence in patient with history of breast conservation therapy for DCIS. Routine surveillance.
H. Mammography screening
Variant 3: Adult. Evaluation for local recurrence in patient with history of breast conservation therapy for DCIS. Routine surveillance.
I. Mammography with IV contrast
Variant 3: Adult. Evaluation for local recurrence in patient with history of breast conservation therapy for DCIS. Routine surveillance.
J. MRI breast without and with IV contrast
Variant 3: Adult. Evaluation for local recurrence in patient with history of breast conservation therapy for DCIS. Routine surveillance.
K. MRI breast without IV contrast
Variant 3: Adult. Evaluation for local recurrence in patient with history of breast conservation therapy for DCIS. Routine surveillance.
L. Sestamibi MBI
Variant 3: Adult. Evaluation for local recurrence in patient with history of breast conservation therapy for DCIS. Routine surveillance.
M. US breast
Variant 4: Adult. Evaluation for ipsilateral local recurrence in a patient with history of mastectomy for DCIS. Routine surveillance.
Variant 4: Adult. Evaluation for ipsilateral local recurrence in a patient with history of mastectomy for DCIS. Routine surveillance.
A. CT chest with IV contrast
Variant 4: Adult. Evaluation for ipsilateral local recurrence in a patient with history of mastectomy for DCIS. Routine surveillance.
B. CT chest without and with IV contrast
Variant 4: Adult. Evaluation for ipsilateral local recurrence in a patient with history of mastectomy for DCIS. Routine surveillance.
C. CT chest without IV contrast
Variant 4: Adult. Evaluation for ipsilateral local recurrence in a patient with history of mastectomy for DCIS. Routine surveillance.
D. Digital breast tomosynthesis screening
Variant 4: Adult. Evaluation for ipsilateral local recurrence in a patient with history of mastectomy for DCIS. Routine surveillance.
E. FDG-PET breast dedicated
Variant 4: Adult. Evaluation for ipsilateral local recurrence in a patient with history of mastectomy for DCIS. Routine surveillance.
F. Mammography screening
Variant 4: Adult. Evaluation for ipsilateral local recurrence in a patient with history of mastectomy for DCIS. Routine surveillance.
G. Mammography with IV contrast
Variant 4: Adult. Evaluation for ipsilateral local recurrence in a patient with history of mastectomy for DCIS. Routine surveillance.
H. MRI breast without and with IV contrast
Variant 4: Adult. Evaluation for ipsilateral local recurrence in a patient with history of mastectomy for DCIS. Routine surveillance.
I. MRI breast without IV contrast
Variant 4: Adult. Evaluation for ipsilateral local recurrence in a patient with history of mastectomy for DCIS. Routine surveillance.
J. Sestamibi MBI
Variant 4: Adult. Evaluation for ipsilateral local recurrence in a patient with history of mastectomy for DCIS. Routine surveillance.
K. US breast
Variant 5: Adult. Suspected local recurrence based on symptoms, physical examination, or laboratory value in patient with history of breast conservation therapy for DCIS. Initial imaging.
Variant 5: Adult. Suspected local recurrence based on symptoms, physical examination, or laboratory value in patient with history of breast conservation therapy for DCIS. Initial imaging.
A. CT chest with IV contrast
Variant 5: Adult. Suspected local recurrence based on symptoms, physical examination, or laboratory value in patient with history of breast conservation therapy for DCIS. Initial imaging.
B. CT chest without and with IV contrast
Variant 5: Adult. Suspected local recurrence based on symptoms, physical examination, or laboratory value in patient with history of breast conservation therapy for DCIS. Initial imaging.
C. CT chest without IV contrast
Variant 5: Adult. Suspected local recurrence based on symptoms, physical examination, or laboratory value in patient with history of breast conservation therapy for DCIS. Initial imaging.
D. Digital breast tomosynthesis diagnostic
Variant 5: Adult. Suspected local recurrence based on symptoms, physical examination, or laboratory value in patient with history of breast conservation therapy for DCIS. Initial imaging.
E. FDG-PET breast dedicated
Variant 5: Adult. Suspected local recurrence based on symptoms, physical examination, or laboratory value in patient with history of breast conservation therapy for DCIS. Initial imaging.
F. Image-guided core biopsy breast
Variant 5: Adult. Suspected local recurrence based on symptoms, physical examination, or laboratory value in patient with history of breast conservation therapy for DCIS. Initial imaging.
G. Image-guided fine needle aspiration breast
Variant 5: Adult. Suspected local recurrence based on symptoms, physical examination, or laboratory value in patient with history of breast conservation therapy for DCIS. Initial imaging.
H. Mammography diagnostic
Variant 5: Adult. Suspected local recurrence based on symptoms, physical examination, or laboratory value in patient with history of breast conservation therapy for DCIS. Initial imaging.
I. Mammography with IV contrast
Variant 5: Adult. Suspected local recurrence based on symptoms, physical examination, or laboratory value in patient with history of breast conservation therapy for DCIS. Initial imaging.
J. MRI breast without and with IV contrast
Variant 5: Adult. Suspected local recurrence based on symptoms, physical examination, or laboratory value in patient with history of breast conservation therapy for DCIS. Initial imaging.
K. MRI breast without IV contrast
Variant 5: Adult. Suspected local recurrence based on symptoms, physical examination, or laboratory value in patient with history of breast conservation therapy for DCIS. Initial imaging.
L. Sestamibi MBI
Variant 5: Adult. Suspected local recurrence based on symptoms, physical examination, or laboratory value in patient with history of breast conservation therapy for DCIS. Initial imaging.
M. US breast
Variant 6: Adult. Suspected local recurrence based on symptoms, physical examination, or laboratory value in patient with history of mastectomy for DCIS. Initial imaging.
Variant 6: Adult. Suspected local recurrence based on symptoms, physical examination, or laboratory value in patient with history of mastectomy for DCIS. Initial imaging.
A. CT chest with IV contrast
Variant 6: Adult. Suspected local recurrence based on symptoms, physical examination, or laboratory value in patient with history of mastectomy for DCIS. Initial imaging.
B. CT chest without and with IV contrast
Variant 6: Adult. Suspected local recurrence based on symptoms, physical examination, or laboratory value in patient with history of mastectomy for DCIS. Initial imaging.
C. CT chest without IV contrast
Variant 6: Adult. Suspected local recurrence based on symptoms, physical examination, or laboratory value in patient with history of mastectomy for DCIS. Initial imaging.
D. Digital breast tomosynthesis diagnostic
Variant 6: Adult. Suspected local recurrence based on symptoms, physical examination, or laboratory value in patient with history of mastectomy for DCIS. Initial imaging.
E. FDG-PET/CT skull base to mid-thigh
Variant 6: Adult. Suspected local recurrence based on symptoms, physical examination, or laboratory value in patient with history of mastectomy for DCIS. Initial imaging.
F. Image-guided biopsy chest
Variant 6: Adult. Suspected local recurrence based on symptoms, physical examination, or laboratory value in patient with history of mastectomy for DCIS. Initial imaging.
G. Image-guided fine needle aspiration chest
Variant 6: Adult. Suspected local recurrence based on symptoms, physical examination, or laboratory value in patient with history of mastectomy for DCIS. Initial imaging.
H. Mammography diagnostic
Variant 6: Adult. Suspected local recurrence based on symptoms, physical examination, or laboratory value in patient with history of mastectomy for DCIS. Initial imaging.
I. Mammography with IV contrast
Variant 6: Adult. Suspected local recurrence based on symptoms, physical examination, or laboratory value in patient with history of mastectomy for DCIS. Initial imaging.
J. MRI breast without and with IV contrast
Variant 6: Adult. Suspected local recurrence based on symptoms, physical examination, or laboratory value in patient with history of mastectomy for DCIS. Initial imaging.
K. MRI breast without IV contrast
Variant 6: Adult. Suspected local recurrence based on symptoms, physical examination, or laboratory value in patient with history of mastectomy for DCIS. Initial imaging.
L. US breast
Variant 7: Adult. Known DCIS with microinvasion found on prior mammography, ultrasound, or MRI during initial evaluation. Axillary evaluation needed. Next imaging study.
Variant 7: Adult. Known DCIS with microinvasion found on prior mammography, ultrasound, or MRI during initial evaluation. Axillary evaluation needed. Next imaging study.
A. CT chest with IV contrast
Variant 7: Adult. Known DCIS with microinvasion found on prior mammography, ultrasound, or MRI during initial evaluation. Axillary evaluation needed. Next imaging study.
B. CT chest without and with IV contrast
Variant 7: Adult. Known DCIS with microinvasion found on prior mammography, ultrasound, or MRI during initial evaluation. Axillary evaluation needed. Next imaging study.
C. CT chest without IV contrast
Variant 7: Adult. Known DCIS with microinvasion found on prior mammography, ultrasound, or MRI during initial evaluation. Axillary evaluation needed. Next imaging study.
D. Digital breast tomosynthesis diagnostic
Variant 7: Adult. Known DCIS with microinvasion found on prior mammography, ultrasound, or MRI during initial evaluation. Axillary evaluation needed. Next imaging study.
E. FDG-PET/CT whole body
Variant 7: Adult. Known DCIS with microinvasion found on prior mammography, ultrasound, or MRI during initial evaluation. Axillary evaluation needed. Next imaging study.
F. Lymphoscintigraphy axilla
Variant 7: Adult. Known DCIS with microinvasion found on prior mammography, ultrasound, or MRI during initial evaluation. Axillary evaluation needed. Next imaging study.
G. Mammography with IV contrast
Variant 7: Adult. Known DCIS with microinvasion found on prior mammography, ultrasound, or MRI during initial evaluation. Axillary evaluation needed. Next imaging study.
H. MRI breast without and with IV contrast
Variant 7: Adult. Known DCIS with microinvasion found on prior mammography, ultrasound, or MRI during initial evaluation. Axillary evaluation needed. Next imaging study.
I. MRI breast without IV contrast
Variant 7: Adult. Known DCIS with microinvasion found on prior mammography, ultrasound, or MRI during initial evaluation. Axillary evaluation needed. Next imaging study.
J. US axilla
Variant 7: Adult. Known DCIS with microinvasion found on prior mammography, ultrasound, or MRI during initial evaluation. Axillary evaluation needed. Next imaging study.
K. US-guided core biopsy axillary node
Variant 7: Adult. Known DCIS with microinvasion found on prior mammography, ultrasound, or MRI during initial evaluation. Axillary evaluation needed. Next imaging study.
L. US-guided fine needle aspiration biopsy axillary node
Variant 8: Adult. Known DCIS without microinvasion found on prior mammography, ultrasound, or MRI during initial evaluation. Axillary evaluation needed. Next imaging study.
Variant 8: Adult. Known DCIS without microinvasion found on prior mammography, ultrasound, or MRI during initial evaluation. Axillary evaluation needed. Next imaging study.
A. CT chest with IV contrast
Variant 8: Adult. Known DCIS without microinvasion found on prior mammography, ultrasound, or MRI during initial evaluation. Axillary evaluation needed. Next imaging study.
B. CT chest without and with IV contrast
Variant 8: Adult. Known DCIS without microinvasion found on prior mammography, ultrasound, or MRI during initial evaluation. Axillary evaluation needed. Next imaging study.
C. CT chest without IV contrast
Variant 8: Adult. Known DCIS without microinvasion found on prior mammography, ultrasound, or MRI during initial evaluation. Axillary evaluation needed. Next imaging study.
D. Digital breast tomosynthesis diagnostic
Variant 8: Adult. Known DCIS without microinvasion found on prior mammography, ultrasound, or MRI during initial evaluation. Axillary evaluation needed. Next imaging study.
E. FDG-PET/CT whole body
Variant 8: Adult. Known DCIS without microinvasion found on prior mammography, ultrasound, or MRI during initial evaluation. Axillary evaluation needed. Next imaging study.
F. Lymphoscintigraphy axilla
Variant 8: Adult. Known DCIS without microinvasion found on prior mammography, ultrasound, or MRI during initial evaluation. Axillary evaluation needed. Next imaging study.
G. Mammography with IV contrast
Variant 8: Adult. Known DCIS without microinvasion found on prior mammography, ultrasound, or MRI during initial evaluation. Axillary evaluation needed. Next imaging study.
H. MRI breast without and with IV contrast
Variant 8: Adult. Known DCIS without microinvasion found on prior mammography, ultrasound, or MRI during initial evaluation. Axillary evaluation needed. Next imaging study.
I. MRI breast without IV contrast
Variant 8: Adult. Known DCIS without microinvasion found on prior mammography, ultrasound, or MRI during initial evaluation. Axillary evaluation needed. Next imaging study.
J. US axilla
Variant 8: Adult. Known DCIS without microinvasion found on prior mammography, ultrasound, or MRI during initial evaluation. Axillary evaluation needed. Next imaging study.
K. US-guided core biopsy axillary node
Variant 8: Adult. Known DCIS without microinvasion found on prior mammography, ultrasound, or MRI during initial evaluation. Axillary evaluation needed. Next imaging study.
L. US-guided fine needle aspiration biopsy axillary node
Summary of Highlights
Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Gender Equality and Inclusivity Clause
The ACR acknowledges the limitations in applying inclusive language when citing research studies that predates the use of the current understanding of language inclusive of diversity in sex, intersex, gender, and gender-diverse people. The data variables regarding sex and gender used in the cited literature will not be changed. However, this guideline will use the terminology and definitions as proposed by the National Institutes of Health.
Appropriateness Category Names and Definitions

Appropriateness Category Name

Appropriateness Rating

Appropriateness Category Definition

Usually Appropriate

7, 8, or 9

The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.

May Be Appropriate

4, 5, or 6

The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.

May Be Appropriate (Disagreement)

5

The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.

Usually Not Appropriate

1, 2, or 3

The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.
Relative Radiation Level Information

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared with those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria® Radiation Dose Assessment Introduction document.

Relative Radiation Level Designations

Relative Radiation Level*

Adult Effective Dose Estimate Range

Pediatric Effective Dose Estimate Range

O

0 mSv

 0 mSv

☢

<0.1 mSv

<0.03 mSv

☢☢

0.1-1 mSv

0.03-0.3 mSv

☢☢☢

1-10 mSv

0.3-3 mSv

☢☢☢☢

10-30 mSv

3-10 mSv

☢☢☢☢☢

30-100 mSv

10-30 mSv

*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies.”
References
1. Pinder SE, Fox S, Schnitt S, van Deurzen C, Weaver D, Wesseling J. Ductal carcinoma in situ. WHO Classification of Tumours—Breast Tumours, 5th ed.; Board, E., Ed; 2019:78.
2. Grimm LJ, Rahbar H, Abdelmalak M, Hall AH, Ryser MD. Ductal Carcinoma in Situ: State-of-the-Art Review. [Review]. Radiology. 302(2):246-255, 2022 02.
3. Rauch GM, Kuerer HM, Scoggins ME, et al. Clinicopathologic, mammographic, and sonographic features in 1,187 patients with pure ductal carcinoma in situ of the breast by estrogen receptor status. Breast Cancer Res Treat. 139(3):639-47, 2013 Jun.
4. Siegel RL, Miller KD, Wagle NS, Jemal A. Cancer statistics, 2023. CA Cancer J Clin 2023;73:17-48.
5. Wapnir IL, Dignam JJ, Fisher B, et al. Long-term outcomes of invasive ipsilateral breast tumor recurrences after lumpectomy in NSABP B-17 and B-24 randomized clinical trials for DCIS. J Natl Cancer Inst. 2011;103(6):478-488.
6. Worni M, Akushevich I, Greenup R, et al. Trends in Treatment Patterns and Outcomes for Ductal Carcinoma In Situ. J Natl Cancer Inst. 107(12):djv263, 2015 Dec.
7. Brennan ME, Turner RM, Ciatto S, et al. Ductal carcinoma in situ at core-needle biopsy: meta-analysis of underestimation and predictors of invasive breast cancer. Radiology 2011;260:119-28.
8. Han JS, Molberg KH, Sarode V. Predictors of invasion and axillary lymph node metastasis in patients with a core biopsy diagnosis of ductal carcinoma in situ: an analysis of 255 cases. Breast J 2011;17:223-9.
9. Heymans C, van Bastelaar J, Visschers RGJ, Vissers YLJ. Sentinel Node Procedure Obsolete in Lumpectomy for Ductal Carcinoma In Situ. Clin Breast Cancer. 17(3):e87-e93, 2017 06.
10. James TA, Palis B, McCabe R, et al. Evaluating the role of sentinel lymph node biopsy in patients with DCIS treated with breast conserving surgery. Am J Surg 2020;220:654-59.
11. Kotani H, Yoshimura A, Adachi Y, et al. Sentinel lymph node biopsy is not necessary in patients diagnosed with ductal carcinoma in situ of the breast by stereotactic vacuum-assisted biopsy. Breast Cancer. 23(2):190-4, 2016 Mar.
12. Magnoni F, Massari G, Santomauro G, et al. Sentinel lymph node biopsy in microinvasive ductal carcinoma in situ. Br J Surg. 106(4):375-383, 2019 03.
13. Prendeville S, Ryan C, Feeley L, et al. Sentinel lymph node biopsy is not warranted following a core needle biopsy diagnosis of ductal carcinoma in situ (DCIS) of the breast. BREAST. 24(3):197-200, 2015 Jun.
14. Sorrentino L, Sartani A, Bossi D, et al. Sentinel node biopsy in ductal carcinoma in situ of the breast: Never justified?. Breast Journal. 24(3):325-333, 2018 05.
15. van Roozendaal LM, Goorts B, Klinkert M, et al. Sentinel lymph node biopsy can be omitted in DCIS patients treated with breast conserving therapy. Breast Cancer Res Treat. 156(3):517-525, 2016 Apr.
16. Watanabe Y, Anan K, Saimura M, et al. Upstaging to invasive ductal carcinoma after mastectomy for ductal carcinoma in situ: predictive factors and role of sentinel lymph node biopsy. Breast Cancer. 25(6):663-670, 2018 Nov.
17. Zhang K, Qian L, Zhu Q, Chang C. Prediction of Sentinel Lymph Node Metastasis in Breast Ductal Carcinoma In Situ Diagnosed by Preoperative Core Needle Biopsy. Front. oncol.. 10:590686, 2020.
18. Lara JF, Young SM, Velilla RE, Santoro EJ, Templeton SF. The relevance of occult axillary micrometastasis in ductal carcinoma in situ: a clinicopathologic study with long-term follow-up. Cancer. 2003;98(10):2105-2113.
19. Matsen CB, Hirsch A, Eaton A, et al. Extent of microinvasion in ductal carcinoma in situ is not associated with sentinel lymph node metastases. Ann Surg Oncol. 21(10):3330-5, 2014 Oct.
20. Pimiento JM, Lee MC, Esposito NN, et al. Role of axillary staging in women diagnosed with ductal carcinoma in situ with microinvasion. J Oncol Pract 2011;7:309-13.
21. Vieira CC, Mercado CL, Cangiarella JF, Moy L, Toth HK, Guth AA. Microinvasive ductal carcinoma in situ: clinical presentation, imaging features, pathologic findings, and outcome. Eur J Radiol. 73(1):102-7, 2010 Jan.
22. Bijker N, Meijnen P, Peterse JL, et al. Breast-conserving treatment with or without radiotherapy in ductal carcinoma-in-situ: ten-year results of European Organisation for Research and Treatment of Cancer randomized phase III trial 10853--a study by the EORTC Breast Cancer Cooperative Group and EORTC Radiotherapy Group. J Clin Oncol 2006;24:3381-7.
23. Houghton J, George WD, Cuzick J, et al. Radiotherapy and tamoxifen in women with completely excised ductal carcinoma in situ of the breast in the UK, Australia, and New Zealand: randomised controlled trial. Lancet 2003;362:95-102.
24. McCormick B, Winter K, Hudis C, et al. RTOG 9804: a prospective randomized trial for good-risk ductal carcinoma in situ comparing radiotherapy with observation. J Clin Oncol. 33(7):709-15, 2015 Mar 01.
25. Allred DC, Anderson SJ, Paik S, et al. Adjuvant tamoxifen reduces subsequent breast cancer in women with estrogen receptor-positive ductal carcinoma in situ: a study based on NSABP protocol B-24. J Clin Oncol. 2012;30(12):1268-1273.
26. Margolese RG, Cecchini RS, Julian TB, et al. Anastrozole versus tamoxifen in postmenopausal women with ductal carcinoma in situ undergoing lumpectomy plus radiotherapy (NSABP B-35): a randomised, double-blind, phase 3 clinical trial. Lancet 2016;387:849-56.
27. NCCN Clinical Practice Guidelines in Oncology. Breast Cancer. Version 4.2023.  Available at: https://www.nccn.org/professionals/physician_gls/pdf/breast.pdf.
28. Elshof LE, Tryfonidis K, Slaets L, et al. Feasibility of a prospective, randomised, open-label, international multicentre, phase III, non-inferiority trial to assess the safety of active surveillance for low risk ductal carcinoma in situ - The LORD study. Eur J Cancer. 51(12):1497-510, 2015 Aug.
29. Francis A, Thomas J, Fallowfield L, et al. Addressing overtreatment of screen detected DCIS; the LORIS trial. Eur J Cancer. 51(16):2296-303, 2015 Nov.
30. Hiroji I. Single-arm confirmatory trial of endocrine therapy alone for estrogen receptor-positive, low-risk ductal carcinoma in situ of the breast (JCOG1505, LORETTA trial).  Available at: https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000032260.
31. Hwang ES, Hyslop T, Lynch T, et al. The COMET (Comparison of Operative versus Monitoring and Endocrine Therapy) trial: a phase III randomised controlled clinical trial for low-risk ductal carcinoma in situ (DCIS). BMJ Open. 9(3):e026797, 2019 03 12.
32. Kanbayashi C, Iwata H. Current approach and future perspective for ductal carcinoma in situ of the breast. [Review]. Jpn J Clin Oncol. 47(8):671-677, 2017 Aug 01.
33. Duffy SW, Dibden A, Michalopoulos D, et al. Screen detection of ductal carcinoma in situ and subsequent incidence of invasive interval breast cancers: a retrospective population-based study. Lancet Oncol. 17(1):109-14, 2016 Jan.
34. American Society of Clinical Oncology Choosing Wisely; Last Reviewed 2021 Available at: https://old-prod.asco.org/news-initiatives/current-initiatives/cancer-care-initiatives/value-cancer-care/choosing-wisely
35. Dershaw DD, Abramson A, Kinne DW. Ductal carcinoma in situ: mammographic findings and clinical implications. Radiology 1989;170:411-5.
36. Gruber IV, Rueckert M, Kagan KO, et al. Measurement of tumour size with mammography, sonography and magnetic resonance imaging as compared to histological tumour size in primary breast cancer. BMC Cancer. 13:328, 2013 Jul 05.
37. Ikeda DM, Andersson I. Ductal carcinoma in situ: atypical mammographic appearances. Radiology 1989;172:661-6.
38. Stomper PC, Margolin FR. Ductal carcinoma in situ: the mammographer's perspective. AJR Am J Roentgenol 1994;162:585-91.
39. Holmberg L, Wong YN, Tabar L, et al. Mammography casting-type calcification and risk of local recurrence in DCIS: analyses from a randomised study. Br J Cancer. 108(4):812-9, 2013 Mar 05.
40. Barreau B, de Mascarel I, Feuga C, et al. Mammography of ductal carcinoma in situ of the breast: review of 909 cases with radiographic-pathologic correlations. Eur J Radiol 2005;54:55-61.
41. Evans A, Pinder S, Wilson R, et al. Ductal carcinoma in situ of the breast: correlation between mammographic and pathologic findings. AJR Am J Roentgenol 1994;162:1307-11.
42. Yang WT, Tse GM. Sonographic, mammographic, and histopathologic correlation of symptomatic ductal carcinoma in situ. AJR Am J Roentgenol 2004;182:101-10.
43. Stein RG, Wollschlager D, Kreienberg R, et al. The impact of breast cancer biological subtyping on tumor size assessment by ultrasound and mammography - a retrospective multicenter cohort study of 6543 primary breast cancer patients. BMC Cancer. 16:459, 2016 07 13.
44. Marinovich ML, Bernardi D, Macaskill P, Ventriglia A, Sabatino V, Houssami N. Agreement between digital breast tomosynthesis and pathologic tumour size for staging breast cancer, and comparison with standard mammography. BREAST. 43:59-66, 2019 Feb.
45. Marinovich ML, Macaskill P, Irwig L, et al. Meta-analysis of agreement between MRI and pathologic breast tumour size after neoadjuvant chemotherapy. Br J Cancer 2013;109:1528-36.
46. Gilbert FJ, Tucker L, Gillan MG, et al. The TOMMY trial: a comparison of TOMosynthesis with digital MammographY in the UK NHS Breast Screening Programme--a multicentre retrospective reading study comparing the diagnostic performance of digital breast tomosynthesis and digital mammography with digital mammography alone. Health Technology Assessment (Winchester, England). 19(4):i-xxv, 1-136, 2015 Jan.
47. Sudhir R, Sannapareddy K, Potlapalli A, Krishnamurthy PB, Buddha S, Koppula V. Diagnostic accuracy of contrast-enhanced digital mammography in breast cancer detection in comparison to tomosynthesis, synthetic 2D mammography and tomosynthesis combined with ultrasound in women with dense breast. British Journal of Radiology. 94(1118):20201046, 2021 Feb 01.
48. Kuhl CK, Schrading S, Bieling HB, et al. MRI for diagnosis of pure ductal carcinoma in situ: a prospective observational study. Lancet. 2007;370(9586):485-492.
49. Avril N, Rose CA, Schelling M, et al. Breast imaging with positron emission tomography and fluorine-18 fluorodeoxyglucose: use and limitations. J Clin Oncol 2000;18:3495-502.
50. Fujii T, Yanai K, Tokuda S, et al. Clinicopathological Features of Ductal Carcinoma In Situ from 18F-FDG-PET Findings. Anticancer Res. 37(9):5053-5056, 2017 09.
51. Grana-Lopez L, Herranz M, Dominguez-Prado I, Argibay S, Villares A, Vazquez-Caruncho M. Can dedicated breast PET help to reduce overdiagnosis and overtreatment by differentiating between indolent and potentially aggressive ductal carcinoma in situ?. European Radiology. 30(1):514-522, 2020 Jan.
52. Berg WA, Gutierrez L, NessAiver MS, et al. Diagnostic accuracy of mammography, clinical examination, US, and MR imaging in preoperative assessment of breast cancer. Radiology. 2004; 233(3):830-849.
53. Cheung YC, Chen K, Yu CC, Ueng SH, Li CW, Chen SC. Contrast-Enhanced Mammographic Features of In Situ and Invasive Ductal Carcinoma Manifesting Microcalcifications Only: Help to Predict Underestimation?. Cancers (Basel). 13(17), 2021 Aug 30.
54. Shetat OMM, Moustafa AFI, Zaitoon S, Fahim MII, Mohamed G, Gomaa MM. Added value of contrast-enhanced spectral mammogram in assessment of suspicious microcalcification and grading of DCIS. Egyptian Journal of Radiology and Nuclear Medicine 2021;52:186.
55. Cheung YC, Juan YH, Lin YC, et al. Dual-Energy Contrast-Enhanced Spectral Mammography: Enhancement Analysis on BI-RADS 4 Non-Mass Microcalcifications in Screened Women. PLoS ONE. 11(9):e0162740, 2016.
56. Houben IP, Vanwetswinkel S, Kalia V, et al. Contrast-enhanced spectral mammography in the evaluation of breast suspicious calcifications: diagnostic accuracy and impact on surgical management. Acta Radiol 2019;60:1110-17.
57. Tardivel AM, Balleyguier C, Dunant A, et al. Added Value of Contrast-Enhanced Spectral Mammography in Postscreening Assessment. Breast J. 2016 Sep;22(5):520-8.
58. Patel BK, Garza SA, Eversman S, Lopez-Alvarez Y, Kosiorek H, Pockaj BA. Assessing tumor extent on contrast-enhanced spectral mammography versus full-field digital mammography and ultrasound. Clinical Imaging. 46:78-84, 2017 Nov - Dec.
59. Scott-Moncrieff A, Sullivan ME, Mendelson EB, Wang L. MR imaging appearance of noncalcified and calcified DCIS. Breast Journal. 24(3):343-349, 2018 05.
60. Greenwood HI, Heller SL, Kim S, Sigmund EE, Shaylor SD, Moy L. Ductal carcinoma in situ of the breasts: review of MR imaging features. [Review]. Radiographics. 33(6):1569-88, 2013 Oct.
61. Orel SG, Mendonca MH, Reynolds C, Schnall MD, Solin LJ, Sullivan DC. MR imaging of ductal carcinoma in situ. Radiology 1997;202:413-20.
62. Rosen EL, Smith-Foley SA, DeMartini WB, Eby PR, Peacock S, Lehman CD. BI-RADS MRI enhancement characteristics of ductal carcinoma in situ. Breast J 2007;13:545-50.
63. Jansen SA, Newstead GM, Abe H, Shimauchi A, Schmidt RA, Karczmar GS. Pure ductal carcinoma in situ: kinetic and morphologic MR characteristics compared with mammographic appearance and nuclear grade. Radiology 2007;245:684-91.
64. Boetes C, Strijk SP, Holland R, Barentsz JO, Van Der Sluis RF, Ruijs JH. False-negative MR imaging of malignant breast tumors. Eur Radiol 1997;7:1231-4.
65. Kuhl CK. Why do purely intraductal cancers enhance on breast MR images? Radiology 2009;253:281-3.
66. Lehman CD.. Magnetic resonance imaging in the evaluation of ductal carcinoma in situ. [Review]. J Natl Cancer Inst Monogr. 2010(41):150-1, 2010.
67. Chou SS, Romanoff J, Lehman CD, et al. Preoperative Breast MRI for Newly Diagnosed Ductal Carcinoma in Situ: Imaging Features and Performance in a Multicenter Setting (ECOG-ACRIN E4112 Trial). Radiology. 301(1):66-77, 2021 10.
68. Hwang ES, Kinkel K, Esserman LJ, Lu Y, Weidner N, Hylton NM. Magnetic resonance imaging in patients diagnosed with ductal carcinoma-in-situ: value in the diagnosis of residual disease, occult invasion, and multicentricity. Ann Surg Oncol 2003;10:381-8.
69. Rahbar H, Partridge SC, Demartini WB, et al. In vivo assessment of ductal carcinoma in situ grade: a model incorporating dynamic contrast-enhanced and diffusion-weighted breast MR imaging parameters. Radiology. 263(2):374-82, 2012 May.
70. Dillon MF, Mc Dermott EW, O'Doherty A, Quinn CM, Hill AD, O'Higgins N. Factors affecting successful breast conservation for ductal carcinoma in situ. Ann Surg Oncol 2007;14:1618-28.
71. Fancellu A, Turner RM, Dixon JM, Pinna A, Cottu P, Houssami N. Meta-analysis of the effect of preoperative breast MRI on the surgical management of ductal carcinoma in situ. [Review]. Br J Surg. 102(8):883-93, 2015 Jul.
72. Schouten van der Velden AP, Schlooz-Vries MS, Boetes C, Wobbes T. Magnetic resonance imaging of ductal carcinoma in situ: what is its clinical application? A review. Am J Surg 2009;198:262-9.
73. Allen LR, Lago-Toro CE, Hughes JH, et al. Is there a role for MRI in the preoperative assessment of patients with DCIS?. Ann Surg Oncol. 17(9):2395-400, 2010 Sep.
74. Sun Y, Wei W, Yang HW, Liu JL. Clinical usefulness of breast-specific gamma imaging as an adjunct modality to mammography for diagnosis of breast cancer: a systemic review and meta-analysis. Eur J Nucl Med Mol Imaging 2013;40:450-63.
75. Spanu A, Sanna D, Chessa F, Cottu P, Manca A, Madeddu G. Breast scintigraphy with breast-specific gamma-camera in the detection of ductal carcinoma in situ: a correlation with mammography and histologic subtype. J Nucl Med 2012;53:1528-33.
76. Hunt KN, Conners AL, Goetz MP, et al. Comparison of 99mTc-Sestamibi Molecular Breast Imaging and Breast MRI in Patients With Invasive Breast Cancer Receiving Neoadjuvant Chemotherapy. AJR Am J Roentgenol. 213(4):932-943, 2019 10.
77. Lee MH, Ko EY, Han BK, Shin JH, Ko ES, Hahn SY. Sonographic findings of pure ductal carcinoma in situ. J Clin Ultrasound. 41(8):465-71, 2013 Oct.
78. Sickles E. Sonographic Detectability Of Breast Calcifications: SPIE; 1983.
79. Watanabe T, Yamaguchi T, Tsunoda H, et al. Ultrasound Image Classification of Ductal Carcinoma In Situ (DCIS) of the Breast: Analysis of 705 DCIS Lesions. Ultrasound Med Biol. 43(5):918-925, 2017 05.
80. Vourtsis A, Berg WA. Screening Breast Ultrasound Using Handheld or Automated Technique in Women with Dense Breasts. Journal of Breast Imaging 2019;1:283-96.
81. Weinstein SP, Slanetz PJ, Lewin AA, et al. ACR Appropriateness Criteria® Supplemental Breast Cancer Screening Based on Breast Density. J Am Coll Radiol 2021;18:S456-S73.
82. Izumori A, Takebe K, Sato A. Ultrasound findings and histological features of ductal carcinoma in situ detected by ultrasound examination alone. Breast Cancer 2010;17:136-41.
83. Tagliafico AS, Calabrese M, Mariscotti G, et al. Adjunct Screening With Tomosynthesis or Ultrasound in Women With Mammography-Negative Dense Breasts: Interim Report of a Prospective Comparative Trial. J Clin Oncol 2016;34:1882-88.
84. Destounis S, Arieno A, Santacroce A. Comparison of Cancers Detected by Screening Breast Ultrasound and Digital Breast Tomosynthesis. Academic Radiology. 29(3):339-347, 2022 03.
85. Byng D, Retel VP, Schaapveld M, Wesseling J, van Harten WH. Treating (low-risk) DCIS patients: What can we learn from real-world cancer registry evidence?. Breast Cancer Res Treat. 187(1):187-196, 2021 May.
86. Grimm LJ, Ghate SV, Hwang ES, Soo MS. Imaging Features of Patients Undergoing Active Surveillance for Ductal Carcinoma in Situ. Acad Radiol. 24(11):1364-1371, 2017 11.
87. U.S. National Library of Medicine. Letrozole in Treating Postmenopausal Women With Ductal Carcinoma in Situ.  Available at: https://classic.clinicaltrials.gov/ct2/show/NCT01439711.
88. Hwang ES, Hyslop T, Hendrix LH, et al. Phase II Single-Arm Study of Preoperative Letrozole for Estrogen Receptor-Positive Postmenopausal Ductal Carcinoma In Situ: CALGB 40903 (Alliance). Journal of Clinical Oncology. 38(12):1284-1292, 2020 04 20.
89. Pinsky RW, Rebner M, Pierce LJ, et al. Recurrent cancer after breast-conserving surgery with radiation therapy for ductal carcinoma in situ: mammographic features, method of detection, and stage of recurrence. AJR Am J Roentgenol 2007;189:140-4.
90. Liberman L, Van Zee KJ, Dershaw DD, Morris EA, Abramson AF, Samli B. Mammographic features of local recurrence in women who have undergone breast-conserving therapy for ductal carcinoma in situ. AJR Am J Roentgenol 1997;168:489-93.
91. Shaaban AM, Hilton B, Clements K, et al. Pathological features of 11,337 patients with primary ductal carcinoma in situ (DCIS) and subsequent events: results from the UK Sloane Project. Br J Cancer. 124(5):1009-1017, 2021 03.
92. Cheung S, Booth ME, Kearins O, Dodwell D. Risk of subsequent invasive breast cancer after a diagnosis of ductal carcinoma in situ (DCIS). BREAST. 23(6):807-11, 2014 Dec.
93. Sprague BL, McLaughlin V, Hampton JM, Newcomb PA, Trentham-Dietz A. Disease-free survival by treatment after a DCIS diagnosis in a population-based cohort study. Breast Cancer Res Treat 2013;141:145-54.
94. Correa C, McGale P, Taylor C, et al. Overview of the randomized trials of radiotherapy in ductal carcinoma in situ of the breast. J Natl Cancer Inst Monogr. 2010;2010(41):162-177.
95. Fitzpatrick SE, Eaton M, McLeay W, Dean NR. Outcomes of DCIS treated with breast conserving surgery without radiotherapy on recurrence, survival, and health-related quality of life. ANZ J Surg 2023:[E-pub ahead of print].
96. Rakovitch E, Pignol JP, Hanna W, et al. Significance of multifocality in ductal carcinoma in situ: outcomes of women treated with breast-conserving therapy. J Clin Oncol. 25(35):5591-6, 2007 Dec 10.
97. Rudloff U, Jacks LM, Goldberg JI, et al. Nomogram for predicting the risk of local recurrence after breast-conserving surgery for ductal carcinoma in situ. J Clin Oncol 2010;28:3762-9.
98. Flowers CI, Mooney BP, Drukteinis JS. Clinical and imaging surveillance following breast cancer diagnosis. Am Soc Clin Oncol Educ Book 2012:59-64.
99. Mehta TS, Lourenco AP, Niell BL, et al. ACR Appropriateness Criteria® Imaging After Breast Surgery. J Am Coll Radiol 2022;19:S341-S56.
100. Khatcheressian JL, Hurley P, Bantug E, et al. Breast cancer follow-up and management after primary treatment: American Society of Clinical Oncology clinical practice guideline update. [Review]. J Clin Oncol. 31(7):961-5, 2013 Mar 01.
101. Wallace AS, Nelson JP, Wang Z, Dale PS, Biedermann GB. In support of the Choosing Wisely campaign: Perceived higher risk leads to unnecessary imaging in accelerated partial breast irradiation?. Breast J. 24(1):12-15, 2018 01.
102. Buist DS, Bosco JL, Silliman RA, et al. Long-term surveillance mammography and mortality in older women with a history of early stage invasive breast cancer. Breast Cancer Res Treat. 142(1):153-63, 2013 Nov.
103. Smith-Gagen J, Carrillo JE, Ang A, Perez-Stable EJ. Practices that reduce the Latina survival disparity after breast cancer. J Womens Health (Larchmt). 22(11):938-46, 2013 Nov.
104. Lee JM, Buist DS, Houssami N, et al. Five-year risk of interval-invasive second breast cancer. J Natl Cancer Inst. 107(7), 2015 Jul.
105. Lowry KP, Braunstein LZ, Economopoulos KP, et al. Predictors of surveillance mammography outcomes in women with a personal history of breast cancer. Breast Cancer Research & Treatment. 171(1):209-215, 2018 Aug.
106. Solin LJ.. The impact of adding radiation treatment after breast conservation surgery for ductal carcinoma in situ of the breast. [Review]. J Natl Cancer Inst Monogr. 2010(41):187-92, 2010.
107. American College of Radiology. ACR Practice Parameter for the Performance of Screening and Diagnostic Mammography.  Available at: https://gravitas.acr.org/PPTS/GetDocumentView?docId=8+&releaseId=2
108. Patel BK, Lee CS, Kosiorek HE, Newell MS, Pizzitola VJ, D'Orsi CJ. Variability of Postsurgical Imaging Surveillance of Breast Cancer Patients: A Nationwide Survey Study. AJR. American Journal of Roentgenology. 210(1):222-227, 2018 Jan.
109. Hasan S, Gresswell S, Colosimo B, et al. Surveillance Mammography After Breast Conservation Therapy: Is Tomosynthesis Worth It?. Am J Clin Oncol. 42(8):682-686, 2019 08.
110. Sia J, Moodie K, Bressel M, et al. A prospective study comparing digital breast tomosynthesis with digital mammography in surveillance after breast cancer treatment. Eur J Cancer. 61:122-7, 2016 07.
111. Yoon JH, Kim EK, Kim GR, et al. Comparing recall rates following implementation of digital breast tomosynthesis to synthetic 2D images and digital mammography on women with breast-conserving surgery. European Radiology. 30(11):6072-6079, 2020 Nov.
112. Orel SG, Fowble BL, Solin LJ, Schultz DJ, Conant EF, Troupin RH. Breast cancer recurrence after lumpectomy and radiation therapy for early-stage disease: prognostic significance of detection method. Radiology 1993;188:189-94.
113. Arasu VA, Joe BN, Lvoff NM, et al. Benefit of semiannual ipsilateral mammographic surveillance following breast conservation therapy. Radiology. 264(2):371-7, 2012 Aug.
114. American College of Radiology. ACR Practice Parameter for the Performance of Contrast-Enhanced Magnetic Resonance Imaging (MRI) of the Breast.  Available at: https://gravitas.acr.org/PPTS/GetDocumentView?docId=6+&releaseId=2
115. Giannotti DG, Hanna SA, Cerri GG, Barbosa Bevilacqua JL. Analysis of Skin Flap Thickness and Residual Breast Tissue After Mastectomy. Int J Radiat Oncol Biol Phys. 102(1):82-91, 2018 09 01.
116. Papassotiropoulos B, Guth U, Chiesa F, et al. Prospective Evaluation of Residual Breast Tissue After Skin- or Nipple-Sparing Mastectomy: Results of the SKINI-Trial. Ann Surg Oncol 2019;26:1254-62.
117. Carlson GW, Page A, Johnson E, Nicholson K, Styblo TM, Wood WC. Local recurrence of ductal carcinoma in situ after skin-sparing mastectomy. J Am Coll Surg 2007;204:1074-8; discussion 78-80.
118. Chan LW, Rabban J, Hwang ES, et al. Is radiation indicated in patients with ductal carcinoma in situ and close or positive mastectomy margins? Int J Radiat Oncol Biol Phys 2011;80:25-30.
119. Hwang ES. The impact of surgery on ductal carcinoma in situ outcomes: the use of mastectomy. J Natl Cancer Inst Monogr 2010;2010:197-9.
120. Pawloski KR, Tadros AB, Sevilimedu V, et al. Patterns of invasive recurrence among patients originally treated for ductal carcinoma in situ by breast-conserving surgery versus mastectomy. [Review]. Breast Cancer Res Treat. 186(3):617-624, 2021 Apr.
121. NCCN Clinical Practice Guidelines in Oncology. Breast Cancer. NCCN Evidence Blocks™. Version 4.2023.  Available at: https://www.nccn.org/professionals/physician_gls/pdf/breast_blocks.pdf.
122. ESMO. Breast Cancer Pocket Guideline 2022.  Available at: https://interactiveguidelines.esmo.org/esmo-web-app/toc/index.php?subjectAreaID=8&loadPdf=1.
123. Chapman MC, Hayward JH, Woodard GA, Joe BN, Lee AY. The Role of Breast MRI in Detecting Asymptomatic Recurrence After Therapeutic Mastectomy. AJR Am J Roentgenol. 215(1):254-261, 2020 07.
124. Lee JH, Kim EK, Oh JY, et al. US screening for detection of nonpalpable locoregional recurrence after mastectomy. Eur J Radiol. 82(3):485-9, 2013 Mar.
125. Moy L, Heller SL, Bailey L, et al. ACR Appropriateness Criteria® Palpable Breast Masses. J Am Coll Radiol 2017;14:S203-S24.
126. Holbrook AI, Moy L, Akin EA, et al. ACR Appropriateness Criteria® Breast Pain. J Am Coll Radiol 2018;15:S276-S82.
127. Willems SM, van Deurzen CH, van Diest PJ. Diagnosis of breast lesions: fine-needle aspiration cytology or core needle biopsy? A review. J Clin Pathol 2012;65:287-92.
128. Robertson C, Ragupathy SK, Boachie C, et al. Surveillance mammography for detecting ipsilateral breast tumour recurrence and metachronous contralateral breast cancer: a systematic review. [Review]. Eur Radiol. 21(12):2484-91, 2011 Dec.
129. Amitai Y, Menes TS, Weinstein I, Filyavich A, Yakobson I, Golan O. What is the yield of breast MRI in the assessment of palpable breast findings?. Clin Radiol. 72(11):930-935, 2017 Nov.
130. Olsen ML, Morton MJ, Stan DL, Pruthi S. Is there a role for magnetic resonance imaging in diagnosing palpable breast masses when mammogram and ultrasound are negative? J Womens Health (Larchmt) 2012;21:1149-54.
131. Yalniz C, Campbell D, Le-Petross C, et al. The role of magnetic resonance imaging in patients with palpable breast abnormalities and negative mammographic and sonographic findings. Breast Journal. 26(7):1289-1295, 2020 07.
132. Wang M, He X, Chang Y, Sun G, Thabane L. A sensitivity and specificity comparison of fine needle aspiration cytology and core needle biopsy in evaluation of suspicious breast lesions: A systematic review and meta-analysis. [Review]. BREAST. 31:157-166, 2017 Feb.
133. Brancato B, Crocetti E, Bianchi S, et al. Accuracy of needle biopsy of breast lesions visible on ultrasound: audit of fine needle versus core needle biopsy in 3233 consecutive samplings with ascertained outcomes. Breast 2012;21:449-54.
134. Bianchi S, Vezzosi V. Microinvasive carcinoma of the breast. Pathol Oncol Res 2008;14:105-11.
135. Shiino S, Quinn C, Ball G, et al. Prognostic significance of microinvasion with ductal carcinoma in situ of the breast: a meta-analysis. [Review]. Breast Cancer Res Treat. 197(2):245-254, 2023 Jan.
136. Amin MB, Edge S, Greene F, et al. AJCC Cancer Staging Manual. 8th ed. New York, NY: Springer; 2017.
137. Yu KD, Wu LM, Liu GY, et al. Different distribution of breast cancer subtypes in breast ductal carcinoma in situ (DCIS), DCIS with microinvasion, and DCIS with invasion component. Ann Surg Oncol 2011;18:1342-8.
138. Lyman GH, Temin S, Edge SB, et al. Sentinel lymph node biopsy for patients with early-stage breast cancer: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol. 32(13):1365-83, 2014 May 01.
139. Lai HW, Chang YL, Chen ST, et al. Revisit the practice of lymph node biopsy in patients diagnosed as ductal carcinoma in situ before operation: a retrospective analysis of 682 cases and evaluation of the role of breast MRI. World Journal of Surgical Oncology. 19(1):263, 2021 Sep 01.
140. National Academies of Sciences, Engineering, and Medicine; Division of Behavioral and Social Sciences and Education; Committee on National Statistics; Committee on Measuring Sex, Gender Identity, and Sexual Orientation. Measuring Sex, Gender Identity, and Sexual Orientation. In: Becker T, Chin M, Bates N, eds. Measuring Sex, Gender Identity, and Sexual Orientation. Washington (DC): National Academies Press (US) Copyright 2022 by the National Academy of Sciences. All rights reserved.; 2022.
141. American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://edge.sitecorecloud.io/americancoldf5f-acrorgf92a-productioncb02-3650/media/ACR/Files/Clinical/Appropriateness-Criteria/ACR-Appropriateness-Criteria-Radiation-Dose-Assessment-Introduction.pdf.
Disclaimer
The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked.  Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document.  The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged.  The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination