docBreast Calcs Benign and Malig
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Breast Calcs Benign and Malig
Armed Forces Institute of Pathology www.radpath.com Armed Forces Institute of Pathology Breast Disease www.radpath.org Armed Forces Institute of Pathology Evaluation of Breast Calcifications Leonard M. Glassman MD FACR American College of Radiology Breast Imaging Scientist Armed Forces Institute of Pathology Washington DC Washington Radiology Associates, PC Washington DC glassmanl@afip.osd.mil Importance of Calcification • Important in mammography • 45% of all breast cancers present as calcification on mammography • Both invasive carcinoma and DCIS can present as calcification – Can not tell which when only calcification – Calcification and mass is usually invasive disease Is It a Calcification? • Artifacts are common in screen film systems but rare in digital systems Common Artifacts • Dust and lint on film or screens • Fingerprints • Metallic fragments • Powder, ointment or deodorant Artifacts • Fingerprint • Thread Carcinoma and Calcification • Calcifications are not malignant • Calcifications are not alive • Calcifications represent a cast of a space Carcinoma and Calcification • If the space represents a normal or benign anatomic space then the underlying process will be benign – Dilated ducts Carcinoma and Calcification • Not all irregular calcifications represent carcinoma – Tissue necrosis happens in benign processes also • 20 – 35% positive predictive value – Varies with number of lawyers • Degenerating fibroadenoma Analysis of Calcifications • • • • • • Shape is most important Size Density Number Distribution Change over time Shape of Malignant Calcifications • Not typically benign • Heterogeneous or pleomorphic – Not all the same – Irregular shape – Not smooth (round or rods) round or hollow • Amorphous or indistinct • Too small to characterize Shape • Tumor tissue necrosis yields small irregular spaces which yields small irregular calcifications • Tumor tissue secretion into the duct lumen yields amorphous calcifications Magnification • Write and read – Magnification views and magnifying lens – Standard for evaluation of calcifications • Shape and number • Is magnification necessary in digital mammography? Magnification • Standard • Magnification Classes of Calcifications • Typically benign • Intermediate concern – Amorphous or indistinct – Coarse heterogeneous • Higher probability of malignancy – Fine pleomorphic – Fine linear Typically Benign Calcifications Need No Follow-up • • • • • • • Lobular Sutural Coarse or popcorn Skin Vascular Milk of calcium Dystrophic • • • • • Secretory Parasitic Pectoral muscle Lucent centered Egg shell Lobular Calcifications • Tightly clustered • Round • Fit together like a jigsaw puzzle Sutural Calcifications • Look like sutures • Usually post radiation therapy Calcified Fibroadenoma • Coarse or "popcorn-like” • Calcification generally peripheral Peripheral Calcification Calcified Fibroadenoma Calcified Fibroadenoma Skin Calcifications • Faint peripheral clusters with lucent centers • Tangent view Skin Calcifications Vascular Calcifications • Parallel tracks associated with blood vessels • Calcifications are on the outside of the tube • Diabetes and heart disease? • Mention when seen in women under 50? Vascular Ductal Vascular Calcification Milk of Calcium Secretory Calcifications • Large rods – Luminal calcifications – Oriented toward nipple – Relatively smooth surface – May branch Secretory Calcifications Lucent Centered • Skin calcifications Egg Shell Intermediate Concern • Amorphous or indistinct – Not sharply defined • Coarse heterogeneous – Crushed stone Amorphous or Indistinct Coarse Heterogeneous Coarse Heterogeneous Coarse Heterogeneous Coarse Heterogeneous Higher Probability of Malignancy • Fine pleomorphic (granular) • Fine linear Fine Pleomorphic Fine Pleomorphic Fine Pleomorphic Fine Linear Fine Linear Fine Linear Fine Linear • Casting Size • Large calcifications are usually benign • Minute (<1mm) calcifications are often malignant Size Macro Micro Size • DCIS • Fibroadenoma Microcalcifications • Invasive ductal carcinoma • Invasive ductal carcinoma Density • Dense calcifications are usually benign • Faint calcifications can be malignant Density • Dense FA • Faint DCIS Number • Cluster is 5 particles or more in 1 cubic cm. Is 5 important? • Benign • Malignant Distribution of Calcifications • • • • • • Grouped or Clustered Linear Segmental Regional Scattered/diffuse Multiple groups Clustered Malignant • 5 or more in 1 cc Clustered • This • Not this Clustered Benign Distribution of Calcifications • Linear, Segmental and Regional – Represent degrees of involvement of a ductal system – Regional is >2cm and not ductal in distribution Linear Segmental Regional Scattered Osteosarcoma • • • • Primary in the breast 27 to 89 years old Median 64.5 years Highly aggressive tumors Primary Osteosarcoma Change Over Time • Benign processes can change • Malignant processes almost always change within 3 years • Short interval follow-up – Probably benign findings – <2% chance of malignancy Management of Calcifications • Make benign diagnosis when possible • Biopsy when suspicious – High probability malignant – Intermediate probability • Short interval follow-up when probably benign Conclusion • Analysis of calcifications is usually straightforward – Benign – Short interval follow-up – Biopsy • Magnification often needed for analysis • You can not always be right but you should be consistent – 33% positive predictive value
