Breast Calcifications

Transcription

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2 Marton Lanyi Diagnosis and Differential Diagnosis of Breast Calcifications With 200 Figures in 383 Separate Illustrations and 11 Tables Springer-Verlag Berlin Heidelberg New York London Paris Tokyo

3 Dr. med. MARTON LANYI Rontgeninstitut KaiserstraBe Gummersbach FRG Translated from the German edition by TERRY C. TELGER 6112 Waco Way Fort Worth, TX USA German edition Diagnostik und Differentialdiagnostik der Mamrnaverkalkungen Springer-Verlag Berlin Heidelberg 1986 ISBN-13: e-isbn-13: DOl: / Library of Congress Cataloging in Publication Data. Lanyi, M. (Marton). Diagnosis and differential diagnosis of breast calcifications. Translation of: Diagnostik und Differentialdiagnostik der Mammaverkalkungen. Bibliography: p.lncludes index. 1. Breast - Calcification - Diagnosis. 2. Diagnosis, Differential. 3. Breast - Radiography.1. TItle. [DNLM: 1. Breast Diseases - diagnosis. 2.Calcinosis- radiography. 3. Mammography. WP 840 L296d] RG496.C34L '907' ISBN-13: (U.S.) This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically those of translation, reprinting, re-use of illustrations, broadcasting, reproduction by photocopying machine or similar means, and storage in data banks. Duplication of this publication or parts thereof is only permitted under the provisions of the German Copyright Law of September 9, 1965, in its version of June 24, 1985, and a copyright fee must always be paid. Violations fall under the prosecution act of the German Copyright Law. Springer-Verlag Berlin Heidelberg 1988 Sof tcover reprint of the hardcover I st edition 1988 The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. Product Liability: The publisher can give no guarantee for information about drug dosage and application thereof contained in this book. In every individual case the respective user must check its accuracy by consulting other pharmaceutical literature. 2121/

4 Preface Very thorough knowledge of breast pathology is a sine qua non for interpretation of breast films... progress in X-ray diagnosis could only be made by careful comparison of the film with the actual specimen. H.INGLEBY Multiplication of the same e"oneous diagnosis does not make that diagnosis co"ect. J.G.AzZOPARDI Paradoxically enough, our specialty considers the radiologist who mistakes a skin fibroma or the calcifications in a sponge kidney for a kidney stone to lack basic knowledge, while the radiologist who immediately calls for the surgeon because of a few white spots on a mammogram is thought to be acting according to the rules of medical practice. Misunderstandings and confusion with regard to breast pathology as well as the comfortable philosophy that superfluous biopsies are the price we have to pay for the early detection of carcinomas have in many places led to a loss of confidence in mammography. Yet this is a method with which carcinomas can be detected earlier than with any other imaging technique. A quarter of a century ago, during a population screening for breast cancer in Budapest, I first detected a clinically occult breast carcinoma on grounds of a cluster of microcalcifications. The possibility of being able to make a histological diagnosis of a carcinoma based on tiny, white spots on the X-ray was fascinating. My disappointment was all the greater when the pathologist later found benign processes for apparently similar phenomena. It became clear to me, after reading the book by INGLEBY and GERSHON-COHEN (1960), that it would only be possible to solve the problems of a differential diagnosis of this X -ray phenomena by means of detailed, systematic, and comparative mammographic and histologic analyses. Yet three prerequisites for such an analysis were missing at that time, namely, good mammography technology, sufficient material, and the possibility to collate the image of a microcalcification to its pathological manifestation. Just 13 years ago I was able to initiate the systematic work. The technological prerequisites were available, I had collected sufficient material about microcalcifications, and I had found someone, my friend and pathologist Professor P. CITOLER, who was ready to determine the spatial relationship between microcalcifications and histological transformations. It took me 7 years to develop the differential diagnosis system described in this book, and another 2 years to test its practical viability. I examined mammograms without prior knowledge of the histology from almost 1000 cases operated on because of micro-

5 VI Preface calcifications (from the Universities of Cologne, Nijmegen, and San Francisco, the Institute Curie in Paris, the Radiological Institute in Cologne, and the Knappschaftskrankenhaus in Dortmund). The results steadily improved. By analyzing the incorrect diagnoses, I was able to further refine the system and determine its limitations. Now, one year after the publication of the book in German, the English edition is ready and will make the differential diagnostic system accessible throughout the world. It may thus reach radiologists who in their darkened rooms are using a magnifying glass to try to make a definite diagnosis on the basis of a few white spots on a mammogram. I hope that this book may help them. I would not have been able to write this book without the help of numerous colleagues and friends from Europe and America. They have sent me interesting cases, prepared histophotograms, made material available to me in order to test my system of differential diagnosis, and were the first readers whose probing questions uncovered the weak spots in my manuscript and who drove me to express myself more clearly. I would like to express my gratitude first to them: Dr. E.AL BRING, Gelsenkirchen, Prof. V. BARTH, Esslingen, Prof. K. BREZINA, Vienna, Dr. P. D. C. BROKS, Utrecht, Prof. P. CITOLER, Cologne, Prof. O. FISCHEDICK, Dortmund, Prof. M. FRIEDRICH, Berlin, Dr. l.h.c.l.hendriks, Nijmegen, Prof. W.HOEFFKEN, Cologne, Dr. R. HOLLAND, Nijmegen, Prof. H. KIEFER, Wiesbaden, Dr. M. LEGAL, Paris, Dr. K.LENDvAI, Porz, Prof. K.l.LENNARTZ, Dusseldorf, Prof. H.LENZ, Eschweiler, Dr. R.MOLLER, Siegburg, Dr. K.NEUFANG, Cologne, Dr. Z. PENTEK, Szeksziud, Hungary, Dr. M. RADO, Bergheim, Dr. E. Ross, Vallendar, Dr. E. SICKLES, San Francisco, Prof. K. H. v AN DE WEYER, Trier, Prof. H. H. ZIPPEL, Marburg. The illustrations and photographs were prepared by E. STORCH at the Radiological Institute of Cologne, E. WITTE at the Catholic University of Nijmegen, and H. LAMBACH, a graphic artist. The statistics were compiled and checked by Professor P. SCHWAN ENBERG of the Technical University of Gummersbach. The translation of a specialized text about radiology and pathology requires linguistic as well as medical knowledge. If, as I hope, the translation of this book is well done, credit is due to TERRY TELGER, the translator, and MICHAEL WILSON, head of copy editing at Springer-Verlag. I am also grateful to the radiologist Dr. l. G. BLICKMAN for reviewing the manuscript. WILLI BISCHOFF is responsible for the good optical presentation of the book. My special thanks go to BERNHARD LEWERICH, who recognized the importance of the subject at an early stage and who urged and supported the preparation of the English edition. M.LANYI

6 Contents 1 Historical Review, Critical Analysis of the Literature, Statement of Problem and Goals Technical Prerequisites for the Evaluation of Breast Microcalcifications Factors Influencing Visualization ofimage Details Image Optimization and Dose Reduction Microfocal Spot Magnification Mammography Future Developments Pathogenesis, Pathophysiology, and Composition of Breast Calcifications Calcifications Within the Lobular and Ductal System of the Breast Normal Anatomy and Radiographic Anatomy 4.2 Pathology and Radiography of Calcifications of Lobular Origin Pathology and Radiography of Calcifications ofintraductal Origin Calcifications in Intra- and Peri canalicular Fibroadenomas. 6 Calcifications Outside the Lobular and Ductal System of the Breast Calcifications in Fat Necrosis of Varying Etiology. 6.2 Malignant Mixed Tumors with Osseous Metaplasia. 6.3 Calcified Arteries and Thrombi Calcifications in Parasitic Diseases 6.5 Calcified Foreign Bodies Calcified Sebaceous Glands Scattered Calcifications and Ossifications of the Stroma, Subcutaneous Tissue, and Skin Calcifications in the Axillary Lymph Nodes 6.9 Artifacts That Mimic Calcifications Differential Diagnosis of Microcalcifications. 7.1 Checklist Questions and Answers

7 VIII 8 Clinically Occult, Mammographically Suspicious Microcalcification Clusters: Pre-, Intra-, and Postoperative Measures Preoperative Localization Intraoperative Specimen Radiography 8.3 Postoperative Study References.. Subject Index Contents