Armed Forces Institute of Pathology.

Transcription

1 Armed Forces Institute of Pathology

2 Armed Forces Institute of Pathology Breast Disease

3 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

4 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

5 Is It a Calcification? Artifacts are common in screen film systems but rare in digital systems

6 Common Artifacts Dust and lint on film or screens Fingerprints Metallic fragments Powder, ointment or deodorant

7 Artifacts Fingerprint Thread

8 Carcinoma and Calcification Calcifications are not malignant Calcifications are not alive Calcifications represent a cast of a space

9 Carcinoma and Calcification If the space represents a normal or benign anatomic space then the underlying process will be benign Dilated ducts

10 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

11 Analysis of Calcifications Shape is most important Size Density Number Distribution Change over time

12 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

13 Tumor tissue necrosis yields small irregular spaces which yields small irregular calcifications Tumor tissue secretion into the duct lumen yields amorphous calcifications Shape

14 Magnification Write and read Magnification views and magnifying lens Standard for evaluation of calcifications Shape and number Is magnification necessary in digital mammography?

15 Magnification Standard Magnification

16 Classes of Calcifications Typically benign Intermediate concern Amorphous or indistinct Coarse heterogeneous Higher probability of malignancy Fine pleomorphic Fine linear

17 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

18 Lobular Calcifications Tightly clustered Round Fit together like a jigsaw puzzle

19 Sutural Calcifications Look like sutures Usually post radiation therapy

20 Calcified Fibroadenoma Coarse or "popcorn-like Calcification generally peripheral

21 Peripheral Calcification

22 Calcified Fibroadenoma

23 Calcified Fibroadenoma

24 Skin Calcifications Faint peripheral clusters with lucent centers Tangent view

25 Skin Calcifications

26 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?

27 Vascular Ductal

28 Vascular Calcification

29 Milk of Calcium

30 Secretory Calcifications Large rods Luminal calcifications Oriented toward nipple Relatively smooth surface May branch

31 Secretory Calcifications

32 Skin calcifications Lucent Centered

33 Egg Shell

34 Intermediate Concern Amorphous or indistinct Not sharply defined Coarse heterogeneous Crushed stone

35 Amorphous or Indistinct

36 Coarse Heterogeneous

37 Coarse Heterogeneous

38 Coarse Heterogeneous

39 Coarse Heterogeneous

40 Higher Probability of Malignancy Fine pleomorphic (granular) Fine linear

41 Fine Pleomorphic

42 Fine Pleomorphic

43 Fine Pleomorphic

44 Fine Linear

45 Fine Linear

46 Fine Linear

47 Casting Fine Linear

48 Size Large calcifications are usually benign Minute (<1mm) calcifications are often malignant

49 Size Macro Micro

50 Size DCIS Fibroadenoma

51 Microcalcifications Invasive ductal carcinoma Invasive ductal carcinoma

52 Density Dense calcifications are usually benign Faint calcifications can be malignant

53 Density Dense FA Faint DCIS

54 Number Cluster is 5 particles or more in 1 cubic cm.

55 Is 5 important? Benign Malignant

56 Distribution of Calcifications Grouped or Clustered Linear Segmental Regional Scattered/diffuse Multiple groups

57 Clustered Malignant 5 or more in 1 cc

58 Clustered This Not this

59 Clustered Benign

60 Distribution of Calcifications Linear, Segmental and Regional Represent degrees of involvement of a ductal system Regional is >2cm and not ductal in distribution

61 Linear

62 Segmental

63 Regional

64 Scattered

65 Osteosarcoma Primary in the breast 27 to 89 years old Median 64.5 years Highly aggressive tumors

66 Primary Osteosarcoma

67 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

68 Management of Calcifications Make benign diagnosis when possible Biopsy when suspicious High probability malignant Intermediate probability Short interval follow-up when probably benign

69 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