Leonard M. Glassman MD Analysis of Breast Calcifications

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1 Importance of Calcification Leonard M. Glassman MD FACR American Institute for Radiologic Pathology Washington Radiology Associates, PC Washington DC 45% of all breast cancers present as calcification on mammography Both invasive carcinoma and DCIS can present as calcification Usually can t tell which when only calcification Calcification and mass is usually invasive disease Carcinoma and Calcification Carcinoma and Calcification Calcifications are not malignant Calcifications are not alive Calcifications represent a cast of a space If the space represents a normal or benign anatomic space then the underlying process will be benign Dilated ducts Carcinoma and Calcification Carcinoma and Calcification If tissue necrosis is present the calcification will be irregular Carcinoma If the ductal lumen is irregular the calcification will be irregular Carcinoma 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 1

2 Classes of Calcifications Classes of Calcifications Typically benign Suspicious Moderate concern (typically low grade) Amorphous or indistinct Coarse heterogeneous Serious concern (typically high grade) Fine pleomorphic Fine linear Typically benign Typically benign calcifications need no follow-up or biopsy BIRADS 2 Typically Benign Lobular Calcifications Skin Vascular Coarse or popcorn Large rods Round <1 mm round <0.5 mm punctate Rim Includes egg shell and lucent centered Dystrophic Milk of calcium Suture Dystrophic Milk of calcium Suture Lobular Parasitic Pectoral muscle Tightly clustered Round Fit together like a jigsaw puzzle Sutural Calcifications Calcified Fibroadenoma Look like sutures Usually post radiation therapy Coarse or "popcorn-like Calcification generally peripheral 2

3 Peripheral Calcification Calcified Fibroadenoma Calcified Fibroadenoma Skin Calcifications Faint peripheral clusters with lucent centers Tangent view Skin Calcifications Skin Calcifications 3

4 Vascular Calcifications Vascular Ductal Parallel tracks associated with blood vessels Mocklenburg's medial sclerosis Calcifications are on the outside of the tube Diabetes and heart disease? Mention when seen in women under 50? Vascular Calcification Mockenberg s Medial Sclerosis Milk of Calcium Fibrocystic Change Milk of Calcium 4

5 Secretory Calcifications Duct Ectasia Secretory Calcifications Large rods Luminal calcifications Oriented toward nipple Relatively smooth surface May branch Secretory Calcifications? Pectoral Muscle Calcifications Skin calcifications Rim Fat necrosis Rim 5

6 Analysis of Calcifications Shape of Suspicious Calcifications Shape is most important Size Density Number Distribution Change over time Not typically benign Not smooth (round or rods) round or hollow Coarse heterogeneous Not all the same Irregular shape (crushed stone) Amorphous or indistinct Too small to characterize Fine pleomorphic Fine linear Smooth Round Hollow Shape Tumor tissue necrosis yields small irregular spaces which yields small irregular calcifications Tumor tissue secretion into the duct lumen yields amorphous calcifications Not an Exact Science Magnification Invasive ductal carcinoma Fibrocystic change Write and read Magnification views and magnifying lens Standard for evaluation of calcifications Shape and number Is magnification necessary in digital mammography? 6

7 Magnification Moderate Concern Standard Magnification Amorphous or indistinct Not sharply defined Fibrocystic Atypical ductal hyperplasia DCIS Coarse Crushed stone Atypical ductal hyperplasia DCIS Invasive ductal carcinoma Amorphous or Indistinct Amorphous or Indistinct Coarse Heterogeneous Coarse Heterogeneous 7

8 Leonard M. Glassman MD Analysis of Coarse Heterogeneous DCIS Coarse Heterogeneous Serious Concern Fine Pleomorphic Fine pleomorphic (granular) Fine linear Atypical ductal hyperplasia DCIS Invasive ductal carcinoma Fine Pleomorphic 8

9 Fine Pleomorphic Invasive Lobular Carcinoma Fine Linear Fine Linear Fine Linear Size Casting Large calcifications are usually benign Minute (<1mm) calcifications are often malignant 9

10 Macro Size Micro Size DCIS Fibroadenoma Microcalcifications Density Invasive ductal carcinoma Invasive ductal carcinoma Dense calcifications are usually benign Faint calcifications can be malignant Density Number Dense FA Faint DCIS Groupis 5 particles or more in 1 cubic cm. 10

11 Is 5 important? Distribution of Calcifications Benign Malignant Grouped Linear Segmental Regional Scattered/diffuse Multiple groups Grouped Malignant Grouped 5 or more in 1 cc This Not this Grouped Benign Distribution of Calcifications Linear, Segmental and Regional Represent degrees of involvement of a ductal system Regional is >2cm and not ductal in distribution 11

12 Linear Linear Segmental Regional Scattered 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 12

13 Likely Benign But New Work up of Calcifications This Not this Old examinations Almost always benign if stable (or almost stable) for 2-3 years Magnification views CC and horizontal beam (true lateral usually) 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 13