Breast calcification: Management and Pictorial Review

Transcription

1 Breast calcification: Management and Pictorial Review Poster No.: C-0692 Congress: ECR 2014 Type: Educational Exhibit Authors: V. de Lara Bendahan, M. F. Ramos Solis, A. Amador Gil, C Gómez de las Heras, J. C. Pérez Herrera, M. Barral, J. M Sánchez Crespo, J. L. Ortega Garcia ; Cádiz/ES, Sevilla/ES, 3 Osuna/ES, Puerto Real/ES, Vejer de la Frontera, Cádiz/ES, Jerez de la Frontera/ES Keywords: Breast, Mammography, Education, Screening, Education and training DOI: /ecr2014/C-0692 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 20

2 Learning objectives Breast calcifications are common findings on mammography and may reflect both benign and malignant causes. Approximately 95% of all ductal carcinoma in situ is diagnosed because of mammographically detected microcalcifications [1]. The diagnostic approach to breast calcifications is to analyze the morphology, distribution and sometimes change over time. In this review we will focus on: - Description of breast calcifications - Categorization in BIRADS lexicon - Determine the patient management Page 2 of 20

3 Background The basic functional unit in the breast is the lobule, also called the terminal ductal lobular unit (TDLU). This is an important structure because most invasive cancers arise from the TDLU, but it also is the site of origin of ductal carcinoma in situ (DCIS), lobular carcinoma in situ, fibroadenoma and fibrocystic disease, apocine metaplasia, adenosis and epitheliosis. Most calcifications in the breast form either within the terminal ducts (intraductal calcifications) or within the acini (lobular calcifications) [1]: - Lobular calcifications These calcifications fill the acini, which are often dilated. This results in uniform, homogeneous and sharply outlined calcifications, that are often punctate or round. When the acini become very large may fill these cavities. However when there is more fibrosis, as in sclerosing adenosis, the calcifications are usually smaller and less uniform. In these cases it can be difficult to differentiate them from intraductal calcifications. Lobular calcifications usually have a diffuse or scattered distribution, and are almost always benign. - Intraductal calcifications These calcifications are calcified cellular debris or secretions within the intraductal lumen, that explains the fragmentation and irregular contours of the calcifications. These calcifications are extremely variable in size, density and form. Sometimes they form a complete cast of the ductal lumen. This explains why they often have a fine linear or branching form and distribution. Intraductal calcifications are suspicious of malignancy. Page 3 of 20

4 Findings and procedure details The diagnostic approach to breast calcifications is to analyze the morphology, distribution and sometimes change over time. Authors of the BI-RADS lexicon have divided microcalci#cation morphologic descriptors into the following designated categories that predict benignity or malignancy [2]: - Typically benign - Intermediate concern - Higher probability of malignancy Morphology (Fig 1) (Fig 2) The morphology and size of calcifications are the most important factor in the differentiation between benign and malignant [3]. If calcifications cannot be readily identified as `typically benign Fig. 3 on page 9, Fig. 4 on page 9, Fig. 5 on page 10, Fig. 6 on page 11 or as 'high probability of malignancy' Fig. 7 on page 12, they are termed of 'intermediate concern or suspicious' Fig. 8 on page 13. Page 4 of 20

5 Fig. 1: Microcalci#cations morphologic descriptors: Typically benign. (Categorization in BIRADS lexicon) References: Radiology, SAS, H.U. Puerto Real, Cádiz - Cádiz/ES Page 5 of 20

6 Fig. 2: Microcalci#cations morphologic descriptors: Intermediate concern and higher probability of malignancy. (Categorization in BIRADS lexicon) References: Radiology, SAS, H.U. Puerto Real, Cádiz - Cádiz/ES Distribution (Fig 9) The distribution of breast calcifications is also useful in differentiating benign from indeterminate and malignant causes [4]. In the BI-RADS atlas the following descriptions are given for the distribution of calcifications: Diffuse, Regional, Clustered, Segmental and Linear. Fig. 10 on page 14, Fig. 11 on page 15, Fig. 12 on page 16. Page 6 of 20

7 Fig. 9: Microcalci#cations distribution modifiers(categorization in BIRADS lexicon) References: Radiology, SAS, H.U. Puerto Real, Cádiz - Cádiz/ES Change over time There are conflicting data concerning the value of absence of change over time. It is said that the absence of interval change in microcalcifications that are probably benign on the basis of morphologic criteria is a reassuring sign and an indication for continued mammographic follow-up. On the other hand in a retrospective study that included indeterminate and suspicious clusters of microcalcifications, stability could not be relied on as a reassuring sign of benignancy. In this group of patients with biopsy proven malignancy, 25% of patients had stable microcalcifications for 8-63 months [1]. It seems that the morphology of calcifications is far more important than stability, and stability can only be relied on if the calcifications have a probably benign form. The odds for invasive carcinoma versus ductal carcinoma-in-situ (DCIS) are statistically significantly higher among patients with increasing or new microcalcifications. The Page 7 of 20

8 likelihood that carcinoma will be invasive increases significantly when a suspicious or indeterminate cluster of calcifications is new or increasing. Page 8 of 20

9 Images for this section: Fig. 3: Calcifications typically benign: Need no follow up. (BI-RADS-2) Radiology, SAS, H.U. Puerto Real, Cádiz - Cádiz/ES Page 9 of 20

10 Fig. 4: Calcifications typically benign Radiology, SAS, H.U. Puerto Real, Cádiz - Cádiz/ES Page 10 of 20

11 Fig. 5: Calcifications typically benign Radiology, SAS, H.U. Puerto Real, Cádiz - Cádiz/ES Page 11 of 20

12 Fig. 6: LEFT: Punctate calcifications (typically benign), but they were ipsilateral to a cancer RIGHT: Punctate calcifications new on follow up. They showed cluster distribution and they were classified as Bi-RADS 4 (3-95% chance of malignancy). Radiology, SAS, H.U. Puerto Real, Cádiz - Cádiz/ES Page 12 of 20

13 Fig. 7: High Probability of Malignancy: These were classified as BI-RADS 5. Radiology, SAS, H.U. Puerto Real, Cádiz - Cádiz/ES Page 13 of 20

14 Fig. 8: Suspicious Calcifications (Intermediate Concern): Usually these calcifications are biopsied to determine their exact nature Radiology, SAS, H.U. Puerto Real, Cádiz - Cádiz/ES Page 14 of 20

15 Fig. 10: LEFT: Diffuse calcifications is typically seen in benign entities. RIGHT: Cluster calcifications are both seen in benign and malignant disease and are of intermediate concern. A single cluster of calcification favors a malignant entity. Radiology, SAS, H.U. Puerto Real, Cádiz - Cádiz/ES Page 15 of 20

16 Fig. 11: Regional calcifications: Since this distribution may involve most of a quadrant or more than a single quadrant, malignancy is less likely. However, evaluation must include element shape as well as distribution: LEFT: Punctata and amorphous. Biopsy revealed CDIS RIGHT: Fine linear and pleomorphic. Biopsy revealed CDIS Radiology, SAS, H.U. Puerto Real, Cádiz - Cádiz/ES Page 16 of 20

17 Fig. 12: LEFT: Linear distribution with mass associated, sugestive of malignancy. Biopsy revealed Invasive ductal carcinoma. RIGHT: Coarse Heterogeneous and fine linear with segmental distribution, sugestive of malignancy. Biopsy revealed Invasive ductal carcinoma. Radiology, SAS, H.U. Puerto Real, Cádiz - Cádiz/ES Page 17 of 20

18 Conclusion Breast calcifications are common findings on mammography and may reflect both benign and malignant causes. Microcalci#cation descriptor in the BI-RADS lexicon can help stratify the risk of malignancy in patients selected to undergo breast biopsy. Evaluation of breast calcification morphology and distribution with evaluation of any interval changes can aid in determining patient management. Page 18 of 20

19 Personal information Victoria de Lara Bendahán, M.D. Department of Radiology, Hospital Universitario de Puerto Real, Puerto Real (Cádiz), España. Page 19 of 20

20 References Radiology Assistant Website. Calcifications differential diagnosis. American College of Radiology (ACR) Breast Imaging Reporting and Data th System Atlas (BI-RADS Atlas). Mammography 4 edition. Reston, Va: American College of Radiology; Amanda Demetri-Lewis, Priscilla J. Slanetz, Ronald L. Eisenberg. Breast Calcifications: The Focal Group. AJR 2012; 198:W325-W343. Kopans DB. Breast imaging, 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2007:73-75, 443, 444, , Page 20 of 20