Pathologic outcomes of coarse heterogeneous calcifications detected on mammography Poster No.: C-1957 Congress: ECR 2011 Type: Scientific Paper Authors: H. J. Lim, K. R. Cho, K. W. Hwang, B. K. Seo, O. H. Woo, Y. W. Oh; Seoul/KR Keywords: DOI: Breast, Mammography, Ultrasound, Decision analysis, Neoplasia 10.1594/ecr2011/C-1957 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. www.myesr.org Page 1 of 12
Purpose The purpose of this study is to investigate the clinical significance and pathologic outcomes of coarse heterogeneous microcalcifications detected on mammography, which is not comprehensively evaluated before. Methods and Materials The retrospective review of our institutional database from January 2006 to May 2010 revealed 48 women with coarse heterogeneous calcifications(chc) on screening or diagnostic mammograms(mg). # Among them, 28 patients underwent image guided or surgical biopsy (n=25) or long term imaging follow up at least two years (n=3) were included in this study. # MG was available in all 28 women and breast ultrasonography(us) was performed in 26 cases. # One of three breast radiologists who were blinded to the pathologic results interpreted the digital MG of these patients in terms of distribution(clustered, linear, segmental, regional, and diffuse), presence of associated mass, and mass size. # We also reviewed the US findings at the corresponding area of CHC on MG and analyzed with following criteria; presence of mass, ductal change, and change of parenchymal echogenicity. # The age of the patients ranged from 28 to 72 years (mean, 44.8 years). # Of 25 lesions with pathologic diagnosis, 14 (56%) were benign and Page 2 of 12
11 (44%) were malignant. # Three women demonstrated no interval change on the follow-up MG at least 2 years were considered as benign cases. Results Of the 14 "pathologically proven" benign lesions, fibrocystic change (FCC), n=7(50%), atypical ductal hyperplasia, n=4(28%), papilloma (n=1), fibrosis(n=1) (Figre 1). Of the 11 "pathologically proven" malignancies, invasive ductal carcinoma (IDC), n= 5(45%), ductal carcinoma in situ (DCIS), n=5(45%), metastatic carcinoma, n=1 (adenocarca. from stomach)(figure 2). Table 1. MG findings of 28 cases (diagnosed by pathology & F/U imaging study at least 2 years) MG findings in total (n=28) cases Benign (n=17) Malignant (n=11) Presence of associated mass 3 (18%) 4 (36%) Size (cm) 0.7 2.9 Clustered 15(88%) 8 (73%) Distribution of coarse herogeneous calcifications Linear 1 (6%) 1 (9%) Regional 1 (6%) 0 Segmental 0 2 (18%) Diffuse 0 0 (Figure 3) Table 2. Breast US findings (n=26) US findings (n=27) Benign (n=16) Malignant (n=10) Page 3 of 12
Presence of associated mass 7 (44%) 5 (50%) Ductal change 1 (0.6%) 1 (10%) Hypoechoic change parenchymal 1 (0.6%) 2 (20%) Case 1 (Figure 4). A 28-year-old woman with pathology proven FCC of right breast. A. MG (RCC, RMLO) reveals CHC with regional distribution in Rt. breast upper to mid outer quadrant. B. On US, a 1.6 cm-sized, ovoid, circumscribed margined mass is noted at right breast,10 o'clock direction. Case 2 (Figure 5). A 53-year-old woman with pathology proven FCC of right breast. A. RCC MG shows about 1cm sized relatively oval shaped isodense mass with clustered CHC in the right breast upper central portion. B. On US, this lesion is about 0.8cm sized indistinct margined hypoechoic mass with internal CHC. Case 3 (Figure 6). A 39-year-old woman with pathology proven fibrosis of right breast, LIQ. A. There are linear arranged CHC in the lower portion of right breast on RCC MG. B. This correlates with localized ductal dilatations with internal calcifications at the right 5-6 o'clock direction on US. Case 4 (Figure 7). A 61-year-old woman with pathology proven IDC of right breast. A. MG(RCC) reveals about 5.1x3.6cm sized, partially obscured, irregular shaped, hyperdense mass with segmental CHC in Rt. breast upper outer quadrant. B. On MRI, this lesion is irregular Page 4 of 12
margined irregular shaped, well enhancing mass with T1 iso/t2 high SI. This shows early strong enhancement and delayed washout on dynamic study. Case 5 (Figure 8). A 41-year-old woman with pathology proven DCIS of left breast. A. On magnification MG, segmental CHC are seen in left UOQ. B. This correlates with ill defined hypoechoic parenchymal change with echogenic dots, suspicious malignant finding, in the left 2 o'clock direction on breast US. Images for this section: Page 5 of 12
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Fig. 1: "Pathologically proven" benign lesions (n=14) Fig. 2: "Pathologically proven" malignancies(n=11) Page 7 of 12
Fig. 3: Distribution of CHC on MG Fig. 4: Case 1. A 28-year-old woman with pathology proven FCC of right breast. A. MG (RCC, RMLO) reveals CHC with regional distribution in Rt. breast upper to mid outer quadrant. B. On US, a 1.6 cm-sized, ovoid, circumscribed margined mass is noted at right breast,10 o'clock direction. Page 8 of 12
Fig. 5: Case 2. A 53-year-old woman with pathology proven FCC of right breast. A. RCC MG shows about 1cm sized relatively oval shaped isodense mass with clustered CHC in the right breast upper central portion. B. On US, this lesion is about 0.8cm sized indistinct margined hypoechoic mass with internal CHC. Fig. 6: Case 3. A 39-year-old woman with pathology proven fibrosis of right breast, LIQ. A. There are linear arranged CHC in the lower portion of right breast on RCC MG. B. This correlates with localized ductal dilatations with internal calcifications at the right 5-6 o'clock direction on US. Page 9 of 12
Fig. 7: Case 4. A 61-year-old woman with pathology proven IDC of right breast. A. MG(RCC) reveals about 5.1x3.6cm sized, partially obscured, irregular shaped, hyperdense mass with segmental CHC in Rt. breast upper outer quadrant. B. On MRI, this lesion is irregular margined irregular shaped, well enhancing mass with T1 iso/t2 high SI. This shows early strong enhancement and delayed washout on dynamic study. Fig. 8: Case 5. A 41-year-old woman with pathology proven DCIS of left breast. A. On magnification MG, segmental CHC are seen in left UOQ. B. This correlates with ill defined hypoechoic parenchymal change with echogenic dots, suspicious malignant finding, in the left 2 o'clock direction on breast US. Page 10 of 12
Conclusion # CHC is categorized as intermediate concern on ACR BI-RADS 4th edition. # Bent et al. proposed CHC in a clustered, linear ductal, or segmental distribution should be classified as intermediate suspicion of malignancy (positive predictive value 36%). # From our results, CHC often confirmed as malignancy, especially when this depicted as clustered (8/11, 73%), linear (1/11, 9%) or segmental (2/11, 18%) distribution and associated with a mass on MG (4/11, 36%) or US (5/10, 50%). # In benign lesions of our study, clustered distribution was most frequent (15/17, 88%). In addition, linear distribution was also noted in one case of benign lesion (1/17, 6%). # So, it can be inferred that we need to consider benign as well as malignant pathology when we encounter CHC with these patterns of distribution and presence of associated mass. # When radiologists interpret CHC detected on MG, substantial possibility of malignancy need to be reminded and should not hesitate in recommending an appropriate biopsy to avoid delayed diagnosis. Page 11 of 12
References # American College of Radiology. Breast imaging reporting and data system (BI-RADS). 4th ed. Reston, Va: American College of Radiology, 2003. # Burnside ES, Ochsner JE, Fowler KJ, Fine JP, Salkowski LR, Rubin DL, Sisney GA. Use of microcalcification descriptors in BI-RADS 4th edition to stratify risk of malignancy. Radiology 2007;242(2):388-395 # Bent CK, Basset LW, D'Orsi CJ, Sayre JW. The positive predictive value of BI-RADS microcalcification descriptors and final assessment categories. AJR 2010;194:1378-1383 # Chan KKK, Lui CY, Chan KK, Yan AT, Wong K, Fung PY, Chan LK, Lam HS. Stratifying risk for malignancy using microcalcification descriptors from the breast imaging reporting and data system 4th edition: experience in a single center in Hong Kong. J HK Coll Radiol. 2009;11:149-153 # Varas X, Leborgne JH, Mezzera J, Jaumandreu S, Leborgne F. Revisiting the mammographic follow-up of BI-RADS category 3 lesions. AJR 2002;179:691-695 Personal Information Page 12 of 12