Microcalcifications detected on mammography classified as BIRADS 4 and 5 and their correlations with histopatologic findigns

Microcalcifications detected on mammography classified as BIRADS 4 and 5 and their correlations with histopatologic findigns Poster No.: C-0401 Congress: ECR 2010 Type: Educational Exhibit Topic: Breast Authors: M. Kosterska-Spalska, T. Drozdz, A. Duda-Tazbir, I. Wiek-Smuga; Kielce/PL Keywords: suspicious, indeterminate microcalcifications, BIRADS category, radio-pathological correlations DOI: 10.1594/ecr2010/C-0401 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 27

Learning objectives To describe and illustrate mammographic findings of suspicious microcalcifications.to evaluate microcalcifications classified as BIRADS4 (a,b,c) and 5 and outline their correlations with histological findings using stereotactic biopsy. Background Microcalcifications are mammographic halmark of nonpalpable noninvasive breast carcinomas and can be found in 80% of DCIS. Due to wiedespread usage of screening mammography the incidence of DCIS has highly increased. In addition to breast screening programme in 2008 in our center we have selected 132 mammographies with suspicious microcalcifications classified accordind to BIRADS as 4 (a,b,c) and 5 category. In all these cases stereotactic biopsy was performed. After histological identification the mammographic and patologic features were compared. To standardize mammographic reporting the American College of Radiology implemented The Breast Imaging Reporting and Database System, known as BIRADS. ACR BI-RADS categories to describe breast calcifications: 0 - need additional imaging evaluation 1 - negative 2 - benign finding (involuting, calcified fibroadenomas, multiple secretory calcifications,oil cyst,vascular calcifications, calcified architectural distortion clearly related to prior surgery) 3 - probably benign finding - initial short - interval follow up suggested (less then 2% risk of malignancy; cluster of round (punctate) calcifications) 4 - suspicious abnormality - biopsy should be considered 5 - highly suggestive of malignancy - appropriate action should be taken Page 2 of 27

Acording to BIRADS we can devide calcifications into BENIGN INDETERMINATE MALIGNANT (suspicious) Calcifications should be assessed according to well-established attributes which are : SHAPE- SIZE - DENSITY - NUMBER - DISTRIBUTION - LOCATION and associated findings. (Fig.1, Fig.2) Suspicious calcifications: SHAPE (probably the most important element in their analysis): casting, branching, heterogeneous, pleomorphic, irregular, comma shaped, angular,amorphous,indistinct. Situated within the ducts or within the terminal ductal lobular unit (TDLU). (Fig.1, Fig.3, Fig.4, Fig.5.) SIZE mostly seen on mammograms are not larger than 0,5mm, sometimes may reach size up to 1-2mm. Heterogeneity of their size should be alarming DENSITY inhomogeneous, mostly low-density calcifications NUMBER aggregation of indeterminate microcalcifications may indicate disease - five or more microcalcifications within 1cm 3 should raise suspicions DISTRIBUTION calcifications may be distributed in clusters, may fill the segment or may be diffusely scattered over a region. Grouped or clustered calcifications which are BIRADS 4 or 5 are the most common distribution raising suspicion but only 25% of them prove to be malignant. Segmental distribution should be always warning (especially if they are seen in at least two projections). Linear and branching calcifications heading toward the nipple may represent an intraductal malignancy spreading through the ductal system - should be included in BIRADS 4 or 5 (Fig.2, Fig.3.). Page 3 of 27

Always consider other characteristics associated with any of the groups that may change the level of suspicion. Images for this section: Page 4 of 27

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Fig. 1: BIRADS classification - morphology of calcifications Page 6 of 27

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Fig. 2: BIRADS classification - distribution of calcification Fig. 3: Schematic image of linear, fine, branching also cold casting type calcifications a)fragmented casting - type calcifications within the ducts b)dotted casting - casting type calcifications within the ducts Page 8 of 27

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Fig. 4: Schematic image of powdery, cotton - ball like, punctate, amorphous calcifications, within the TDLU. Page 10 of 27

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Fig. 5: Schematic image of crushed-stoned like calcifications, granular,pleomorphic calcifications, within the TDLU. Fig. 6: Innumerable casting-type and granular -type calcifications spread over a large area of the breast.architectural distortion and large axillary node is associated. BIRADS5. HP- ca ductale invasivum, CDIS component Page 12 of 27

Fig. 7: Cluster of irregular in shape, size and density, fragmented and some casting - type calcifications - malignant type of microcacifications.birads 4c. HP- DCIS(non comedo),ng2 Fig. 8: Numerous, irregular in shape, size and density calcifications - malignant type.birads5. HP - DCIS (comedo) Page 13 of 27

Fig. 9: Innumerable granular-type microcalcifications of varying form, size and density, some of them are of the casting - type.typical mammographic appearance of malignant -type calcifications.birads5. HP -DCIS (comedo),ng2 Page 14 of 27

Fig. 10: Segmental distribution of granular, calcifications.birads4c. HP- DCIS (comedo), NG2 pleomorphic, irregular Page 15 of 27

Fig. 11: Typical intraductal casting-type calcifications, some branching, follow the course of a duct.birads5. HP -DCIS (comedo), NG2 Page 16 of 27

Fig. 12: Cluster of microcalcifications, amorphous, pleomorphic with mixed density. Indeterminate calcifications.birads4b. HP - DCIS, NG2 Page 17 of 27

Imaging findings OR Procedure details We have evaluated suspicious and indeterminate microcalcifications based on their morfology and distribution and classified them as Birads 4 or 5. Its correlation with anatomopathological findings and results of stereotactic biopsy with rates of DCIS, invasive breast cancer, high risk and benign leasions are described and illustrated. INDETERMINATE microcalcifications: Amorphous or indistinct:often roud or flake - shaped calcifications that are so small or hazy that a more specific morphologic classification cannot be determined (biopsy is warranted), powdery or cotton-ball like calcifications.(fig.1, Fig.2, Fig.7) HIGHER PROBABILITY OF MALIGNANCY : Pleomorphic or heterogeneous calcifications (granular), irregular calcifications with varying size and shapes that usually less than 0,5mm diameter(fig.3, Fig.4, ). Fine linear, branching (casting) calcifications. Thin, irregular calcifications that appear linear, but are discontinuous and less than 0,5mm in width. Their appearance suggests filling of the lumen of a duct involved irregularly by breast cancer. (Fig.5, Fig.6) 132 women with suspicious microcalcifications (indereminate and malignant) detected on mammographz underwent stereotactoic biopy. Each finding was classified according to BIRADS as 4 or 5 and most of cases were classified as 4 and 4b, less as 5. Anatomo-pathological correlations: 22 findings were malignant ( 13 cases of DCIS and 9.- invasive cancer) 9 cases were border- line findings as lobular neoplasia, atypical ductal hyperplasia, collumnar cell change end they were classified again as BIRADS3 (Fig.8). 101 finding were benign included fibro-cystic leasions, adenosis slcerosans, papilloma intraductale, usual ductal hzperplasia, atropha lipomatosa. Page 18 of 27

Images for this section: Fig. 1: Stereotactic biopsy :poorly seen amorphous, powdery microcalcifications. BIRADS 4b. HP -DCIS, NG1. Page 19 of 27

Fig. 2: Stereotactic biopsy.indeterminate, amorhous, some cotton-ball lite calcifications. BIRADS4b. HP- ca ductale invasivum, DCIS component Page 20 of 27

Fig. 3: Cluster of pleomorphic, various in size and density calcifications. BIRADS4b. HPDCIS, NG2. Page 21 of 27

Fig. 4: Segmental distribution of numerous granular, pleomorphic and some casting-type of calcifications indicating presence of malignancy.birads5. HP- DCIS (comedo). Page 22 of 27

Fig. 5: pleomorphic, irregular, granular segmental distributed microcalcifications. BIRASDS 4b. HP- CDIS, NG2. Page 23 of 27

Fig. 6: Stereotactic biopsy.punctate, amorphous, poorly defined calcifications. Indeterminate calcifications.birads4. HP -DCIS,NG2 Page 24 of 27

Fig. 7: Large area of irregular, pleomorphic microcalcifications, different size and density microcalcifications. BIRADS4. HP-DCIS (comedo), NG2. Page 25 of 27

Fig. 8: Diffuse lobular -type microcalcifications. BIRADS4a. HP- Atypical ductal hyperplasia Page 26 of 27

Conclusion There are significant advantages of using BIRADS category to classify calcifications. The categorization of microcalcifications in classes of suspicion allowed the standarization of the mammographic language and help to suggest subsequent diagnostic and therapeutic strategy. The main difficulty in the description and interpretation was found for punctate, amorphous and pleomorphic microcalcifications. Amorphous and punctate especially if they are in linear or segmental distribution sholud always be considered as suspicious and categorized as BIRADS4, but we can see the high number of low suspicious microcalcifications undergoing stereotactic biopsy mostly describe as punctate calcifications categorized as BIRADS4a. Pleomorphic microcalcifications are representing the most numerous group were biopsy is warranted. Radio-pathology correlation is necessary and will help to reduce false-positive rate in the future. A benign histopathology results in cases with BIRADS 4a and some b may eliminate the need for surgery biopsy. Personal Information E-mail (Monika Kosterska-Spalska): mtkosterscy"neostrada.pl References 1.Mammografia w diagnostyce raka sutka - J.Dziukowa i Ewa Wesoowska 2.Diagnosis of diseases of the breast - Lawrence W.Basset, Valerie P.Jackson, KarinL.Fu,YaoS.Fu. 3.Teaching Atlas of Mammography - L. Tabar, P.B.Dean. 4.American College of Radiology (source - www.acr.org) 5. Infoacademy Microcalcification Site: calcifications 6.mammographic Analysis of Breast calcifications -InIkede DM.Breast Imaging, The Requisisetes.USA.Mosby,2004 Page 27 of 27