Both amorphous calcifications and associated noncalcified duct dilatation or masses may be seen by tomosynthesis, but the best way to analyze amorphous calcifications is with 2D magnifica- tion mammograms (Fig. 3.51; Fig. e3.6).
B
A C
2D Tomo slice Mag 2D
FIG. E3.6 Suspicious morphology: amorphous: conventional 2D mammogram versus tomosynthesis. Final di- agnosis: fibroadenoma. (A) Conventional 2D mammogram, (B) Tomosynthesis key slice. (C) Magnification 2D mammogram. Conventional 2D mammogram (A) shows one fairly dense calcification. However, amorphous cal- cifications near the dense calcification are difficult to identify. Tomosynthesis (B) visualizes the amorphous calcifi- cations in a curvy shape. Magnification 2D view (C) confirms the amorphous calcifications and shows them more sharply. The result of the stereotactic biopsy was involuting fibroadenomas associated with microcalcifications.
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B
A C
2D Tomo slice Mag 2D
FIG. 3.51 Suspicious morphology: amorphous, conventional 2D mammogram versus tomosynthesis. Final di- agnosis: invasive ductal carcinoma and ductal carcinoma in situ. (A) Conventional 2D mammogram, (B) Tomo- synthesis key slice, (C) Magnification 2D mammogram. On conventional 2D mammogram (A), amorphous cal- cification is difficult to be identified. However, tomosynthesis (B) visualizes amorphous calcification more clearly.
Magnification 2D view (C) confirms the amorphous calcifications and shows them more sharply.
B A
C
FIG. 3.50 Suspicious morphology: amorphous. Final diagnosis: malignancy, after biopsy. (A) Ductal carcinoma in situ (DCIS). (B) Invasive ductal carcinoma with atypical ductal hyperplasia. (C) DCIS.
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B
A C
FIG. 3.52 Suspicious morphology: coarse heterogeneous. Final diagnosis: malignancy. (A) Ductal carcinoma in situ. (B) Invasive ductal carcinoma (IDC). (C) IDC.
B A
D C
FIG. 3.53 Suspicious morphology: coarse heterogeneous. Final diagnosis: benign. (A) Multiple fibroadenomas.
Cluster coarse heterogeneous calcifications (arrows) near the typical popcorn calcification (arrowhead) were prov- en to be fibroadenomas by biopsy. (B) Multiple fibroadenomas. Clusters of coarse heterogeneous calcifications (arrows) were proven to be fibroadenomas by biopsy. (C) Benign dystrophic calcification. Ten years after surgery and radiation therapy for right breast cancer, a new coarse calcification (arrow) was identified at the lumpectomy sited during the annual follow-up. Stereotactic biopsy showed benign calcification without carcinoma. Note that there is a skin marker (arrowheads) representing the surgical scar on the skin surface. (D) Benign dystrophic calcification in irradiated breast tissue (circle). Note the metal clips after surgery.
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B A
C D
F E
FIG. 3.54 Suspicious morphology: fine pleomorphic. Final diagnosis: malignancy. (A) Ductal carcinoma in situ (DCIS). The fine pleomorphic and amorphous calcifications line up in linear or branching patterns, suggesting intraductal spread of cancer. In addition to the fine pleomorphic calcifications, adjacent groups may be fine-linear and fine linear–branching calcifications. It is not unusual to have more than one calcification morphology in any particular group or distribution. (B) DCIS. The fine pleomorphic calcifications form in tight groups. Some calcifi- cations seem like fine-linear and fine linear–branching calcifications. (C) DCIS. Note three BB markers on the skin.
(D) Invasive ductal cancer (IDC) and DCIS. The grouped fine pleomorphic calcifications are accompanied with a small density. (E) IDC. (F) Invasive lobular carcinoma and lobular carcinoma in situ with pleomorphic features.
Note that this is a rare case, because calcification is usually not seen in lobular carcinomas.
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C D
E F
A B
FIG. 3.56 Suspicious morphology: fine linear or fine-linear branching. Final diagnosis: malignancy. This morphology has the highest risk of cancer. (A) Ductal carcinoma in situ (DCIS). (B) DCIS. (C) DCIS and invasive ductal carcinoma (IDC). (D) IDC and DCIS. Note a BB skin marker. (E) DCIS with microscopic IDC and lobular carcinoma in situ. (F) IDC.
ductal hyperplasia by biopsy.
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Calcification Distribution
The ACR BI-RADS lexicon terms for the arrangement of calci- fications in the breast include diffuse, regional, grouped, lin- ear, and segmental (Fig. 3.57). Among them, terms suspicious for cancer are grouped, linear (calcifications in a line that may show branching), and segmental (Fig. 3.58; Table 3.4). This is because the calcifications in these distributions may reflect
cancer growing in diseased breast ducts within a specific breast lobe, the so-called “sick lobe,” as described by Tot and Gere (2008). Generally, the decision to biopsy calcifications is based on the worst features of the individual calcification forms, their distribution within the breasts, if they are new or increase in number, the clinical scenario, and whether they are associated with a palpable mass.
Diffuse Regional Grouped Linear Segmental
FIG. 3.57 BI-RADS Calcification Distributions. Distribution of calcifications is classified into the five types, includ- ing diffuse, regional, grouped, linear, and segmental. (From ACR BI-RADS Mammography, In ACR BI-RADS atlas, breast imaging reporting and data system, Reston, VA, 2013, American College of Radiology.)
0%
26%
31%
60%
62%
Likelihood of malignancy Malignancy Not malignancy
0%
Diffuse
Regional
Grouped
Linear
Segmental
100%
FIG. 3.58 Likelihood of malignancy according to the distribution pattern of calcifications. The values are pre- sented as the percentage of cancer cases among all cases biopsied, based on the studies of Libernman et al., Burnside et al., and Bent et al. (Modified from ACR BI-RADS Mammography, In ACR BI-RADS atlas, breast imaging reporting and data system, Reston, VA, 2013, American College of Radiology.)
TABLE 3.4 Distribution of Calcifications Based on Breast Imaging Reporting and Data System
BI-RADS Term Distribution Typical Dimension Likelihood of Malignancy
Diffuse Throughout the breast 0%
Regional In a large proportion of breast tissue >2 cm in greatest dimension 26%
Grouped In a small portion of breast tissue <2 cm in greatest dimension (minimum 5 calcifications within 1 cm)
31%
Linear In a line 60%
Segmental In a segmental distribution area of concern 62%
BI-RADS, Breast Imaging Reporting and Data System.
From ACR BI-RADS Mammography, In ACR BI-RADS atlas, breast imaging reporting and data system, Reston, VA, 2013, American College of Radiology.
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Grouped intraparenchymal calcifications are more suspicious for cancer than diffuse scattered calcifications. BI-RADS terms suggesting benign calcification distributions include diffuse and regional.