A B C
2D Tomo-synthesized 2D Tomo slice
FIG. 3.32 Typically benign: dystrophic calcification, conventional 2D mammogram versus tomosynthesis. (A) Conventional 2D mammogram. (B) Tomosynthesis-synthesized 2D mammogram. (C) Tomosynthesis 1-mm slice.
Amorphous calcification surrounding a radiolucent center represents dystrophic calcification in the biopsy site as well as around an oil cyst after breast reduction surgery. The fatty radiolucent center (C; arrow) is more clearly visualized on tomosynthesis slice (C) than 2D (A) and tomosynthesis-synthesized 2D (B).
A B
FIG. 3.33 Typically benign: dystrophic calcification, time course. (A) Seven years after intraoperative radiation therapy (IORT). (B) Eight years after IORT in the same patient. Dystrophic calcification (arrows) developed and became denser over 1 year.
to exclude recurrent tumor. Because of the problem of recur- rent breast cancer in the cancer biopsy site, biopsy may be required for benign dystrophic calcifications that do not have a classic appearance.
A special type of calcification forms after IORT. These are typically tiny, round, and incredibly dense dystrophic calcifica- tions in the biopsy bed. They are so dense they almost look like metal shavings (Fig. 3.34). Unlike whole-breast radiation, which fractionates the dose over 6 weeks over the entire breast, IORT uses more intense, concentrated radiation for several minutes on only the biopsy site and a small margin of tissue around it dur- ing the operation. Because breast cancer recurrences most often occur in or around the biopsy site, the rationale for IORT is that it sterilizes only the biopsy bed and surrounding tissues in which the cancer may recur. The advantage of IORT is that it treats the biopsy bed without the collateral radiation of surrounding tis- sues from whole-breast radiation therapy. Good results with few cancer recurrences have been shown with IORT when synchro- nous ipsilateral cancers are excluded during patient selection.
the x-ray bean directed vertically; Fig. 3.35). Milk of calcium is benign and should be left alone. The unique appearance of milk of calcium is caused by tiny fluid-filled cysts containing calcifica- tions that float around the cyst like fake snow swirling in a snow globe. On the mediolateral mammogram in an upright patient, milk of calcium calcifications layer dependently, settling to the bottom of tiny imperceptible cysts (Figs. 3.36 and 3.37; Fig. e3.4).
The settled calcifications appear dense, linear, or curvilinear and are always parallel to the floor on the mediolateral mammogram.
On the CC projection, the en face calcifications have a cloudlike or smudgy appearance like tea leaves in the bottom of a teacup.
In macrocystic milk of calcium, lateral views show both the cyst itself and a typical layering of semilunar, linear, or curvilinear cal- cifications in the bottom of the cyst. In other cases, cysts in milk of calcium are too small to be seen, and only the characteristic settled linear calcifications on the lateral view indicate their pres- ence. Milk of calcium should be suspected when calcifications are plainly seen on the lateral or mediolateral oblique view but are hard to see or look like a vague smudge on the standard or even magnified CC views.
To diagnose suspected milk of calcium, technologists have the patient stand upright for a minute in light compression in the mediolateral projection, allowing the calcifications to layer dependently in the cysts. The fully compressed mediolateral mammogram will show linear and curvilinear calcification in the bottom of the cysts. Milk of calcium is seen best on magnification 2D digital mammography or the tomosynthesis-generated 2D synthesized view: sometimes the characteristic milk of calcium shapes may not be as apparent on tomosynthesis (Fig. e3.5).
Milk of calcium and DCIS are look-alikes on the mediolateral view but can be distinguished from each other on the CC view.
On the lateral view both entities have linear shapes. On the CC view, milk of calcium is amorphous or smudgy, whereas DCIS calcifications retain their linear shapes, distinguishing them from milk of calcium (Table 3.2).
Even though milk of calcium is typically benign and should not undergo biopsy, unrecognized milk of calcium may be recom- mended for stereotactic core biopsy by accident. The biopsy can be stopped in time if one recognizes milk of calcium in the prone projection. Because patients undergoing stereotactic core biopsy lie prone on the stereotactic table for quite a long time, settled milk of calcium may layer dependently, changing its appearance from that seen on scout lateral views. On the upright lateral view, the linear calcifications are perpendicular to the chest wall and parallel to the floor. On the prone stereotactic mammogram, the Dilated acini or lobules
Milk of Calcium FIG. 3.35 Schematic of milk of calcium. Milk of calcium is sedi- mented calcifications within tiny benign cysts, enlarged fluid-filled acini, or ductules. Note the crescentic or teacup shape of the cal- cifications falling to the bottom of the tiny cysts.
X-ray tube
X-ray tube
Craniocaudal view
Lateral view
Linear or curvilinear calcification
Smudgy or
amorphous calcification
FIG. 3.36 Schematic of milk of calcium in craniocaudal (CC) and lateral views. The schematic shows the sedimented calcium parti- cles appearing linear or curvilinear on the lateral view. En face the calcifications look smudgy on the CC view.
MLO
A B
CC
FIG. 3.37 Typically benign: milk of calcium. (A) On the mediolateral oblique view, sedimented calcifications take a linear or curvilinear appearance. Generally, the lateral views are best to see the typical linear or curvilinear appearance, but often oblique views, commonly used in screening mammography, provide enough information to make the diagnosis. (B) En face the calcifications look smudgy on the craniocaudal (CC) view.
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A B
C D
Mag Lateral
Tomo MLO Tomo CC
Mag CC
FIG. E3.5 Milk of calcium: conventional 2D magnification mammogram versus tomosynthesis. (A) A magnification 2D lateral view. (B) A magnification 2D craniocaudal (CC) view. (C) A mediolateral oblique (MLO) tomosynthesis 1-mm slice. (D) A CC tomosynthesis 1-mm slice. Compared with conventional mammography (A and B), which clearly shows the curvilinear teacup milk of calcium appearance on the lateral and smudgy CC calcifications, the tomosynthesis slices do not show the calcification shapes as characteristic for milk of calcium, requiring recall (C and D).
A B
Lateral CC
FIG. E3.4 Typically benign: milk of calcium. (A) The sedimented milk of calcium particles appear linear on the lateral view. (B) En face the calcifications look smudgy on the craniocaudal (CC) view.
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linear calcifications are parallel to the chest wall and parallel to the floor. Thus milk of calcium should be suspected if the calcifi- cations change from perpendicular to parallel to the chest wall on lateral versus prone stereotactic mammograms, allowing the radiologist to stop the biopsy.