Cracking the Case: Challenging Calcifications

Introduction

Hello. My name is Sona Chikarmenay. I'm an assistant professor of radiology and associate chair of faculty development in the breast imaging section in the department of Radiology at Brigham and Women's Hospital. And today I'll be talking about cracking the case: Challenging calcifications.

Learning Objectives

• Review challenging cases of calcifications based on their morphology and distribution.
• Review the importance of technique beyond just motion artifact.
• Discuss the use of ultrasound and MRI for calcifications and review some important pitfalls.
• Provide a brief overview of synthetic mammography and calcifications.

Challenging Cases of Calcifications

Case 1

This is a case of a woman who was called back for calcifications in her left breast. These MLO and CC blown-up views demonstrate calcifications in the upper outer breast at posterior depth. You can see these are denoted by the orange arrow. She was called back and subsequent magnification views were obtained. Here we see a lateral magnification view and a CC magnification view.

Evaluation

• Important to evaluate calcifications on magnification views.
• Consider morphology and distribution.
• Initial diagnostic workup thought these calcifications to be vascular.
• Despite initial thoughts, the calcifications' linear morphology and distribution suggested biopsy.

Follow-Up

• At six months, calcifications increased in conspicuity.
• Stereotactic biopsy revealed ductal carcinoma in situ.

Case 2

Another screening callback with grouped calcifications in the retroariolar region. Magnification views were performed and initially thought to be vascular.

Evaluation

• Look at the entire breast for other vascular calcifications.
• Assess morphology for the toothpaste sign indicative of ductal carcinoma in situ.

Follow-Up

• Six-month follow-up showed stability but eventual increase in irregularity.
• Stereotactic biopsy at twelve months revealed DCIS intermediate to high grade.

Technique Beyond Motion Artifact

Case 1

A 54-year-old woman with a screening mammogram showing a skin fold, preventing evaluation of the underlying tissue.

Importance

• Magnification views needed to detect amorphous calcifications.
• Stereotactic biopsy confirmed invasive ductal carcinoma with DCIS grade two.

Case 2

A 67-year-old woman with screening mammogram showing two groups of calcifications. Only magnification views obtained at six months.

Follow-Up

• Patient missed twelve-month follow-up, returned at twenty-four months with a palpable mass.
• Found to be invasive ductal carcinoma.

Case 3

A 59-year-old woman with subpectoral silicone implants, making it difficult to push the implants for an implant-displaced view.

Follow-Up

• Stable calcifications on six-month follow-up.
• Twelve-month follow-up showed increased coarse heterogeneous calcifications.
• Biopsy confirmed invasive ductal carcinoma with DCIS intermediate to high grade stage one.

Multimodality Correlation

Case 1

A 38-year-old woman with a palpable finding in the upper outer breast. Diagnostic mammogram showed calcifications, and ultrasound showed a hypoechoic mass.

Follow-Up

• Six-month follow-up showed additional amorphous calcifications.
• Biopsy confirmed invasive ductal carcinoma with DCIS.

Case 2

A 41-year-old woman with bloody nipple discharge. Segmental calcifications with punctate and amorphous appearance in the retroariolar and inner breast.

Evaluation

• Ultrasound showed duct ectasia.
• Six-month follow-up showed more conspicuous calcifications.
• Biopsy confirmed high-grade ductal carcinoma in situ.

Synthetic Mammography

Advantages

• Reduces radiation dose and acquisition time.
• Increases the conspicuity of calcifications and architectural distortion.

Disadvantages

• Higher false positive recall rate.
• Smaller calcifications may be harder to detect.

Key Points

• Ensure calcifications are present on both CC and MLO projections.
• Use DBT slices to confirm the presence of calcifications.

Conclusion

Today we reviewed challenging cases of morphology and distribution, the importance of technique beyond just motion artifact, some pitfalls when using ultrasound and MRI for calcifications, and a brief overview of synthetic mammography, which is being adopted across the country. Thank you very much for listening to this lecture.