Consensus review: A method of assessment of calcifications that appropriately undergo a six-month follow-up

A comparative study of the diagnostic value of contrast-enhanced breast MR imaging and mammography on patients with BI-RADS 3-5 microcalcifications

Objective

To retrospectively investigate the diagnostic value of breast MRI in patients with BI-RADS 3–5 microcalcifications in mammography.

Methods

Eighty-four patients with BI-RADS 3–5 microcalcifications on mammography underwent breast MR exams before surgical biopsy with a hookwire position under mammographic guidance. Two radiologists reviewed each lesion with BI-RADS by consensus. The diagnostic value of mammography and MRI was compared.

Results

Histopathological examination revealed 49 benign lesions and 42 malignant lesions. In the assessments of mammography, 21 lesions (23.1%) were assigned to category 3, 51 lesions (56.0%) to category 4, and 19 lesions (20.9%) to category 5. The area under the receiver operating characteristic(ROC) curve for mammography and MR assessment was 0.844, and 0.945, respectively (p<0.05). In cases of category 3 microcalcifications, the specificity of mammography and MR was 100%, and 95.2% (p = 1.000), respectively. In cases of category 4 microcalcifications, the specificity, PPV and accuracy of mammography was 0%, 45.1% and 45.1%; whereas those for MR was 82.1% (p<0.05), 80.8% (P = 0.003) and 86.3% (p<0.05). All microcalcifications of category 5 were correctly diagnosed by mammography and MR.

Conclusions

Breast MRI has the potential to significantly improve the diagnosis of category 4 microcalcifications on mammography. Among mammographic category 4 microcalcifications, about 82% of benign lesions can be degraded to BI-RADS 1∼3 by MRI. However for microcalcifications of category 3 and 5, MR exams do not show significant improvement over mammography.

Microcalcifications Detected as an Abnormality on Screening Mammography: Outcomes and Followup over a Five-Year Period

Objectives. This study reviewed the outcome of women attending a breast screening program recalled for assessment of microcalcifications and examined the incidence of a breast carcinoma detected during the following five years in any of the women who were given a benign diagnosis at assessment. Method. A retrospective study consisted of 235 clients attending an Australian BreastScreen program in 2003, who were recalled for investigation of microcalcifications detected on screening mammography. Records for the following five years were available for 168 women in the benign outcome group including those who did not require biopsy at initial assessment. Results. Malignant disease was detected in 26.0% (n = 146) of the women who underwent biopsy. None of the women in the benign outcome group, with available five-year follow-up records, developed a subsequent breast cancer, arising from the calcifications initially recalled in 2003. Conclusions. This study highlights the effectiveness of an Australian screening program in diagnosing malignancy in women with screen detected microcalcification. This has been achieved by correctly determining 38% (n = 235) of the women as benign without the need for biopsy or early recall. A low rate of open surgical biopsies was performed with no cancer diagnoses missed at the time of initial assessment.

Independent predictors of breast malignancy in screen-detected microcalcifications: biopsy results in 2545 cases

Background:

Mammographic microcalcifications are associated with many benign lesions, ductal carcinoma in situ (DCIS) and invasive cancer. Careful assessment criteria are required to minimise benign biopsies while optimising cancer diagnosis. We wished to evaluate the assessment outcomes of microcalcifications biopsied in the setting of population-based breast cancer screening.

Methods:

Between January 1992 and December 2007, cases biopsied in which microcalcifications were the only imaging abnormality were included. Patient demographics, imaging features and final histology were subjected to statistical analysis to determine independent predictors of malignancy.

Results:

In all, 2545 lesions, with a mean diameter of 21.8 mm (s.d. 23.8 mm) and observed in patients with a mean age of 57.7 years (s.d. 8.4 years), were included. Using the grading system adopted by the RANZCR, the grade was 3 in 47.7% 4 in 28.3% and 5 in 24.0%. After assessment, 1220 lesions (47.9%) were malignant (809 DCIS only, 411 DCIS with invasive cancer) and 1325 (52.1%) were non-malignant, including 122 (4.8%) premalignant lesions (lobular carcinoma in situ, atypical lobular hyperplasia and atypical ductal hyperplasia). Only 30.9% of the DCIS was of low grade.

Mammographic extent of microcalcifications >15 mm, imaging grade, their pattern of distribution, presence of a palpable mass and detection after the first screening episode showed significant univariate associations with malignancy. On multivariate modeling imaging grade, mammographic extent of microcalcifications >15 mm, palpable mass and screening episode were retained as independent predictors of malignancy. Radiological grade had the largest effect with lesions of grade 4 and 5 being 2.2 and 3.3 times more likely to be malignant, respectively, than grade 3 lesions.

Conclusion:

The radiological grading scheme used throughout Australia and parts of Europe is validated as a useful system of stratifying microcalcifications into groups with significantly different risks of malignancy. Biopsy assessment of appropriately selected microcalcifications is an effective method of detecting invasive breast cancer and DCIS, particularly of non-low-grade subtypes.

Synchronous benign-appearing calcifications in patients with ductal carcinoma in situ may not be benign

BACKGROUND

The management of multiple synchronous groups of benign-appearing calcifications in patients with a diagnosis of breast cancer or a high-risk lesion requiring excision is unclear. The purpose of this study was to examine the results of biopsies of synchronous benign-appearing microcalcifications, in patients with a concurrent abnormal pathology result requiring surgery.

METHODS

A review was performed of all breast stereotactic-guided vacuum biopsies done at Elmhurst Hospital Center (Elmhurst, NY, USA) between January 2006 and February 2009. Patients with an abnormal pathology result that had further biopsies of synchronous benign or probably benign microcalcifications were included.

RESULTS

Two hundred and fifty-two patients had abnormal biopsy results. Twenty-eight patients with additional clusters of microcalcifications reported as benign or probably benign underwent 34 additional biopsies. Abnormal pathology results were found in half of these biopsies, changing the surgical plan in 14 patients. In patients with ductal carcinoma in situ (DCIS) this rate was 71%. Four patients had their diagnosis upgraded.

CONCLUSIONS

In patients with abnormal findings on stereotactic biopsy of microcalcifications, synchronous benign-appearing microcalcifications are associated with a high rate of abnormal pathology. A 'second look' at the mammogram and further biopsy of other clusters of benign-appearing microcalcifications should be considered in patients with DCIS who are planning to undergo breast-conserving treatment.