4. Breast p123-127 (Calcifications)

Question 1

Calcifications (4)

Answer 1

Earliest sign of breast cancer.
3 types
- Artefact
- Benign
- Suspicious

Question 2

Artefact calcifications (3)

Answer 2

Deoderant
- high density material seen in axilla
- High density speck that doesn’t change position with different views (implies it’s on the receptor)
Zinc oxide
- Ointment for breasts, can collect on moles and mimic calcifications.
- Disappears on follow up
Metallic artefact
- Electrocautery devices can leave small metal fragments in the breast.
- Will be very dense and adjacent to a scar

Question 3

Benign vs suspicious (3)

Answer 3

Based on morphology and distribution.
Most cancers start in ducts, so linear or segmental calcification is most concernng.
Bilateral scattered calcifications are least concerning.

Question 4

Dermal calcifications (4)

Answer 4

Benign, found anywhere women sweat (folds, cleavage, axilla).
Often grouped like paw of a bear, or foot of a baby.
They stay in same place on CC and MLO views (tattoo sign).
Tangential view to confirm they’re dermal.

Question 5

Vascular calcifications

Answer 5

Parallel linear calcifications, usually obviously vascular.

Question 6

Popcorn calcifications (2)

Answer 6

Immediate buzzord for degenerating fibroadenomas.
Usually begin around the periphery and slowly coalesce over subsequent images.

Question 7

Secretory, rod like calcifications (5)

Answer 7

Big, easily seen and point to the nipple.
Usually bilateral
“Cigar chaped with lucent center”
“Dashes but no dots”
10-20 years after menopause, happen after duct has involuted.

Question 8

Eggshell calcifications (4)

Answer 8

Due to fat necrosis.
Can be from any trauma (surgical or accident).
If very big, can be called “liponecrosis macrocystica”.
Lucent centered is a buzzword.

Question 9

Dystrophic calcifications (3)

Answer 9

Seen after radiation, trauma or surgery.
Usually big.
“Irregular in shape”, can also have lucent centre.

Question 10

Milk of calcium (4)

Answer 10

Very characteristic look.
On CC, calcifications look powdery and spread out, on MLO they may layer.
on ML, they layer into a more linear appearance, with a curved bottom “tea cupped”.
Due to fibrocystic change, it’s fluid-fluid in a lobule.

Question 11

No calcification on biopsy? (2)

Answer 11

Milk of calcium needs to be viewed with polarised light to assess birefringence.
Otherwise calcifications can’t be seen.

Question 12

Round calcifications (4)

Answer 12

Develop in lobules, usually scattered, bilateral and benign.
Usually due to fibrocystic change when benign.
If bilateral, multiple and similar, they’re benign.
If solitary or different, it’s suspcious. (like a mass).

Question 13

Amorphous calcifications (8)

Answer 13

Suspicious.
Look like powdered sugar, should not be able to count each one.
Scattered and bilateral suggest benign, segmental is concerning.
DDx
- Fibrocystic change (most likely)
- Sclerosing adenitis
- Columnar cell change
- DCIS (low grade)

Question 14

Coarse heterogenous calcifications (9)

Answer 14

Suspicious.
Countable, but their tips are dull.
Usually bigger than 0.5mm.
Distribution and comparison to priors is important.
Can be associated with mass (fibroadenoma or papilloma)
DDx
- Fibroadenoma
- Papilloma
- Fibrocystic change
- DCIS (low to intermediate grade)

Question 15

Fine pleomorphic calcifications (6)

Answer 15

Countable and sharp, usually smaller than 0.5mm.
Highest suspicion for malignancy
DDx
- Fibroadenoma (less likely)
- Papilloma (less likely)
- Fibrocystic change
- DCIS (high grade)

Question 16

Fine linear/fine linear branching calcifications (2)

Answer 16

This distribution makes fine pleomorphic calcifications look even more suspicious.
DDx narrows to basically DCIS or atypical look for secretory or vascular calcifications.

Question 17

Calcifications associated with focal asymmetry/mass (3)

Answer 17

Increased density around suspicious calcifications increases risk of cancer.
Sometimes called “puff of smoke” sign or a “warning shot”.
US is useful for extent of disease.

Question 18

Calcifications in/near lumpectomy scar (2)

Answer 18

Local recurrence rate is around 6%.
New calcifications with suspicious morphology (not fat necrosis) should be biopsied.

Question 19

When to US calcifications (3)

Answer 19

US not usually used to evaluate pure calcification finding.
Exceptions are
- If patient had mass associated with calcifications
- if patient had palpable finding