Breast calcifications and DCIS

Question 1

What is breast calcification?

Answer 1

• Breast calcifications are small calcium deposits that develop in a woman’s breast tissue.
• They are very common and usually benign.

Question 2

What are the types of breast calcifications?

Answer 2

• Macrocalcifications look like large white spots on a mammogram and are often dispersed randomly within the breast. Common and are considered noncancerous.
• Microcalcifications are small calcium deposits that look like white specks on a mammogram. But if they appear in certain patterns and are clustered together, they may be a sign of precancerous cells or early breast cancer.

Question 3

What are the symptoms of breast calcifications?

Answer 3

• Doesn’t cause any symptoms as they are too small to be felt.
• Usually noticed on a mammogram.

Question 4

What are the causes of calcifications?

Answer 4

• Normal aging
• Breast cancer
• Cell secretions or debris
• DCIS
• Fibroadenoma
• Mammary duct ectasia
• Previous injury or surgery to the breast (fat necrosis)
• Previous radiation therapy for cancer.
• Products that contain radiopaque materials or metals, such as deodorants, creams or powders, may mimic calcifications on a mammogram, making it more difficult to interpret whether the calcifications are due to benign or cancerous change

Question 5

What is the management of clustered microcalcifications?

Answer 5

• Another mammogram may be performed to get a more detailed look at the area in question. The calcifications will be determined to be either “benign,” “probably benign,” or “suspicious.”
• The biopsy will need to be performed using mammographic (stereotactic) guidance as calcification can’t usually be well seen on ultrasound.

Question 6

What is specimen x-ray?

Answer 6

• When core biopsy samples are obtained during a stereotactic biopsy, they are always x-rayed to determine whether they contain representative calcification from the area of concern. This is a specimen x-ray

Question 7

What is breast cancer in situ?

Answer 7

Breast cancer in situ comprises ductal carcinoma in situ (DCIS), a non-invasive breast cancer that is confined to the duct in which it originates and does not extend beyond the basement membrane, and lobular carcinoma in situ (LCIS), a neoplastic proliferation of cells that is a risk factor for invasive breast cancer.

Question 8

What is the aetiology of DCIS?

Answer 8

• Ductal carcinoma in situ (DCIS) is proliferation of malignant-appearing epithelial cells that have not penetrated the basement membrane.
• The terminal duct lobular unit is the origin of most lesions. DCIS is part of a continuum of progression from benign disease to invasive cancer, which includes typical hyperplasia, atypical hyperplasia, DCIS, and invasive breast cancer.

Question 9

What is the architectural classification of DCIS?

Answer 9

Comedo

Non-comedo: 
Cribriform 
Micropapillary 
Papillary 
Solid 
Clinging

Question 10

Presentation of DCIS

Answer 10

Key factors include family history of breast cancer, benign breast disease on prior biopsy or hereditary syndromes such as Li-Fraumeni syndrome, Cowden’s syndrome, or hereditary breast ovarian cancer syndrome.

FHx of breast cancer:
o BRCA-related genes 1 and 2 (cancers of breast, fallopian tube, prostate, and ovary).
o Li-Fraumeni syndrome (breast cancer, osteosarcoma, and soft tissue sarcomas).

Nipple discharge

Breast lump

Eczema-like rash on breast

Ulceration

Question 11

What is the management of DCIS?

Answer 11

High-risk patients are recommended mastectomy:
o For example, those with DCIS in two or more quadrants (multicentric disease).
o If there are two or more sites of disease in the same quadrant (multifocal disease), mastectomy should be considered because it may not be feasible to surgically clear the disease and achieve a good cosmetic outcome with breast-conserving therapy

In DCIS patients with no palpable mass, the area will be localised on the by inserting a fine wire into the area of calcification under mammographic guidance. This is called a stereotactic wire localisation. The surgeon will then use the wire to identify the area in theatre. The wire is removed with the surgical specimen.

Because there is often little to see macroscopically with DCIS, it is not always possible to completely remove the area with an adequate margin of healthy tissue. If this is the case, then a re-excision is offered which is where further tissue is removed from the margins of the surgical cavity in an attempt to completely remove the DCIS.

If an area of invasive cancer is found on excised specimen of DCIS, then a sentinel node biopsy of axilla is offered.

Question 12

Complications of DCIS

Answer 12

Tamoxifen-related endometrial cancer
Invasive breast cancer
Radiotherapy-related adverse events
Tamoxifen-related PE