26 October 2005 – Case of the Week #25
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We thank Dr. David S. Brenner, Assistant Medical Director, Department of Pathology and Director, Division of Microbiology, Bayhealth Medical Center in Dover, Delaware (USA) for contributing this case. We invite you to contribute a Case of the Week by emailing NPernick@PathologyOutlines.com with microscopic images (any size, we will shrink if necessary) in JPG or GIF format, a short clinical history, your diagnosis and any other images (gross, immunostains, EM, etc.) that you have and that may be helpful or interesting. We will write the discussion (unless you want to), list you as the contributor, and send you a check for $35 (US) for your time after we send out the case. Please only send cases with a definitive diagnosis.
Case of the Week #25
A 61 year old woman had a needle core biopsy for suspicious calcifications noted on mammography of her left breast. The biopsy was examined at multiple levels, revealing only benign fibrocystic disease, but no calcifications (see figure 1, figure 2). The slides were reexamined using polarized microscopy (figure 3).
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Calcium oxalate crystals
The widespread use of mammography has led to detection of breast tumors as small as 1-2 mm through the presence of associated microcalcifications. In general, microcalcifications are present in 50% of carcinomas versus 20% of benign breast disease, and fine clusters and perhaps other patterns of microcalcification are considered suspicious by radiologists. However, only 20% of “suspicious” microcalcifications are actually malignant, and many surgical pathologists routinely receive biopsy specimens with accompanying radiographs containing microcalcifications that, to our non-radiologist eyes, do not appear suspicious at all.
It is important to detect microcalcifications in glass slides corresponding to the microcalcifications in radiographs or radiographic reports. If not found, it is recommended to either submit additional tissue (if the specimen was only partially submitted for histologic exam) or to obtain additional levels (particularly for core biopsies). However, this case illustrates an additional possibility – recognition that calcium oxalate microcalcifications are easily missed on H&E, but can be seen with polarized microscopy (AJSP 1990;14:961).
Calcium oxalate crystals are typically associated with benign cysts or terminal ductules that are apocrine or GCDFP-15 positive. They may be associated with LCIS, but only rarely with invasive carcinoma (AJSP 1991;15:586). In at least one reported case, the crystals were dislodged from a specimen, and found only in the centrifuged fixative (AJSP 1997;21:255). One final cause of “missing” microcalcifications should be noted – detection of calcium phosphate microcalcifications has been described as being reduced with glyoxal fixative (Hum Path 2004;35:1058)
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