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Breast-nonmalignant
Fibrocystic disease
Microcalcifications of breast
Reviewer: Hind Nassar, MD, Johns Hopkins Medical Institute
Revised: 6 October 2012, last major update June 2010
Copyright: (c) 2002-2010, PathologyOutlines.com, Inc.
Definition
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● Deposits of calcium in breast tissue visible on mammographic imaging
Terminology
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● Microcalcifications are either calcium phosphate (basophilic, nonbirefringent) or calcium oxalate (seen with polarized microscopy, not H&E, Am J Surg Pathol 1990;14:961, Archives 1989;113:1367, Mod Pathol 1992;5:146)
Epidemiology
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● Can occur at any age but more common after menopause
Etiology
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● Can be associated with both benign and malignant lesions
Clinical features
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● Presence of microcalcifications on mammography has led to detection of breast tumors as small as 1-2 mm
● Microcalcifications are present in 50% of carcinomas versus 20% of benign breast disease, but only 20% of “suspicious” microcalcifications are actually part of a malignant process
Xray
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● Suspicious microcalcifications are irregular and fine; non-suspicious are coarse and chunky
● Pathologists must detect microcalcifications in glass slides that correspond to those in radiographs - if not present, submit additional tissue, obtain additional levels or use polarized microscopy to look for calcium oxalate (Pathologica 2007;99:5)
● Exhaustive searching for microcalcifications yields a small increase in specific diagnostic information but with a high technical cost (Mod Pathol 2001;14:350)
● Note: microcalcifications may be missing from biopsy due to retrieval failure (Radiology 2006;239:61)
● Note: recommended to examine all vacuum assisted breast biopsy specimens histologically, even those without microcalcifications (Eur Radiol 2008;18:925)
● Detection of calcium phosphate microcalcifications is reduced with glyoxal fixative (Hum Pathol 2004;35:1058)
Radiologic BI-RADS (Breast Imaging Reporting and Data System of American College of Radiology) classification:
● Category 0 - need additional imaging evaluation
● Category 1 - negative
● Category 2 - benign finding
● Category 3 - probably benign finding-short term interval follow up suggested
● Category 4 - suspicious abnormality-biopsy should be considered
● Category 5 - highly suggestive of malignancy-appropriate action should be taken
References: American College of Radiology
Suggested that radiologists subcategorize BI-RADS 4 as 4A (low suspicion for malignancy), 4B (intermediate suspicion of malignancy), and 4C (moderate concern, but not classic for malignancy), Breast J 2010;16:28
LeGal classification of microcalcifications
● Type 1 - annular
● Type 2 - regularly punctiform
● Type 3 - too fine for precizing the shape
● Type 4 - irregularly punctiform
● Type 5 - vermicular (Bull Cancer 1984;71:57)
Xray images
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DCIS
Other images: The Radiology Assistant
Case reports
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● 61 year old woman with suspicious mammographic calcifications (Case of the Week #25)
● Gold salts within intramammary nodes may simulate microcalcifications (Hum Pathol 1988;19:992)
Micro description (Histopathology)
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● Calcium phosphate microcalcifications are associated with benign and malignant disease; are blue/purple psammoma like chunks
● Calcium oxalate crystals are typically within benign cysts or terminal ductules that are histologically apocrine or GCDFP-15 positive; are associated with LCIS, but only rarely with invasive carcinoma (Am J Surg Pathol 1991;15:586)
● Calcium oxalate crystals may be present in centrifuged fixative (Am J Surg Pathol 1997;21:255)
Micro images
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Calcium oxalate calcifications
With polarized light Without polarized light
Benign lesions with microcalcifications
Fibrocystic disease Sclerosing adenosis
ADH Sclerosing adenosis Mucocele-like lesion
Columnar cell change #1; #2 Cystically dilated ducts
Malignant lesions with microcalcifications
Cribriform DCIS LCIS involving adenosis
Virtual Slides
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Microglandular adenosis with microcalcifications
Positive stains
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● Von Kossa for calcium phosphate
Differential Diagnosis
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● FloSeal hemostatic sealant (AJR Am J Roentgenol 2008;191:1371): mimics malignant calcifications
Additional references
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End of Breast-nonmalignant > Fibrocystic disease > Microcalcifications of breast
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