Coarse Heterogeneous Calcifications

Presentation and Presenting Images

A 52-year-old female with a personal history of left breast cancer treated with lumpectomy, radiation therapy, and chemotherapy presents for screening mammography.

42.2 Key Images

( ▶ Fig. 42.3, ▶ Fig. 42.4, ▶ Fig. 42.5, ▶ Fig. 42.6)

42.2.1 Breast Tissue Density

The breasts are heterogeneously dense, which may obscure small masses.

42.2.2 Imaging Findings

There is a group of calcifications in the right breast at the 1 o’clock location in the posterior depth ( ▶ Fig. 42.3 and ▶ Fig. 42.4). These calcifications are seen on the DBT images ( ▶ Fig. 42.5 and ▶ Fig. 42.6). In the area of the calcifications, the DBT does not reveal any associated mass.

42.3 BI-RADS Classification and Action

Category 0: Mammography: Incomplete. Need additional imaging evaluation and/or prior mammograms for comparison.

42.4 Diagnostic Images

( ▶ Fig. 42.7, ▶ Fig. 42.8, ▶ Fig. 42.9, ▶ Fig. 42.10, ▶ Fig. 42.11, ▶ Fig. 42.12)

42.4.1 Imaging Findings

The diagnostic imaging demonstrates a 1.5-cm group of coarse heterogeneous calcifications at the 1 o’clock location in the posterior depth ( ▶ Fig. 42.7, ▶ Fig. 42.8 and ▶ Fig. 42.9) They do not layer on the mediolateral magnification view ( ▶ Fig. 42.8). There is no associated mass. These calcifications were sampled using stereotactic biopsy. Multiple cores contain the calcifications of interest ( ▶ Fig. 42.10). The postprocedure images reveal removal of many of the calcifications and the presence of the biopsy marker clip (bar-shaped) anterior and superior to the epicenter of the biopsy ( ▶ Fig. 42.11 and ▶ Fig. 42.12).

42.5 BI-RADS Classification and Action

Category 4B: Moderate suspicion for malignancy

42.6 Differential Diagnosis

Ductal carcinoma in situ (DCIS): Coarse heterogeneous calcifications can be suggestive of DCIS; there is an increased likelihood if they are in a linear or segmental distribution.
Fibroadenoma: Fibroadenomas can be seen mammographically as only calcifications. A biopsy with sufficient sampling of the calcifications and a pathologic diagnosis of a fibroadenoma associated with the calcifications could be considered concordant.
Invasive carcinoma: Typically coarse heterogeneous calcifications that present as an invasive cancer are associated with a spiculated or indistinct mass. The DBT did not reveal a mass associated with these calcifications.

42.7 Essential Facts

Coarse heterogeneous calcifications have a 15% positive predictive value (PPV) of malignancy.
Beyond morphology, the distribution of calcifications is an important predictor of malignancy. Grouped calcifications have a PPV of malignancy just over 30%, compared to linear and segmental calcifications, which have PPVs of 60% and 62%, respectively.
The X-ray source, motion, pixel size, and reconstruction algorithms of a digital breast tomosynthesis (DBT) system will affect its detection of calcifications.
DBT has good in-plane resolution (direction perpendicular to the X-ray plane), but its out-of-plane resolution is poor. The relatively poor z-depth resolution of DBT contributes to the blurring of calcifications.
Full-field digital mammography (FFDM) has a higher in-plane resolution compared to current DBT.

42.8 Managing and Digital Breast Tomosynthesis Principles

To improve the sensitivity and specificity of DBT for calcifications, it may require a hybrid approach to reading mammograms. The FFDM would be used to assess calcifications and the DBT would provide more information about masses, asymmetries, and architectural distortion.
Larger studies are needed to determine the success of DBT compared to FFDM for detection (sensitivity) and characterization (specificity) of microcalcifications. Current studies suggest that FFDM outperforms DBT.

42.9 Further Reading

[1] Helvie MA. Digital mammography imaging: breast tomosynthesis and advanced applications. Radiol Clin North Am. 2010; 48(5): 917‐929 PubMed

[2] Sickles EA, D’Orsi CJ, Bassett LW, et al. ACR BI-RADS Mammography. In: ACR BI-RADS Atlas, 5th edition. Reston, VA: American College of Radiology; 2013