Everything You Wanted to Know About Calcifications

Introduction

Hello, my name is Sona. I'm an assistant professor of radiology at Brigham and Women's Hospital, as well as a staff radiologist in the breast imaging division. Today I'll be talking about everything you wanted to know about calcifications, but were afraid to ask.

Opening Objectives

  • Understand appropriate BI-RADS descriptors
  • Understand proper diagnostic workup
  • Review cases on morphology and distribution

Topics

Calcifications can be hard to diagnose, but our learning objectives will make them less difficult. We will cover:

  • Appropriate BI-RADS descriptors
  • Proper diagnostic workup
  • Cases on morphology and distribution
  • Management of benign, suspicious, and probably benign calcifications

Case Summaries

Case 1

  • 67-year-old woman, asymptomatic
  • Fine linear branching calcifications
  • BI-RADS 4C: invasive ductal carcinoma and ductal carcinoma in situ

Case 2

  • 69-year-old woman with a palpable finding
  • Punctate and round calcifications, segmental distribution
  • Invasive ductal carcinoma with DCIS grade 1 of 3

Case 3

  • Screening callback
  • Faint calcifications, superficial location
  • Skin localization confirmed skin calcifications

Case 4

  • 47-year-old woman with prior breast conservation therapy
  • Fat necrosis confirmed with progression of rim coarse calcifications

Case 5

  • Multiple groups of calcifications
  • Vascular calcifications identified
  • Group amorphous calcifications: biopsy proven malignant DCIS

Case 6

  • Screening callback
  • Layering calcifications confirmed with milk of calcium appearance

Case 7

  • 42-year-old woman
  • Grouped pleomorphic calcifications: biopsy confirmed DCIS
  • Contralateral breast: Group layering calcifications, biopsy confirmed benign

Case 8

  • 54-year-old woman with history of breast conservation therapy
  • New calcifications similar to original DCIS
  • Recurrent DCIS confirmed by biopsy

Case 9

  • Biopsy proven malignancy in the upper outer breast
  • Suspicious calcifications found anterior to known malignancy
  • Biopsy confirmed DCIS, leading to mastectomy

Conclusion

If there are new or suspicious findings on imaging prior to definitive surgery, it is important to communicate that information to the surgeon. Some practices have surgeons performing the biopsies, while in others, radiologists perform them. This can change the management for the patient.

At our practice, all breast biopsies are performed by radiologists. However, in many different practices, this is not the case. If you find something that needs biopsy on the day of localization, whether it be a wire localization or a seed localization, it is important to communicate this information to the surgeon. It may be that another biopsy is indicated or that another seed can be placed, but it is a difficult conversation with the surgeon. The surgeon often has the best rapport with the patients and may want to give that news to the patient.

Communication is key, and we have to look at what is the best outcome for the patient. It's better to diagnose this prior to going into the operating room or detecting it a year later after the patient has had radiation or a lumpectomy, just to be able to give the patient the best outcome.

Q and A Session

Q: How does one communicate new or suspicious findings on imaging prior to surgery to the surgeon?

A: At our practice, all biopsies are performed by radiologists, but at other practices, it may be different. Communication with the surgeon is crucial to determine the best course of action for the patient. This may involve another biopsy or additional seed placement, but ultimately, the goal is to ensure the best outcome for the patient by diagnosing any issues before surgery.