5-14. Which of the following statements about Case 5-14 is false (Figure 5-24)?
A. The abnormal finding is a spiculated mass.
B. The rate of change is too slow for a breast cancer.
C. A malpractice claim should not be encouraged.
D. The lesion is probably not palpable.
E. This change warrants biopsy.
5-15. With respect to the calcifications in Case 5-15 (Figure5-25), which statement is false?
A. They may be described as pleomorphic.
B. The coarse nature of some of the calcifications suggests this is a benign process.
C. They signal an aggressive malignancy.
D. They are most likely due to necrosis in duct walls.
E. Magnification should be performed to assess the extent of disease.
5-16. With respect to the calcifications in Case 5-16 (Figure5-26), which statement is true?
A. They may be described as granular.
B. The regional distribution makes them highly sus-picious.
C. Follow-up alone would be inadequate.
D. The new onset indicates a high probability of ma-lignancy.
E. They have a less than 20% chance of being malig-nant.
5-14. This case shows back-to-back craniocaudal views of the right breast obtained 1 year apart. In the interval, a small spiculated mass has enlarged so as to become more apparent (arrow) (B is the correct answer to Question 5-14).
5-15. The mammogram of the patient in this case shows a cluster of microcalcifications posteriorly in the central aspect of the breast. Previous mammograms have been normal (B is the correct answer to Question 5-15).
5-16. Magnification view of a portion of the breast of the patient in this case shows coarse calcifications, some of which are rounded or ringlike (E is the correct an-swer to Question 5-16).
Case 5-14 illustrates the concept of developing density. A de-veloping density is any opacity that increases in size or density over time. All such opacities should be evaluated critically, as they can be signs of carcinoma. This concept is based on the natural behavior of breast cancer, which generally grows slowly. With periodic screening, the early tumor will be imaged but unrecognized on early images and may not be detected until 1, 2, 3, or more years later. Tumors 5 mm or smaller are very difficult to differentiate from normal breast tissue, but masses larger than 1 cm are more easily detected. The typical breast cancer has been present for several years by the time it is 1 cm in size. Therefore, breast cancers are routinely visible in retrospect on previous mammograms if the patient has had frequent screening. This does not mean, however, that mal-practice has occurred. If the cancer is still small, no harm has been done and more harm could potentially be done by biop-sying all such tiny densities, because most of them would be normal breast (Statement C is true). Being suspicious but judi-cious with any developing density, therefore, is necessary to de-tect breast cancer early without unnecessary biopsy.
This patient has a small (about 1 cm) spiculated mass in the central part of the breast (Statement A is true). It has in-creased slightly in size over 1 year, with a growth rate typical for breast carcinoma (Statement B is false and is the correct answer to Question 5-14). Being so small in a medium-sized breast, it is unlikely to be palpable (Statement D is true) and, therefore, would require imaging guidance for any biopsy. The spiculated margins, the rate of growth, and the patient’s age group all make this a very suspicious lesion, and biopsy is warranted (Statement E is true). This lesion was an infiltrat-ing ductal carcinoma.
Case 5-15 illustrates a new finding after a previous normal screening. There is a cluster of microcalcifications in the cen-tral area. Note that the calcifications are small and irregular, but we do not see their configuration exquisitely; nor can we be confident of the extent of disease, because there may be other smaller calcifications that we do not see. The patient, therefore, requires recall for magnification mammography (Figure 5-27) (Statement E is true). On magnification, we can appreciate that the calcifications are of many different sizes and shapes (ie, pleomorphic) (Statement A is true). Malig-nant microcalcifications are usually less than 0.5 mm in size, and the very coarse calcifications are classically benign. How-ever, there is significant overlap, and configuration is gener-ally a more helpful sign. Malignant calcifications are usually either granular or linear and branching.
These granular, linear, and branching calcifications are typical of intraductal carcinoma. The aggressive type of in-traductal carcinoma, comedo or high-nuclear-grade carci-noma, causes necrosis in the cancerous mammary duct walls. Calcifications form in areas of necrosis, forming a “cast” of the duct. This process results in the linear and branching forms of calcification (Statements C and D are true). Patho-logic analysis of this tissue showed intraductal carcinoma of the comedo type.
Lesser degrees of necrosis result in smaller, more granular calcifications, whereas extensive necrosis yields rather large rod-shaped or branched calcifications. Option B is false be-cause, although large calcifications alone are usually benign, the mixture of tiny irregular calcifications with the coarse casting calcifications remains very suspicious for malignancy.
In Case 5-16, the mammogram detail shows typical be-nign calcifications. Benign calcifications take many forms, but if we see rings with lucent centers, as in this case, we can rest assured that they are benign. These rings are calcifying microcystic areas of fat necrosis. This is a very common be-nign finding. Punctate, or dotlike, calcifications are also usu-ally benign if uniform and smooth. Granular calcifications are more angular, like broken needle tips, and would be more suspicious (Statement A is false).
Benign calcifying processes such as fibroadenoma, scleros-ing adenosis, and fat necrosis can all be unifocal, or regional, as well as multifocal or diffuse; therefore, distribution alone does not make calcifications suspicious (Statement B is false).
Benign processes of many types do present in adulthood and therefore may appear de novo after a previously normal screening examination. Again, the configuration of calcifica-tions is more helpful (Statement D is false).
For obviously benign calcifications such as these, routine follow-up alone is adequate (Statement C is false). Some cal-cifications are obviously malignant as in Case 5-15. A third group of calcifications is classified as indeterminate, and these require further evaluation, either close mammo-graphic follow-up or some type of biopsy. Taken as a group, biopsied microcalcifications historically have had a rate of malignancy of only 20%. Therefore, Option E is true, be-cause these ringlike calcifications have a better-than-average chance of being benign.
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