microcalcification in benign breast disease
DESCRIPTION
MICROCALCIFICATION IN BENIGN BREAST DISEASE. Dr Azar Naimi MD.ACP Poursina research Lab. Hormoz Island. Type I: calcium oxalate dihydrate crystals ( Weddelite ) are birefringent , predominantly in benign lesions. In ducts. - PowerPoint PPT PresentationTRANSCRIPT
![Page 1: MICROCALCIFICATION IN BENIGN BREAST DISEASE](https://reader036.vdocuments.us/reader036/viewer/2022062305/568165e7550346895dd90710/html5/thumbnails/1.jpg)
MICROCALCIFICATION IN BENIGN BREAST
DISEASEDr Azar Naimi MD.ACPPoursina research Lab
![Page 2: MICROCALCIFICATION IN BENIGN BREAST DISEASE](https://reader036.vdocuments.us/reader036/viewer/2022062305/568165e7550346895dd90710/html5/thumbnails/2.jpg)
Hormoz Island
![Page 3: MICROCALCIFICATION IN BENIGN BREAST DISEASE](https://reader036.vdocuments.us/reader036/viewer/2022062305/568165e7550346895dd90710/html5/thumbnails/3.jpg)
Type I: calcium oxalate dihydrate crystals (Weddelite) are birefringent, predominantly in benign lesions. In ducts.
![Page 4: MICROCALCIFICATION IN BENIGN BREAST DISEASE](https://reader036.vdocuments.us/reader036/viewer/2022062305/568165e7550346895dd90710/html5/thumbnails/4.jpg)
Type II: calcium phosphates largely in the form of hydroxyapatite are not birefringent: in benign and malignant lesions. In ducts and stroma.
![Page 5: MICROCALCIFICATION IN BENIGN BREAST DISEASE](https://reader036.vdocuments.us/reader036/viewer/2022062305/568165e7550346895dd90710/html5/thumbnails/5.jpg)
Hormoz Island
![Page 6: MICROCALCIFICATION IN BENIGN BREAST DISEASE](https://reader036.vdocuments.us/reader036/viewer/2022062305/568165e7550346895dd90710/html5/thumbnails/6.jpg)
What should we do if we receive a kind of specimen, excised for non palpable lesion with microcalcification?
For first step, radiography of the intact specimen is an essential part of the processing of these specimens. This is to ensure that the lesion is contained the calcification.
A specimen X-ray should be sent to the pathologist along with the specimen.
![Page 7: MICROCALCIFICATION IN BENIGN BREAST DISEASE](https://reader036.vdocuments.us/reader036/viewer/2022062305/568165e7550346895dd90710/html5/thumbnails/7.jpg)
![Page 8: MICROCALCIFICATION IN BENIGN BREAST DISEASE](https://reader036.vdocuments.us/reader036/viewer/2022062305/568165e7550346895dd90710/html5/thumbnails/8.jpg)
If the mammographic abnormality reveals microcalcification, the pathologist should make every effort to identify them in histologic sections.
If X-ray of the sliced tissue specimen is available, all abnormal areas seen should be submitted and labelled on the radiograph.
![Page 9: MICROCALCIFICATION IN BENIGN BREAST DISEASE](https://reader036.vdocuments.us/reader036/viewer/2022062305/568165e7550346895dd90710/html5/thumbnails/9.jpg)
If these are not identified in the sections the following steps should be followed:
The microcalcification may represent calcium oxalate crystals. These requires polarization lenses to visualize.
X-ray of the paraffin blocks and any remaining wet tissue, if any. Multiple level sections can be made of the blocks containing the calcification.
Calcification can be leached out by acidic fixatives or shattered out by the microtome blade. The PH of the fixative should be checked regularly.
![Page 10: MICROCALCIFICATION IN BENIGN BREAST DISEASE](https://reader036.vdocuments.us/reader036/viewer/2022062305/568165e7550346895dd90710/html5/thumbnails/10.jpg)
Hormoz Island
![Page 11: MICROCALCIFICATION IN BENIGN BREAST DISEASE](https://reader036.vdocuments.us/reader036/viewer/2022062305/568165e7550346895dd90710/html5/thumbnails/11.jpg)
WHICH BENIGN BREAST LESIONS MAY BE
ENCOUNTERED WITH MICROCALCIFICATION ?
![Page 12: MICROCALCIFICATION IN BENIGN BREAST DISEASE](https://reader036.vdocuments.us/reader036/viewer/2022062305/568165e7550346895dd90710/html5/thumbnails/12.jpg)
If radiology is looking for a calcs, then report a specific pathologic identity that would be compatible with calcs.
![Page 13: MICROCALCIFICATION IN BENIGN BREAST DISEASE](https://reader036.vdocuments.us/reader036/viewer/2022062305/568165e7550346895dd90710/html5/thumbnails/13.jpg)
Sclerosing adenosis Radial scar Columnar cell change Intraductal papilloma ALH Mucocele like lesions Apocrine metaplasia Old fibroadenoma Old fat necrosis Calcification associated with lactational change Ductectasia
![Page 14: MICROCALCIFICATION IN BENIGN BREAST DISEASE](https://reader036.vdocuments.us/reader036/viewer/2022062305/568165e7550346895dd90710/html5/thumbnails/14.jpg)
Which of these Breast Lesions do they need
excision after Core Biopsy ?
![Page 15: MICROCALCIFICATION IN BENIGN BREAST DISEASE](https://reader036.vdocuments.us/reader036/viewer/2022062305/568165e7550346895dd90710/html5/thumbnails/15.jpg)
Hormoz Island
![Page 16: MICROCALCIFICATION IN BENIGN BREAST DISEASE](https://reader036.vdocuments.us/reader036/viewer/2022062305/568165e7550346895dd90710/html5/thumbnails/16.jpg)
Sclerosing adenosisMicrocalcifications are present in > 50% of cases and may be prominentCalcs usually numerous, fine textured and located within sclerosed acinar lumens
![Page 17: MICROCALCIFICATION IN BENIGN BREAST DISEASE](https://reader036.vdocuments.us/reader036/viewer/2022062305/568165e7550346895dd90710/html5/thumbnails/17.jpg)
Hormone imbalance and dysregulation of ER may play a role in development of SA
Most common in peri menopausal women
![Page 18: MICROCALCIFICATION IN BENIGN BREAST DISEASE](https://reader036.vdocuments.us/reader036/viewer/2022062305/568165e7550346895dd90710/html5/thumbnails/18.jpg)
Most common presentation: Finding during screening mammography
Less commonly presents as a palpable mass
Classified as proliferative disease without atypia
![Page 19: MICROCALCIFICATION IN BENIGN BREAST DISEASE](https://reader036.vdocuments.us/reader036/viewer/2022062305/568165e7550346895dd90710/html5/thumbnails/19.jpg)
SCLEROSING ADENOSISMAMMOGRAM MICROCALCIFICATION
![Page 20: MICROCALCIFICATION IN BENIGN BREAST DISEASE](https://reader036.vdocuments.us/reader036/viewer/2022062305/568165e7550346895dd90710/html5/thumbnails/20.jpg)
Lobulocentric proliferation of acini around a central duct with stromal sclerosis and compression of lumens
Arises within terminal duct lobular unit Must be at least 2x larger than average lobule 2 cell layers may be best appreciated at
periphery May be difficult to see if center of lesion
is sampled in a core needle biopsy
![Page 21: MICROCALCIFICATION IN BENIGN BREAST DISEASE](https://reader036.vdocuments.us/reader036/viewer/2022062305/568165e7550346895dd90710/html5/thumbnails/21.jpg)
Most common benign lesion mistaken for invasive carcinoma
More difficult to diagnose on core needle biopsy when borders and lobulocentric pattern may not be evaluable
1.5-2x increased relative risk for development of invasive carcinoma or 5-7% actual lifetime risk
![Page 22: MICROCALCIFICATION IN BENIGN BREAST DISEASE](https://reader036.vdocuments.us/reader036/viewer/2022062305/568165e7550346895dd90710/html5/thumbnails/22.jpg)
Consider surgical consultation about excisional biopsy: No, unless radiographically discordant
![Page 23: MICROCALCIFICATION IN BENIGN BREAST DISEASE](https://reader036.vdocuments.us/reader036/viewer/2022062305/568165e7550346895dd90710/html5/thumbnails/23.jpg)
Persian Golf
![Page 24: MICROCALCIFICATION IN BENIGN BREAST DISEASE](https://reader036.vdocuments.us/reader036/viewer/2022062305/568165e7550346895dd90710/html5/thumbnails/24.jpg)
Radial scar
Typically, these lesions are identified as 'distortions of architecture'/'stellate lesions' on mammogramsIf calcs are seen, which is not uncommon, they are an added extra rather than the main imaging diagnostic feature
![Page 25: MICROCALCIFICATION IN BENIGN BREAST DISEASE](https://reader036.vdocuments.us/reader036/viewer/2022062305/568165e7550346895dd90710/html5/thumbnails/25.jpg)
RADIAL SCARCalcs are normally luminal, fine textured and associated with the various pathological processes seen as part of these lesions e.g. sclerosing adenosis within the lesioncolumnar cell changeusual type epithelial hyperplasia
![Page 26: MICROCALCIFICATION IN BENIGN BREAST DISEASE](https://reader036.vdocuments.us/reader036/viewer/2022062305/568165e7550346895dd90710/html5/thumbnails/26.jpg)
RADIAL SCARMAMMOGRAM GROSS APPEARANCE
![Page 27: MICROCALCIFICATION IN BENIGN BREAST DISEASE](https://reader036.vdocuments.us/reader036/viewer/2022062305/568165e7550346895dd90710/html5/thumbnails/27.jpg)
Complex sclerosing lesion (CSL) is less specific term. Sometimes defined as a RSL > 1 cm in size
Most RSLs are microscopic findings Larger RSLs may present as
mammographic density or even palpable mass
Both in situ and invasive carcinomas have been reported in association with RSL(>2 cm)
![Page 28: MICROCALCIFICATION IN BENIGN BREAST DISEASE](https://reader036.vdocuments.us/reader036/viewer/2022062305/568165e7550346895dd90710/html5/thumbnails/28.jpg)
RADIAL SCAR
Central nidus, varying degrees of fibrosis andfibroelastosis in stellate or radial configurationo Associated proliferative epithelial componento Varying degrees of proliferative epithelial changeso Smaller ducts can become entrapped in dense fibrous stroma within central fibrotic region
![Page 29: MICROCALCIFICATION IN BENIGN BREAST DISEASE](https://reader036.vdocuments.us/reader036/viewer/2022062305/568165e7550346895dd90710/html5/thumbnails/29.jpg)
RSL is histologic risk factor for subsequent development of breast carcinoma
Presence of epithelial atypia, increased size, and multiple lesions are likely associated with increased risk for development of malignancy
Studies to identify myoepithelial cells may be helpful in difficult case.
However, results of myoepithelial cell studies to rule out malignancy must be interpreted with caution
![Page 30: MICROCALCIFICATION IN BENIGN BREAST DISEASE](https://reader036.vdocuments.us/reader036/viewer/2022062305/568165e7550346895dd90710/html5/thumbnails/30.jpg)
Few small-series studies have shown that 40% of patients with radial scar on CNB had carcinoma (DCIS or invasive) at excision; and 22% reported ADH on follow-up excision
Should be excised
![Page 31: MICROCALCIFICATION IN BENIGN BREAST DISEASE](https://reader036.vdocuments.us/reader036/viewer/2022062305/568165e7550346895dd90710/html5/thumbnails/31.jpg)
![Page 32: MICROCALCIFICATION IN BENIGN BREAST DISEASE](https://reader036.vdocuments.us/reader036/viewer/2022062305/568165e7550346895dd90710/html5/thumbnails/32.jpg)
Columnar Cell ChangeFrequently accompanied by microcalcificationCalcs often fine - may be luminal, intra-epithelial or in adjacent stromaOxalate calcs uncommon
![Page 33: MICROCALCIFICATION IN BENIGN BREAST DISEASE](https://reader036.vdocuments.us/reader036/viewer/2022062305/568165e7550346895dd90710/html5/thumbnails/33.jpg)
Cells line dilated terminal ductal lobular units (TDLUs)
Cystic spaces frequently contain luminal secretions and flocculent material
Molecular studies show genetic changes similar to those found in low-grade DCIS and invasive cancer
Morphologic spectrum based on presence and degree of epithelial atypia
![Page 34: MICROCALCIFICATION IN BENIGN BREAST DISEASE](https://reader036.vdocuments.us/reader036/viewer/2022062305/568165e7550346895dd90710/html5/thumbnails/34.jpg)
COLUMNAR CELL CHANGE WITH INTRA-EPITHELIAL CALC
COLUMNAR CELL CHANGE WITH PERIDUCTAL CALCS
![Page 35: MICROCALCIFICATION IN BENIGN BREAST DISEASE](https://reader036.vdocuments.us/reader036/viewer/2022062305/568165e7550346895dd90710/html5/thumbnails/35.jpg)
![Page 36: MICROCALCIFICATION IN BENIGN BREAST DISEASE](https://reader036.vdocuments.us/reader036/viewer/2022062305/568165e7550346895dd90710/html5/thumbnails/36.jpg)
![Page 37: MICROCALCIFICATION IN BENIGN BREAST DISEASE](https://reader036.vdocuments.us/reader036/viewer/2022062305/568165e7550346895dd90710/html5/thumbnails/37.jpg)
FEA
What does this mean? Flat epithelial atypia “older term” clinging carcinoma FEA(Flat Epithelial Atypia) represents columnar cell
lesion with varying degrees of cytologic atypia Intraductal alteration of the epithelial cells of 1-5 layers
of “low grade” nuclei Frequently coexists with lobular neoplasia and/or
tubular carcinoma If FEA is encountered on excision: Perform multiple levels to look for architectural
changes of ADH or low-grade DCIS Submit all tissue for microscopic examination
![Page 38: MICROCALCIFICATION IN BENIGN BREAST DISEASE](https://reader036.vdocuments.us/reader036/viewer/2022062305/568165e7550346895dd90710/html5/thumbnails/38.jpg)
FEA found on needle core biopsy:• Surgical excision is recommended• Diagnosis is upgraded to more serious lesion in 20-30% of cases CCC found on needle core biopsy (without atypia)• Most likely incidental finding as result of microcalcifications• Can be followed as long as there are no other worrisome clinical or mammographic findings
![Page 39: MICROCALCIFICATION IN BENIGN BREAST DISEASE](https://reader036.vdocuments.us/reader036/viewer/2022062305/568165e7550346895dd90710/html5/thumbnails/39.jpg)
Hormoz Island
![Page 40: MICROCALCIFICATION IN BENIGN BREAST DISEASE](https://reader036.vdocuments.us/reader036/viewer/2022062305/568165e7550346895dd90710/html5/thumbnails/40.jpg)
Intraductal papilloma
Benign epithelial proliferative lesions characterized bypapillary ingrowths into major ducts (LDP) or smallerducts (SDP)
![Page 41: MICROCALCIFICATION IN BENIGN BREAST DISEASE](https://reader036.vdocuments.us/reader036/viewer/2022062305/568165e7550346895dd90710/html5/thumbnails/41.jpg)
Presentation of LDP: Nipple discharge present in 80% of cases:
unilateral and spontaneous• Sanguinous or serosanguinous: 70%• Bloody (less common): May be due to papilloma twisting on stalk and infarction Palpable subareolar mass Presentation of SDP Finding on screening mammography Incidental finding in a biopsy for another lesion Usually does not cause discharge or a palpable
mass
![Page 42: MICROCALCIFICATION IN BENIGN BREAST DISEASE](https://reader036.vdocuments.us/reader036/viewer/2022062305/568165e7550346895dd90710/html5/thumbnails/42.jpg)
Arborizing fronds of tissue with well-developed central fibrovascular core
Lined by epithelial cells, myoepithelial cell layer Presence of myoepithelial cells and their
distribution in lesion is helpful diagnostic feature
May require use of myoepithelial markers to aid in the diagnostic evaluation in problematic cases
![Page 43: MICROCALCIFICATION IN BENIGN BREAST DISEASE](https://reader036.vdocuments.us/reader036/viewer/2022062305/568165e7550346895dd90710/html5/thumbnails/43.jpg)
Intra ductal papillomaCalcification commonFine luminal calcs and/or coarser calcs seen at periphery associated with sclerosis in and around the papilloma
![Page 44: MICROCALCIFICATION IN BENIGN BREAST DISEASE](https://reader036.vdocuments.us/reader036/viewer/2022062305/568165e7550346895dd90710/html5/thumbnails/44.jpg)
Mild increased risk of subsequent carcinoma: 1.5-2.0x relative risk or - 5-7% lifetime risk
Risk similar to that for moderate or florid ductal epithelial hyperplasia
Surgical consultation for lesions> 10 mm.
![Page 45: MICROCALCIFICATION IN BENIGN BREAST DISEASE](https://reader036.vdocuments.us/reader036/viewer/2022062305/568165e7550346895dd90710/html5/thumbnails/45.jpg)
In core needle biopsies: Management of lesions diagnosed as benign papillomas
on core needle biopsy is controversial Risk of carcinoma on excision of benign papillomas is
very low When cases are carefully selected and there is good
radiologic/pathologic correlation, carcinomas on excision are absent or rare « 5%)
However, distinction between benign papillomas and atypical papillomas can be difficult, and some authorities recommend excision of all papillary lesions on core needle biopsy
Papillomas with atypia should be excised as 20-60% of cases will reveal carcinoma on excision
![Page 46: MICROCALCIFICATION IN BENIGN BREAST DISEASE](https://reader036.vdocuments.us/reader036/viewer/2022062305/568165e7550346895dd90710/html5/thumbnails/46.jpg)
![Page 47: MICROCALCIFICATION IN BENIGN BREAST DISEASE](https://reader036.vdocuments.us/reader036/viewer/2022062305/568165e7550346895dd90710/html5/thumbnails/47.jpg)
Atypical Lobular HyperplasiaALH is composed of a monomorphic proliferation ofdiscohesive polygonal or cuboidal cells that are small andround. In lobules, these cells begin to fill acinar spaces,but few are widely distendedrciJ.
![Page 48: MICROCALCIFICATION IN BENIGN BREAST DISEASE](https://reader036.vdocuments.us/reader036/viewer/2022062305/568165e7550346895dd90710/html5/thumbnails/48.jpg)
ALH is an incidental finding in breast biopsies performed for other indications
Calcifications often present in areas adjacent to ALH
The hallmark feature of ALH, LCIS, and invasive lobular carcinoma is loss of E-cadherin expression
ALH is cytologically identical to lobular carcinoma in situ (LClS) but is more limited in extent
![Page 49: MICROCALCIFICATION IN BENIGN BREAST DISEASE](https://reader036.vdocuments.us/reader036/viewer/2022062305/568165e7550346895dd90710/html5/thumbnails/49.jpg)
Calcification in ALH
![Page 50: MICROCALCIFICATION IN BENIGN BREAST DISEASE](https://reader036.vdocuments.us/reader036/viewer/2022062305/568165e7550346895dd90710/html5/thumbnails/50.jpg)
ALH is associated with a 4-5x increased relative risk or a 13-17% lifetime risk of developing invasive carcinoma
In some studies, a strong family history of breast cancer doubles risk of invasive carcinoma to 8x
Ductal involvement by ALH (pagetoid extension) is associated with 8x risk or a 26% lifetime risk
• LClS has a l0x increased relative risk or a lifetime riskof - 30%• Carcinomas that occur in women after a diagnosis of LN average> 10 years to diagnosis
![Page 51: MICROCALCIFICATION IN BENIGN BREAST DISEASE](https://reader036.vdocuments.us/reader036/viewer/2022062305/568165e7550346895dd90710/html5/thumbnails/51.jpg)
ALH may be found as an incidental finding in a core needle biopsy
• If there is no other reason for excision, the value of excision based solely on presence of ALH is unclear Likelihood of cancer on excision is higher in
the following settings:• Radiologic lesion is a mass or highly suspicious calcifications (linear &/or branching)• ALH shows atypical features, such as higher nuclear grade, or is associated with calcifications
![Page 52: MICROCALCIFICATION IN BENIGN BREAST DISEASE](https://reader036.vdocuments.us/reader036/viewer/2022062305/568165e7550346895dd90710/html5/thumbnails/52.jpg)
What is the recommendation? Surgical consultation Up to 20% upgraded at
lumpectomy
![Page 53: MICROCALCIFICATION IN BENIGN BREAST DISEASE](https://reader036.vdocuments.us/reader036/viewer/2022062305/568165e7550346895dd90710/html5/thumbnails/53.jpg)
Hormoz Beach
![Page 54: MICROCALCIFICATION IN BENIGN BREAST DISEASE](https://reader036.vdocuments.us/reader036/viewer/2022062305/568165e7550346895dd90710/html5/thumbnails/54.jpg)
Mucocele like lesionsUncommon breast lesion, composed of mucin containingcysts that may rupture
![Page 55: MICROCALCIFICATION IN BENIGN BREAST DISEASE](https://reader036.vdocuments.us/reader036/viewer/2022062305/568165e7550346895dd90710/html5/thumbnails/55.jpg)
MLL is usually asymptomaticScreening mammograms may show mass or calcifications Range from benign to ADH or DCIS to
mucinous carcinoma 30% of mucocele-like lesions were
identified as mucinous carcinoma on surgical excision
![Page 56: MICROCALCIFICATION IN BENIGN BREAST DISEASE](https://reader036.vdocuments.us/reader036/viewer/2022062305/568165e7550346895dd90710/html5/thumbnails/56.jpg)
Data are limited, and excision is recommended whenever an atypical mucocele-like lesion or acellular stromal mucin identified on CNB
![Page 57: MICROCALCIFICATION IN BENIGN BREAST DISEASE](https://reader036.vdocuments.us/reader036/viewer/2022062305/568165e7550346895dd90710/html5/thumbnails/57.jpg)
Sunset in Hormoz