| Part1Correlation between the benign and malignant of breast lesions with microcalcification[Background and Objective]Mammography is the most sensitive screening for the breast microcalcification. Calcifications of the breast benign and malignant lesions which were found on mammography often present a difficult and complex diagnostic challenge. Although the characteristic of calcifications is different between the benign and malignant of breast lesions in a way. Learning more about the characteristic of calcifications, we would know more about the difference of the benign and malignant of breast lesions with calcifications. It would be help to make treatment plan. In this part, we would discuss the BI-RADS, morphous, distribution, and the combination of morphous and distribution of the microcalcification of the breast benign and malignant lesions.[Materials and Methods]1. Clinical informationThe cases of the breast lesions with microcalcification by the pathology from March2009to December2012were retrospectively analyzed (the benign breast lesions140cases, the malignant breast lesions284cases). All cases were female, who took digital mammography screening preoperative.2. Methods2.1EquipmentMolybdenum target X-ray was Siemens full field digital mammography (Mammomat Novation DR).Regulation automatic exposure with the position of axial view (CC) and loxosis view was obtained preoperative. Side position and amplification would be added if it was need any time.2.2Stander of the image evaluationThe images were retrospectively analyzed by two senior radiologists according to the Breast Imaging-Reporting And Data System (BI-RADS).The BI-RADS, the morphous, distribution, the combination of morphous and distribution of the microcalcifications of the breast benign and malignant lesions would be discussed. Every doctor acknowledged the procedure and observation before the formal experiment.2.3Classification of the report2.3.1Classification of calcification pattern:1)Typically benign:(1) Lucent centered deposits of skin calcifications.(2) Parallel tracks, or linear tubular calcifications of vascular calcifications.(3)Coarse (popcorn) calcifications occurring in involuting fibroadenomas.(4)Large rod like calcifications that are continuous rods but may occasionally be branching, usually more than lmm in diameter, and may have lucent centres, as seen in duct ectasia.(5) Round calcifications are usually considered benign when small (<1mm), and they are present within the lobular acini.(6) Lucent centre calcifications are benign calcifications that range from<1mm to>1cm. They are smooth surfaced, round or oval, and have lucent centres. These are seen in fat necrosis or calcified debris in ducts, or in some fibroadenomas.(7) Eggshell or rim calcifications are thin calcifications that appear as calcium deposit on the surface of a sphere, and the calcification is usually<1mm on side view, and are seen in cyst wall.(8)Milk of calcium calcifications are well defined, semilunar, crescent or curvilinear shape (teacup shaped), consistent with sedimented calcifications in cysts.(9) Suture calcifications are mostly linear, with knots frequently visible, and represent calcium on suture material, and are relatively common in the post irradiated breast.(10) Dystrophic calcifications tend to be irregular,>0.5mm and have lucent centres, and are usually formed in the irradiated or traumatized breast.(11)Punctate calcification-round or oval,<0.5mm with well defined margins.2)Intermediate concern, suspicious calcifications:①Amorphous or indistinct calcifications are often round or’flake’shape but are small or hazy in appearance, and a more specific morphological classification cannot be determined.②Coarse heterogeneous calcifications-these are irregular conspicuous calcifications that are larger than0.5mm, and tend to coalesce.3) Higher probability of malignancy:①Fine pleomorphic calcifications.②Fine linear, or fine linear branching calcifications are thin irregular calcifications that appear linear, but are discontinuous and <0.5mm in width, suggesting filling of ductal lumen of a cancer involved duct.2.3.2Classification of calcification distribution:1) Diffuse or scattered-calcifications that are distributed randomly throughout the breast.2) Regional-calcifications within a large volume of breast tissue (>2cc), not necessarily conforming to a ductal distribution.3) Grouped or clustered-when there are at least5calcifications occurring in a small volume (<1cc).4) Linear-calcifications arrayed in a line that may have branching points.5) Segmental -worrisome, as the distribution suggests deposits within a duct and its branches, suggestive of multifocal cancer within a breast segment.2.3.3Breast Imaging-Reporting Data SystemCategory0-need additional imaging evaluation-assessment is incomplete, needing additional imaging evaluation-almost always used in the screening setting only. Category1-negative-no abnormalities detected. Category2-benign findings-some features worthy of description, but are confidently diagnosed as benign. Category3-probably benign, short follow up interval suggested-the lesions have a high probability of being benign, but stability over time is preferably to be established.Category4-suspicious abnormality-biopsy should be considered-although the lesions do not have the characteristic morphologies of breast cancer, they possess a definite probability of being malignant.Category5-highly suggestive of malignancy, appropriate action should be taken. Category6-known biopsy proven malignancy-reserved for lesions with biopsy proof of malignancy.2.4Quality controlDiagnosis were carried out by two radiologist.If there were any inconformity on the sign observed, the final results were obtained by discussion between the superior doctors.2.5Statistics analysisChi-square and Wilcoxon analysis were performed with the use of statistical software (SPSS, version13.0), with P<0.05to indicate a significant difference.[Results]1. There were140benign breast lesions (149laterals) and284malignant breast lesions (284laterals). The benign breast lesions including:60adenosis (62laterals),65breast fibrocystic change (71laterals) and15other benign lesions (16laterals). The malignant breast lesions including:200IDC (200laterals),60DCIS (60laterals),11ILC (11laterals) and13other malignant lesions (13laterals).2. There was statistical significance in the age of onset(P=0.00).The mean age of the breast benign lesions with microcalcification was42.68,but the malignant’s was52.60.3. There was statistical significance in the BI-RADS classification of the breast benign and malignant lesions with microcalcification (P=0.00). Most of the microcalcification breast benign lesions were assessed for BI-RADS3-4category, but most of the microcalcification breast malignant lesions were assessed for BI-RADS4～5category.4.There was statistical significance in the morphous, distribution, the combination of morphous and distribution of the microcalcification of the breast benign and malignant lesions (all P value<0.05). The significant features of the benign breast lesion were punctate calcification, clustered, diffuse punctate calcification; while the breast malignant lesions were fine pleomorphic calcifications, clustered, segmental fine pleomorphic calcifications.5.There was no statistical significance in the characteristic of the microcalcification of the breast benign lesions (P value>0.05).The microcalcifications were most found in the breast benign lesions:adenosis clustered fine pleomorphic calcifications (9/62), breast fibrocystic change diffuse punctate calcification (14/71),and other benign lesions clustered punctate calcification (3/11).6.There was no statistical significance in the characteristic of the microcalcification of the breast malignant lesions (P value>0.05).The segmental fine pleomorphic calcifications was more likely to found in the IDC (28/200)and DCIS(13/60).However, the feature of the calcifications of ILC was various, we could found scatter amorphous calcifications, regional/segmental fine pleomorphic calcifications or segmental fine linear or fine linear branching calcifications. There was scatter amorphous or fine pleomorphic calcifications, segmental fine linear fine linear branching calcifications could be found in the other subtype breast malignant lesions.[Conclusions]1. The age of onset of the breast malignant lesions with microcalcification is older than the benign’s. There are some difference of the BI-RADS, morphous, distribution,and the combination of morphous and distribution of the microcalcification between the breast benign and malignant lesions. And these features are very important for us to diagnose and differential diagnose them. However, the comitans signs are also important for our routine work.2. The fine pleomorphic or fine linear fine linear branching calcifications which distribute by means of clustering or segment are most frequently found in the breast malignant lesions. Of the breast malignant lesions, especially the breast fibrocystic change, the diffuse punctate calcifications are very common.Part2The diagnosis value of the microcalcification in breast carcinoma [Background and Objective]The incidence of the breast carcinoma has been increasing, and that seriously threats the female heath and life. The earlier detection, the earlier diagnosis and the earlier therapy of breast carcinoma are extremely significant for prognosis, especially for asymptomatic patient. The microcalcification is the significant or the only sign found on the mammography screening for nonpalpable breast carcinoma. The earlier detection and differential diagnosis for breast calcification will help to discover the early stage breast carcinoma. The signs of mammography screening, prognosis and therapeutic measure are diverse, respecting the different pathology, histopathology stage and molecule subtype of the breast carcinoma. The TNM and the immunohistochemistry information are important for the therapy for breast carcinoma. Exploring the features of microcalcification, histological stage, the TNM and the immunohistochemistry characteristic of the pathology subtype breast carcinoma, would provide more information for clinical treatment.[Materials and Methods]1. Clinical informationThere were283cases of breast carcinoma with microcalcification by the pathology from March2009to December2012were retrospectively analyzed. All cases were female, who took digital mammography screening preoperative.2. Methods2.1EquipmentIt is the same as the first part.2.2Stander of the image evaluationThe images were retrospectively analyzed by two senior radiologists according to the Breast Imaging-Reporting And Data System (BI-RADS) and TNM system. The morphous, distribution, the combination of morphous and distribution of the microcalcification, pathology type, histological stage and the immunohistochemistry of the breast carcinoma with microcalcification would be discussed. Every doctor acknowledged the procedure and observation before the formal experiment.2.3The standard of the molecule subtypes in immunohistochemistryThe expression of ER and PR was judged according to nucleus dyeing, the cells were positive when the brown pellet was found in the nucleus. If the dyeing cells were less than10%, it was judged as negative. When the dyeing cells were more than10%, it was judged as positive. The expression of HER2was judged according to the result of Cer-B-2.When the expression of Cer-B-2was less than+++, the expression of HER2was judged negative, otherwise it was positive. When the expression of Cer-B-2was++, it would be detected by FISH.Breast carcinoma was classified into the following four molecule subtypes: luminal A (ER and/or PR-positive, HER2-negative), luminal B(ER and/or PR-positive, HER2-positive), HER2-overexpressing(ER and PR-negative, HER2positive) and triple-negative(ER-negative, PR-negative and HER2-negative).2.4Statistics analysisChi-square analysis were performed with the use of statistical software (SPSS, version13.0), with P<0.05to indicate a significant difference.[Results]1. In the study, there were200IDC,60DCIS,11ILC and12other pathology subtypes breast cancer. There was no statistical significance in the age onset of the pathology subtypes breast cancer (P value>0.05),the41-50age group was the most common of all pathology subtypes.2. There was no statistical significance in morphous, distribution, the combination of morphous and distribution of the microcalcification of the calcified breast carcinoma without mass (P value>0.05). The fine pleomorphic calcifications were the most frequently found in the IDC,DCIS and other pathology subtypes breast cancer (40.7%,56.4%,50.0%respectively); the fine pleomorphic,fine linear or fine linear branching calcifications were the most frequently found in the ILC(50.0%respectively). The distribution of microcalcification:IDC segment (42.4%), DCIS (38.5%),ILC segment (75.0%), and the other pathology subtypes breast cancer cluttered or segment or regional (33.3%respectively).3. The correction of the characteristic of microcalcification and the stage of histology of the calcified breast carcinoma without mass:all of cases, the Ⅰ, Ⅱ and Ⅲ grade IDC (totally59) was6.8%,84.7%and8.5%respectively; the low, intermediate and high grade DCIS(totally39) was7.7%,10.2%and82.0%respectively. The most common characteristic of microcalcification:the Ⅱ grade IDC segment fine pleomorphic calcifications (16.0%), Ⅲ grade IDC segment mixture malignant calcifications (40.0%),and Ⅰ grade IDC regional fine pleomorphic calcifications or segment fine linear/fine linear branching calcifications or cluttered/regional coarse heterogeneous calcifications (25.0%respectively); the high grade DCIS segment fine pleomorphic calcifications (25.0%), intermediate grade DCIS cluttered fine pleomorphic calcifications(50.0%),and low grade DCIS linear fine pleomorphic calcifications or diffuse mixture malignant calcifications or segment coarse heterogeneous calcifications(33.3%respectively).4. The statue of lymph node and the size of tumor of the calcified breast carcinoma without mass:There was no statistical significance in the statue of lymph node and the size of tumor and distribution of the microcalcification of the calcified breast carcinoma without mass (P value>0.05).The statue of lymph node: N0(58.3%),N1(22.9%),N2(8.3%) and N3(10.4%).the correction of the calcification feature and the statue of lymph node:No segment fine pleomorphic calcifications (8.9%),N1segment fine linear/fine linear branching calcifications (27.3%),N2segment fine pleomorphic calcifications (37.5%),and N3regional fine pleomorphic calcifications (20.0%).The size of tumor:Tis (11.6%),T1(35.8%),T2(41.0%),T3(7.4%) and T4(4.2%). The correction of the calcification feature and the tumor size: Tis/T2-segment fine pleomorphic calcifications (27.3%,28.2%), T1-segment fine linear/fine linear branching calcifications (15.4%),T3-fine pleomorphic calcifications or mixture malignant calcifications (28.6%respectively), and T4-diffuse benign/fine pleomorphic calcifications or cluttered/regional mixture malignant calcifications (25.0%respectively).5.The correction of the feature of microcalcifications and immunohisto- chemistriy:there was statistical significance in the microcalcification feature of molecule subtypes breast carcinoma(P<0.05);but the cluttered fine pleomorphic calcifications(18.0%) were found most frequently in Luminal A, segment fine pleomorphic calcifications were most common in all of Luminal B,HER2over-expression and TNBC(19.4%,19.2%,21.4%respectively).[Conclusions]1. The age is not different in the pathology subtype breast carcinoma, the41-50age group is seen most frequently. The most prevalent histological types is II grade IDC.2. There is no specific feature of the microcalcification of the calcified breast carcinoma without mass. The most common morphous and distribution of them are: IDC fine pleomorphic calcifications, cluttered; DCIS fine pleomorphic calcifications, segment; ILC fine pleomorphic or fine linear/fine linear branching calcifications, segment; others’ fine pleomorphic calcifications, various distribution.3. The feature of microcalcification of the IDC with microcalcification without mass:the segment fine pleomorphic calcifications are the most frequently found in the Ⅱ grade, the segment mixture malignant calcifications are the most common in the Ⅲ grade, but there is no specific feature of the microcalcification the I grade. The most common morphous of microcalcification of DCIS is fine pleomorphic, and the most common distribution of microcalcification is:high segment, intermediate cluttered, low grades no specify.4. The distribution of microcalcification of the breast carcinoma with microcalcification without mass, which are found lymph node metastasis, is segment or regional. With the larger of the tumor, the extent of microcalcification distribution is expanding.5. It is very difficulty for the radiologists to discriminate the molecule subtypes of breast carcinoma only by the feature of microcalcification.It must correct other imaging signs and clinical information.Part3Tripe-receptors negative breast carcinoma with microcalcification:the incidence, feature and significance of microcalcification[Background and Objective]Triple-receptors negative breast carcinoma (TNBC) is defined by an absence of expression of estrogen receptor, progesterone receptor and HER2by immunohistochemistry. Approximately10-17%of infiltrating breast cancers fall into this subset and are frequently high grade with pushing margins and poor Nottingham Prognostic Index. Microcalcification is less found in the TNBC.In the part, we will explore the mammography appearance of TNBC with microcalcification and other relevant clinical information.[Materials and Methods]1. Clinical informationThere were89cases of TNBC and350cases NTNBC by the pathology from March2009to December2012were retrospectively analyzed. All cases were female, who took digital mammography screening preoperative.2. Methods2.1EquipmentIt is the same as the first part.2.2Stander of the image evaluationThe images were retrospectively analyzed by two senior radiologists according to the Breast Imaging-Reporting And Data System BI-RADS) and TNM system. The morphous and distribution of the microcalcification, statue of lymph node and pathology type of the TNBC with microcalcification would be discussed. Every doctor acknowledged the procedure and observation before the formal experiment.2.3The standard of the molecule subtypes in immunohistochemistryIt is the same as the second part.2.4Statistics analysisChi-square analysis were performed with the use of statistical software (SPSS, version13.0), with P<0.05to indicate a significant difference.[Results]1. In our study, the total TNBC89cases, Luminal A211cases, Luminal B43cases, and HER2-overexpressing96cases, the cases of the molecule subtypes breast tumor with microcalcification were:TNBC28cases (31.5%), Luminal A133cases (63.5%), Luminal B31cases (72.1%), and HER2-overexpressing73cases (76.0%).2. The morphous and distribution of the microcalcification:there was statistical significance in morphous of the microcalcification of the molecule subtype breast carcinoma (P value<0.05).However, the fine pleomorphic calcifications were the most frequently found in all of the molecule subtypes(TNBC35.7%, Luminal42.4%, and HER2-overexpressing45.2%). There was statistical significance in distribution of the microcalcification of the molecule subtype breast carcinoma (P value <0.05).The most common distribution of the microcalcification:Luminal cluttered (42.4%), TNBC(35.7%) and HER2-overexpressing (37.0%) segment.3.The pathology types:There was no statistical significance in the pathology type of the molecule subtype breast carcinoma with microcalcification (P value>0.05).The IDC was the prevalent histological types of them(TNBC78.6%, Luminal A70.9%, Luminal B74.2%, and HER2-overexpressing68.5%).4. The statue of lymph node:There was statistical significance in statue of lymph node of the molecule subtype breast carcinoma with microcalcification (P value<0.05).The incidence of the lymph node metastasis of the TNBC (71.4%) was higher than the NTNBC (44.5%).[Conclusions]1. The incidence of microcalcification of the molecule subtypes breast tumor is different, the incidence of microcalcification is highest in HER2-overexpressing, but it is lowest in TNBC.2.Although there was statistical significance in morphous of the microcalcification of the molecule subtype breast carcinoma, but the fine pleomorphic calcifications can be found in all of the molecule subtype breast carcinoma. The distribution of the microcalcification of the molecule subtype breast carcinoma is specificity in a way,we can differentiate them by this character.3.It is more likely to found lymph node metastasis in the TNBC than the NTNBC. |
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