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Case 05



Work-up calcifications with suspicious morphology and distribution regardless of whether they enhance or not!

These calcifications have a segmental (suspicious distribution) but are predominantly round (possibly benign from acinar source). AND they do not enhance.
Overall, it is difficult to know whether these are benign or malignant based on imaging alone, since we know that malignant calcifications do not need to enhance.

For this reason, biopsy is the best next step (not ultrasound, breast MRI, or return to screen).

Stereotactic core biopsy was performed revealing BENIGN histopathology including FEA, UDH, columnar cell change, and microcysts. It's great that these were benign, but biopsy was still the best next step. DCIS and less commonly invasive cancer can present as calcifications without enhancement. Because of this, some experts suggest that CEM is not helpful for calcification evaluation.

Long R, Cao K, Cao M,et al. Improving the Diagnostic Accuracy of Breast BI-RADS 4 Microcalcification-Only Lesions Using Contrast-Enhanced Mammography. Clin Breast Cancer. 2021 Jun;21(3):256-262.e2.

Cheung YC, Chen K, Yu CC, et al. Contrast-Enhanced Mammographic Features of In Situ and Invasive Ductal Carcinoma Manifesting Microcalcifications Only: Help to Predict Underestimation? Cancers (Basel). 2021 Aug 30;13(17):4371.

Houben IP, Vanwetswinkel S, Kalia V, et al. Contrast-enhanced spectral mammography in the evaluation of breast suspicious calcifications: diagnostic accuracy and impact on surgical management. Acta Radiol. 2019 Sep;60(9):1110-1117.

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