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Case 06

(continued)

Answer:

Suspicious calcifications with mass enhancement more often reflects invasive cancer rather than DCIS.

These calcifications are pleomorphic and are associated with a focal asymmetry on low-energy images. They are associated with mass enhancement on recombined images. This is highly concerning for malignancy. Studies have shown that this is more likely to represent an invasive cancer compared to DCIS.

Given that mass enhancement was appreciated, a targeted ultrasound of the upper outer left breast was performed. An irregular enhancing mass was seen.

This mass was ultimately targeted for ultrasound-guided core biopsy. In general, ultrasound-guided core biopsies are easier for patients to tolerate. For this reason, it's worth attempting ultrasound if you think you'll find a target. If no target is seen, then stereotactic core biopsy would be the way to go. Breast MRI or return to screening would not be appropriate as the best next step.

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.

Cheung YC, Tsai HP, Lo YF, et al. Clinical utility of dual-energy contrast-enhanced spectral mammography for breast microcalcifications without associated mass: a preliminary analysis. Eur Radiol. 2016 Apr;26(4):1082-9.

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