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Beth Israel Deaconess Medical Center and Harvard Medical School Boston, MA 02215
The article by Moy et al. [1] on the pendent view to assess milk of calcium in breast microcysts states that "occasionally a carcinoma may arise adjacent to microcysts...even if milk of calcium is present, biopsy should be considered if punctate microcalcifications are found."
I would like to emphasize that many, and probably most, of the calcifications representing milk of calcium within microcysts do not layer on horizontal beam radiographs. A common error I have seen on the oral board examinations in breast imaging is for the applicant to properly suggest and document the presence of milk of calcium layering within microcysts only to recommend biopsy because many of the calcifications, or a small focus of them, did not layer. As a general rule, a cluster of micro-calcifications containing any layering milk of calcium should be considered benign.
Several years ago, our department attempted to assess whether the presence and conspicuity of milk of calcium within microcysts could be augmented by increasing the time the breast remained in vertical compression before obtaining the cross-table lateral mammogram. We obtained standard lateral magnification radiographs immediately after applying compression, and again after the breast had remained compressed for an additional 30 sec. The rationale was similar to that of prolonging the time the patient remains upright, or in the lateral decubitus position, to better diagnose a small pneumoperitoneum on horizontal beam radiographs. Regrettably, unlike the pendent view described by Moy et al. [1], this delay technique was not found to be helpful in better depicting the layering of milk of calcium in microcysts.
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Massachusetts General Hospital Boston, MA 02114
We appreciate Dr. Hall's comments. His observation escaped all of our reviews. The sentence in question in our article [1] should have read "...biopsy should be considered if suspicious pleomorphic calcifications are found." We have seen several cancers that were immediately adjacent to milk of calcium and indicated their presence by producing suspicious, pleomorphic calcifications. They were different from the layering, amorphous deposits, but could easily have been overlooked when the obvious milk of calcium was seen.
We certainly agree that not all calcifications in benign cysts layer. This is especially true of very small cysts. In addition, the calcium in benign cysts may form concretions that are fixed in position. However, we would disagree that "a cluster of microcalcifications containing any layering milk of calcium should be considered benign." As with any cluster, the calcifications should be analyzed, and intervention determined by the worst morphologic characteristics. In the review of patients with milk of calcium by Linden and Sickles [2], eight cancers were associated with milk of calcium in approximately 200 women. These numbers translate into 40 cases in 1,000 women. Even accounting for the selection biases in the group, this is a high prevalence rate, and caution is important.
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