AJR 2002; 179:685-689
© American Roentgen Ray Society
Calcifications Associated with Lactational Changes of the Breast: Mammographic Findings with Histologic Correlation
Cecilia L. Mercado1,
Tova C. Koenigsberg2,
Diane Hamele-Bena3 and
Suzanne J. Smith1
1 Department of Radiology, New York Presbyterian Hospital, 161 Fort Washington
Ave., AP10, New York, NY 10032.
2 Institute for Breast Care, Hackensack University Medical Center, 20 Prospect
Ave., Ste. 513, Hackensack, NJ 07601.
3 Department of Pathology, New York Presbyterian Hospital, New York, NY
10032.
Received December 24, 2001;
accepted after revision February 21, 2002.
Address correspondence to C. L. Mercado.
Abstract
OBJECTIVE. We sought to describe the mammographic appearance of
calcifications associated with histologically confirmed lactational changes of
the breast.
CONCLUSION. Calcifications associated with lactational changes of
the breast may have a suspicious appearance on mammography. These
calcifications may be identified on a patient's original screening mammogram
or may be a new finding on an annual screening examination. Correlating a
clinical history of recent lactation or a postpartum state is important in
establishing a concordance between the mammographic and histologic findings.
However, despite the benign nature of these calcifications, biopsy is
recommended because of their suspicious morphologic features.
Introduction
Breast imaging is occasionally performed during a patient's lactating or
postpartum period. Most of these patients are imaged for specific clinical
indications, although many studies are performed for screening purposes alone.
The histologic diagnoses most commonly encountered in this setting are
galactoceles and lactating adenomas, which are associated with breast masses.
To the best of our knowledge, only one case report has described
calcifications detected on mammography in association with lactational changes
[1]. We present four cases of
postpartum patients in whom mammographically detected suspicious
calcifications were histologically shown to represent the sequelae of
lactational change alone.
Materials and Methods
We reviewed the clinical records and imaging studies of four patients who
had received a histologically based diagnosis of microcalcifications
associated with lactational changes of the breast. The patients ranged in age
from 27 to 39 years and were seen in the breast imaging center of one
institution between July 1995 and February 2000.
Three of the four patients had no specific clinical symptoms and had been
referred for screening mammography. The fourth patient had been referred to
the center by a breast surgeon for evaluation of bilateral nodularity,
although no focal mass was palpated. All four patients were postpartum and
were currently breast feeding or had a history of lactation within the
previous 6 months. Standard mammographic views of both breasts were obtained
in all patients, with additional magnification views of the areas of
calcifications. The calcifications were characterized according to the Breast
Imaging Reporting and Data System (BI-RADS)
[2] categories. Sonographic
evaluation was performed only in the patient in whom the breast surgeon noted
bilateral nodularity.
Two patients underwent open surgical biopsy. In the other two patients,
sampling was achieved via stereotactic core biopsy using an 11-gauge
directional vacuum biopsy device (Mammotome; Biopsys—Ethicon
Endo-Surgery, Cincinnati, OH) and a dedicated prone table (U. S. Surgical,
Norwalk, CT). Two of the patients had bilateral biopsies, and two patients
underwent unilateral biopsies of focal indeterminate clusters.
The pathologic specimens from both the stereotactic core biopsies and the
surgical excisions were reviewed by a pathologist with expertise in breast
pathology. The two patients who had undergone core biopsy sampling had
follow-up mammography. The institutional review board did not require formal
approval or informed consent by the patients for this retrospective
review.
Results
Three of the four patients had breast tissue that appeared extremely dense
and nodular on mammography. The fourth patient had scattered fibroglandular
parenchyma. In all patients, scattered bilateral calcifications with focal
clusters were also present. Magnification images showed the calcifications to
be granular and heterogeneous, with some in a linear and branching
distribution (Figs.
1A,1B,1C
and
2A,2B).
The mammograms of two of the patients revealed a distinct pattern of casting
calcifications (Figs.
3A,3B,3C
and
4A,4B,4C).
Three of the four cases were graded as BI-RADS category 4, and the fourth case
was considered a BI-RADS category 5 at the time of original interpretation. No
discrete sonographic finding was identified in the single patient (with the
clinical history of bilateral nodularity) who had undergone sonographic
evaluation of both breasts.
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Fig. 1A. —39-year-old asymptomatic woman who had been lactating within
6 months of presentation. Craniocaudal spot-compression magnification
mammograms of right (A) and left (B) breasts show several
clusters of heterogeneous and granular calcifications. Some clusters display
linear distribution.
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Fig. 1B. —39-year-old asymptomatic woman who had been lactating within
6 months of presentation. Craniocaudal spot-compression magnification
mammograms of right (A) and left (B) breasts show several
clusters of heterogeneous and granular calcifications. Some clusters display
linear distribution.
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Fig. 1C. —39-year-old asymptomatic woman who had been lactating within
6 months of presentation. Photomicrograph of histopathologic specimen shows
group of large, coarse microcalcifications in area of clustered dilated ducts.
Note large microcalcifications (thick arrow) present in homogeneous,
eosinophilic secretions in one duct and smaller microcalcification (thin
arrow) in lobule displaying focal distention of lobular glands,
consistent with lactational changes. (H and E, x50)
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Fig. 2B. —39-year-old asymptomatic woman. Photomicrograph of
histopathologic specimen shows coarse microcalcification in dilated duct. Note
also homogeneous eosinophilic secretions in duct and acinar lumina. (H and E,
x125)
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Fig. 3A. —39-year-old asymptomatic woman who had been lactating within
6 months of presentation. Craniocaudal spot-compression magnification
mammograms of right (A) and left (B) breasts show scattered
microcalcifications (arrow, B) that are heterogeneous in
appearance with granular, linear, and casting forms.
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Fig. 3B. —39-year-old asymptomatic woman who had been lactating within
6 months of presentation. Craniocaudal spot-compression magnification
mammograms of right (A) and left (B) breasts show scattered
microcalcifications (arrow, B) that are heterogeneous in
appearance with granular, linear, and casting forms.
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Fig. 3C. —39-year-old asymptomatic woman who had been lactating within
6 months of presentation. Photomicrograph of histopathologic specimen shows
large, coarse microcalcifications in dilated ducts. (H and E, x125)
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Fig. 4A. —27-year-old woman who was lactating and who presented with
bilateral nodularity. True lateral spot-compression magnification mammogram of
left breast shows both scattered and focal clusters of heterogeneous
microcalcifications.
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Fig. 4B. —27-year-old woman who was lactating and who presented with
bilateral nodularity. Craniocaudal spot-compression magnification mammogram of
left breast obtained 12 months after A shows scattered granular and
heterogeneous microcalcifications. Parenchymal involution allows better
visualization of occasional clusters in focal linear and branching pattern.
Overall decrease in number of calcifications was noted.
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Fig. 4C. —27-year-old woman who was lactating and who presented with
bilateral nodularity. Photomicrograph of histopathologic specimen of breast
shown in A shows psammoma body—like microcalcification with
concentric laminated structures in dilated acinus. Acinar cells display
vacuolated cytoplasm and occasional luminal cytoplasmic buds representing
lactational changes. (H and E, x375)
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Histologically, most of the lobules in all four patients exhibited
prominent secretory activity with lactational features (Fig.
4A,4B,4C).
The acini composing the hyperplastic lobules were often distended and were
lined by epithelial cells containing enlarged nuclei with prominent nucleoli
and vacuolated cytoplasm. The ductules appeared prominent, and some were
ectatic and possessed attenuated epithelial linings. Many of the dilated
lobular acini and ductules contained eosinophilic secretions with a variable
foamy, wispy, or homogeneous appearance.
Small and large calcifications were present at histologic examinations in
all patients. The smaller microcalcifications were round and similar to
psammoma bodies with concentric laminated structures; these lesions were
located predominantly in acini displaying lactational changes. Larger
calcifications were present in dilated ductules. Some of these ductules were
lined by epithelial cells with lactational features, and others possessed an
attenuated epithelium; all were adjacent to acini with lactational features.
Most of these larger calcifications were amorphous and fragmented. These
calcifications rarely displayed laminated structures.
In two patients, a group of coarse calcifications was present in an area of
clustered, dilated ducts. In some foci, microcalcifications were present in
the central portions of eosinophilic secretions and hence appeared to be
arising from these secretions.
Follow-up mammograms in three of our patients showed no significant
interval change in the calcifications over a period ranging from 6 months to 1
year. In the fourth patient, who was lactating at the time of diagnosis, the
follow-up mammogram showed a diffuse decrease in the calcifications as well as
an interval decrease in overall breast parenchymal density.
Discussion
The physiologic and pathologic findings seen in association with pregnancy
and lactation have been well described
[3,
4]. These developments begin in
the second month of pregnancy, during which time lobular enlargement and
formation of new terminal duct lobular units occur. During the second and
third months of pregnancy, the lobular epithelial cell cytoplasm becomes
vacuolated, and secretions accumulate in distended lobular glands as lobular
growth progresses [4]. These
physiologic and pathologic changes correspond to the mammographic findings
that have been reported in association with pregnancy and lactation. The
imaging findings include increased breast parenchymal density and an overall
increase in breast size
[5,6,7].
In addition, focal masses detected during this period have been shown to
represent galactoceles, lactating adenomas, enlarging fibroadenomas, and,
uncommonly, breast carcinoma.
Calcifications seen in association with lactational changes of the breast
have, to the best of our knowledge, been described in only a single recent
case report [1]. Stucker et al.
[1] described bilateral diffuse
and occasional clustered microcalcifications in a regional distribution with
focal linear and branching patterns, which aroused concern over the possible
presence of carcinoma. These calcifications were confirmed at biopsy to
represent lactational changes. Rosen
[4] and Shin and Rosen
[8] described mammographically
detected calcifications in six cases of pregnancy-like (pseudolactational)
hyperplasia. They noted that some of the calcifications in the patients in
their study had smoothly rounded or lobulated contours and distinctive,
unevenly spaced internal laminated structures. This appearance is similar to
the psammoma body—type calcifications noted among our patients.
In all our patients, the calcifications were depicted mammographically as
having a bilateral and diffuse distribution, with focal clusters noted as
well. The individual microcalcifications were morphologically round. In two
patients, however, the microcalcifications were distributed linearly with a
branching pattern—imaging features that aroused suspicions that
carcinoma was present. Additionally, in two patients, the calcifications
appeared to be in a casting pattern, suggesting that the microcalcifications
were outlining ducts.
The histopathologic findings obtained for all four patients correlated well
with the imaging findings. Most of the mammary tissue in the patients showed
lactational changes. Microcalcifications were found in both the ducts and the
lobules. The small, psammomatous microcalcifications present within the
lobular acini likely accounted for the granular pattern of some of the
calcifications seen in focal clusters. The larger calcifications noted within
an area of clustered dilated ducts in two patients likely corresponded to the
distinct casting pattern of calcifications seen on mammography in these two
patients.
The advent of in vitro fertilization and the national increase in women
choosing to delay childbearing may lead to more women presenting for screening
mammography during the lactational period. In examining this specific
population, radiologists should bear in mind that bilateral calcifications
with the imaging features described herein may represent the benign sequelae
of lactational changes alone. However, the suspicious mammographic appearance
of these calcifications is sufficient cause for recommending tissue sampling
to confirm their benign nature.
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Abstract
Introduction
