AJR AJR Integrative Imaging Dec 2008 articles
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DOI:10.2214/AJR.06.5013
AJR 2006; 186:902
© American Roentgen Ray Society

Computer-Aided Detection (CAD) of Amorphous Calcifications

Ferris M. Hall

Beth Israel Deaconess Medical Center and Harvard Medical School Boston, MA 02115

Soo et al. [1] make the important evidence-based conclusion that "CAD sensitivity for malignant amorphous calcifications is markedly lower than previously reported.... Breast imaging radiologists who use CAD systems should continue to search diligently for these difficult-to-detect lesions." These authors note that in their series these calcifications had a 16% rate of malignancy and were "frequently overlooked because they are at the threshold of visibility on routine mammography" and that "identification and biopsy of all (italics by Dr. Hall) cases of amorphous calcifications are necessary."

I would like to put these findings and statements in a different context, suggesting a less rigorous—and more controversial—approach to the assessment of subtle, lower-risk amorphous calcifications. Ductal carcinoma in situ (DCIS) is often considered two different diseases: high and low grade. Amorphous calcifications usually fall into the latter group and, like many prostate carcinomas, they have been shown to have a relatively long quiescent stage, measured in years or decades. Most biopsies of amorphous calcifications are benign, and even when the diagnosis of low-grade DCIS is made, there is general agreement that relatively few lives are saved by this very early mammographic diagnosis as compared with finding small invasive carcinomas. Therefore, in my opinion, there is less urgency about diagnosing low-grade DCIS, particularly in a population of regularly screened women. The vast majority of women with early low-grade DCIS would have these lesions picked up, still at a very early stage, often years later, with little reduction in mortality.

Mammographers in the United Kingdom and most other affluent countries ignore or follow these calcifications more often than do their counterparts in the United States, which undoubtedly contributes to their substantially lower call-back rates. This presumably reflects population affluence, medical costs, and medicolegal climates. Of course, the ideal cost-benefit ratio of any examination is in the eyes of the beholder.

In conclusion, those amorphous breast microcalcifications, which are at the lower end of suspicion, have not only a low probability of being cancer but, more important, also have a low, albeit finite, survival benefit from biopsy and removal even when they turn out to be DCIS. I believe many of us do too many biopsies for these subtle amorphous calcifications, particularly those that often cannot be seen well enough to stereotactically biopsy and can only be wire-localized using magnification mammograms. The positive predictive value for the biopsy of calcifications is less than for masses but, in my opinion, it should be above 20%.


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  1. Soo MS, Rosen EL, Xia JQ, Ghate S, Baker JA. Computer-aided detection of amorphous calcifications. AJR2005; 184:887 -892[Abstract/Free Full Text]

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This Article
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