DOI:10.2214/AJR.06.5013-1
AJR 2006; 186:902-903
© American Roentgen Ray Society
Reply
Mary Scott Soo1,
Sujata Ghate1,
Jay A. Baker1 and
Eric Rosen2
1 Duke University Medical Center Durham, NC 27710
2 University of Washington Seattle, WA
We would like to thank Dr. Hall for his experience and perspective. His
letter reflects the difficulties and frustrations encountered by many
radiologists in regard to mammographic screening, and we share his concerns
about medical costs, oppressive medical-legal climates, excessive numbers of
core breast biopsies, and low positive predictive values. Unfortunately, Dr.
Hall's suggestion for a less rigorous and more controversial approach to the
management of amorphous calcifications was not specifically outlined in his
letter.
However, if it alludes to the use of either short-term mammographic
follow-up or annual screening for these lesions, this approach could encounter
numerous hurdles before it could be put into effect. First, short-term
follow-up in breast imaging has traditionally been recommended only for
lesions that have a less than 2% likelihood of malignancy. In our series
[1] and in the series of Berg
et al. [2], amorphous
calcifications have a 16-20% chance of malignancy, and the American College of
Radiology's Breast Imaging Reporting and Data System manual clearly
labels these as suspicious, placing them in assessment category 4, for which
biopsy is routinely recommended
[3]. Altering this policy to
allow follow-up of suspicious amorphous calcifications would require changing
a consensus among radiologists and clinicians that has been years in the
making. Second, amorphous calcifications would be particularly difficult
lesions to follow. Given the difficulty in counting each small indistinct
calcific particle, accurately determining whether the number of calcifications
had increased during the follow-up interval would be extremely difficult.
Waiting for more highly suspicious changes, such as development of pleomorphic
or linear branching calcifications or for development of an associated mass,
raises the concern of a worsened prognosis for the patient.
If Dr. Hall's suggestion is rather that these lesions be ignored and that
the patient undergo annual screening, again this would be inadvisable because
of the 16-20% likelihood of malignancy. In the absence of a scientifically
backed revised management plan, radiologists will likely be unwilling to
merely annually follow such lesions, especially in the United States where
medical-legal concerns pressure radiologists to diagnose breast cancer at its
earliest point of detection. In addition, although a given population of women
might undergo regular screening, guaranteeing that any individual patient with
amorphous calcifications will return for routine screening borders on
impossible.
Finally, and perhaps most important, although the positive predictive value
of the subset of amorphous calcifications is only to 16-20%, in our series
[1] and in the large series of
Berg et al. [2], 18-25% of
malignant amorphous calcifications encountered were either high-grade ductal
carcinoma in situ (DCIS) or invasive cancer rather than the low-grade, more
indolent DCIS to which Dr. Hall refers. Unfortunately the distinction between
benign versus malignant and high-grade versus lower-grade lesions cannot be
made at mammography, making accurate follow-up of any of these problematic
and, in our opinion, inadvisable.
Fortunately, regarding tissue sampling of amorphous calcifications, the
progressive improvements in digital stereotactic technology have resulted in a
high success rate for minimally invasive core biopsy of these lesions under
stereotactic guidance. In our series
[1] and in the series by Berg
et al. [2], stereotactic
biopsies of amorphous calcifications were successfully performed in 96% and
92% of attempted cases, respectively. Therefore, as is the current standard of
practice, we think that biopsy of amorphous calcifications should be
recommended as soon as they develop or are detected, given their 16-20%
likelihood of malignancy, which includes high-grade DCIS and invasive
carcinoma.
References
- Soo MS, Rosen EL, Xia JQ, Ghate S, Baker JA. Computer-aided
detection of amorphous calcifications. AJR2005; 184:887
-892[Abstract/Free Full Text]
- Berg WA, Arnoldus CL, Teferra E, Bhargavan M. Biopsy of amorphous
breast calcifications: pathologic outcome and yield at stereotactic biopsy.
Radiology 2001;220
: 781-786[Abstract/Free Full Text]
- American College of Radiology. Breast imaging reporting
and data system (BI-RADS), 4th ed. Reston, VA: American College
of Radiology, 2003
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