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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.
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