Катенёв В.Л.
Случай из практики «Эти удивительные микрокальцинаты».
(Рентгенологическое отделение МУЗ «Красногвардейская центральная районная больница» Белгородской области)
Общий фон - инволютивная железа. В верхнем наружном квадранте определяется снижение прозрачности за счёт очаговых образований местами сливного характера.
Произведено «выделение» отдельных участков железы и их изучение.
Цифровая обработка свидетельствует, что тени, которые на «первичном изображении» визуализировавшиеся, как однородные, фактически не являются таковыми. Некоторое, довольно гомогенное снижение прозрачности отдельных участков, фактически представляет собой «диффузное скопление микрокальцинатов».
Следующие представленные изображения и последующие свидетельствуют, что субстратом довольно нечетких очаговых теней, полученных на первичном изображении, являются также микрокальцинаты.
Последние три иллюстрации свидетельствуют, что отдельные микрокальцинаты, как таковые, имеют различные размеры и различную форму.
И сразу возникли следующие вопросы - недоумения:
1. Как свидетельствует классическая аналоговая рентгеномаммология, двумя основными рентгенологическими признаками рака молочной железы являются:
- непосредственное отображение опухолевого узла на рентгенограмме;
- скопление микрокальцинатов.
2. Возникает недоумение, как вообще на аналоговых маммограммах, можно было диагностировать микрокальцинаты, а главное как можно было измерить их размеры (именно в условиях практической работы в ЛПУ).
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Breast calcifications:
Indicative of focally active process; often requiring biopsy.
75-80% of biopsied clusters of calcifications represent a benign process
10-30% of microcalcifications in asymptomatic patients are associated with cancers
Composition: hydroxyapatite/tricalcium phosphate/calcium oxalate
Results of breast biopsies for microcalcification:
(without any other mammographic findings)
Benign lesions (80%)
1. Mastopathy without proliferation 44%
2. Mastopathy with proliferation 28%
3. Fibroadenoma 4%
4. Solitary papilloma 2%
5. Miscellaneous 2%
Malignant lesions (20%)
1. Lobular carcinoma in situ
in 8% no spatial relationship to LCIS 10%
2. Infiltrating carcinoma 6%
3. Ductal carcinoma in situ 4%
A positive biopsy rate of >35% is desirable goal!
Location:
intramammary
Ductal microcalcifications
0.1-0.3 mm in size, irregular, sometimes mixed linear + punctate
Occurrence: secretory disease, epithelial hyperplasia, atypical ductal hyperplasia, intraductal carcinoma
Lobular microcalcifications
smooth round, similar in size + density
Occurrence: cystic hyperplasia, adenosis, sclerosing adenosis, atypical lobular hyperplasia, lobular carcinoma in situ, cancerization of lobules (= retrograde migration of ductal carcinoma to involve lobules), ductal carcinoma obstructing egress of lobular contents
N.B.: lobular and ductal microcalcifications occur frequently in fibrocystic disease + breast cancer!
Extramammary: arterial wall, duct wall, fibroadenoma, oil cyst, skin, etc.
Size: malignant calcifications usually <0.5 mm; rarely >1.0 mm
Number: 5 calcifications per 1 cm2 have a low probability for malignancy
Morphology:
Benign-
Smooth round calcifications: formed in dilated acini of lobules
Solid/lucent-centered spheres: usually due to fat necrosis
Crescent-shaped calcifications that are concave on horizontal beam lateral projection = sedimented milk of calcium at bottom of cyst
Lucent-centered calcifications: around accumulated debris within ducts/in skin
Solid rod-shaped calcifications/lucent-centered tubular calcifications: formed within/around normal/ectatic ducts
Eggshell calcifications in rim of breast cysts
Calcifications with parallel track appearance = vascular calcifications
Malignant-
= calcified cellular secretions/necrotic cancer cells within ducts
calcifications of vermicular form
varying in size
linear/branching shape
Distribution
Clustered heterogeneous calcifications: adenosis, peripheral duct papilloma, hyperplasia, cancer
Segmental calcifications within single duct network: suspect for multifocal cancer within lobe
Regional/diffusely scattered calcifications with random distribution throughout large volumes of breast: almost always benign
Time course
malignant calcifications can remain stable for >5 years!
Density
Malignant Calcifications
Granular calcifications = resembling fine grains of salt
amorphous, dotlike/elongated, fragmented
grouped very closely together
irregular in form, size, and density
Casting calcifications = fragmented cast of calcifications within ducts
variable in size + length
great variation in density within individual particles + among adjacent particles
jagged irregular contour
Y-shaped branching pattern
clustered (>5 per focus within an area of 1 cm2)
Benign Calcifications
Lobular calcifications = arise within a spherical cavity of cystic hyperplasia, sclerosing adenosis, atypical lobular hyperplasia
sharply outlined, homogeneous, solid, spherical pearl-like
little variation in size
numerous + scattere
associated with considerable fibrosis
adenosis
diffuse calcifications involving both breasts symmetrically
periductal fibrosis
diffuse/grouped calcifications + irregular borders, simulating malignant process
Sedimented milk of calcium
Frequency: 4%
multiple, bilateral, scattered/occasionally clustered calcifications within microcysts
smudge-like particles at bottom of cyst on vertical beam
crescent-shaped on horizontal projection = teacup-like
Plasma cell mastitis = periductal mastitis
sharply marginated calcifications of uniform density = intraductal form
sharply marginated hollow calcifications = periductal form
Peripheral eggshell calcifications
with radiolucent lesion
liponecrosis micro-/macrocystica calcificans (= fatty acids precipitate as calcium soaps at capsular surface) as calcified fat necrosis/calcified hematoma
May mimic malignant calcifications!
with radiopaque lesion
degenerated fibroadenoma
macrocyst
high uniform density in periphery
usually subcutaneous
no associated fibrosis
Papilloma
solitary raspberry configuration in size of duct
central/retroareolar
Degenerated fibroadenoma
bizarre, coarse, sharply outlined, popcorn-like very dense calcification within dense mass (= central myxoid degeneration)
eggshell type calcification (= subcapsular myxoid degeneration)
Arterial calcifications
parallel lines of calcifications
Dermal calcifications
Site: sebaceous glands
hollow radiolucent center
polygonal shape
peripheral location (may project deep within breast even on 2 views at 90° angles)
linear orientation when caught in tangent
same size as skin pores
Proof: superficial marking technique
Metastatic calcifications
Cause: hyperparathyroidism (in up to 68%)
Calcifications in Branching Tubular Opacity
Ductal carcinoma in situ
Atypical ductal hyperplasia
Secretory disease
Peripheral papillomatosis
Vascular: calcified artery; Mondor disease (= thrombophlebitis of superficial vein)
Fat necrosis
S/P Galactography
Уважаемый Dr.Mario, а это ваши личные наблюдения? Если нет, то не подскажете источник?
Ульяна Владимировна!
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Я имела в виду, это статья самого Доктора Марио или он взял ее из какого-либо источника и выложил на сайт для информации...
Спасибо. Вечером жену посажу за перевод.