It is well known that benign and malignant changes of the breast show calcifications [
X-rays were retrospectively taken of paraffin embedded breast specimens from 32 patients. All specimens with a thickness of 3 mm contained microcalcifications (10
BIRADS classification in conventional radiography and microradiography. Changes by microradiography were only rated if diagnosis changed from the benign group (BIRADS 2 and 3) in to the malignant group (BIRADS 4 and 5) and backwards, respectively. No change correct is “No (c)” and no change false is “No (f)”.
Results for examiner 1
Examiner 1 | |||||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Conventional specimen radiography | Microradiography | ||||||||||||||||
BIRADS | Correct/false | BIRADS | Correct/false | Histology | Change by microradiography | ||||||||||||
2 | 3 | 4 | 5 | 2 | 3 | 4 | 5 | Benign/malignant | |||||||||
Case 1 | × | False | × | Correct | Benign | Correct | |||||||||||
Case 2 | × | False | × | False | Benign | No (f) | |||||||||||
Case 3 | × | Correct | × | Correct | Benign | No (f) | |||||||||||
Case 4 | × | Correct | × | False | Benign | False | |||||||||||
Case 5 | × | Correct | × | Correct | Benign | No (c) | |||||||||||
Case 6 | × | False | × | False | Benign | No (f) | |||||||||||
Case 7 | × | Correct | × | False | Benign | False | |||||||||||
Case 8 | × | Correct | × | Correct | Benign | No (c) | |||||||||||
Case 9 | × | False | × | False | Benign | No (f) | |||||||||||
Case 10 | × | Correct | × | False | Benign | False | |||||||||||
Case 11 | × | Correct | × | False | Benign | False | |||||||||||
Case 12 | × | False | × | False | Benign | No (f) | |||||||||||
Case 13 | × | False | × | False | Malignant | No (f) | |||||||||||
Case 14 | × | Correct | × | Correct | Malignant | No (c) | |||||||||||
Case 15 | × | False | × | False | Malignant | No (f) | |||||||||||
Case 16 | × | False | × | False | Benign | No (f) | |||||||||||
Case 17 | × | Correct | × | Correct | Benign | No (c) | |||||||||||
Case 18 | × | False | × | False | Benign | No (f) | |||||||||||
Case 19 | × | Correct | × | Correct | Benign | No (c) | |||||||||||
Case 20 | × | Correct | × | Correct | Benign | No (c) | |||||||||||
Case 21 | × | False | × | False | Malignant | No (f) | |||||||||||
Case 22 | × | Correct | × | False | Malignant | False | |||||||||||
Case 23 | × | Correct | × | Correct | Malignant | No (c) | |||||||||||
Case 24 | × | False | × | False | Benign | No (f) | |||||||||||
Case 25 | × | Correct | × | False | Malignant | False | |||||||||||
Case 26 | × | Correct | × | Correct | Benign | No (c) | |||||||||||
Case 27 | × | False | × | Correct | Benign | Correct | |||||||||||
Case 28 | × | False | × | False | Benign | No (f) | |||||||||||
Case 29 | × | Correct | × | False | Benign | False | |||||||||||
Case 30 | × | False | × | False | Malignant | No (f) | |||||||||||
Case 31 | × | Correct | × | Correct | Malignant | No (c) | |||||||||||
Case 32 | × | Correct | × | Correct | Malignant | No (c) | |||||||||||
| |||||||||||||||||
Total | 2 | 14 | 13 | 3 | 18 | 14 | 2 | 13 | 16 | 1 | 13 | 19 | 22 | 10 | 2 | 10 (c)/13 (f) | 7 |
Results for examiner 2
Examiner 2 | |||||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Conventional specimen radiography | Microradiography | ||||||||||||||||
BIRADS | Correct/false | BIRADS | Correct/false | Histology | Change by microradiography | ||||||||||||
2 | 3 | 4 | 5 | 2 | 3 | 4 | 5 | Benign/malignant | |||||||||
Case 1 | × | Correct | × | Correct | Benign | No (c) | |||||||||||
Case 2 | × | Correct | × | Correct | Benign | No (c) | |||||||||||
Case 3 | × | Correct | × | Correct | Benign | No (c) | |||||||||||
Case 4 | × | Correct | × | False | Benign | False | |||||||||||
Case 5 | × | Correct | × | False | Benign | False | |||||||||||
Case 6 | × | False | × | False | Benign | No (f) | |||||||||||
Case 7 | × | Correct | × | Correct | Benign | No (c) | |||||||||||
Case 8 | × | Correct | × | False | Benign | False | |||||||||||
Case 9 | × | False | × | False | Benign | No (f) | |||||||||||
Case 10 | × | Correct | × | Correct | Benign | No (c) | |||||||||||
Case 11 | × | Correct | × | Correct | Benign | No (c) | |||||||||||
Case 12 | × | False | × | False | Benign | No (f) | |||||||||||
Case 13 | × | False | × | False | Malignant | No (f) | |||||||||||
Case 14 | × | Correct | × | False | Malignant | False | |||||||||||
Case 15 | × | False | × | False | Malignant | No (f) | |||||||||||
Case 16 | × | Correct | × | False | Benign | False | |||||||||||
Case 17 | × | Correct | × | Correct | Benign | No (c) | |||||||||||
Case 18 | × | False | × | False | Benign | No (f) | |||||||||||
Case 19 | × | Correct | × | Correct | Benign | No (c) | |||||||||||
Case 20 | × | Correct | × | Correct | Benign | No (c) | |||||||||||
Case 21 | × | False | × | False | Malignant | No (f) | |||||||||||
Case 22 | × | Correct | × | Correct | Malignant | No (c) | |||||||||||
Case 23 | × | Correct | × | False | Malignant | False | |||||||||||
Case 24 | × | Correct | × | False | Benign | False | |||||||||||
Case 25 | × | False | × | False | Malignant | No (f) | |||||||||||
Case 26 | × | False | × | Correct | Benign | Correct | |||||||||||
Case 27 | × | False | × | Correct | Benign | Correct | |||||||||||
Case 28 | × | False | × | False | Benign | No (f) | |||||||||||
Case 29 | × | False | × | False | Benign | No (f) | |||||||||||
Case 30 | × | False | × | False | Malignant | No (f) | |||||||||||
Case 31 | × | False | × | Correct | Malignant | Correct | |||||||||||
Case 32 | × | Correct | × | Correct | Malignant | No (c) | |||||||||||
| |||||||||||||||||
Total | 6 | 14 | 7 | 5 | 18 | 14 | 9 | 9 | 10 | 4 | 14 | 18 | 22 | 10 | 3 | 11 (c)/11 (f) | 7 |
Results for examiner 3
Examiner 3 | |||||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Conventional specimen radiography | Microradiography | ||||||||||||||||
BIRADS | Correct/false | BIRADS | Correct/false | Histology | Change by microradiography | ||||||||||||
2 | 3 | 4 | 5 | 2 | 3 | 4 | 5 | Benign/malignant | |||||||||
Case 1 | × | False | × | False | Benign | No (f) | |||||||||||
Case 2 | × | False | × | False | Benign | No (f) | |||||||||||
Case 3 | × | Correct | × | Correct | Benign | No (c) | |||||||||||
Case 4 | × | Correct | × | False | Benign | False | |||||||||||
Case 5 | × | Correct | × | Correct | Benign | No (c) | |||||||||||
Case 6 | × | Correct | × | False | Benign | False | |||||||||||
Case 7 | × | Correct | × | False | Benign | False | |||||||||||
Case 8 | × | False | × | False | Benign | No (f) | |||||||||||
Case 9 | × | False | × | Correct | Benign | Correct | |||||||||||
Case 10 | × | Correct | × | False | Benign | False | |||||||||||
Case 11 | × | Correct | × | False | Benign | False | |||||||||||
Case 12 | × | False | × | False | Benign | No (f) | |||||||||||
Case 13 | × | False | × | False | Malignant | No (f) | |||||||||||
Case 14 | × | Correct | × | Correct | Malignant | No (c) | |||||||||||
Case 15 | × | False | × | False | Malignant | No (f) | |||||||||||
Case 16 | × | Correct | × | False | Benign | False | |||||||||||
Case 17 | × | Correct | × | Correct | Benign | No (c) | |||||||||||
Case 18 | × | False | × | False | Benign | No (f) | |||||||||||
Case 19 | × | Correct | × | Correct | Benign | No (c) | |||||||||||
Case 20 | × | False | × | Correct | Benign | Correct | |||||||||||
Case 21 | × | False | × | False | Malignant | No (f) | |||||||||||
Case 22 | × | Correct | × | Correct | Malignant | No (c) | |||||||||||
Case 23 | × | Correct | × | Correct | Malignant | No (c) | |||||||||||
Case 24 | × | Correct | × | Correct | Benign | No (c) | |||||||||||
Case 25 | × | False | × | Correct | Malignant | Correct | |||||||||||
Case 26 | × | Correct | × | Correct | Benign | No (c) | |||||||||||
Case 27 | × | False | × | Correct | Benign | Correct | |||||||||||
Case 28 | × | False | × | False | Benign | No (f) | |||||||||||
Case 29 | × | Correct | × | False | Benign | False | |||||||||||
Case 30 | × | False | × | False | Malignant | No (f) | |||||||||||
Case 31 | × | Correct | × | Correct | Malignant | No (c) | |||||||||||
Case 32 | × | False | × | Correct | Malignant | Correct | |||||||||||
| |||||||||||||||||
Total | 12 | 7 | 9 | 4 | 17 | 15 | 7 | 6 | 11 | 8 | 15 | 17 | 22 | 10 | 5 | 10 (c)/10 (f) | 7 |
Results for examiner 4
Examiner 4 | |||||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Conventional specimen radiography | Microradiography | ||||||||||||||||
BIRADS | Correct/false | BIRADS | Correct/false | Histology | Change by microradiography | ||||||||||||
2 | 3 | 4 | 5 | 2 | 3 | 4 | 5 | Benign/malignant | |||||||||
Case 1 | × | False | × | False | Benign | No (f) | |||||||||||
Case 2 | × | False | × | False | Benign | No (f) | |||||||||||
Case 3 | × | Correct | × | Correct | Benign | No (c) | |||||||||||
Case 4 | × | Correct | × | False | Benign | False | |||||||||||
Case 5 | × | Correct | × | Correct | Benign | No (c) | |||||||||||
Case 6 | × | Correct | × | False | Benign | False | |||||||||||
Case 7 | × | Correct | × | False | Benign | False | |||||||||||
Case 8 | × | False | × | False | Benign | No (f) | |||||||||||
Case 9 | × | False | × | Correct | Benign | Correct | |||||||||||
Case 10 | × | Correct | × | False | Benign | False | |||||||||||
Case 11 | × | Correct | × | False | Benign | False | |||||||||||
Case 12 | × | Correct | × | False | Benign | False | |||||||||||
Case 13 | × | False | × | False | Malignant | No (f) | |||||||||||
Case 14 | × | Correct | × | Correct | Malignant | No (c) | |||||||||||
Case 15 | × | False | × | False | Malignant | No (f) | |||||||||||
Case 16 | × | Correct | × | False | Benign | False | |||||||||||
Case 17 | × | Correct | × | Correct | Benign | No (c) | |||||||||||
Case 18 | × | Correct | × | False | Benign | False | |||||||||||
Case 19 | × | Correct | × | Correct | Benign | No (c) | |||||||||||
Case 20 | × | False | × | Correct | Benign | Correct | |||||||||||
Case 21 | × | False | × | False | Malignant | No (f) | |||||||||||
Case 22 | × | Correct | × | Correct | Malignant | No (c) | |||||||||||
Case 23 | × | Correct | × | Correct | Malignant | No (c) | |||||||||||
Case 24 | × | Correct | × | False | Benign | False | |||||||||||
Case 25 | × | Correct | × | False | Malignant | False | |||||||||||
Case 26 | × | Correct | × | Correct | Benign | No (c) | |||||||||||
Case 27 | × | False | × | Correct | Benign | Correct | |||||||||||
Case 28 | × | False | × | False | Benign | No (f) | |||||||||||
Case 29 | × | Correct | × | False | Benign | False | |||||||||||
Case 30 | × | Correct | × | False | Malignant | False | |||||||||||
Case 31 | × | Correct | × | Correct | Malignant | No(c) | |||||||||||
Case 32 | × | False | × | Correct | Malignant | Correct | |||||||||||
| |||||||||||||||||
Total | 13 | 6 | 8 | 5 | 21 | 11 | 8 | 5 | 11 | 8 | 13 | 19 | 22 | 10 | 4 | 9 (c)/7 (f) | 12 |
Results for examiner 5
Examiner 5 | |||||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Conventional specimen radiography | Microradiography | ||||||||||||||||
BIRADS | Correct/false | BIRADS | Correct/false | Histology | Change by microradiography | ||||||||||||
2 | 3 | 4 | 5 | 2 | 3 | 4 | 5 | Benign/malignant | |||||||||
Case 1 | × | False | × | Correct | Benign | Correct | |||||||||||
Case 2 | × | False | × | False | Benign | No (f) | |||||||||||
Case 3 | × | False | × | Correct | Benign | Correct | |||||||||||
Case 4 | × | Correct | × | Correct | Benign | No (c) | |||||||||||
Case 5 | × | Correct | × | False | Benign | False | |||||||||||
Case 6 | × | False | × | Correct | Benign | Correct | |||||||||||
Case 7 | × | False | × | Correct | Benign | Correct | |||||||||||
Case 8 | × | False | × | Correct | Benign | Correct | |||||||||||
Case 9 | × | False | × | False | Benign | No (f) | |||||||||||
Case 10 | × | Correct | × | False | Benign | False | |||||||||||
Case 11 | × | False | × | False | Benign | No (f) | |||||||||||
Case 12 | × | False | × | Correct | Benign | Correct | |||||||||||
Case 13 | × | Correct | × | False | Malignant | False | |||||||||||
Case 14 | × | Correct | × | Correct | Malignant | No (c) | |||||||||||
Case 15 | × | False | × | False | Malignant | No (f) | |||||||||||
Case 16 | × | False | × | False | Benign | No (f) | |||||||||||
Case 17 | × | Correct | × | Correct | Benign | No (c) | |||||||||||
Case 18 | × | False | × | False | Benign | No (f) | |||||||||||
Case 19 | × | Correct | × | Correct | Benign | No (c) | |||||||||||
Case 20 | × | False | × | Correct | Benign | Correct | |||||||||||
Case 21 | × | False | × | False | Malignant | No (f) | |||||||||||
Case 22 | × | Correct | × | False | Malignant | False | |||||||||||
Case 23 | × | Correct | × | False | Malignant | False | |||||||||||
Case 24 | × | False | × | Correct | Benign | Correct | |||||||||||
Case 25 | × | False | × | False | Malignant | No (f) | |||||||||||
Case 26 | × | Correct | × | Correct | Benign | No (c) | |||||||||||
Case 27 | × | False | × | Correct | Benign | Correct | |||||||||||
Case 28 | × | False | × | False | Benign | No (f) | |||||||||||
Case 29 | × | Correct | × | Correct | Benign | No (c) | |||||||||||
Case 30 | × | False | × | False | Malignant | No (f) | |||||||||||
Case 31 | × | Correct | × | False | Malignant | False | |||||||||||
Case 32 | × | Correct | × | False | Malignant | False | |||||||||||
| |||||||||||||||||
Total | 3 | 8 | 8 | 13 | 13 | 19 | 12 | 11 | 6 | 3 | 15 | 17 | 22 | 10 | 9 | 6 (c)/10 (f) | 7 |
BIRADS classification in conventional specimen radiography and microradiography. Summary of five examiners.
Case | Numbers of diagnosis |
Numbers of diagnosis |
Histology |
Diagnosis of the | |||
---|---|---|---|---|---|---|---|
Nr. | BIRADS |
BIRADS |
BIRADS |
BIRADS |
|||
1 | 1 | 4 | 3 | 2 | Benign | Fibrocystic mastopathy | |
2 | 0 | 5 | 1 | 4 | Benign | Fibrocystic mastopathy | |
3 | 4 | 1 | 5 | 0 | Benign | Fibrocystic mastopathy | |
4 | 5 | 0 | 1 | 4 | Benign | Fibrocystic mastopathy | |
5 | 5 | 0 | 3 | 2 | Benign | Fibrocystic mastopathy | |
6 | 2 | 3 | 1 | 4 | Benign | Fibrocystic mastopathy | |
7 | 4 | 1 | 2 | 3 | Benign | Fibrocystic mastopathy | |
8 | 2 | 3 | 2 | 3 | Benign | Fibrocystic mastopathy | |
9 | 0 | 5 | 2 | 3 | Benign | Fibrocystic mastopathy | |
10 | 5 | 0 | 1 | 4 | Benign | Fibrocystic mastopathy | |
11 | 4 | 1 | 1 | 4 | Benign | Fibrocystic mastopathy | |
12 | 1 | 4 | 1 | 4 | Benign | Fibrocystic mastopathy | |
13 | 4 | 1 | 5 | 0 | Malignant | Intraductal high-grade comedocarcinoma | |
14 | 0 | 5 | 1 | 4 | Malignant | Ductal carcinoma in situ | |
15 | 5 | 0 | 5 | 0 | Malignant | Ductal carcinoma in situ | |
16 | 3 | 2 | 0 | 5 | Benign | Fibrocystic mastopathy | |
17 | 5 | 0 | 5 | 0 | Benign | Fibrocystic mastopathy | |
18 | 1 | 4 | 0 | 5 | Benign | Fibrocystic mastopathy | |
19 | 5 | 0 | 5 | 0 | Benign | Fat tissue necrosis | |
20 | 2 | 3 | 5 | 0 | Benign | Pericanalicular fibroadenoma | |
21 | 5 | 0 | 5 | 0 | Malignant | Ductal carcinoma in situ | |
22 | 0 | 5 | 2 | 3 | Malignant | Ductal carcinoma in situ | |
23 | 0 | 5 | 2 | 3 | Malignant | Ductal carcinoma in situ | |
24 | 3 | 2 | 2 | 3 | Benign | Fibrocystic mastopathy | |
25 | 3 | 2 | 4 | 1 | Malignant | Ductal carcinoma in situ | |
26 | 4 | 1 | 5 | 0 | Benign | Fibrocystic mastopathy | |
27 | 0 | 5 | 5 | 0 | Benign | Fibrocystic mastopathy | |
28 | 0 | 5 | 0 | 5 | Benign | Fibrocystic mastopathy | |
29 | 4 | 1 | 1 | 4 | Benign | Fibrocystic mastopathy | |
30 | 4 | 1 | 5 | 0 | Malignant | Intraductal high-grade comedocarcinoma | |
31 | 1 | 4 | 1 | 4 | Malignant | Intraductal high-grade comedocarcinoma | |
32 | 2 | 3 | 1 | 4 | Malignant | Cribriform intraductal carcinoma in situ | |
correct | 60 | 26 | 51 | 19 | |||
false | 24 | 50 | 31 | 59 | |||
| |||||||
Total | 84 | 76 | 82 | 78 |
Using microradiography microcalcifications can be shown in high resolution at the cell level including a histological correlation (Figures
Cribriform intraductal carcinoma in situ (nonhigh grade). Microcalcifications (b) that are amorphous and indistinct in microradiography and in conventional specimen radiography (a). Histological evidence of gravel-like calcifications (arrow in (c)). In the histological as well as the microradiographic image, the calcifications have not yet condensed to form larger structures compared to Figure
Intraductal comedo type breast carcinoma (high grade). Microradiography shows fine linear calcifications with smooth borders (large arrow in (b)) in which the calcified tumor necrosis completely fills the duct (large arrow in (c)). Linear calcifications with rough, irregular borders are also shown (small arrow in (b)). In these areas the calcifications are not significantly progressed and they do not completely fill the duct (small arrow in (c)). These microradiographic differences are not detectable in conventional specimen radiography (a).
Fibrocystic mastopathy with sclerosing adenosis. Round microcalcification that is typically benign in microradiography (b) appears linear and amorphous in conventional specimen radiography as a result of the superposition (a). The calcification is marked by arrows in the histological picture (c).
Fibrocystic mastopathy with sclerosing adenosis. Conventional specimen radiography show some amorphous and indistinct calcifications (a). The amorphous calcifications are microradiographically displayed as a summation effect of round and smooth calcifications of varying sizes. Diffuse amorphous microcalcifications are also visible (triangles in (b)) and result in the spotted shadowing in conventional specimen radiography. Fibrocystic mastopathy with sclerosing adenosis is demonstrated histologically (c). Only a few fragments of the large round calcifications in the cysts are histologically visible (arrow in (c)). The amorphous calcifications are almost completely lost during histological preparation. As a result of the shape of the calcification area and the specimen, the amorphous calcifications can be clearly correlated to a histological area of sclerosing adenosis (triangles in (b) and (c)). The calcifications are intraluminal calcifications in sclerosing adenosis.
Amorphous and indistinct microcalcifications (Figure
Analysis of individual cases showed that the high resolution of microradiography improved, worsened, or did not change the evaluation of calcifications with respect to malignancy.
Linear calcifications with smooth and indistinct borders (Figure
Groups of round calcifications (Figure
Almost identical amorphous and indistinct calcifications with a malignant cause in Figure
These benign calcifications showed additional small calcifications in high resolution (Figure
Fibrocystic mastopathy and adenosis. Microradiography demonstrates fine pleomorphic calcifications. This implies a malignant genesis as the cause of calcification. However, histology only detects adenosis in which the dilated ducts and acini are deformed that tracing of the irregular wall borders shows fine pleomorphic calcifications.
Although the diagnostic validity due to the higher resolution in microradiography is improved in single cases (Figure
Change of diagnosis by microradiography.
Correct change | None change | False change | Total | ||
---|---|---|---|---|---|
Correct diagnosis in microradiography | Correct diagnosis in conventional and microradiography | Incorrect diagnosis in conventional and microradiography | Incorrect diagnosis in microradiography | ||
Examiner 1 | 2 | 10 | 13 | 7 | 32 |
Examiner 2 | 3 | 11 | 11 | 7 | 32 |
Examiner 3 | 5 | 10 | 10 | 7 | 32 |
Examiner 4 | 4 | 9 | 7 | 12 | 32 |
Examiner 5 | 9 | 6 | 10 | 7 | 32 |
| |||||
Total | 23 | 46 | 51 | 40 | 160 |
However, the differences were not significant. In the BIRADS 2 and 3 group (Table
When detecting breast carcinomas via mammography, the evidence of calcification in addition to soft tissue lesions plays an important role. The most important components of the assessment of microcalcifications are the morphology of the individual calcifications and the configuration of the group [
The histopathological reason for different types of calcifications can be demonstrated effectively. The comparison of the structural analysis of microcalcifications in conventional specimen radiography and microradiography shows that the typical benign calcifications in microradiography may appear malignant in conventional radiography due to superposition. In opposition to our expectations, this study did not show an improvement in diagnostic accuracy when evaluating microcalcifications using microradiography compared to conventional radiography. An improvement in diagnostic validity was only shown in a few cases with benign microcalcifications, but this was offset by the irregular visualization of the benign microcalcifications caused by the higher resolution, resulting in a higher BIRADS category. The diagnostic validity for microradiography with respect to the probability of malignancy tended to be worse than that of conventional specimen radiography. Similar results were demonstrated by Grunert et al. [
In our study, the probability for malignancy in the BIRADS 2 and 3 group was very high at more than 20%. Normally BIRADS category 3 (“probably benign”) is associated with an estimated low risk of malignancy (<2%) [
It is known that 13.6% of calcifications from breast specimens are lost during embedding and 12.6% are lost after embedding during cutting [
Microradiography allows an exact structural analysis of microcalcifications with high accuracy and histological correlation. In some cases, the knowledge of the microradiographic appearance of breast microcalcifications improves the understanding of calcifications in mammography because they are the result of the superposition of microradiographic images. The improved resolution in mammography does not necessarily result in correct evaluation of microcalcifications. An improvement can probably be achieved by examiners becoming familiar with high-resolution radiography. For future studies, microradiography can help determine the degree to which higher resolution is useful in mammography, even though the procedure can only be used on specimens.
Since many microcalcifications can not be assigned surely to a benign or malignant cause, when in doubt the diagnosis must be confirmed by biopsy.