Case Study: Breast Screening
Question#1: Probable Diagnosis
The most probable diagnosis of this patient from the given history and examination is breast calcifications. They are usually a congregations of calcium deposits that form in breast tissue, frequently in women above the age of 50 years (Grimm et al., 2019). The clusters are usually painless and small in size to be palpated during normal breast examination.
Breast calcifications are usually idiopathic and they can rarely be found in young women. Consequently, they tend to appear with ageing. They are usually benign but sometimes they point towards carcinogenesis of breast cancer (Grimm et al., 2019).
Question#2: Differential Diagnosis
Ddx#1: Ductal carcinoma in situ: The neoplastic proliferation of epithelial cells within the ductal system (Grimm et al., 2019). It is usually characterized by subtle to marked cytological atypia and tends to progress to invasive breast cancer. Ductal carcinoma in situ is typically non-palpable, asymptomatic.
It is commonly discovered incidentally as suspicious microcalcifications on routine mammographic screening or adjacent to other lesions in the breast in pleomorphic, grouped, linear or segmental form (Grimm et al., 2019).
Ddx#2: previous radiation therapy: Studies have shown that calcifications sometimes develop following breast-conserving surgery and radiotherapy for breast carcinoma (Houben et al., 2019). These calcifications are usually benign and mostly non-palpable during normal physical examination of the breast (Houben et al., 2019). However, they are usually identified incidentally during routine mammography.
Ddx#3: Atherosclerosis of Breasts’ blood vessels: Microcalcification can occur within atherosclerotic blood vessels (Margolies et al., 2019). These calcifications can occur in linear or clustered form, and mostly occur with ageing. They are rarely identified during the physical examination of the breast and can rather be identified during routine mammography of the breast (Margolies et al., 2019).
Question#3(a): Diagnostic Studies
Mammography: Following the discovery of the calcifications, a mammogram should be performed again, this time concentrating and magnifying the calcified areas and tissue to obtain more comprehensive images, allowing any malignancies to be ruled out. It is also crucial to get a follow-up mammogram to monitor for changes over time that could indicate cancer (Houben et al., 2019).
Biopsy: This is essential for highly suspicious microcalcifications that occur in tight, irregularly shaped cluster or a line, suggestive of breast cancer. Inspection of the biopsied tissue under microscope is fundamental to confirm the diagnosis of breast cancer (Horvat et al., 2019).
Magnetic Resonance Imaging (MRI): This is highly sensitive mode of imaging and is important in determining whether the mammographic lesion is due to a previous surgery or a recurrence of breast cancer (Horvat et al., 2019).
Imaging for metastases: This can be done through chest x-ray and Computed Tomography of the abdomen to check for any spread of breast malignancy that may have originated from calcified lesion to other body organs (Horvat et al., 2019).
Question#3(b): Possible Treatment
Watchful treatment: Although breast calcification may indicate presence of a malignant process, they are not cancer and rarely turn into cancer. Once determined not to be malignant, there is no need to be treated or removed. However, once cancer is found, either or a combination of chemotherapy, radiotherapy, hormone therapy, biological/targeted therapy, or/and surgery can be indicated (O’Grady & Morgan, 2018).
Grimm, L. J., Miller, M. M., Thomas, S. M., Liu, Y., Lo, J. Y., Hwang, E. S., Hyslop, T., & Ryser, M. D. (2019). Growth dynamics of mammographic calcifications: Differentiating ductal carcinoma in situ from benign breast disease. Radiology, 292(1), 77–83. https://doi.org/10.1148/radiol.2019182599
Horvat, J. V., Keating, D. M., Rodrigues-Duarte, H., Morris, E. A., & Mango, V. L. (2019). Calcifications at digital breast tomosynthesis: Imaging features and biopsy techniques. Radiographics: A Review Publication of the Radiological Society of North America, Inc, 39(2), 307–318. https://doi.org/10.1148/rg.2019180124
Houben, I. P., Vanwetswinkel, S., Kalia, V., Thywissen, T., Nelemans, P. J., Heuts, E. M., Smidt, M. L., Meyer-Baese, A., Wildberger, J. E., & Lobbes, M. (2019). Contrast-enhanced spectral mammography in the evaluation of breast suspicious calcifications: diagnostic accuracy and impact on surgical management. Acta Radiologica (Stockholm, Sweden: 1987), 60(9), 1110–1117. https://doi.org/10.1177/0284185118822639
Margolies, L. R., Yip, R., Hwang, E., Oudsema, R. H., Subramaniam, V. R., Hecht, H., & Narula, J. (2019). Breast arterial calcification in the mammogram report: The patient perspective. AJR. American Journal of Roentgenology, 212(1), 209–214. https://doi.org/10.2214/ajr.18.20171
O’Grady, S., & Morgan, M. P. (2018). Microcalcifications in breast cancer: From pathophysiology to diagnosis and prognosis. Biochimica et Biophysica Acta. Reviews on Cancer, 1869(2), 310–320. https://doi.org/10.1016/j.bbcan.2018.04.006
Case Study Assignment Instructions
A 59-year-old woman comes into the doctor\’s office for a health maintenance examination. The breasts are nontender and without masses. Mammography revealed a small cluster of calcifications.
What is the probable diagnosis?
What are other possible diagnoses?
At this stage of the case study, what diagnostic studies and basic treatments are most appropriate to order and why?
Reference for management of the case study: