mixed diffuse calc in apocrine

8/7/2019 mixed diffuse calc in apocrine

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D an ie l B . K opan s, M D # {149 }Phuong L N guy en , M D2 #{149}F red erick C . K o erne r , M D #{149}G eorge W h ite , M D #{149}K ath leen A . M cC arthy , M D #{149}D eborah A . H a ll, M D #{149}H elen M rose , M D #{149}G ilda C ard eno sa , M D #{149}E liz a P ile -S pe ilm an

M ixed F orm , D iffu se ly S cattered C a lc ifica tion sin B reast C ancer w ith A pocr in e F eatu res

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D iffu se ly sca ttered ca lcif ica tio n sv isib le w ith m amm ography are a l-m ost a lw ays b en ign . C er ta in pat-tern s, h ow ev er , sh ou ld a rou se con -ce rn . For ex am p le , ex ten s iv e com e-docarc in om a is asso cia ted w ith la rg ea reas o f m amm ograph ica lly v is ib leca lc ium depositIon . T he authorsid en tif ied 1 0 w om en in whom ca lci-fica tion s w ere v isib le th roughou tla rg e v o lum es of b rea st tissu e a tm amm ography . T he ca lc ifica tion sd id no t resem b le th ose typ ica l o f cx -ten siv e com edo ca rc in om a , y et th eyw ere as soc ia ted w ith exten siveb reast can cer . T heir m amm ograph icpa t te rn was cha ra c ter ized by a strik -in g ly w ild , chaotic app ea ran ce w ithp rofu se d eposit ion of ca lc ium . A s inm any can cers, th e pa rtic les w ereh e terog en eou s , bu t un lik e in m ostca rc in om a s, m any depo sits h ad atyp ica lly ben ign m orpho lo gy . H is -to log ic exam ina tio n show ed tha tev en th ese typ ica lly b en ign ca lcif i-ca tion s w ere a ssoc ia ted w ith m alig -n an t ce lls . T h e au thors be lieve th atth e apo cn in e fea tu res d isp layed bym any of th e can cer ce lls in th ese 10pa tien ts m ay exp la in th e unu sua lp ro fu sio n of ca lc ium depos its .

Index te rm s: B reas t, ca lc ifica tion , 00 .81 2 #{149}B rea st neo pla sm s, d iagn os is, 0 0 .3 21 1

R adio logy 1990 ; 177 :8 07-81 1

I From the D epar tm ent of R adio lo gy , M assa -ch use tts G ene ra! H o sp ita l a nd the M assachu-set ts G en era l H osp ita l C ancer C en ter, H arv ardM edica l Sch oo l, 3 2 F ru it S t. B o ston , MA 02114(D .B .K ., G .W ., K .A .M ., D .A .H ., H .M ., G .C .); andthe D ep artm en t of Pa tho log y , M assa chu set tsG eneral H o sp ita l, B o sto n (P .L .N ., F .C .K .). R e-ceived N ov em ber 14 , 198 9; rev ision req ues tedJanua ry 10 , 1 99 0; a ccep ted A ugu st 8 ; fin al re v i-sio n re ceiv ed S ep tem ber 5 . A ddre ss repr in t re-ques ts to D .B .K .

2 C urren t add res s: D epar tm ent o f Pa tho log yan d L abo ratory M edic ine, U n ive rsity of M m -ne so ta H o sp ita l, M inn eap olis.c R SNA , 1990

T H E prim ary fo cu s o f m amm ogra -ph y is th e ea rly de tec tion of

b reast can ce r . Th e v isua lizatio n ofsm a ll g ro ups o f ca lc ifica tion s o ftenrevea ls cancer ea rly in its deve lo p -m en t, an d the de tec tio n o f th ese clu s-ters is p ossib le o n ly th rou gh the useo f m amm ograph ic sc reen in g . Th ed iffe ren tiatio n of pa rticle s a ssoc ia tedw ith m a lign an t d isease from tho sefo un d w ith ben ign p ro cesse s is th enex t step afte r de tectio n and rep re -sen ts a d ifficu lt cha llen ge fo r the ra-d io log ist. T h e co nven tio na l teach in gis tha t w ide ly scatte red ca lcif icatio nsneed n o t a ro use conce rn , s ince theya re inv ariab ly asso cia ted w ith ben ig nprocesse s su ch as m ic rocyst fo rm a-tion and sc le ro sing adeno sis (1 -3 ).T h is is a lm ost a lw ays true . O ne ex-cep tion to th is teach in g is the f ind in go f segm en ta lly d istr ibu ted casting ca lcif icatio ns o f an ex tensiv e com e-d ocan cin om a (3 ). T h is pa tte rn occu rsw ith su ffic ien t frequency and is su f-f icien tly d istinc tive tha t it is rare lycon fused w ith ben ig n ca lcif icatio ns.A second ob se rva tio n in th e com m onw isd om is th at sph erical, c en tra lly lu -cen t ca lc ifica tions are v irtu ally n ev era sso c iated w ith m a lig nancy (1 -4 ) ex -cep t by co in cid en ce . W e h av e ob -served 1 0 w om en w ho had a typ ica lca lc ifica tio ns th at, d esp ite th eir d if-fu se and sca tte red na tu re and m anyben ign , sphe rica l fo rm s , w ere asso ci-ated w ith d iffu se b reast cance r. Theh isto lo g ic rev iew of these can cers m e-vea led sev era l s im ila r fea tu res .

SUB JECTS AND M ETHOD SBetween 1982 and 1988 , 2 ,1 42 breast

can ce rs w ere d iag nosed a t th e M assach u-se tis G enera l H osp ita l. In som e of thesecases, w e no ted a pa tte rn o f ca lc ifica tiona t m amm ograph y th at w as aty p ic al in ou rexperience . T he ca lc if ica tions w eresp read th ro ughou t larg e (m ore than 3cm 3) v o lum es of b reast tissu e. T he re w as apro fusion of ca lc ium depos ition , and theovera ll im press ion w as a w ild o r d iso r-g an ized pa tte rn o f calc if ica tion . S u spec t-

ing tha t these cancers m igh t h av e sim ilarh isto log ic fea tu res , w e then pro spec tive lyid en tified n in e w om en w ho had m amm o -g raph ica lly sim ilar ca lcif icatio ns d istn ib -u ted th ro ughou t a la rge vo lum e of theb reast. A 10 th case w as sen t to us fo r co n-su lta tion . The h isto log ic sec tion s o f thesecase s w ere rev iew ed to de term in e if them ew e re s im il ar it ie s.

M am m og raph ic f ind in gs w ere com re la t-ed w ith fin d ing s seen o n tissue sectio nsp repa red in the usu al fa sh ion (hem a tox y-lin -eos in sta in ) f rom spec im ens rem oveda t the tim e of b iop sy (n ine o f 10 ) and m as-tec tom y (e igh t o f 1 0 ) . D uring h is to log icex am ina tion , w e reco rded the fo llow ing :d iag nos is , m ic roscop ic appearance of thetum or cells , and the size , shape , and lo ca -tion of the ca lc ifica tions and the ir re la -t ion sh ip to m alignan t ce lls. W e a tte mp te dto rela te the m o rp ho lo gy o f the ca lcif ica-tion s seen a t m amm ography to the h is to -l og ic o bs er va ti on s.

RESULTSThe 10 p atien ts rang ed in ag e from

24 to 7 0 years (m ean 48 yea rs ). T h epa tien ts und erw en t m am m og raph yfo r m any d iffe ren t reasons. O ne pa -tien t h ad a b loo dy n ipp le d ischa rg e.A secon d had d iffuse b reast th icken -ing . T hree had pa lpab le abno rm ali-ties (8 mm , 12 m m , an d 15 mm ) tha tacco un ted fo r a sm all po rtion o f the ird iffu se can ce rs . Th e rem a inde r o f thecan cers w ere clin ica lly occu lt an dw ere d iagn osed b y m ean s o f g u idedsam p ling . O ne of these pa tien ts had astron g fam ily h isto ry o f p rem eno-p au sa l b rea st cance r, and in a secondpa tien t the d iagno sis o f lobu lar ca rci-nom a in situ w as m ad e on the b as iso f a p rio r b iopsy spec im en from th esam e b reast.

M amm ograph ic F ea tu resT he les ions w ere v is ib le m amm o-

g raph ica lly on ly as ca lc ifica tions, cx -cep t in on e w om an , w hose p a lpab lem ass w as v isib le as a sp icu la ted le -sion w ith ca lcif ica tio ns sepa ra te fromthe m ass. In a ll 10 p atien ts , th e calc i-


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F igure 1 . C ran iocauda l p ro jec tion show scalcification s oc cup yin g a larg e vo lum e o fbreas t t issu e. C an cer w a s pre sen t th ro ug h-ou t .

80 8 #{149}Rad io logy D ecem ber 19 90

f ica tions w ere u n ilate ra l and d istn ib -u ted in a la rge vo lum e of tissue (F ig1). T he pro fus ion of ca lc ium depos i-tion w as the m ost strik ing fea tu re o fthese cases . T he cancers p roducedpartic les tha t w ere he te rogeneou s insize, dens ity , sh ap e, and p atte rn o faggrega tion . M o st o f the depos itspa radox ica lly d isp layed the fea tu reso f ca lcifica tio ns usua lly assoc ia tedw ith ben ign processes. T he m ostp reva len t fo rm s w ere large (1 -2 mm ),irreg u lar , an d dense (F igs 2 , 3 ). 0 th -en s w ere am orph ous (F ig 4), andm any calc ifica tion s had lucen t cen-tens (F ig 5 ) . Som e appea red as pm ec ip -ita ted and agg rega ted depos its tha tp rodu ced th e pa tte rn assoc ia ted w ithm ilk of ca lc ium in cy sts (5 ) (F ig 6) .V astly ou tnum bered by these ben-ign fo rm s w ere a few ca lc ifica tio nsd isp lay ing the m ore ty p ical cas tin gm o rpho lo gy seen in m any breast can -ce rs (6 ) (F ig 7 ). A lthou gh presen t ina ll th e pa tien ts , th ese la tte r fo rm sw ere o ften d iff icu lt to f ind du e to th epro fus io n of o th er ca lc ifica tions .

F igure 2 . C a lc ifica tions (sim ila r to those inF ig 1 ) occupy in g a large v o lum e of tissuew ere p resen t in a second pa tien t w ith d if-fuse b rea st can cer .

Thus, the p redom inan t ca lc ifica tion swere large r than th ose usua lly a sso c i-ated w ith cance r, an d m any had m om -pho log ica lly ben ign shapes. T hem ark ed pro fu sion of the ca lcif ica-tions and the genera l w ild appear-an ce an d d istr ibu tio n w em e fea tu re sth at had draw n our a tten tion to th esecases .

H isto log ic F ea tu resIn f iltra ting and in tradu cta l canc i-

nom a w as presen t in six o f the 10 p a -tien ts; in tradu c ta l ca rc in om a w ith ou tan in filtra ting com ponen t w as iden-tified in th e rem ain ing fo ur pa tien ts.O f th e thou sands o f ca lcif icatio nsp resen t on h is to log ic sec tions , v irtu -a lly a ll w ere e ith e r su rroun ded bym alignan t ce lls on w ith in 0 .1 cm ofthem . C onverse ly , tis sue tha t d id no tha rbor ca rc inom a con ta ined on ly oc -casiona l ca lc ifica tions . T he m a jo rityo f th e depo sits w ere assoc iated w iththe in situ com ponen t o f the cancer .

F igure 3 . C lose -up view of a th ird p atie n trev eals n um ero us d ense calc ifications , m anyla rg er than 1 mm in d iam ete r. V irtu ally allw ere assoc iated w ith can cer.

F igure 4 . A m orphous depos its w ere fou ndin a fou rth p atie n t w ith can ce r that occupiedthe low er in ner qu ad ran t o f th e breas t.

A s is usu ally th e case , n o ca lc ifica -tions w ere assoc ia ted w ith the in fil-trating com ponen t o f th e tum ors .

T he cy to log ic appearances of a ll 10tum o rs w ere sim ila r and seem ed tobe a comm on fea tu re . In filtra ting an din tradu c ta l ca rc inom a w as in p art theu sua l no t o therw ise sp ec ified type ,bu t in each of these cases , p rom inen tap ocn ine fea tu res w ere no ted in asub popu la tion o f ce lls . M any of thece lls ex h ib ited abu ndan t g ranu la r eo -s inoph ilic cy top lasm and hyperchro -m atic nuc lei. L arge and irregu la r nu-c leo li w ere frequen tly ob served (F ig8 ). A lthou gh the apo cr in e fea tu resw ere presen t in each case , thechan ges w ere n o t su ffic ien tly ex ten -s ive to w arran t th e specific d iag nos iso f apocrine cancer.


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Figure 5 . S ph erical, lu cen t-cen te red c alc ifi-ca tio ns w ere aty p ic ally form ed in as soc ia-t ion w ith breas t can ce r.

Figu re 6 . C lose inspec tio n of the ho rizo n-ta l be am lateral dem onstra te s precip ita tedm ilk o f calcium layer ing in th e d ependentpo rtio n o f c anc er- lined cys ts.

W e believe tha t each m amm o-graph ic pa tte rn of ca lc ium depos itioncou ld b e corre la ted w ith a h isto log icpa tte rn . T he casting ca lc ifica tions oc-curred in reg ion s o f in trad uc ta l ca rc i-nom a disp lay ing cen tra l necro sis, a sin com edocarc inom a (F ig 9 ). T he sec-ond pa tte rn (la rge , d en se , irreg u larcalc if ica tion s) w as assoc ia ted w ithdepo sits o f ca lc ium ad jacen t to , o rw ith in the w alls o f, duc ts co n tain ingin trad uc ta l carc inom a (F ig 1 0). A l-though these depos its w ere n o t in d i-rec t con tac t w ith m alig nan t ce lls ,they w ere in prox im ity to th em . Th eca lcifica tio ns h av ing the m ost un usu -a l h is to log ic coun te rpart w ere th ose

F igure 7. A ltho ugh m o st cas ting fo rm sw ere obscu red b y the pro fusion of o ther de-pos its, these d em on stra te the typ ical a ppe ar-an ce usu ally asso c ia ted w ith cancer.

sphe rica l fo rm s u sua lly a ssoc ia tedw ith depo sits in ben ign cysts . T hetis sue con ta in ing th ese ca lc ificationsd isp layed cys tica lly d ila ted ac in if illed w ith partic les o f ca lc ium sa ltsand lined by m alignan t ce lls rath erthan the expec ted ben ign ac inarcells . T he m alignan t ce lls w ere an-ran ged in o n ly a few ce ll layers , thu sprese rv ing th e a rch itec tu re o f th e d i-la ted ac inus (F ig 11). N ecro tic m ater i-a l w as no t seen in th ese ac in i linedw ith m alig nan t ce lls.

D ISCUSS IONA pprox im ate ly 50% o f n onpa lpa-

b le , m amm ograph ically de tec ted can -cers are found as a resu lt o f ca lc iumdepos ition . T he ca lcifica tio ns usu a llyassoc ia ted w ith breast cancer appearas a sm all c lus te r occupy in g a tissuevo lum e of 1-2 cm 3 on the m amm o-gram . T hey are a lm os t a lw ays irregu -lam , jagg ed , o r po in ted , and , w henty p ical, they are d is tribu ted in linea ro r b ranch in g arrays . H is to lo g ic sec -tio ns usua lly revea l the ca lcific de-pos its in necro tic debris o f th e in tra-duc ta l com ponen t o f the tum or. Ithas been po stu la ted tha t in th is situa -tio n , the in nerm os t lay ers o f m alig -nan t ce lls d ie an d drop in to th e lu -m en o f th e duc t. T he accum u la tednecro tic d eb ris p rov ides a n idus fo rth e crys talliza tion of ca lc ium sa lts . A sth e d ep osits en la rge , they com e to filland ou tline the d uc t sy stem in w hichthey arise . T h e sh ap es of the ca lc ifi-ca tion s a re irregu la r in part becau sethey assum e the co nfigura tion of the

invo lved , irregu la r duc ts . T h is ty p i-cal casting app earan ce is w ell k now nto m ost rad io log is ts . E ven in the un-usu a l s itua tion in w h ich these ca lc ifi-ca tio ns o ccup y an ex tens ive area, th epa tte rn w ou ld no t be con fu sed w ith aben ig n p ro cess.

Converse ly , the ca lc ifica tions asso -c iated w ith ben ign breast d isea se s a reusu a lly so lita ry . W hen m ultip le , theca lc ifica tio ns a re d istribu ted rand om -ly th roughou t a la rg e vo lum e of thebreas t. M orpho log ica lly , a cen tra la rea o f lucen cy in a ca lc ium depos it isv irtua lly a lw ays assoc ia ted w ith be-n ign pro cesses . T he c lass ic c rescen ticshapes of ca lcium prec ip ita ted incys ts , o r in a she ll-like d istribu tion ,a re a lso said to in va riab ly rep re sen tben ign chang es.

T he m amm ograph ic m an ifes ta tionsof b reast cancers in our se rie s sha redtw o unu sua l fea tu res : T he ca lc ifica -tions w ere d is tribu ted th rou ghou t ala rg e vo lum e o f th e b reast, and theca lc ifica tio ns w ere so num ero us,dense , an d he te rog en eo us tha t theypro duced a w ild , chao tic appearancetha t inc luded m any of the roun d andcu rv ilinea r sh ap es usu ally a sso cia tedw ith b en ig n processes. A lthoughtyp ica l ca stin g ca lcif icatio ns cou ld b efou nd in m any of the 10 cases, theyw ere v irtu ally h idd en by the p ro fu -s ion of sph er ica l and h o llow fo rm sas w ell as c lassic p recip ita ted m ilk o fca lc ium.

T he orig in of the chao tic , p ro fusedep osition of ca lc ium defin ing them amm ograp h ic pa tte rn cann o t beread ily ex p lained . P recip ita tio n ofca lc ium salts in n ecro tic debris , p ro -du c in g the occas iona l cas ting pa tte rn ,accoun ts fo r on ly a sm all p ercen tageo f th e ca lc ifica tion s fou nd in thesecases . It d oes no t accoun t fo r the de-po sition of ca lc ium in th e s trom a ad-jacen t to d uc ts (F ig 8) o r the dep osi-tion o f ca lc ium in the lum en of cys ti-ca lly d ila ted ac in i lined w ithm alignan t ce lls in th e absen ce of ce l-lu la r d eb ris (F ig 9). W e are com -pe lled , th e re fo re , to exp lo re o ther o b-serva tion s to elu cid ate th e pa ttern o fca lc ium depo sition . It is im portan t tore ite ra te tha t our 1 0 cases h ad b eense lected pro spec tive ly based on s im i-lam and unu sua l m amm og raph ic fea -tum es , w ith ou t p rio r k now led ge ofh is to log ic charac te ristic s. S ubsequen tm icroscop ic exam ina tion revea ledth at ca rc in om a w as presen t in eachcase and tha t som e of the m alignan tce lls d isp layed apo crin e fea tu res. A l-th ough th is h is to lo g ic appearancew as no t u n ifo rm ly dem ons tratedth roughou t th e tum ors , the freq uen t-ly o bse rv ed p rox im ity o f these apo -


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81 0 #{149}Rad io logy D ecem ber 1 990

8.F ig ure s 8 , 9 . (8 ) M a lign an t du cta l c ells d isp lay ing ap ocrine featu res . Th e cy to p la sm is abu ndant and granu lar . Th e n uc lei are la rge ; som ea re hyp erchrom a tic , an d o the rs h av e larg e n ucleo l i. (H em a tox ylin -eosin s ta in ; o rig ina l m agnifica tion , X 500 .) (9 ) Th e da rk ly s ta in ed struc -tu re s are c alcifica tio ns w ith in n ecro tic cel lu la r deb ris. Sev era l la yers o f m alig nan t cells lin e th ese d ila ted du cts. D eg ene rating c ells ap paren t-ly p rov ide the n idu s for c alc ific atio n . (H em ato xylin -eos in sta in ; o rig in al m agnific atio n , X 50 .)

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10. 11.F ig ures 10 , 11 . (10) T he dark ly sta in ing ag grega tes a re la rge ca lcifica tio ns in the s trom a ad jacen t to du c ts filled w ith in traduc ta l ca rc inom a(m uch o f th e cen te r of ea ch d epo sit h as fra gm ented d urin g cu tting and ha s falle n ou t of the sec tion ). T he se calcificat ion s a re su rro und ed bycolla gen ou s con nec tiv e tis sue . (H em atox ylin -eosin s ta in ; o rig in al m agn ific atio n , X 79 .) (11 ) A t h igh m agnificat ion , the an ap la stic ch ara cter is-tic s o f th e m a lign an t cel ls lin ing the cyst ical ly d ila te d a cin i (c on tain ing calcificat ion s) are app aren t. (H em atoxy lin -eo sin sta in ; o r ig in al m ag-n ifica tio n , X 500 .)

cr ine neop last ic ce lls to the ca lc ium de -po sits su ggests a p ossib le ro le of ap o -cr ine ch an ge in the d ep osition of ca lci-urn in th ese m amm ary carc inom as .

T he p henom enon of apocn ine m e-tap las ia of the b reas t is no t u nder-s tood , bu t in d irect ev idence sugg es tstha t ce lls d isp lay ing apo cr in e fea -tunes have h ig her sec re to ry ac tiv itythan do resting ce lls (7 ,8 ). M easure -m en ts o f the con cen tra tion of ca lc i-um in breast cys t flu id have been d if-ficu lt to in te rp re t because o f the van-ab le cond itions of spec im en co l-lec tion and sto rage (9 ). S tud ies sug-gest tha t in clin ica lly ben ign cy sts

w itho u t p recip ita ted ca lc ium , calc i-um is p resen t in concen tra tio ns s im i-lan to those in p lasm a or ex tracellu la rflu id (10 ,1 1). It w ou ld seem , the re -fo re , tha t ca lc ium p rec ip ita tionw ould requ ire som e m echan ism toin crease ca lc ium ion con cen tra tion .W e sp ecu la te tha t the probab le in -creased secre to ry ra te asso cia ted w ithapocrine m etap lasia m igh t p rov idesuch a m echan ism and tha t som e ofth e ca lc ium depos ited in these 10cases m ay be re la ted to the in creasedsec reto ry ac tiv ity o f the ad jacen tap ocn ine n eo p las tic ce lls .

F rom a c lin ica l pe rspec tive , w e be-

liev e it is im portan t fo r rad io log is tsto b e aw are o f th e unu sua l m amm o -graph ic pa ttern observed in thesecases and the im plications of th is p a t-te rn . O ur 10 th case illu stra tes the p it-fa ll w e hop e to avo id . W e rev iew edm amm ogram s sen t to us in consu lta-tio n . T he re fe rr in g rad io log is t hadnever seen such ex tensiv e, h ete rog e-neous ca lcifica tions bu t w as persuad-ed by the ir d is tr ib u tio n and the nu -m erous spherica l fo rm s to m ere ly fo l-low up the pa tien t. A t ou r u rg ing , ab iopsy w as perfo rm ed , and it m e-vea led ex tens iv e in tradu cta l ca rc ino-m a w ith apo cn in e fea tu res .


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A lth ough it is im portan t to beaw are o f th is un usu al p re sen ta tion ofd iffuse b reast cance r, w e strong lycau tion aga inst ove rin te rp re ta tion o fd iffuse ly sca tte red ca lc ifica tion s.T hese 10 cases rep re sen t ra re p re sen -ta tions . T he m ajo rity o f d iffuselysca tte red ca lc ifica tions a re as soc iatedw ith b en ign processe s. T he ca lc ifica -tion s in these b en ign cond ition s a reusu ally ro und and , a lthou gh som e-w h a t am orp hous, are m o rp ho lo g ical-ly un ifo rm , a ltho ugh they m ay v aryin size . S ph erical, c en tra lly lu cen t d e-posits a re v ir tua lly a lw ays asso cia tedw ith ben ign cond ition s. T he n ad io lo -g ist sh ou ld be con cerned , how eve r ,w h en these types o f ca lc ifica tions a reu n ila tera l and in te rspe rsed w ith o th -en ty pes w ith m ore irregu la r appea r-

ances re su lting in an ove rall he te ro -gen eity tha t p ro duces a w ild , chao ticapp earance . W hen th is la tte r pa tte rnoccurs , d iffu se b reast cancer shou ldb e s us pe cte d. #{ 149}

Refe r en ces1 . W olfe JN . X ero rad iography : b reas t ca lc i-

fications . S pring fie ld , I ll: T h om as, 1 977 .2 . H oe ffk in W , L any i M . M ammography .

Philade lph ia : S aunders , 1977 .3 . T ab ar L , D ean PB . Teach ing atla s ofm am mography . N ew Y o rk : T h iem e-S tra t-ton , 198 3 .

4 . S ick les EA . B reast ca lc ifica tions : m amm o-graph ic eva lu a tion . R ad io logy 1986 ;160:289-293.

5 . L inden 55 , S ick les EA . S ed im ented calci-urn in ben ign b reas t cysts. A JR 1989 ;152:967-971 .

6. Stom per PC , C onno lly JL , M ey er JE , H ar-ris JR . C lin ica lly o ccu lt duc ta l ca rc inom ain situ de tec ted w ith m amm og rap hy :ana lysis o f 10 0 cases w ith rad io log ic -patho log ic cor rela tio n . R adio log y 1988;172:235-241 .

7. A hm ed A . A pocr ine m etap!a sia in cys tichy perp la stic m astop ath y . J P ath o l 197 5;115:211-214 .

8 . E useb i V , M illis RR , C a ttan i M G , Bu sso latiG , A zzopard i JG . A po cr in e carc inom a o fth e bre ast: a m orp holog ic an d im m uno cy -to chem ic al stu dy . Am J P atho l 198 6;123:532-541 .

9 . G atzy JT , Zayto un M P, G ask ins K , P ear l-m an W H . E le ctro ly tes of bre ast cy st flu -id . C lin C hem 1979 ; 25 :74 5-7 48 .

10 . G aira rd B , G ros CM , K oeh l C , R enaud R .P ro tein s and io n ic com pon ents in b rea stc yst flu ids . In : A ng eli A , ed . Endo crin o l-o gy of cystic breas t d is ease . N ew Y ork : R a-y en , 1 98 3; 1 91 -1 95 .

1 1. B rad low H L , S k idm ore PD , S chw ar tz M K ,F leisher M , Schw a rtz D . C ations in breas tcy st f lu id . In : A ng eli A , ed . Endo crin o lo gyof cyst ic bre ast d isea se . N ew Yo rk : R av en ,1 98 3; 1 97 -2 01 .

mixed diffuse calc in apocrine

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