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Now we're gonna talk about mammographic calcifications and DBT.

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So according to BI RADS, calcifications identified on mammography are grouped

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into two large categories, typically benign and suspicious. Typically benign

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calcifications include skin, vascular, coarse, large rod like, round, rim,

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dystrophic, milk of calcium and suture calcifications. These are not typically

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hard to identify or put into these categories.

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Suspicious calcification morphologies include amorphous, coarse heterogeneous,

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fine pleomorphic, and fine linear or fine linear branching. And all those

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suspicious calcifications meet the criteria for recommendation of biopsy.

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We know that because previous research has shown that the

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positive predictive value of calcifications with these descriptors, amorphous,

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coarse heterogeneous, fine pleomorphic or fine linear, fine linear branching,

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all are above the 2% threshold, which we recommend biopsy for.

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So in this case, amorphous, 21%, 13%, 29%.

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And these top ones, amorphous, coarse heterogeneous and fine pleomorphic,

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all fall in the BI RADS IV subcategory 4B because there's between 10%

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and 50% risk of malignancy. The only one that falls in the BI RADS category

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4C is fine linear or fine linear branching because there's a 70%

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chance of malignancy with that morphologic descriptor. You may notice that

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there are no calcifications that fall under the 4A category.

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In addition, there are no calcifications that definitely fall under the

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BI RADS V category either. Calcifications may appear more or less suspicious

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as compared to full field digital mammography. Part of that is related to

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computational reconstruction of those projection images, which may enhance

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or decrease the appearance of calcifications. The acquisition time of DBT,

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as I mentioned previously, increases the susceptibility of the motion artifact,

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which can make calcifications, especially subtle ones, more difficult or

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impossible to see. DBT, however, can help to better assess dermal calcifications

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or artifact, which we saw on previous cases.

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For example, in this case, we can see that these calcifications are projecting

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on the medial aspect, right. And we see here again that situation where

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there are multiple image slices that are added to the DBT stack but gets

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on the detector side. So despite the fact that these calcifications are

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clearly in the skin, there's a few more slices here.

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But we can be confident that if we see them at that location,

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that they are dermal calcifications and therefore fall under the typically

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benign category. Similarly, in this case, we see some

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calcified material at the superior aspect of both breasts in the axillary

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regions, and this is compatible with deodorant artifact on the skin. And

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we can prove that by seeing that, that material is demonstrated

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in the skin on DBT slices. So a lot of work has gone

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into trying to understand the impact of DBT on the evaluation

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and detection of calcifications. There has been no significant improvement

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in the detection of malignant calcifications in DBT. If we look at DBT plus

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SM, we have about an 85% sensitivity for malignant calcs, and DBT plus

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full field digital mammography has about an 88% sensitivity a little bit

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better, probably related to that increased better resolution with the full

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field digital mammogram, but specificity is improved with DBT. However,

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we may get some better visualization particularly if the reconstruction

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algorithm sort of increases the conspicuity of calcifications, and classification

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into the benign or malignant may be improved or putting into one of

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those specific categories. In addition, we have some localization information

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which might be helpful in determining distances between groups of calcifications

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may be more accurately assessed. At the current time, magnification views

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are still recommended for diagnostic evaluation of calcifications identified

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at screening mammography, and that's purely related to the improved resolution

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of magnified mammograms. So in this image here of a synthesized mammogram

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taken from a screening mammogram, these same calcifications you can see

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a lot better resolution, a lot more calcifications on the magnified view.

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And therefore its still recommended to do magnification views in the workup

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of all calcifications. And here, especially in this case, we can see that

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these calcifications on the SM view don't look particularly suspicious,

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maybe a couple of little round calcifications. Maybe you might get the fine

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pleomorphic here, but here we can distinctly see some fine pleomorphic calcifications.

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There's a lot more of them. In addition, you might also wonder about

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associated asymmetry.