J Breast Cancer.  2016 Dec;19(4):459-464. 10.4048/jbc.2016.19.4.459.

Increased Malignant Microcalcifications after Neoadjuvant Chemotherapy in Advanced Breast Cancer

• Shin GW
• Park YM
• Yoon HK
• Jung SJ
• Kim TH
• Lee A
• Lee SM

• KMID: 2362934
• DOI: http://doi.org/10.4048/jbc.2016.19.4.459

Abstract

In patients with advanced breast cancer, most new calcifications detected on a mammogram after neoadjuvant chemotherapy are benign dystrophic calcifications, but this is not always observed. We present a patient with advanced breast cancer who had paradoxically increased malignant microcalcifications concomitant with primary tumor regression after undergoing neoadjuvant chemotherapy. After the neoadjuvant chemotherapy, the follow-up mammogram revealed that local, fine pleomorphic microcalcifications had markedly increased. Pathologically, these calcifications were ductal carcinoma in situ. We concluded that, in patients with breast cancer undergoing neoadjuvant chemotherapy, newly developed microcalcifications on follow-up mammograms should be carefully evaluated, and any suspicious malignant microcalcifications should be included in surgical excision planning.

Keyword

Breast neoplasms; Calcinosis; Mammography; Neoadjuvant therapy

MeSH Terms

Breast Neoplasms*
Breast*
Calcinosis
Carcinoma, Intraductal, Noninfiltrating
Drug Therapy*
Follow-Up Studies
Humans
Mammography
Neoadjuvant Therapy

Figure

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  Figure 1 Initial mammograms. The cranio-caudal (A) and medio-lateraloblique (B) mammogram show fine pleomorphic microcalcifications in the left upper inner breast (arrows). However, masses are not detected on the mammogram because of the extremely dense fibroglandular breast tissue.

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  Figure 2 Initial ultrasonograms. The transverse (A) and longitudinal (B) ultrasonograms show an irregular hypoechoic infiltrative masses in the left upper inner and outer breast. Microcalcifications, however, are not detected on ultrasonography.

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  Figure 3 Initial magnetic resonance imaging (MRI) of the left breast. The early phase of the dynamic sagittal MRI with subtraction shows a nonmass enhancement lesion with segmental distribution and heterogeneous internal enhancement pattern in the left upper outer (arrow) and upper inner (not shown) quadrants.

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  Figure 4 Follow-up left mammograms after neoadjuvant chemotherapy. The cranio-caudal (A) and medio-lateraloblique (B) mammograms show markedly increased number of fine pleomorphic microcalcifications (arrows), involving both upper inner and upper outer quadrants of the left breast.

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  Figure 5 Follow-up ultrasonograms after neoadjuvant chemotherapy. The transverse (A) and longitudinal (B) ultrasonograms show a reduction in tumor size (arrows).

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  Figure 6 Follow-up breast magnetic resonance imaging (MRI) after chemotherapy. The early phase of the dynamic sagittal MRI with subtraction shows the decrease in the tumor extent in left upper outer quadrant (arrow).

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  Figure 7 Histopathologic features of the core biopsy specimen of the left breast mass. (A) Invasive ductal carcinoma showing high histologic grade and small portion of ductal carcinoma in situ with necrosis and calcification (arrow) are observed (H&E stain). Invasive cancer tissue is luminal type B, showing positive reaction for estrogen receptor (B), low progesterone receptor expression (<20%) (C), high Ki-67 labelling index (>20%) (D), and 1+ reaction for human epidermal growth factor receptor 2 (E) (A–E, magnification, ×40).

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  Figure 8 Histopathologic features of the surgical specimen of the left mastectomy after neoadjuvant chemotherapy. (A) Small amount of residual invasive carcinoma tissues are scattered, and relatively conspicuous ductal carcinoma in situ lesions (H&E stain, ×40) (B) with necrosis and calcification (arrow) are seen (H&E stain, ×100). Invasive cancer tissue is changed to luminal type A after neoadjuvant therapy, showing positive reaction for estrogen receptor (C) and progesterone receptor (D), low Ki-67 labelling index (E), and 1+ reaction for human epidermal growth factor receptor 2 (F) (C-F, magnification, × 40).

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