Light and Electron Microscopic Study of an Invasive Cribriform Carcinoma with Extensive Microcalcification Developing in a Breast with Silicone Augmentation

Although recent epidemiologic studies suggest that silicone augmentation of the breast is not associated with an increased risk of mammary carcinoma, cases of breast carcinoma arising in augmented breasts are being increasingly encountered as a large number of patients who had augmentation are getting older. A case of a 51-year-old woman with a 20-year history of breast augmentation who developed an invasive cribriform carcinoma associated with extensive microcalcification is presented. The patient had submammary silicone implants 20 years ago that were replaced, because of local complications, in subpectoral positions 10 years later. Dispersive X-ray microanalysis failed to demonstrate silicone in sections of the tumor and adjacent breast tissue. Appropriately fixed tumor tissue was available for electron microscopic examination. The tumor cells were rich in mitochondria, and their luminal surfaces were endowed with abundant microvilli, but the cell surfaces that came closest to the calcified microspheriols were devoid of microvilli and had cellular buddings between the microspheriols. It is suggested that the tumor cells might have been actively involved in the process of microcalcification.     

Nanoanalytical analysis of bisphosphonate-driven alterations of microcalcifications using a 3D hydrogel system and in vivo mouse model

Vascular calcification predicts atherosclerotic plaque rupture and cardiovascular events. Retrospective studies of women taking bisphosphonates (BiPs), a proposed therapy for vascular calcification, showed that BiPs paradoxically increased morbidity in patients with prior acute cardiovascular events but decreased mortality in event-free patients. Calcifying extracellular vesicles (EVs), released by cells within atherosclerotic plaques, aggregate and nucleate calcification. We hypothesized that BiPs block EV aggregation and modify existing mineral growth, potentially altering microcalcification morphology and the risk of plaque rupture. Three-dimensional (3D) collagen hydrogels incubated with calcifying EVs were used to mimic fibrous cap calcification in vitro, while an ApoE^−/− mouse was used as a model of atherosclerosis in vivo. EV aggregation and formation of stress-inducing microcalcifications was imaged via scanning electron microscopy (SEM) and atomic force microscopy (AFM). In both models, BiP (ibandronate) treatment resulted in time-dependent changes in microcalcification size and mineral morphology, dependent on whether BiP treatment was initiated before or after the expected onset of microcalcification formation. Following BiP treatment at any time, microcalcifications formed in vitro were predicted to have an associated threefold decrease in fibrous cap tensile stress compared to untreated controls, estimated using finite element analysis (FEA). These findings support our hypothesis that BiPs alter EV-driven calcification. The study also confirmed that our 3D hydrogel is a viable platform to study EV-mediated mineral nucleation and evaluate potential therapies for cardiovascular calcification.

Atherosclerotic plaque rupture is the leading cause of myocardial infarction and stroke (1, 2). Studies assessing the correlation between calcium scores and cardiovascular events have demonstrated a predictive power that is superior to and independent from that of lipid scores (3, 4). Additionally, clinical imaging studies have revealed that the risk of plaque rupture is further heightened by the presence of small, “spotty” calcifications, or microcalcifications (5, 6), and cardiovascular risk is inversely correlated with the size of calcific deposits, quantified as a calcium density score (7). Indeed, computational modeling has demonstrated that, while large calcifications can reinforce the fibrous cap (8), microcalcifications (typically 5 to 15 μm in diameter) uniquely mediate an increase in mechanical stress of the relatively soft, collagen-rich fibrous cap (9–12).Histologic studies have revealed the presence of cell-derived vesicles within calcifying atherosclerotic lesions (13–16). The inflammatory environment of the atherosclerotic lesion can induce vascular smooth muscle cells (vSMCs) to take on an osteochondrogenic phenotype and release calcifying extracellular vesicles (EVs) (17–19). Macrophages have also been shown to release procalcifying vesicles (20, 21). Thus, just as bone formation is hypothesized to be an active, cell-driven process (22, 23), mediated by calcifying matrix vesicles, atheroma-associated calcification may similarly be initiated by the production and aggregation of calcifying EVs (11, 20, 24–28).One proposed strategy for halting pathologic calcification has been the use of bisphosphonates (BiPs). BiPs are analogs of pyrophosphate (29), a naturally occurring compound derived in vivo from adenosine triphosphate (ATP) (30). Pyrophosphate binds to calcium phosphate and inhibits calcification via physicochemical mechanisms, namely, by blocking calcium and phosphate ions from forming crystals, preventing crystal aggregation, and preventing mineral transformation from amorphous calcium phosphate to hydroxyapatite (29). BiPs were identified as pyrophosphate analogs that, unlike pyrophosphate itself, resist enzymatic hydrolysis. A second, distinct property of BiPs is the ability to inhibit bone resorption via biological activity directed against osteoclasts following osteoclast endocytosis of the BiP molecule adsorbed to the surface of bone (29, 31). First-generation, or nonnitrogen-containing BiPs, are incorporated into nonhydrolyzable ATP analogs, and induce osteoclast apoptosis by limiting ATP-dependent enzymes. In contrast, nitrogen-containing BiPs inhibit farnesyl pyrophosphate synthetase and thereby induce osteoclast apoptosis (31).In vivo animal investigations have been performed to explore the potential for BiPs to inhibit cardiovascular calcification. Studies of first-generation BiPs revealed that the doses required to inhibit cardiovascular calcification also critically compromised normal bone mineralization (29, 32). However, newer, nitrogen-containing BiPs effectively arrested cardiovascular calcification in animal models at doses that did not compromise bone formation (32). Further, while it has been proposed that BiP treatment modifies cardiovascular calcification via its impact on bone-regulated circulating calcium and phosphate levels, a study in uremic rats demonstrated that BiP treatment inhibited medial aortic calcification with no significant change in plasma calcium and phosphate levels (33). The same study demonstrated that BiP treatment inhibited calcification of explanted rat aortas, indicating that BiPs can act directly on vascular tissue, independent of bone metabolism (33).Retrospective clinical data examining the effect of BiP therapy on cardiovascular calcification has demonstrated conflicting findings and intriguing paradoxes. In women with chronic kidney disease, BiP therapy decreased the mortality rate for patients without a prior history of cardiovascular disease (34), but for those patients with a history of prior cardiovascular events, BiP therapy was associated with an increased mortality rate (35). In another study, BiP therapy correlated with a lower rate of cardiovascular calcification in older patients (>65 y), but a greater rate in younger patients (<65 y) (36). These clinical findings motivated our study, in which we sought to further understand how BiP therapy impacts cardiovascular outcomes. Given that cardiovascular calcification, and especially the presence of microcalcification, is a strong and independent risk factor for adverse cardiac events, and BiPs are prescribed to modulate pathologies of mineralization, we hypothesize that BiPs modulate cardiovascular outcomes by altering the dynamics of cardiovascular calcification.EVs are smaller than the resolution limits of traditional microscopy techniques, hindering studies into the mechanisms of calcification nucleation and growth. We previously developed an in vitro collagen hydrogel platform that allowed the visualization of calcific mineral development mediated by EVs isolated from vSMCs (24). Using superresolution microscopy, confocal, and electron microscopy techniques, we showed that calcification requires the accumulation of EVs that aggregate and merge to build mineral. Collagen serves as a scaffold that promotes associations between EVs that spread into interfibrillar spaces. The resultant mineral that forms within the collagen hydrogel appears spectroscopically similar to microcalcifications in human tissues and allows the study of these structures on the time scale of 1 wk. In this study, we utilized this three-dimensional (3D) acellular platform to examine the direct effect of ibandronate, a nitrogen-containing BiP, on the EV-directed nucleation and growth of microcalcifications, a process that cannot be isolated from cellular and tissue-level mechanisms in a more complex, in vivo system. In parallel, we utilized a mouse model of atherosclerosis to assess the effect of ibandronate therapy on plaque-associated calcification, comparing mineral morphologies between the in vitro and in vivo samples. We hypothesize that BiPs block EV aggregation and modify existing mineral growth, potentially altering microcalcification morphology and the risk of plaque rupture. Understanding the EV-specific action of BiPs is imperative both to develop anticalcific therapeutics targeting EV mineralization and to understand one potential mechanism driving the cardiovascular impact of BiPs used in clinical settings.     

Metastatic microcalcification in the lungs and stomach due to hyperparathyroidism: A case report

We present a case of a 34-year-old man who was admitted to our hospital with a six-month history of nausea and vomiting that had worsened over the past two weeks. Diagnosis of primary hyperparathyroidism (PHPT) due to a single parathyroid adenoma was confirmed by laboratory results and imaging but following pharmacological therapy the patient developed a dry cough. Single-photon emission tomography/computed tomography (SPECT/CT) with technetium-99m-diphosphonate (^99mTc-MDP) was used to assist in the diagnosis and results showed diffuse metastatic microcalcification in the lungs and stomach. The patient underwent right parathyroidectomy and ^99mTc-MDP SPECT/CT scan six months later showed a significantly reduced radioactive distribution in the lungs and none in the stomach. Diffuse metastatic microcalcification in the lungs and stomach due to PHTP is rare and can easily be misdiagnosed.     

数字化乳腺X线引导下切除活检及导丝定位钙化患者的影像学病理及相关表现

目的:分析数字化乳腺X线引导下切除活检及导丝定位钙化患者的X线征象。方法:回顾性分析2015年12月至2017年12月间收治102例数字化乳腺X线引导下切除活检及导丝定位钙化患者进行实验研究,观察X影像中分布征象及微钙化形态,比较X征象与乳腺癌A、B、C不同数据系统(BI-RADS)分型之间的差异。结果:102例乳腺癌患者中,良性病变患者80例(78.43%),恶性病变患者22例(21.56%)。不同类型病变的钙化类型与BI-RADS分型差异明显(P <0.05);恶性病变在BI-RADS4C中占比最大(9/12,75.00%),良性病变在BI-RADS4A中占比最大(24/27,88.88%),良性病变在BI-RADS类患者构成比差异明显(P<0.05)。结论:乳腺疾病可通过数字化乳腺X线引导下活检术诊断乳腺癌,乳腺病灶是否钙化的主要影响因素是BI-RADS和钙化类型,具有一定的临床价值,值得推广应用。     

基于小波分析和灰度纹理特征的乳腺X线图像微钙化点区域的提取

目的乳腺癌的早期发现对患者意义重大。为帮助医生进行乳腺癌的早期检查和诊断,本文提出利用小波分析与图像纹理特征提取相结合的方法来提取乳腺X线图像微钙化点区域,在提高检查准确性的同时避免漏检误检。方法首先利用灰度共生矩阵所提取的能量、熵、对比度、相关性以及小波分解后得到的各层高频系数的方差、能量作为图像的特征向量,然后利用支持向量机进行训练建立最优分类模型。最后利用建立的最优分类模型实现乳腺X线图像微钙化点区域的提取并利用检出率和误检率对结果进行评估。结果使用临床数据进行验证,结果表明利用小波分析与图像纹理特征提取相结合的方法能有效提取乳腺图像中的微钙化点区域。结论基于小波分析和灰度纹理特征的乳腺X线图像微钙化点区域的提取方法比单一的图像纹理特征提取或小波分析等方法,提取的效果更好。另外,该方法设计简单,更易于实现乳腺癌的自动化诊断。     

Utility of an upright-type 11-gauge stereotactic vacuum-assisted biopsy device （Mammotome@） for the diagnosis of breast microcalcifications

Objective： The aim of this study was to evaluate the utility of an upright-type 11-gauge stereotactic vacuum-assisted biopsy device （Mammotome@） for the diagnosis of breast microcalcifications Methods： Between May 2001 and October 2005, 154 biopsies in 152 patients with microcalcifications were performed using the upright-type 11-gauge stereotactic vacuum-assisted biopsy device. Patients in whom this biopsy was diagnosed as carcinoma or a borderline lesion, had a subsequent surgical excision of the lesion. Histopathological and radiological features of the two specimens were then compared with each other. Results： Microcalcification was identified on specimen mammograms and microscopic slides in 97.4% of cases. Of 154 Mammotome biopsies 98 （63.6%） were benign, 51 （33.1%） were malignant, 3 （1.9%） showed atypical hyperplasia, and 2 （1.3%） were indeterminate, respectively. Of the 48 cases that received surgical excision, 6 of 36 ductal carcinomas in situ （16.7%） upstaged to invasive ductal carcinoma and 1 of 2 atypical ductal hyperplasias was upstaged to ductal carcinoma in situ. The positive predictive value of the 11-gauge Mammotome for the diagnosis of invasion in breast cancer was 100%. Linear calcification and pleomorphic calcification linear/segmental distribution was reliable indications of malignancy. The mean follow-up time of the benign lesions was 22 months, and without evidence of lesion growth. Complications included vasovagal reactions （6.3%）, bleeding （0.6%） and hematoma （2.6%）. Conclusion： The upright stereotactic 11-gauge Mammotome procedure is an effective and reliable method for the diagnosis of breast microcalcifications. It has minimal side effects. For lesions diagnosed as ADH or DCIS with the 11-gauge Mammotome, subsequent surgical excision should be performed.     

彩超与麦默通结合在触诊阴性的乳腺微小钙化中的应用

目的探讨彩超与麦默通在触诊阴性的乳腺微小钙化中的应用。方法应用彩超及麦默通微创技术诊治78例触诊阴性的乳腺微小钙化灶病人,切除标本常规行冰冻切片检查。结果经冰冻切片及术后石蜡切片检查,在78例乳腺微小钙化中发现乳腺癌15例及乳腺病变63例。本组手术时间是9～24 min,术中平均失血量是10 ml。手术后发生局部血肿4例。结论应用彩超结合麦默通微创技术是有助于诊治阴性触诊的微小钙化灶以及发现早期的乳腺癌。     

乳腺断层摄影合成技术的临床价值

目的:探讨数字乳腺断层合成X线成像(DBT)结合合成2D图像(SM)对乳腺微钙化的检出和诊断效能。方法:回顾性分析228例乳腺影像及病理资料。3名影像医师独立阅读DBT结合全视野数字化乳腺摄影(FFDM)、DBT结合SM、FFDM、SM 4种模式下影像资料,记录微钙化有无,根据BI-RADS 2013版对微钙化进行分类,分析不同密度乳腺类型中良、恶性微钙化的检出率及诊断效能。结果:不管在致密型乳腺或所有腺体类型乳腺中,4种阅片模式对微钙化检出敏感度的差异无统计学意义(P>0.05),特异度均为100%。DBT结合SM与DBT结合FFDM对微钙化诊断敏感度、特异度及ROC曲线下面积的差异无统计学意义(P>0.05);FFDM的敏感度高于SM,特异度低于SM,ROC曲线下面积高于SM,差异均具有统计学意义(P<0.05)。结论:DBT结合SM与DBT结合FFDM对乳腺微钙化的检出、诊断效能相似。     

数字乳腺X射线影像中微钙化点的检测方法的探讨与研究

乳腺癌是女性最常见的恶性肿瘤之一,防治的关键在于早期诊断。实现乳腺癌早期诊断的关键技术之一是及时发现乳腺X线影像中的微小钙化点。随着计算机技术的飞速发展,采用计算机辅助诊断技术检测微钙化点已成为乳腺癌早期诊断的研究热点。对一些传统的微钙化点检测方法和近年来广泛收到关注的微钙化点检测方法进行了介绍。文中只涉及到检测方法,而没有讨论检测方法的效果评价。     

How significant is detection of ductal carcinoma in situ in a breast screening programme?

PURPOSE: To compare the histological grades of screen detected and non-screen detected ductal carcinoma in situ (DCIS) and to identify any differences that might support the contention that DCIS found by breast screening represents an over-diagnosis. The aim was also to establish whether any particular mammographic features of DCIS can be used to predict tumour grade reliably. MATERIALS AND METHODS: Biopsy proven cases of DCIS (n=153) were reviewed with respect to grade and subdivided into high, intermediate and low grades using the Van Nuys classification. A more aggressive subset of DCIS (microinvasive and interval cancers) were similarly analysed. Mammograms were reviewed with regard to abnormal features and distribution, and the appearances correlated with grade. RESULTS: Fifty-four percent (53/98) of screen detected and 62% (34/52) of non-screen detected DCIS were high grade. The rest were equally intermediate and low grade, with no statistical difference between the two groups. Eighty-four percent of the aggressive subset of tumours were high grade. Micro-calcification was present in 90% and in 10% there were soft tissue changes alone. Seventy-six percent of linear branching calcification was associated with high grade DCIS. Only 13% of high grade DCIS demonstrated punctate micro-calcification; however, 38% of cases of punctate micro-calfication were associated with high grade tumours and there was a great deal of overlap between the groups. CONCLUSION: Most cases of DCIS in both screen and non-screen detected groups were high grade. Only one in five was low grade. Analysis of the aggressive subgroup underlines the significance of high grade DCIS. Mammographic patterns are not always reliable in the prediction of tumour grade. The detection of DCIS in screening programmes is important and should not be regarded as over-diagnosis.