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General Surgery

Microcalcification/Hookwire Localisation

Breast calcifications are small spots of calcium in the breast. They are common and appear in 50 percent of the mammograms (X-rays images of soft tissues of breast). Breast calcification is usually considered a natural phenomenon that develops with advancing age. Breast calcification is not related with the amount of calcium-intake in the diet. Instead, calcifications often develop as a result of breast injury, infection, fibroadenoma, and cysts as well as stitches or a breast implant.

The blood vessels in the breast may even show calcifications called vascular calcifications. It is rarely seen in younger women, but is common in women after age 60. Normally, vascular calcifications may be seen in around 9% of all mammograms; however for women over 65, almost 50% will have vascular calcifications. Vascular calcifications can be easily identified on a mammogram where they appear as little white spots.

Calcifications are typically too small to be felt, but can be easily viewed on a mammogram as small white spots. In most cases, breast calcifications are harmless, but sometimes it can be a sign of breast cancer. The calcification itself is not cancerous but due to delay in disposal of the collapsed old cancer cells by the body, these cells may show calcification.

Classification

Based upon the size and distribution of the calcium deposits on a mammogram, calcifications can be categorized into two types:

Macro calcifications: These are coarse calcium deposits in the breast which appear like large white spots or dashes on a mammogram that are distributed randomly within the breast. They are more common in women above age 50. Such calcifications are natural, harmless and are a part of normal aging process. Therefore they are not related with cancer and don’t require any examination or treatment.

Microcalcifications: They appear as fine white particles on a mammogram that indicates tiny calcium deposits in the breast. They are usually non-cancerous in nature, but can be an early sign of breast cancer. Therefore, a biopsy or additional mammograms may be required.

Diagnosis

Calcifications appear as small white spots and are often discovered during a routine screening mammogram or when examined for another reason.

Evaluation

Calcifications are often evaluated using an X-ray magnification view of mammogram that examines the size, shape and number of calcifications. Based on this evaluation, calcification can be categorized into 3 classes:

  • Benign calcifications
  • Probably benign calcifications (Indeterminate)
  • Suspicious calcifications

Benign calcifications are harmless and do not require medical attention whereas indeterminate or suspicious calcifications require further tests. However, probably benign calcifications are around 98% likely to be benign. Indeterminate calcifications can either be followed up for 6-12 months or biopsied.

Suspicious calcifications may be perceived, either in benign or malignant conditions. Nearly, one of every four women with calcifications has a breast cancer and those are usually at an early stage (DCIS).

As calcifications are too small, a computerized-based mammogram is usually required to locate and target them accurately, and also facilitate a needle biopsy called stereotactic biopsy.

Hookwire Localization

In some suspicious calcification cases surgery may be recommended for removing the calcification area from the breast. Such conditions may arise due to ineffective removal of calcifications by needle core biopsy. In such cases, the technique called preoperative hookwire localization is recommended to locate exactly the area of calcification to be removed as it cannot be felt by the surgeon.

The preoperative hookwire localized breast surgery can be divided into 2 major steps as:

  • Insertion of hookwire before operation
  • Removal of calcification during operation

Insertion of hookwire before operation: This step is performed in a breast department. A mammogram is used to identify the abnormal areas of the breast. A local anesthesia is injected to numb the breast. A hookwire is then inserted into the affected breast area under the guidance of a mammogram. The mammogram helps confirms the final position of the hookwire inside the breast. Consequently, the wire is fixed in the place with tape and is dressed properly.

Removal of calcification during operation: In this step, with the hookwire in its position the patient is taken to the operation room and is given general anesthesia. The piece of tissue from the tip of the wire is removed and sent for pathological examination. The removedtissue is then X-rayed to confirm calcification.