Full-field digital mammography (FFDM), the standard of care for breast cancer screening, has some limitations. With the advent of digital breast tomosynthesis (DBT), improvements including decreased recall rates and increased cancer detection rates have been observed. The quasi-three-dimensional capability of DBT reduces breast tissue overlap, a significant limitation of FFDM. However, early studies demonstrate that a few cancers detected at FFDM may not be diagnosed at DBT-only screening, and lesions with calcifications as the dominant feature may look less suspicious at DBT or not be visible at all. These findings support the use of combined FFDM and DBT protocols to optimize screening performance. However, this combination would approximately double the patient's radiation exposure. The development of computer algorithms that generate two-dimensional synthesized mammography (SM) views from DBT has improved calcification conspicuity and sensitivity. Therefore, SM may substitute for FFDM in screening protocols, reducing radiation exposure. DBT plus SM demonstrates significantly better performance than that of FFDM alone, although there are reports of missed malignant calcifications. Thus, some centers continue to perform FFDM with DBT. Use of DBT in breast imaging has also necessitated the development of DBT-guided biopsy. DBT-guided biopsy may have a higher success rate than that of stereotactic biopsy, with a shorter procedure time. While DBT brings substantial improvements to breast cancer imaging, it is important to be aware of its strengths and limitations regarding detection of calcifications. This article reviews the imaging appearance of breast calcifications at DBT, discusses calcification biopsy techniques, and provides an overview of the current literature.

Purpose-Successful breast-conserving surgery (BCS) followed by radiation therapy (XRT) is dependent on complete removal of the cancer with clear surgical margins, providing survival rates equivalent to those observed following mastectomy. In patients who have cancers presenting with microcalcifications, post lumpectomy mammograms (PLM) prior to radiation (XRT) can be performed to ensure that no cancer has been left behind. The purpose of this study was to assess the benefit of PLM in patients with malignant breast tumors presenting with microcalcifications.Methods-In this IRB-approved retrospective study, we reviewed medical records for patients with breast cancers presenting with microcalcifications who underwent BCS between February 2008 and June 2013. 198 patients who had a PLM prior to XRT for cancers presenting with microcalcifications were included.Results-Histopathology of the initial lumpectomy revealed invasive carcinoma in 78/198 (39.4%) and DCIS alone in 120/198 (60.6%). 114/198 (58%) patients had negative surgical margins. 7/114 (6%) patients with negative margins had positive PLM and re-excisions that were positive for malignancy: sensitivity 88%, specificity 95%, PPV 58%, NPV 99%. 84/198 patients had positive surgical margins. The diagnostic performance of PLM in this group was: sensitivity 55%, specificity 71%, PPV 66%, NPV 61%. Conclusion-PLMplays an important role in the evaluation of patients undergoing breast conservation for breast cancer presenting with microcalcifications. Residual malignancy was detected on positive PLM in 6% of patients with negative margins.

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