Clinical Abstracts: Microcalcifications from Herbal Medicine

With Comments by Adriane Fugh-Berman, MD

Source: Moon WK, et al. Metallic punctate densities in the breast after Chinese herbal treatment: Mammographic findings. Radiology 2000;214:890-894.

Prior to the 1970s, a topical, lead-containing Chinese medicine, go-yak, was used to treat breast inflammation and abscess in Korea and other parts of Asia. This medication is referred to as go-yak in the article, but go-yak actually is a non-specific term for an herbal salve, so different preparations may have been used. These topical preparations often were placed in open wounds, causing metallic punctate densities that can mimic microcalcifications on mammograms.

This article analyzed mammographic findings in 34 Korean women (ages 37-73 years) with mammograms that showed metallic punctate densities resembling microcalcifications. All subjects had undergone breast abscess drainage 6-42 years prior to mammo-graphy, and had received go-yak, applied into the open wound, for 3-13 weeks afterwards.

In 71% of patients, metallic densities were in the subareolar or central breast; lesions extended into the subcutaneous fat in 85% of subjects. Most lesions were round or punctate, but rod-shaped or linear lesions were seen in seven patients. The number of lesions ranged from five to more than 50. The average size of lesions was smaller than 0.5 mm in 30 patients and between 0.5 and 1 mm in four patients. Skin thickening or nipple retraction was seen in 62% of patients. Thirty of 34 subjects were followed for 3-47 months (mean 12 months); no evidence of malignancy was seen.

In most cases the location, shape, distribution, and density of metallic punctate densities were easy to distinguish from malignant microcalcifications by experienced radiologists. This was tested by combining mammograms of subjects who had received topical Chinese medicine and 34 mammograms with microcalcifications that later proved to be malignant; these were evaluated by two radiologists, with disagreements resolved by consensus. Punctate densities were identified as metallic in 25 of 34 patients; none of the malignant calcifications were regarded as metallic. In six cases, densities were deep-seated, linear, or segmental, with densities similar to that of true calcifications; these required surgical biopsy. Biopsies in the six patients with indeterminate calcifications revealed clustered particles surrounded by a few giant cells. True microcalcifications or atypical cells were not found.

A high concentration of lead was found in tissue samples. Lead concentrations in histopathological specimens were 2,800 and 4,700 mcg/mg in two patients. Analysis of an herb sample showed that lead comprised 20.1% of sample mass.

Comments: Use of a traditional herbal product decades ago can affect diagnostic tests today. This article points out the importance of including herbal medicine use in history-taking, and the importance of knowing about traditional remedies that can have an impact on diagnosis and treatment.