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| IMAGES IN ONCOLOGY |
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| Year : 2022 | Volume
: 59
| Issue : 1 | Page : 136-139 |
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Breast calcifications on mammography: A pictorial essay
Pranjali Joshi, Gaurav Raj, Neha Singh
Department of Radiodiagnosis, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| Date of Submission | 16-Dec-2020 |
| Date of Decision | 31-Jan-2021 |
| Date of Acceptance | 16-Feb-2021 |
| Date of Web Publication | 19-May-2022 |
Correspondence Address:
Gaurav Raj
Department of Radiodiagnosis, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ijc.IJC_1361_20
How to cite this article:
Joshi P, Raj G, Singh N. Breast calcifications on mammography: A pictorial essay. Indian J Cancer 2022;59:136-9 |
| » Introduction | |  |
Calcifications are commonly seen on mammography and maybe the only presenting sign of breast cancer.[1] Mammographic calcifications can be characterized into benign and malignant based on several features including size, morphology, and distribution based on the American College of Radiology (ACR) Breast Imaging-Reporting And Data System (BI-RADS) Atlas 5th edition.[2] It is imperative to correctly identify and classify them since 55% of nonpalpable cancers are diagnosed by the presence of calcifications.[1]
Distribution descriptors:[2]
- Diffuse: These calcifications are randomly distributed within the breast. If they are punctate and amorphous in this distribution, they are usually benign, especially if bilateral [Figure 1].
- Regional: Calcifications occupying more than 2 cm area of the breast tissue are regional [Figure 2].
- Grouped: It is used when a few calcifications are found in a small area. The lower limit is five calcifications in 1 cm. The upper limit of these calcifications is when a large number of calcifications are within 2 cm from each other [Figure 3].
- Segmental: Such calcifications follow the shape of a breast lobe i.e., calcium deposit in ducts and branches. They cover slightly less than a quadrant, having a triangular shape with a tip directed toward the nipple [Figure 4].
- Linear: They are arranged in a linear path that can branch, suggesting calcium deposition in a duct [Figure 5].
 | Figure 1: Mediolateral oblique (MLO) (a) Views of the breast shows diffuse benign round and punctate calcifications distributed randomly in the breast (straight white arrows). (b) Shows diffusely scattered fine pleomorphic and fine linear calcifications; Breast Imaging-Reporting And Data System (BI-RADS) 4C was assigned to this case
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 | Figure 2: Shows regional punctate calcifications on standard MLO (a) Views and tomosynthesis images. (b) These calcifications can be better appreciated on tomosynthesis images.\ (c) Shows fine pleomorphic calcifications seen in regional distribution (straight white arrow); BI-RADS 4B was assigned to this
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 | Figure 3: Shows grouped fine pleomorphic calcifications on standard MLO view, (a) and (b) shows these calcifications on tomosynthesis images (straight white arrows)
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 | Figure 4: Shows coarse heterogeneous and fine pleomorphic calcifications in segmental distribution (straight white arrow) on standard MLO (a), CC (b), and on tomosynthesis images (c). A radiodense mass lesion can also be seen in the posterior part of the breast (curved white arrow). The mass can be better appreciated on tomosynthesis images
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 | Figure 5: Shows an irregular radiodense mass with linear calcifications intralesionally (curved white arrow)
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Morphology descriptors[2]
Typically benign
- Vascular: They occur due to calcium deposits in the walls of mammary arteries and are displayed as parallel paths or railroad tracks [Figure 6].
- Skin: Corresponds to calcifications in the sebaceous gland. Morphology is polygonal or sometimes round with a radiolucent center and located in the inframammary fold, parasternal region, armpit, or areola [Figure 7]a.
- Milk of calcium: Describes sedimented calcifications within tiny benign cysts that are better defined on the lateral views and appear smudgy on the craniocaudal view (CC view) [Figure 7]b and [Figure 7]c.
- Coarse or “Popcorn-like:” These calcifications occurring in involuting fibroadenomas are large, dense, sharply marginated, and >2 to 3 mm in size [Figure 8].
- Large rod-like: Benign secretory disease, duct ectasia, or plasma cell mastitis results in solid, large, dense rod-like, or thinner rod-like calcifications oriented along breast ducts [Figure 9]a.
- Dystrophic: They are coarse, sheet-like, thick calcifications, usually >1 mm, and tend to coalesce [Figure 9]b.
- Round: They are benign and are commonly <1 mm in size. They are called punctate if they are 0.5 mm or less in size [Figure 9]c.
- Rim: They are eggshell-type calcifications with radiolucent centers and are virtually always benign [Figure 10].
 | Figure 6: Shows the classic vascular calcifications seen on standard MLO (a) and enhanced MLO view (b)
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 | Figure 7: MLO view of the right breast in (a) shows skin calcification in the periareolar region (straight white arrow). (b) Is MLO view of the left breast showing crescentic, tea-cup shape of milk of calcium calcifications (straight white arrow), which appear smudgy on corresponding CC views (notched tail arrow) in (c)
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 | Figure 8: Classic popcorn calcifications can be demonstrated (straight white arrows) appearing in a case of multiple involuting fibroadenomas. Surrounding few round calcifications can also be seen (notched tail arrow)
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 | Figure 9: MLO views of the breast show rod-like benign calcifications (straight white arrows) in Figure 9a. Figure 9b (MLO view) shows dystrophic sheet-like calcification at the surgical site in a post lumpectomy patient (straight white arrow). MLO enhanced view of the right breast shows a benign round calcification in the lower quadrant (straight white arrow) in Figure 9c. A note is also made of milk of calcium calcification in the upper quadrant (curved white arrow)
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 | Figure 10: MLO views of the breast show few rim calcifications with lucent centers (straight white arrows)
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Suspicious morphology
- Coarse heterogeneous: They are irregularly shaped calcific particles that vary in size between 0.5 and 1 mm [Figure 4] and [Figure 11].
- Amorphous: They correspond to such small calcifications (<0.1 mm), that it is not possible to either count them or determine their shape [Figure 12].
- Fine pleomorphic: They correspond to calcifications of different sizes and shapes with a size <0.5 mm [Figure 13].
- Fine-linear or fine-linear branching: They have linear forms because Ductal carcinoma in situ (DCIS) grows in branching ducts and looks like little broken needles with pointy ends or may have a “dot-dash” appearance [Figure 14].
 | Figure 11: Coarse heterogeneous calcifications (straight white arrow) can be seen within a partially circumscribed oval radiodense mass likely an involuting fibroadenoma. Superimposed on this mass is a spiculated radiodense malignant lesion. Benign vascular calcifications (curved white arrow) and benign coarse calcifications in a rounded isodense mass likely an involuting fibroadenoma (notched tail arrow) are seen
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 | Figure 12: An irregularly shaped radiodense mass with intralesional amorphous calcifications (straight white arrow) and skin thickening (curved white arrow). BI-RADS 5 category was assigned and Histopathological examination (HPE) was infiltrating ductal carcinoma
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 | Figure 13: Shows fine pleomorphic calcifications in segmental distribution (straight white arrow)
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 | Figure 14: Fine linear and fine-linear branching calcifications are seen in segmental distribution (straight white arrow) and regional distribution (curved white arrow)
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Correct identification of calcifications helps to guide biopsy from suspicious areas within the breast. Calcifications associated with a mass lesion can be targeted with a 14G biopsy gun. However, in cases where calcifications are the only presentation of malignancy, a technique of vacuum-assisted biopsy (VAB) can be undertaken. Such devices range from 7–12 G and can be used to remove tissue volumes equivalent to the weight of a surgical specimen thus making diagnosis easier. VAB gives a larger core and also allows multiple samples to be collected in a single sitting.[3]
| » Conclusion | | |
Breast calcifications should be classified based on their morphology and distribution into the various BI-RADS categories [Table 1]. To correctly do this, adequate knowledge of the patterns of calcifications is essential for guiding appropriate management. | Table 1: The type of calcification and the BI-RADS category allotted to each calcification
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Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| » References | | |
| 1. | Hernández PLA, Estrada TT, Pizarro AL, Cisternas MLD, Tapia CS. Breast calcifications: Description and classification according to BI-RADS 5 th edition. Rev Chil Radiol 2016;22:80-91.  |
| 2. | D'Orsi CJ, Sickles EA, Mendelson EB, Morris EA, et al. ACR BI-RADS Atlas, Breast Imaging Reporting and Data System. Reston, VA: American College of Radiology; 2013. |
| 3. | Park H-L, Hong J. Vacuum-assisted breast biopsy for breast cancer. Gland Surg 2014;3:120-7. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14]
[Table 1]
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