Atlas of Mammography
3rd Edition

Chapter 6
Analysis of Calcifications
Some form of calcification is identified on the majority of mammograms. Many calcifications are clearly benign and require no further workup, whereas others are highly suggestive of malignancy. Between these two groups are various patterns of microcalcifications that are indeterminate in etiology and that often require biopsy for diagnosis.
Calcifications in breast tumors were described in early work by Leborgne (1) in 1951. In 1962, Gershon-Cohen et al. (2) described the forms of microcalcifications that were associated with breast malignancies as irregular in size and shape and ranging from minute to 3 mm in diameter. Approximately 50% of breast cancers are associated with calcifications (3), and as many as 98% of intraductal carcinomas contain microcalcifications (4). In cancers manifesting solely as microcalcifications, as many as 69% are noninvasive (5).
Since the early descriptions of breast calcifications, mammography has advanced, and higher image quality is attainable, thereby enhancing the visibility and detectability of microcalcifications. Publication of the American College of Radiology Imaging Network (ACRIN) trial of full-field digital mammography (6) has shown statistical significance in improved detection of breast cancer in three groups of women: those who are younger than 50 years of age, those who are pre- and perimenopausal, and those with dense breasts. In part, this improvement in detection of cancers may be reflected in the greater detectability of microcalcifications associated with ductal carcinomas.
When a radiologist is interpreting a mammogram, the decision that must be made when calcifications are identified is whether they are clearly benign, probably benign, indeterminate with a suspicion for malignancy, or highly suspicious for breast cancer. Although this assessment can be made on screening views in many cases, diagnostic mammography is often needed for microcalcifications. In particular, magnification views are performed for the complete evaluation of microcalcifications. Once the evaluation of the imaging features of calcifications has been made, a management plan can be recommended, such as routine follow-up annually, early follow-up at 6-month intervals, or biopsy. For those calcifications that are classified as suspicious and for which biopsy is recommended, the positive predictive value of malignancy is about 25% (7).
In order to accurately analyze small calcifications identified on routine screening mammography, additional evaluation is necessary. Magnification mammography is performed to more clearly depict their morphology, and supplemental views, including mediolateral and tangential views, may be performed to determine the answers to the following questions:
  • Are the microcalcifications real or artifactual?
  • What is the morphology of the calcifications?
  • What is the distribution of the calcifications?
  • Where are the calcifications located?
  • Are the microcalcifications clearly benign, such being dermal or milk of calcium?
Once these questions are answered, a management plan can be better determined.
Artifacts and Pseudocalcifications
There are a variety of foreign substances that when present on the skin may have the appearance of microcalcifications on mammography. The technologist must take care to inquire about the presence of such substances, and she should ask the patient to wipe the breast and axilla with a moist cloth if these substances may be present. If the “calcifications” are located very superficially, if they seem to conform to a pattern (such as within skin folds), or if they have a stippled appearance, they may represent pseudocalcifications or artifacts. In this case, the views on which the calcifications are seen should be repeated after skin cleansing.
Substances on the skin (8,9) that can be evident as apparent microcalcifications on mammography include the following: deodorants (Fig. 6.1), bath powders, creams and lotions, ointments such as zinc oxide (Fig. 6.2), and
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adhesive tape. Skin lesions, such as seborrheic keratoses, are particularly prone to trap any cosmetics that may be placed on the skin within the crenulations on their surface.
Figure 6.1 HISTORY: Screening mammogram.
MAMMOGRAPHY: Left MLO (A) view shows faint calcific densities overlying the skin folds in the axilla better seen on the enlarged image (B). These are uniform and stippled in appearance, typical of deodorant artifact.
IMPRESSION: Deodorant artifact.
Figure 6.2 HISTORY: Elderly patient with Stevens Johnson syndrome and multiple skin excoriations on the breasts. She was treating these with an ointment containing zinc oxide. She had marked enlargement and inflammation of the left breast.
MAMMOGRAPHY: Left ML view (A) shows marked increased density of the breast with associated skin thickening. Numerous calcific densities are located anteriorly. On the enlarged images over the subareolar area (B, C), the pseudocalcifications related to the zinc oxide ointment are better seen. The patient was treated with antibiotics for the mastitis, and it resolved.
IMPRESSION: Pseudocalcifications from zinc oxide in skin ulcerations, mastitis.
A cause of pseudocalcifications within the patient’s breast rather than on the skin surface is the deposition of gold in intramammary and axillary lymph nodes in patients with rheumatoid arthritis treated by chrysotherapy (10,11) (Figs. 6.3 and 6.4). Clinical history is key to confirming the diagnosis when this etiology is suspected. On mammography, the characteristic appearance is that of very fine, stippled “microcalcifications” within one or more intramammary or axillary lymph nodes. Additionally, the nodes may be mildly enlarged as a result of the rheumatoid arthritis.
Bullet fragments that are very small and scattered within the breast may have an appearance suggestive of calcifications, but because of the higher density of the metal, they appear more radiopaque than calcium. Other foreign bodies within the breast are usually not confused with true calcifications because of their defining shapes (i.e., surgical clips and markers, retained wire or hooks from needle localization procedures, sutures) and their overall very high density.
Other types of artifacts that may simulate microcalcifications on mammography are related to technical or nonpatient factors, including the following: mammographic equipment artifacts, cassette artifacts, and processing and film-handling artifacts. Most of these are unique to film screen mammography and are related to handling film. With full-field digital mammography, such artifacts do not exist. These artifacts usually have characteristic appearances that aid in differentiating them from true calcifications.
Scratches or “pick-off” from the processor occurs when the film emulsion is damaged as the film makes its transit through the processor, and such artifacts produce white specks on the film. Often these are brighter than true microcalcifications and therefore can be identified as artifactual. The processor must be properly maintained to minimize these.
Debris or dust between the film and screen within the cassette produces a white speck or pseudocalcification and is problematic not only by simulating calcium, but also by
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producing focal blur from poor film screen contact. Cassettes and screens must be cleaned at least weekly according to standards established by the American College of Radiology’s (ACR) Mammography Accreditation Program (12), and in darkroom environments where dust control is a problem, more frequent cleaning is necessary to avoid these artifacts. Cassettes must be numbered so that when a film screen artifact is identified, the cassette may be pulled and recleaned.
Figure 6.3 HISTORY: A 58-year-old woman with a history of rheumatoid arthritis treated with chrysotherapy.
MAMMOGRAPHY: Bilateral MLO (A) views show multiple dense lymph nodes in the axillae. On the magnified view (B), the nodes are noted to contain dense, stippled calcificlike material.
IMPRESSION: Pseudocalcifications: gold deposits secondary to treatment for rheumatoid arthritis.
Figure 6.4 HISTORY: A 68-year-old patient with a history of rheumatoid arthritis, for screening mammography.
MAMMOGRAPHY: Bilateral MLO (A) views show scattered fibroglandular densities and multiple lymph nodes in the axillae. On close inspection of the nodes (B, C), there are faint, stippled calcificlike densities present. These findings represent gold deposits in intramammary nodes, secondary to chrysotherapy for rheumatoid arthritis.
IMPRESSION: Gold deposits in lymph nodes, secondary to chrysotherapy for rheumatoid arthritis.
Other etiologies of white specks or pseudocalcifications relate to improper film handling. Fingerprints on the film occur when the technologist does not handle the film from the corner when loading the cassette. Often the pattern of the whorls in the fingerprint is evident, and the finding is seen on one view only (Figs. 6.5 and 6.6). One can repeat the view to confirm that the abnormality was artifactual without the unnecessary workup of using magnification views.
Mammographic Views to Evaluate Microcalcifications
Once it has been determined that calcifications are real, one must determine where they are located. A clock-face location (one o’clock, etc.) and a position or depth within the breast relative to the nipple (anterior, middle, posterior) is described. If the calcifications are seen on one view only, then additional views are selected to determine their position. If calcifications are seen on one view only and are not artifactual, they often are of dermal or milk-of-calcium origin. One should scrutinize the skin thoroughly to see if calcifications that seem to be within the breast on one view are actually on the skin on the other view.
Figure 6.5 HISTORY: Screening mammogram.
MAMMOGRAPHY: Enlarged CC image shows a cluster of bright white calcificlike densities in a pattern. The stippled appearance and pattern are consistent with a fingerprint artifact that occurred during film handling.
IMPRESSION: Fingerprint artifact.
Figure 6.6 HISTORY: Screening mammogram on a 41-year-old woman.
MAMMOGRAPHY: Coned-down MLO view shows fine calcific densities in a regular pattern. These have a stippled appearance and were found to be absent on a repeat film. The finding represents a fingerprint artifact.
IMPRESSION: Fingerprint artifact.
NOTE: This is an artifact unique to film screen mammography and is not found on digital mammography.
For calcifications that may be dermal, based on their morphology, but that do not project directly within the skin surface on one of the views, two methods of mammographic verification are available. The so-called bead-o-gram can be performed, in which the technologist, using a localization plate as is used in needle localizations, places a BB or radiopaque object over the calcifications on the view on which they are seen (13). The localizer plate is then removed, and a tangential view is performed with the BB in tangent to the beam. If the calcifications are dermal, they will project on the skin with the BB (Fig. 6.7). The second method is to perform stereotactic imaging (14). When dermal calcifications are targeted on a stereotactic pair of images, their z-position or depth will project at the skin surface. Caution should be used to not merely rely on the z-position of the
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calcifications versus the compressed breast thickness to calculate that the calcifications are at the skin surface. Instead, a needle should be placed through the needle guides with the Δ Z at 0 mm to confirm that the needle tip is at the skin surface.
Figure 6.7 HISTORY: A 61-year-old woman for screening mammography.
MAMMOGRAPHY: Left CC view (A) shows multiple small round calcifications. On magnification CC view (B), the very well-defined, round, and lucent forms are noted.
HISTOPATHOLOGY: Dermal calcifications.
For parenchymal calcifications located very posteriorly on the mediolateral oblique (MLO) view and not seen on the craniocaudal (CC) view, exaggerated CC views may help to demonstrate their location on the transverse plane. For calcifications seen far medially and posteriorly on the CC view only, the lateromedial projection may demonstrate their position on the sagittal plane.
Once the location of calcifications is confirmed, a careful assessment of their morphology is undertaken. This is best accomplished with the use of magnification mammography (15). Because the assessment of the borders and shapes of individual calcifications is so critical to the determination of the likelihood of malignancy, the value of a high-quality magnification view cannot be overstated.
Magnification mammography requires the use of a microfocal spot (0.1 mm or less), to reduce geometric unsharpness; the breast is elevated on a magnification stand over the cassette, creating an air gap. Spot compression with collimation to the area of interest helps to reduce the scatter radiation and to displace the tissue, enhancing the image. Magnification in two projections, a CC and a mediolateral (ML), is most beneficial in the evaluation of microcalcifications because of the possibility of a diagnosis of milk of calcium.
For calcifications that are better seen, are more dense, or are more linear on the MLO than the CC view, a 90-degree lateral or ML magnification view is performed to determine if they layer and therefore represent milk of calcium in an area of cystic hyperplasia (Figs. 6.8 and 6.9). Because of subtlety of these differences on the MLO and CC views at times, magnification assessment of microcalcifications that are equivocal should include the ML projection.
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Figure 6.8 HISTORY: A 38-year-old woman with a history of bilateral cysts and new palpable masses.
MAMMOGRAPHY: Right CC (A) and ML (B) magnification views. On the CC view, the breast tissue is very dense, and there are smudged, punctuate, and round microcalcifications diffusely scattered. On the ML magnification view, some of these appear meniscoid and layer in the base of well-circumscribed masses. A cyst was confirmed on ultrasound and corresponded with the mammographic mass.
IMPRESSION: Fibrocystic changes, cyst containing milk of calcium.
NOTE: Obtaining a cross-table lateral projection (ML view) is key to confirming the diagnosis of cystic hyperplasia with milk of calcium. The calcium salts suspended in the cyst fluid are in the dependent portion of the cyst and layer on the upright view.
Figure 6.9 HISTORY: Abnormal screening mammogram necessitating magnification views.
MAMMOGRAPHY: Left CC (A) and ML (B) magnification views show a round mass with circumscribed margins. On the CC view, there are faint smudgy microcalcifications present. On the ML view, these layer in the base of the mass, typical of milk calcium in a cyst.
IMPRESSION: Milk of calcium in a cyst, BI-RADS® 2.
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If microcalcifications are assessed as “probably benign” with a likelihood of malignancy of less than 2% and are followed at more frequent intervals (i.e., at 6 months), the magnification views should be repeated at each mammogram in order to optimize comparison with the prior studies.
Analysis of Calcifications: Radiologic-Histologic Correlation
The Breast Imaging Reporting and Data System (BI-RADS®) of the American College of Radiology provides a lexicon (16) or nomenclature for the description of calcifications on mammography. The lexicon describes calcifications by morphology, distribution, and location and uses the following structure for overall patient assessment: Category 0: needs additional evaluation, i.e., magnification view; Category 1: normal mammogram; Category 2: benign finding, routine follow-up; Category 3: probably benign finding, early follow-up; Category 4: suspicious findings, recommend biopsy; and Category 5: highly suspicious for malignancy, recommend biopsy. Once the diagnostic evaluation of the patient is complete, calcifications identified on the mammogram are placed in one of the categories 2 to 5.
The assessment of calcifications identified on mammography should include the following points of evaluation: morphology, distribution, number, size, variability, interval stability in comparison with prior exams, and associated findings. Morphology of calcifications is the single most important feature, because it is related so closely to the pathologic or histologic finding. The anatomic location of many types of calcifications, particularly microcalcifications, affects their morphology, and thus their potential etiologies can be suggested.
Patterns of Microcalcifications: Benign Etiologies
The terminal duct lobular unit (TDLU) is the basic histopathologic and physiologic unit (17) of the breast. The TDLU is the site of development of most benign and malignant conditions, including fibrocystic changes, fibroadenomas, and ductal and lobular carcinomas. It is also within the TDLU that microcalcifications are secreted or deposited (Fig. 6.10). The shape and variability of the calcifications relates very much to their location within the TDLU. When microcalcifications are located in the ductules, the blind-ending pouches of the lobule (lobular calcifications), they often appear rounded, punctate, or pearllike, and they are relatively similar or uniform in size and shape. They may be tightly grouped in a floretlike appearance or may be scattered throughout the breast. Because these are associated with fibrocystic conditions, the underlying parenchyma may be relatively dense on mammography.
Fibrocystic changes occur in the TDLU. Fibrocystic changes comprise pathologically a group of benign proliferative disorders of the breast, including fibrosis, cysts, adenosis, sclerosing adenosis, epithelial hyperplasia, papillomatosis, atypical hyperplasia, apocrine metaplasia, and chronic inflammation. Clinically, the patients are most commonly in the 30- to 50-year-old group and present with lumpy tender breasts that are cyclically symptomatic. Microcalcifications occur frequently in patients who have fibrocystic changes. The differentiation between ductal calcifications of fibrocystic origin and intraductal carcinoma is often not possible (18,19), and many of these clusters will need to be biopsied. About 15% to 30% of microcalcifications that are biopsied in asymptomatic patients are malignant (20,21,22), and the remainder are benign, mostly representing some form of fibrocystic change (23). Epithelial cells have the potential to secrete calcium actively, and indistinguishable deposits on mammography may be found in benign and malignant conditions. Lobular calcifications can be found in conditions that involve increased activity in the ductules, including adenosis, sclerosing adenosis, cystic hyperplasia, atypical lobular hyperplasia, and lobular carcinoma in situ (LCIS).
Figure 6.10 HISTOLOGY OF CALCIFICATIONS: (A) Normal terminal duct lobular unit composed of the distal duct and the lobule containing multiple small acini or ductules. (B) Formation of lobular calcifications in the terminal ductules within the lobule. Lobular calcifications are smooth and round and similar in morphology. (C) Formation of ductal calcifications in the terminal duct. Ductal calcifications often have a variable morphology and may be linear or branching. (D) Stromal calcifications occur in the periductal space and are often coarse and variable in shape.
Sclerosing adenosis and adenosis often present as a diffuse process involving both breasts, with increased density and fine nodularity. In adenosis there is an increased
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number of ductules within the lobule. The calcifications that occur in this condition are in the lobule, in the blind-ending ductules; therefore their shapes are punctuate, round, smooth, or granular (24). The process is often diffuse, and the calcifications may be in single or multiple groups, or they may be diffusely scattered and bilateral (Fig. 6.11). If the process is localized, however, the calcifications may be clustered, and biopsy often is performed to confirm the histology (24).
Figure 6.11 HISTORY: A 52-year-old woman for screening.
MAMMOGRAPHY: Bilateral CC (A) and left (B) and right (C) magnification ML views show the breasts to be heterogeneously dense. There are bilateral scattered microcalcifications present. On the magnification views (B, C), the uniform round and punctuate shapes are noted, indicating a lobular origin.
IMPRESSION: Diffuse bilateral lobular microcalcifications, consistent with fibrocystic changes.
In sclerosing adenosis, there is lobular proliferation as well as fibrosis or sclerosis in the intralobular zone. The glands may grow haphazardly, producing an appearance
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similar to that of tubular carcinoma (25,26). Because of the sclerosis, the ductules may be narrowed, and the calcifications may be quite small, appearing somewhat indistinct or amorphous. Like adenosis, sclerosing adenosis is often diffuse and bilateral, but this condition may be focal as well.
In the case of cystic hyperplasia, also a form of fibrocystic change, there is greater unfolding and enlargement of the ductules with the formation of microcysts. Calcium salts may be secreted into the fluid within the microcysts (27), and because the calcium is denser than the fluid, it lies in the dependent portion of the cyst. Therefore, when the patient is imaged in the CC projection, the calcifications lie in the bases of the microcysts and are visualized enface. Their appearance may be round or smudged, or they may not be seen. However, when the patient is imaged in the MLO projection, the calcifications are more dense or more apparent, and they may assume a linear shape. The confirmatory view is the ML magnification view, which is a true cross-table lateral projection. In this view, the calcifications layer in the dependent portion of the cysts and assume linear, crescentic, or the teacup shapes (27). The process may be extensive and bilateral, or it may be focal (28). Occasionally, larger macrocysts may also be associated with milk of calcium and show a dense layer of calcification on the ML view (29). Eventually, there may be complete calcification within the wall of the cysts, creating the appearance of small ringlike calcifications.
Papillomatosis, also known as duct hyperplasia of the common type, produces fine round or punctuate microcalcifications that extend over a large area of the breast (30). A dense prominent ductal pattern may be present and is associated with the fine microcalcifications. Occasionally, papillomatosis is focal or segmental, and biopsy is performed because of the distribution of the calcifications.
In periductal fibrosis, the calcifications occur in the stroma and may be diffuse or grouped. On histology, broad islands of fibrous tissue replace the normal fat of the breast. The calcifications of fibrosis may mimic intraductal calcifications found in ductal carcinoma in situ (DCIS) because they may be clustered, with irregular borders, and variable in size, shape, and density. However, the calcifications of fibrosis tend to be more coarse than is usually found in malignancy. The pattern of periductal fibrosis is that of dystrophic calcifications that develop in the stroma rather than in the ductal lumen.
Columnar cell changes have been more recently described as part of the spectrum of lesions involving the TDLU. The columnar epithelium of the ducts is altered with prominent apical cytoplasm snouts, intraluminal secretions, and varying degrees of nuclear atypia and architectural complexity (31). In a review of 100 breast biopsies performed for microcalcifications, Fraser et al. (31) found that columnar alternation with prominent apical snouts and secretion (CAPSS) was identified in 42% of cases. These lesions ranged from a more benign appearance of the epithelium to atypical lesions bordering on DCIS. Calcifications occurred within the CAPSS in 74% of cases, and these microcalcifications were frequently psammomatous. DCIS occurred with equal frequency with and without CAPSS, and when present with CAPSS was usually of the low-grade micropapillary or cribriform types.
Intraductal microcalcifications occur in epithelial hyperplasia, a proliferative disorder with the ducts. The work of Gallagher and Martin (32,33) with whole-organ specimens in patients with breast cancer showed that there is a spectrum of disease, from epithelial hyperplasia to atypical hyperplasia to carcinoma in situ, which occurs as nonobligate phases in the development of breast cancer.
Depending on the extent of the proliferative fibrocystic process, microcalcifications may be focal or extensive and may be present bilaterally. The calcifications are small (less than 1 mm in diameter) and may be irregular in form and variable in size and density, punctuate, or amorphous in appearance when associated with atypical lobular hyperplasia (ALH) or atypical ductal hyperplasia (ADH). Egan et al. (18) found the calcifications in epithelial hyperplasia to be indistinguishable from those of intraductal carcinoma. Stomper et al. (34) found that a majority of atypical hyperplasias were with or adjacent to another mammographic finding that prompted biopsy—often adenosis. A significant relationship existed between mammographic microcalcifications and ADH in these biopsy specimens that were otherwise benign.
The presence of hyperplastic lesions of the breast places a patient at higher risk for the development of carcinoma (35,36,37). In particular, atypical lobular hyperplasia increases the risk of developing breast cancer by approximately 6 times (35), and atypical ductal hyperplasia is associated with 4 to 5 times subsequent risk (36). Additionally, the combined factors of a family history of breast cancer and an atypical lesion on biopsy increase the risk of subsequent breast cancer by 11 times that of women with nonproliferative lesions and no family history (37).
Lobular Neoplasia
Lobular carcinoma in situ, or lobular neoplasia, was described by Foote and Stewart (38) as originating in the TDLU. This lesion is associated with other types of cancers and has a high propensity toward multicentricity and bilaterality (39). In a follow-up of 99 patients with LCIS treated by lumpectomy only, Rosen et al. (40) found that there was an equal risk of the patient developing invasive carcinoma in both the ipsilateral and the contralateral breast. Because about one third of patients with LCIS treated with excision alone will develop invasive carcinoma in either breast, the choices for therapy have ranged from lumpectomy only to bilateral mastectomies historically (40,41). Current management of most of these patients is excision only and mammographic surveillance.
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The mammographic findings in LCIS are nonspecific and variable. However, grouped, round, lobular microcalcifications have been described in this condition (42). These calcifications are indistinguishable from those of lobular hyperplasia or focal sclerosing adenosis. Occasionally, in biopsies of lesions found on mammography in which the histology reveals LCIS, the calcifications may be located in the abnormal lobules (43), or they may be in adjacent benign lobules or areas of stroma (44,45).
Patterns of Microcalcifications: Malignant Etiologies
Microcalcifications that are of ductal origin are often found in the intralobular or extralobular (Fig. 6.12) terminal ducts, and their morphology and distribution reflect their location. Because the calcifications lie within the duct, which is a tubular structure, their distribution is often linear or segmental. Similarly, the individual microcalcifications may be linear or branching in form. Because the calcifications are deposited with the lumen of a duct that is lined by hyperplastic or malignant epithelium, their borders are often jagged or irregular, and there tends to be variability in their forms (pleomorphism), although small amorphous or granular calcifications may also occur in pathologic process in small ducts, specifically ductal hyperplasia, atypical ductal hyperplasia, and DCIS.
Figure 6.12 HISTORY: A 73-year-old woman for screening mammography.
MAMMOGRAPHY: Right magnified CC image (A) and histopathology section (B). There is a cluster of innumerable irregular microcalcifications in the right breast. These calcifications are pleomorphic, linearly arranged, and have jagged irregular margins, all of which are suspicious features for malignancy.
IMPRESSION: Ductal carcinoma, possible comedocarcinoma.
HISTOPATHOLOGY: Comedocarcinoma. The biopsy specimen with comedocarcinoma shows multiple distended ducts filled with intraductal carcinoma and prominent central necrosis. Irregular calcifications are present within the necrotic areas.
NOTE: In comedocarcinoma, there is a thick debris in the ductal lumen that tends to calcify in the characteristic pattern shown here.
The formation of breast microcalcifications can occur by two processes: active cellular secretion of calcium salts or calcification of necrotic debris. Ahmed (46) described the concept of breast epithelial cells actively producing and secreting calcifications into the lumen of the ducts. Breast calcifications may be composed of calcium phosphate or calcium oxalate crystals. The calcium phosphate is readily visualized on hematoxylin and eosin (H&E)-stained slides as deeply purple. However, calcium oxalate crystals are not readily observed on H&E-stained slides (47). The use of polarized light microscopy is most helpful for the demonstration of the birefringent calcium oxalate crystals (47). Calcium oxalate, thought to arise as a secretory process in benign breast disease (48), produces colorless birefringent crystals (49). When no calcium is identified
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on routine H&E staining, pathologists must consider calcium oxalate and use polarized light to evaluate the slides for this type of calcifications (49).
Calcium phosphate crystals are basophilic and nonbirefringent, and they result from cellular degeneration in either benign or malignant disease. Radi (50) found that calcium oxalate accounted for 23% of mammographically detected microcalcifications on biopsy, and none were associated with carcinoma. Others, such as Fondos-Morera et al. (51), found that calcium oxalate may occur in breast cancers, but this type of calcification is more commonly found in benign lesions or associated with LCIS (50,52,53). Calcium oxalate has also been found (54) to be infrequently associated with DCIS.
Stomper et al. (55) found that in 100 cases of intraductal carcinoma, 72% presented as microcalcifications only, and 12% presented as nodules with calcifications. Other less common mammographic features of DCIS include circumscribed nodules, focal asymmetry, dilated ducts, ill-defined nodules, and focal architectural distortion (56). Because the calcifications of DCIS are deposited between crypts formed by irregular projections of epithelial cells, they form casts of the lumina of the ducts and, similarly, have irregular borders. Combinations of forms—including rod-shaped, punctuate, comma-shaped, tear-drop–shaped, Y or branching, and lacy calcifications—may be seen together and are considered of high suspicion for malignancy.
In a study of mammographic findings of various subtypes of DCIS, Evans et al. (57) found that calcification was present in 95% of patients with large-cell DCIS (often the comedo subtype) but in only 58% of patients with small-cell DCIS (solid, cribiform, micropapillary subtypes). Calcifications were found in 96% of cases of DCIS with comedonecrosis versus 61% of cases without necrosis. An abnormal mammogram without calcifications and mammograms showing predominately punctuate microcalcifications were seen more frequently in DCIS without necrosis (57).
The calcifications of comedocarcinoma are more likely to be linear, and this pattern is thought to be secondary to dystrophic calcification of intraluminal cellular debris and a high concentration of calcium in necrotic cells (57,58). Stomper et al. (55) found that linear microcalcifications were present in 47% of comedocarcinoma compared with 18% of the cribiform, solid, or papillary subtypes of DCIS. Granular microcalcifications were found in 53% of comedocarcinomas versus in 82% of the noncomedo subtypes. Barreau et al. (59) found a correlation between granular or linear branching calcifications and grade 3 histology with necrosis. These authors also found a correlation between a lesion being associated with greater than 20 calcifications and being grade 3 with comedonecrosis (59). Holland et al. (58) described the calcifications within well-differentiated DCIS to be small, laminated pearlylike particles in the luminal spaces within the tumorous ducts. Holland et al. (58) found that calcifications in poorly differentiated DCIS were linear, branching, or granular on mammography. The linear calcifications represented the three-dimensional image of the necrotic debris of calcium, which coalesced into casts of the center of the malignant ducts. Although in the majority of cases the calcifications associated with carcinoma are within the malignant ducts, Homer et al. (60) found that in one third of cases, the calcifications were both within the tumor and contiguous to it, and in 5% of cases, the calcifications were not associated with the tumor.
The size of individual calcifications is less important than their morphology for deciding their classification and potential etiology. The assessment of calcifications based on their size can be misleading, because malignancies are usually associated with microcalcifications of 200 μm or less, but this is certainly not always so. Comedocarcinoma, a subtype of DCIS, often manifests mammographically as casting, linear, branching microcalcifications, which can be larger than 200 μm and dense. A pitfall in the mammographic interpretation of microcalcifications is to dismiss somewhat large pleomorphic calcifications as being benign because of their size.
The most common distributions of malignant calcifications are in a focal cluster or group, or in a linear or segmental orientation. If the cancer is more extensive, the malignant calcifications may occur in a larger region of a breast or may even involve an entire breast. Egan et al. (18) found that carcinoma that presented as calcifications only was more often distributed as a cluster (66%); a mixture of scattered and clustered microcalcifications occurred in 34% of cancers. Microcalcifications that are diffusely scattered in all quadrants of both breasts are much more likely to be of benign origin. One should carefully scrutinize diffuse microcalcifications, searching for any cluster or area having a different morphology from the background pattern that might suggest a different etiology. One should also carefully review the mammogram for other clusters of suspicious calcifications when one group has been identified. DCIS has a great tendency to occur in multiple foci. Dershaw et al. (4) found that in 65% of breasts with DCIS, multifocality was present. In 41% of the cases, the maximum tumor expanse was greater than 2.5 cm, and all were multicentric. The detection of multifocal or multicentric carcinoma greatly affects surgical planning and patient management.
Zunzunegui et al. (61) found that in women with small, multifocal breast cancers with extensive casting calcifications and DCIS, the incidence of positive nodes was 33%, and there was a tendency for poor tumor markers. Thurfjell et al. (62) found a worse prognosis when small
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invasive cancers presented as casting or pleomorphic calcifications. Stomper et al. (63) correlated mammographic features with pathologic findings of breast cancers manifested by calcifications only. In this study, 65% of patients had pure DCIS, 32% had DCIS with a focus of invasion, and 44% had invasive cancer. Invasion was more likely when calcification size was greater than 11 mm or morphology was linear, but invasion was not associated with an extent of calcifications greater than 10 mm.
Tabar et al. (64), in a study of invasive breast cancers less than 15 mm in size, found that the presence of casting calcifications was significantly associated with positive lymph node status, poorer histologic grade, and decreased survival. Twenty-year survival rates for women with 10 to 14 mm tumors were 52% when casting calcifications were present versus 86% to 100% for those women who had mammographic features that did not include casting calcifications.
Variability is size, shape, and density of microcalcifications is a worrisome feature (18), but variability must be assessed in conjunction with morphology. Those calcifications with sharp, jagged margins that are variable in appearance are much more likely to be malignant than are variably sized and shaped but smoothly marginated calcifications. DeLafontan et al. (65) found that vermicular shape, linear branching distribution, and irregularity of size of calcifications were strong predictors of malignancy.
Diffusely scattered, diffuse unilateral calcifications having spherical, hollow, or meniscoid shapes (usually associated with benign lesions) have been described (66) in ductal malignancies with apocrine features. However, in apocrine carcinoma, the pattern of microcalcifications is variable, composed of a mixture of milk of calcium with amorphous and pleomorphic microcalcifications that are unilateral. In cases of intraductal carcinoma in which there is retrograde involvement of the lobule (cancerization of the lobule), the lobular form of microcalcification may also be identified (67).
The greater the number of calcifications in an area, the more suspicious for malignancy (30,68,69). Egan et al. (18) found that 84% of breast cancers containing microcalcifications had more than 10 calcifications in a group. Millis et al. (3) found that in 33 cancers, 6 had less than five calcifications in a cluster. However, one should note that there is no definite distinction between less than versus more than five calcifications in a group and the need for biopsy. If microcalcifications are suspicious morphologically and less than five in number, biopsy should still be performed.
Interval changes from a prior mammogram with the development of new or increasing microcalcifications often warrant investigation with biopsy. However, morphology must be the primary consideration. New benign calcifications of fat necrosis, cystic hyperplasia, and dermal or vascular origin need not be evaluated further. On the other hand, stability of microcalcifications from prior studies of at least 2 years’ duration is a helpful indicator that the lesion is probably not malignant. Occasionally, DCIS may be manifested as calcifications that are stable for more than 2 years (70). Because of this, calcifications that are suspicious in morphology but stable on mammography may still need to be biopsied.
The identification of an extensive intraductal component (EIC) associated with an infiltrating cancer may be a predictor of a high risk of finding residual carcinoma on re-excision (71) and a higher local recurrence rate after breast conservation therapy (lumpectomy and breast irradiation) (72). An EIC is defined (73) as the presence of DCIS occupying an area of ≥25% of the area occupied by the infiltrating cancer and the presence of DCIS beyond the edge of the infiltrating tumor. Tumors detected only by mammography or tumors presenting as microcalcifications are more likely to be EIC positive, but this preoperative analysis is not absolute (Figs. 6.13 and 6.14) (74).
The presence of an extensive intraductal component is a major factor for predicting local recurrence after breast conservation and radiotherapy. The presence of malignant-appearing microcalcifications with or without a mass has been found to be associated with an extensive intraductal component, and when the calcifications extend over an area greater than 3 cm, the likelihood of EIC positivity is significantly increased (75).
Patterns of Calcifications as Defined by the BIRADS Lexicon
The ACR BI-RADS® lexicon (16,76) defines microcalcifications based on morphology and distribution. Those calcifications having a benign morphology include the following patterns: skin, vascular, coarse, dystrophic, large rodlike, eggshell or rimlike, lucent-centered or spherical, sutural, milk of calcium, round, and punctate.
Skin Calcifications
Skin calcifications are typically single or grouped, very-well-demarcated, small, round, spherical, or polygonal calcifications (77). These usually appear to be very superficially located because of their dermal origin, although they may superimpose over the parenchyma on the two standard views. They typically occur in sebaceous glands and are related to chronic inflammation (78). Because of their location within the interconnecting lumina of the sebaceous glands, their pattern may be in the form of a paw print. Another sign that calcifications may be dermal is the “tattoo sign” described by Homer et al. (79). In this case, the calcifications lie in a fixed orientation relative to each other on two different views, indicating a superficial location.
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Figure 6.13 HISTORY: A 50-year-old gravida 2, para 1, abortus 1 woman with a firm 2-cm mass in the right upper-outer quadrant.
MAMMOGRAPHY: Right MLO (A), CC (B), and CC magnification views (C). There is a high-density spiculated mass in the outer quadrant, with microcalcifications extending from the mass to the nipple. A magnification of this area (C) shows the typically malignant features of the calcifications: linear shapes, irregular margins, variability in size and shape, and extension throughout the ductal system. Irregular microcalcifications are forming casts of the malignant ducts.
IMPRESSION: Ductal carcinoma.
HISTOPATHOLOGY: Infiltrating ductal carcinoma with an extensive intraductal component.
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Figure 6.14 HISTORY: A 61-year-old patient with a palpable mass lateral in the right breast.
MAMMOGRAPHY: Right CC (A) view shows a high-density indistinct mass located laterally and associated with extensive microcalcifications adjacent to it. On the magnification CC view (B), the fine linear intraductal microcalcifications extending from the mass toward the nipple are seen.
IMPRESSION: Invasive carcinoma with extensive ductal carcinoma in situ.
Dermal calcifications also may occur within or on the surface of skin lesions such as nevi, keratoses, and skin tags. Common locations for dermal calcifications are far medially and posteriorly in the cleavage area, within glands of the areola, and in the axillary region of breast (Figs. 6.15,Figs. 6.16,6.17). Calcifications of dystrophic origin may occur in skin that is scarred, such as at burn sites or within keloids. These calcifications are very well defined and round or spherical in form, and are often more dense than other skin calcifications (Figs. 6.18 and 6.19).
Figure 6.15 HISTORY: A 50-year-old for screening mammography.
MAMMOGRAPHY: Bilateral CC views (A) show fatty replaced breasts and small round calcifications medially (arrows). On the enlarged image of the medial aspect of the breasts (B), the morphology of these calcifications is better delineated. These are very well defined, round, and small lucent-centered calcifications in paw-print patterns, characteristic of dermal calcifications.
IMPRESSION: Dermal calcifications.
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Figure 6.16 HISTORY: Screening mammogram on a 44-year-old woman.
MAMMOGRAPHY: Left MLO view (A) shows heterogeneously dense parenchyma and several small groups of calcifications. The enlarged image (B) shows the very-well-calcified smooth aspect of these calcifications. The pattern is typical of dermal calcifications in glands in the skin.
IMPRESSION: Skin calcifications.
Figure 6.17 Dermal calcifications: small, very-well-defined, round, and lucent shapes.
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Figure 6.18 HISTORY: A 52-year-old woman with a history of burn injury to the thorax, for screening mammography.
MAMMOGRAPHY: Bilateral MLO views (A) show multiple very-well-circumscribed masses in both breasts (arrows), as well as extensive regional calcifications. On the CC views (B), the masses are not identified; however, there is very prominent skin thickening medially (arrows). On an enlarged image (C), the skin thickening with associated lucent-centered calcification is noted.
IMPRESSION: Keloids appearing as pseudomasses with dystrophic calcification in the scars. BI-RADS® 2.
NOTE: The very-well-defined aspect of the “masses” that are seen on one view should suggest the possibility of a skin lesion.
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Figure 6.19 HISTORY: Screening mammogram in a patient with a history of burns to the chest wall and keloid formation.
MAMMOGRAPHY: Left MLO (A) and CC (B) views show extensive small, round, and lucent-centered calcifications over the medial aspect of the breast. This pattern is typical of dystrophic calcifications that occur in the scars on the skin.
IMPRESSION: Keloids with benign dystrophic calcifications in the skin.
Vascular Calcifications
Vascular calcifications occur within arteries of the breast as they do elsewhere in the body. The most common etiologies of vascular calcifications are atherosclerosis and renal disease. Extensive calcification in the small vessels with the breast is usually associated with renal disease (80,81) and secondary hyperparathyroidism. A weak correlation exists between diabetes mellitus and the presence of vascular calcifications (82,83). Kemmeren et al. (84) found that breast arterial calcifications identified on mammography were associated with an increased risk of subsequent cardiovascular death in women older than 50 years and in diabetic women in particular. Moshyedi et al. (85) found that positive predictive value of breast arterial calcifications for coronary artery disease is 0.88, and the negative predictive value is 0.65, which is statistically significant. For women older than age 59, the correlation between vascular calcifications and coronary artery disease was not strong. Vascular calcifications are typically tramline or parallel lines of calcium corresponding to the calcified intima of the artery. These are usually circuitous and are not oriented in the pattern of the ducts toward the nipple-areolar complex (Figs. 6.20,Figs. 6.21,Figs. 6.22,Figs. 6.23,6.24). Early arterial calcifications may be stippled and fine, and the observation of the vessel corresponding to their path is key in suggesting the proper diagnosis. Magnification
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mammography is often essential in this situation for differentiating early vascular calcifications from clustered fine microcalcifications of ductal or lobular origin (86).
Figure 6.20 HISTORY: A 65-year-old woman for screening.
MAMMOGRAPHY: Magnified image of left breast. Circuitous vessels are associated with calcification in the walls, typical of arterial calcification.
IMPRESSION: Arterial calcifications.
Figure 6.21 HISTORY: A 78-year-old woman for screening.
MAMMOGRAPHY: Bilateral CC views (A) demonstrate extensive vascular calcifications. On the enlarged image (B), the typical tram-line appearance of the calcified intima of the arteries is seen.
IMPRESSION: Arterial calcifications.
Figure 6.22 HISTORY: A 54-year-old for screening mammography.
MAMMOGRAPHY: Bilateral MLO (A) and CC (B) views show extensive tramline calcifications in both breasts. These extend toward the axillae, which is a finding typical of arterial calcifications.
IMPRESSION: Arterial calcifications.
Figure 6.23 HISTORY: A 64-year-old woman for screening with a history of hypertension and diabetes, who was placed on dialysis in the last year.
MAMMOGRAPHY: Bilateral CC views (A) 8 years ago and bilateral CC views (B) currently show the interval development of bilateral vascular calcifications. Magnified right CC image (C) shows extensive arterial calcifications in large and small vessels. The extensive nature of these calcifications suggests chronic renal disease.
IMPRESSION: Diffuse arterial calcifications consistent with renal disease.
Figure 6.24 HISTORY: Screening mammogram.
MAMMOGRAPHY: Right CC enlarged image shows a densely calcified artery. Typical tramline calcification is seen in the circuitous structure.
IMPRESSION: Vascular calcification.
Coarse Calcifications
Coarse calcifications are usually of dystrophic origin and are most commonly associated with fibroadenomas (87). Fibroadenomas are generally palpated as firm, well-defined breast masses in women younger than 30 years. The lesions tend to involute after menopause, with mucoid degeneration and calcification occurring later in their natural history. The masses may be large and generally well defined, and may contain large, bizarre irregular calcifications that should not be confused with carcinoma. Early in the stage of calcification (Figs. 6.25,Figs. 6.26,6.27), a few punctuate peripheral microcalcifications may develop, and their peripheral location in a circumscribed mass should suggest a fibroadenoma. Occasionally, degenerating fibroadenomas may contain somewhat irregular, mixed-morphology microcalcifications that are indistinguishable from a ductal lesion, and biopsy is necessary (88). Rarely, fibroadenomas can even develop metaplastic bone formation or ossification (89). Later, the calcifications become more dense and coarse and are easily differentiated from malignancy. In the latest stage, the soft tissue masses are no longer apparent and are totally replaced by typical large coarse “popcornlike” calcifications (Figs. 6.28,Figs. 6.29,Figs. 6.30,6.31).
Figure 6.25 HISTORY: A 60-year-old woman with history of a previously excised left breast fibroadenoma.
MAMMOGRAPHY: Right CC (A) and magnified CC (B) views: There is a circumscribed, lobulated, isodense mass in the subareolar area. A single coarse calcification is eccentrically located in the periphery of mass, most consistent with a calcifying fibroadenoma.
IMPRESSION: Degenerating fibroadenoma.
This pattern of coarse calcification is typically benign, although rarely cancers may contain coarse calcifications. Malignancy with associated coarse calcification occurs when a fibroadenoma is immediately adjacent to or is the site of development of a breast cancer or in the unusual case of a breast cancer with central necrosis and the formation of dystrophic central calcification (Fig. 6.32).
Another cause of large coarse calcifications is that of renal disease with secondary hyperparathyroidism
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(90,91). In this condition, the hypercalcemic state is associated with the deposition of coarse, dense diffuse calcifications in both breasts (Fig. 6.33). Because of the systemic nature of this process, the calcifications occur bilaterally (80,90,91) and diffusely. In patients with chronic renal failure and hypercalcemia, the reduction of serum phosphorus levels with hemodialysis, diet, and medication can be associated with disappearance of breast calcifications (90).
Figure 6.26 HISTORY: A 66-year-old woman for screening mammography.
MAMMOGRAPHY: Left MLO (A) and CC (B) views show very dense and glandular tissue. In the 12 o’clock position, there is a very-well-defined mass with a fatty halo around most of its margin. Dense popcornlike calcifications are present in the mass and are typical of a degenerated fibroadenoma. Other scattered benign calcifications are also seen.
IMPRESSION: Degenerated calcified fibroadenoma.
Figure 6.27 HISTORY: A 69-year-old woman for screening mammography.
MAMMOGRAPHY: Left MLO view shows extensive calcifications throughout the breast. There are extensive vascular calcifications (arrow) and large rodlike calcifications (arrowheads) of secretory disease. In addition, there is a lobulated mass in the subareolar area that contains coarse calcifications, consistent with a degenerated fibroadenoma.
IMPRESSION: Benign calcifications: vascular, secretory disease, and calcified fibroadenoma.
Figure 6.28 HISTORY: Screening mammogram.
MAMMOGRAPHY: Right MLO view shows a dense coarse calcification without an associated mass. The pattern is typical of that of fibroadenoma that has degenerated.
IMPRESSION: Degenerated fibroadenoma with coarse calcification.
Figure 6.29 HISTORY: A 76-year-old woman who has had multiple palpable breast masses for many years.
MAMMOGRAPHY: Bilateral MLO views. The breasts are glandular for the age of the patient. There are multiple, popcornlike, very coarse, dense calcifications in both breasts. These have almost totally replaced the soft tissue masses from which they originated, except for a few partially calcified nodules (arrows). The appearance of these lesions is characteristic of degenerated fibroadenomas.
IMPRESSION: Degenerated fibroadenomas.
Figure 6.30 HISTORY: A 64-year-old asymptomatic woman.
MAMMOGRAPHY: Right magnification view. There is a 1.5-cm well-defined ovoid mass in the right outer quadrant. This lesion contains coarse peripheral macrocalcifications typical of a degenerating fibroadenoma.
IMPRESSION: Degenerated calcified fibroadenoma.
Figure 6.31 HISTORY: A 72-year-old woman with a long history of a right breast mass unchanged in size.
MAMMOGRAPHY: Right CC view. There is a large well-defined mass in the subareolar area that contains coarse bizarre macrocalcifications. The mass has smooth, lobulated margins. The findings are typical of a fibroadenoma with coarse calcifications.
IMPRESSION: Fibroadenoma.
Figure 6.32 HISTORY: A 64-year-old woman with a firm palpable mass in the left breast.
MAMMOGRAPHY: Left CC view (A) and magnified image (B). There is a high-density spiculated mass typical of malignancy. There are relatively coarse dense calcifications, 3–4 mm in diameter, within the mass (B), and larger than are generally considered to be associated with carcinoma. Occasionally, malignancies may contain larger calcifications, and their presence should not alter a diagnosis of carcinoma based on the morphology of the mass.
IMPRESSION: Carcinoma, left breast.
HISTOPATHOLOGY: Infiltrating ductal carcinoma.
Figure 6.33 HISTORY: Elderly patient with a history of renal failure and hypercalcemia.
MAMMOGRAPHY: Left (A) and right (B) CC views show dense parenchyma and extensive coarse and vascular calcifications in a bilateral pattern that suggests a systemic etiology. The extensive nature of the calcifications is typical of tumoral calcinosis secondary to hypercalcemia.
IMPRESSION: Tumoral calcinosis, secondary to hypercalcemia.
Figure 6.34 HISTORY: Screening mammogram in a patient who has a history of silicone injections for breast augmentation.
MAMMOGRAPHY: Left MLO view shows extensive very-high-density nodules throughout the breast. These represent silicone droplets that have been injected, some of which are calcifying.
IMPRESSION: Silicone granulomas from augmentation mammoplasty.
In patients who have undergone breast augmentation by injection of silicone or other substances, such as paraffin or talc, calcifications form at the injection sites and are related to a foreign-body reaction. These calcifications may be coarse and dense (Fig. 6.34) or may be ringlike with a pattern more typical of fat necrosis (92). The calcifications associated with a reaction to an injected substance are usually diffuse and bilateral, and they are associated with a very dense and nodular parenchyma. A similar pattern may be seen with extruded silicone from an extracapsular implant rupture and the formation of silicone granulomas except that the dense nodules and calcifications are more localized to the site of rupture.
A rare cause of large coarse calcifications in the breast is osteogenic sarcoma (93). This lesion shows prominent uptake on a radionuclide bone scan as well.
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Another pattern of calcifications in an osteosarcoma is a more dense, amorphous pattern associated with the osteoid matrix.
Dystrophic Calcifications
Smaller macrocalcifications that have somewhat irregular shapes but relatively smooth edges are classified as dystrophic calcifications. In the newer version of BI-RADS®, these are also termed coarse pleomorphic. The pattern may be confused with suspicious calcifications because the shapes are often variable. However, dystrophic calcifications have smooth edges like rock in a river polished by the water, and these calcifications may look crumbled and coalescent. Dystrophic calcifications occur in the same processes that are associated with coarse calcifications, namely in fibroadenomas, fat necrosis, and in areas of fibrosis. Often dystrophic calcifications are grouped because they are related to a focal process (Figs. 6.35,Figs. 6.36,6.37). Focally extensive dystrophic calcifications are typically seen in scars, particularly following reduction mammoplasty (Figs. 6.38 and 6.39).
The presence of extensive bilateral dystrophic calcifications is found in connective tissue disorders, particularly dermatomyositis (94) and systemic lupus erythematosus (Fig. 6.40). The calcifications are located in the subcutaneous area, are bilateral, and extend up into the axillary region.
Figure 6.35 HISTORY: A 50-year-old woman for screening.
MAMMOGRAPHY: Left CC magnification views (A, B). There are two groups of dystrophic calcifications that are smoothly marginated. The pattern is suggestive of a benign etiology, such as a fibroadenoma, because of the smoothness of the edges of individual calcifications. These had been stable for 4 years.
IMPRESSION: Benign coarse dystrophic calcifications, most consistent with a degenerated fibroadenoma.
Large Rodlike Calcifications
Plasma cells mastitis, or secretory disease, is an aseptic inflammation of the breast thought to be the result of extravasation of intraductal secretions into the periductal connective tissue. As a late phenomenon of secretory disease, calcifications may occur.
In the case of duct ectasia or secretory disease, inspissated secretions within the major lactiferous ducts may calcify in the pattern of large rodlike calcifications (95). Because secretory disease is a process involving the major lactiferous ducts, the pattern of calcification is oriented toward the nipples in the subareolar regions, and the process is usually bilateral. The macrocalcifications have smooth linear shapes, are usually larger and more dense than malignant linear calcifications, and occasionally may be Y-shaped or branching (96,97) (Figs. 6.41,Figs. 6.42,Figs. 6.43,Figs. 6.44,Figs. 6.45,Figs. 6.46,6.47). The calcifications associated with this condition may be intraductal, in the wall of the duct, or periductal, and their morphology depends on the location.
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Figure 6.36 HISTORY: A 78-year-old woman referred for biopsy following an abnormal mammogram.
MAMMOGRAPHY: Left MLO (A) view shows clustered microcalcifications superiorly (arrow). On spot magnification CC (B) and ML (C) views, the calcifications are noted to be in the periphery of a lobular circumscribed mass. The morphology of the calcifications is punctuate and dystrophic. The pattern of calcifications in the periphery of a mass is typical of early degeneration in a fibroadenoma.
IMPRESSION: Early degeneration in a fibroadenoma.
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Figure 6.37 Dystrophic calcifications in a circular configuration: evolving fat necrosis.
Figure 6.38 HISTORY: A 57-year-old who is status postreduction mammoplasty and who reports diffusely lumpy breasts.
MAMMOGRAPHY: Bilateral MLO views (A) show extremely dense tissue. There is overall distortion in the appearance of the parenchyma, consistent with postreduction changes. In the subareolar areas of both breasts, curvilinear calcifications are seen (arrows). On the magnification right CC view (B), the lacy, irregular calcifications are noted. These are varying in shape but are coarse and smoothly marginated, and some of the calcifications have lucent centers, all features of dystrophic calcifications.
IMPRESSION: Extensive dystrophic calcifications related to reduction mammoplasty, BI-RADS® 2.
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Figure 6.39 HISTORY: A 65-year-old gravida 1, para 1 woman after bilateral reduction mammoplasties, referred for screening mammography.
MAMMOGRAPHY: Left (A) and right (B) bilateral CC views and magnified right CC image. There are numerous coarse irregular calcifications that are oriented in a linear arrangement and that were situated directly beneath the surgical scars. A right magnified view (C) shows the calcifications to be more coarse and pleomorphic. The findings are typical of fat necrosis, and the extent and distribution are seen after reduction mammoplasty.
IMPRESSION: Fat necrosis.
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Figure 6.40 HISTORY: A 40-year-old woman with a history of systemic lupus erythematosus and Raynaud disease.
MAMMOGRAPHY: Bilateral MLO (A) and CC (B) views show extensive, somewhat coarse calcifications bilaterally. On the enlarged image (C), the plaquelike appearance of these dystrophic calcification is seen. The calcifications are located superficially in the subcutaneous area and extend beyond the breast toward the axilla. The diffuse, bilateral appearance suggests the possibility of a systemic etiology.
IMPRESSION: Extensive dystrophic calcifications of dermatomyositis.
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With secretory disease, the inspissated secretions may leak through the duct wall and produce a plasma cell reaction with periductal fibrosis. Secretory calcifications are large (up to 5 mm in diameter), smooth bordered, and round, ovoid, linear, or needlelike in shape. The centers may be solid or hollow (if periductal). In addition to the large, rodlike calcifications of secretory disease, the periductal inflammation is associated with lucent-centered or tubular periductal macrocalcifications.
Eggshell or Rimlike Calcifications
Trauma to the breast, either surgical or related to blunt trauma and a bruise, may lead to fat necrosis. The evolution of fat necrosis and particularly the formation of an oil cyst can be identified mammographically as an eggshell or rimlike calcification in the edge of a radiolucent mass (98). These calcifications are typically large (Figs. 6.48,Figs. 6.49,Figs. 6.50,Figs. 6.51,6.52), readily visible, and dense, and they were described as liponecrosis macrocystica by Leborgne (99).
Fat necrosis may appear in a variety of ways mammographically, from an irregular mass with overlying skin retraction, to an oil cyst, to a spectrum of forms of calcifications (98). Fat necrosis occurs after trauma and hemorrhage, such as after biopsy, aspiration, or blunt trauma with hematoma formation. Clinically, the patient may be asymptomatic or may appear with an indurated firm mass with or without overlying skin thickening and retraction. On histology, fat necrosis is characterized by anuclear fat cells with giant cells and phagocytic histiocytes. There may be central necrosis and liquefaction with formation of an oil cyst; aspiration of these lesions yields a clear oily fluid.
The calcifications that occur in fat necrosis may be small, smooth, and ringlike (liponecrosis microcystica calcificans) or they may be large circumlinear calcifications in the walls of oil cysts (liponecrosis macrocystica calcificans) that are characteristically benign (99).
Other less frequent causes of eggshell calcifications are duct ectasia with a greatly dilated duct containing periductal calcification and the calcification of the wall of a breast cyst. Eggshell calcification may also occur within a lipoma that contains an area of fat necrosis (Fig. 6.53).
Eggshell or rimlike calcifications indicate a benign process and do not require further work-up.
Lucent-Centered or Spherical Calcifications
Liponecrosis microcystica is an area of fat necrosis where a large oil cyst does not form (98). Instead, very small areas of fat necrosis occur, and the associated calcifications are spherical, with lucent centers, but smaller than the eggshell pattern. These may vary from 0.5 mm to 2 or 3 mm in diameter. These calcifications are often multiple, and they are associated with the area of trauma (Figs. 6.54,Figs. 6.55,Figs. 6.56,Figs. 6.56,6.57). The calcifications may eventually disappear as the process of fat necrosis is cleared by macrophages (100,101). When fat necrosis is cleared, the spherical calcifications may begin to crumble and look somewhat irregular—having the appearance of dystrophic or even amorphous or pleomorphic microcalcifications—before they disappear completely (Fig. 6.58).
Sutural Calcifications
Another form of characteristically benign calcification on mammography is that of calcification of sutures in the breast. The characteristic feature of sutural calcification is their morphology, namely smooth linear, curvilinear, and knot shapes (Figs. 6.59 and 6.60). These more commonly occur in patients who have undergone lumpectomy and breast irradiation rather than in patients with prior benign breast biopsies (102). Calcified sutures are thought to be a result of delayed resorption of catgut sutures, which provide a matrix on which calcium can precipitate.
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In a study of 335 women who were treated with lumpectomy and radiation therapy (103), 21 developed calcified sutures, whereas none of 1,140 women who also underwent lumpectomy for benign disease were found to have calcified sutures on mammography.
Figure 6.41 HISTORY: A 69-year-old woman for screening.
MAMMOGRAPHY: Bilateral MLO (A) and CC (B) views show scattered fibroglandular densities. There are extensive rodlike calcifications oriented toward the nipples in both breasts. The pattern and distribution of calcifications is typical of secretory disease or plasma cell mastitis.
IMPRESSION: Secretory disease with large rodlike calcifications.
Figure 6.42 HISTORY: An 84-year-old woman for screening mammography.
MAMMOGRAPHY: Right CC (A) and enlarged CC (B) views show segmentally arranged, large rodlike calcifications on a background of scattered fibroglandular densities.
IMPRESSION: Large rodlike calcifications of secretory disease, BI-RADS® 2.
Figure 6.43 HISTORY: A 77-year-old woman for screening mammography.
MAMMOGRAPHY: Bilateral CC (A) views show diffuse, scattered, large rodlike calcifications bilaterally. On the enlarged image (B), the smooth, needlelike character of these benign calcifications is seen.
IMPRESSION: Large rodlike calcifications of secretory disease.
Figure 6.44 HISTORY: Screening mammogram.
MAMMOGRAPHY: Right MLO view shows extensive, large rodlike calcification. These have a smooth needlelike appearance, involve all quadrants, and radiate toward the nipple.
IMPRESSION: Benign calcifications of secretory disease.
Figure 6.45 Extensive tubular, large rodlike calcifications radiating along the pattern of ducts, typical of secretory disease or plasma cell mastitis.
If sutural calcifications are suspected, the radiologist should correlate the relationship of the position of the surgical scar to the location of the calcifications. Also, care must be taken to not assume that linear calcifications are sutures when they may be associated with a recurrence of cancer.
Milk of Calcium
As discussed earlier, a benign pattern of microcalcifications is that of milk calcium in areas of cystic hyperplasia (27). These are microcalcifications that form within the distended ductules of the lobule, and they represent calcium salts suspended in cyst fluid. When viewed enface (i.e., on the CC view), milk of calcium may be very faint or smudged in appearance or may have a rounded shape. On the cross-table lateral view (ML), the heavier calcifications lie in the dependent aspect of the cyst, taking on the contour of its base (Figs. 6.61,Figs. 6.62,6.63). Therefore, their shape on the ML view is linear, crescentic meniscoid, or cup shaped. Cystic hyperplasia is part of the spectrum of fibrocystic changes and therefore may be extensive or focal (28). It is important to carefully assess areas of milk of calcium for other more suspicious calcifications. The presence of milk
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of calcium has been described in apocrine carcinoma (Fig. 6.64) (66); however, in these cases, the pattern of calcifications is very extensive, unilateral, and mixed with pleomorphic microcalcifications as well.
Figure 6.46 HISTORY: Screening mammogram.
MAMMOGRAPHY: Right CC view (A) shows extensive, large rodlike calcifications throughout the breast. These calcifications are smooth, regular in margination, and needlelike in configuration on the enlarged image (B).
IMPRESSION: Benign calcifications of secretory disease.
Figure 6.47 HISTORY: Screening mammography.
MAMMOGRAPHY: Enlarged right CC view shows extensive, large rodlike calcifications. The intraductal calcifications are smooth and needlelike, whereas others are lucent centered or tubular and in the periductal area.
IMPRESSION: Large rodlike calcifications of secretory disease.
Figure 6.48 HISTORY: A 44-year-old woman who had had previous biopsy of a benign lesion in the right outer quadrant, presenting with a 1-cm smooth mass at the edge of the surgical scar.
MAMMOGRAPHY: Right CC view (A) and magnified image (B). There is a well-defined, 1-cm eggshell calcification in the periphery of a radiolucent mass, characteristic of a calcified oil cyst. Other smaller, dense, round, and circular calcifications of fat necrosis (liponecrosis microcystica) are seen. The changes are related to the previous surgery.
IMPRESSION: Fat necrosis, liponecrosis macrocystica and microcystica, BI-RADS® 2.
Figure 6.49 HISTORY: A 54-year-old woman with a history of severe trauma to the upper torso and extremities from farm machinery 1 year previously, presenting with multiple palpable masses in the left breast.
MAMMOGRAPHY: Left CC view (A) and specimen radiograph (B). There are multiple, relatively lucent, well-defined masses (straight arrow) with calcific rims typical of posttraumatic oil cysts and fat necrosis. Clustered pleomorphic microcalcifications are present (curved arrow) and had developed since the mammogram 1 year previously.
IMPRESSION: Oil cysts; new clustered calcifications, favoring fat necrosis and fibrosis. Recommend biopsy.
HISTOPATHOLOGY (OF MICROCALCIFICATIONS): Fibrosis, fat necrosis.
Figure 6.50 HISTORY: Prior car accident with a seat belt injury to the breast.
MAMMOGRAPHY: Right CC magnification view shows regional lucent-centered calcifications typical of fat necrosis. In the same region is a radiolucent mass (arrow), which represents an evolving oil cyst.
IMPRESSION: Calcifications of fat necrosis.
Macrocysts may also contain precipitated calcium salts, creating the appearance of a macroscopic area of milk of calcium. A well-circumscribed isodense mass with meniscoid calcification in its base on the MLO or ML view represents a macrocyst containing milk of calcium and is therefore benign (Fig. 6.65).
Round Calcifications
The ACR lexicon (16) also includes in the benign category calcifications that are round and smooth. These are often multiple and may be 1 to 3 mm in diameter. Round calcifications may occur in multiple conditions, including fat necrosis, in which the central lucency of the oil cyst is not evident; in secretory disease, in which they are mixed with rodlike calcifications; and in areas of fibrocystic change, in which small cysts are completely calcified (Figs. 6.66 to 6.67). This pattern is usually not problematic in characterizing as clearly benign on mammography. Round calcifications represent one of the patterns that may disappear on subsequent mammography (100). Rarely are round calcifications associated with malignancy, but there are usually other features that raise the suspicious in these cases (Fig. 6.68).
Punctate Calcifications
Small, relatively smooth, pearllike, uniform microcalcifications are classified as punctate. These have well-defined margins and are usually multiple and similar in size, shape, and density. Punctate calcifications usually form within the terminal ductules of the lobule, are associated with fibrocystic conditions, and are sometimes also called lobular microcalcifications. Although they may be grouped, because of their fibrocystic origin, punctate calcifications often are scattered diffusely in both breasts. Etiologies of punctate calcifications include such fibrocystic conditions as adenosis, sclerosing adenosis, and lobular hyperplasia (Figs. 6.69,Figs. 6.70,Figs. 6.71,Figs. 6.72,6.73).
Punctuate microcalcifications may be present in biopsies demonstrating lobular neoplasia or LCIS as well. However, in the case of LCIS, the microcalcifications are a nonspecific finding, sometimes occurring in the lobule involved with LCIS but more often in adjacent benign fibrocystic lobules (44). The identification of microcalcifications as punctuate often requires magnification views to verify their smooth contour. The presence of diffuse or scattered punctate microcalcifications does not generally present diagnostic dilemma. However, grouped punctuate microcalcifications that have developed may prompt biopsy, because these can represent in situ carcinoma (Fig. 6.74). Rarely, DCIS may also present with this pattern.
Intermediate Suspicion Patterns of Calcifications
The ACR lexicon (16) defines amorphous calcifications within the spectrum of those that are of an intermediate suspicion for malignancy. These are very small microcalcifications (80–200 μm) in diameter) that are not well defined and that have indistinct margins. Magnification views often demonstrate many more calcifications than are obvious on the routine views. Amorphous calcifications, also described as granular, are often numerous
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and located in a group or multiple groups (Figs. 6.55,Figs. 6.56,Figs. 6.57,Figs. 6.58,Figs. 6.59,Figs. 6.60,6.61). However, occasionally these may be diffusely scattered in both breasts, mixed with punctate microcalcifications or milk of calcium in cases of fibrocystic changes.
Figure 6.51 HISTORY: Patient with a history of a seat belt injury to the left breast and multiple palpable mass.
MAMMOGRAPHY: Left CC (A) and MLO (B) views show extensive calcification over the medial and inferior aspect of the breast. These are associated with large radiolucent masses, better seen on the enlarged image (C). The pattern of calcification is eggshell and coarse pleomorphic, all consistent with fat necrosis and calcified oil cysts.
IMPRESSION: Extensive calcifications of fat necrosis.
Figure 6.52 HISTORY: An 80-year-old woman with a history of right breast trauma from a car accident.
MAMMOGRAPHY: Right CC enlarged view shows extensive spherical, lucent-centered, and round calcifications consistent with fat necrosis. Large radiolucent masses with eggshell calcifications in their walls are also seen, consistent with oil cysts.
IMPRESSION: Extensive calcifications of fat necrosis, oil cysts.
Figure 6.53 HISTORY: A 70-year-old woman with a large palpable mass on the right.
MAMMOGRAPHY: Right MLO (A) view shows a large, radiolucent circumscribed mass superiorly, displacing the normal tissue inferiorly. Within the mass are eggshell calcifications of fat necrosis seen on the enlarged view (B).
IMPRESSION: Lipoma with fat necrosis.
Figure 6.54 HISTORY: A 55-year-old woman with a history of bladder cancer, for screening mammography.
MAMMOGRAPHY: Right CC (A) and MLO (B) views show scattered, round, lucent-centered calcifications in the right breast. On the enlarged image (C), the morphology of these benign calcifications is better seen.
IMPRESSION: Lucent-centered calcifications that are likely secondary to trauma and fat necrosis.
Figure 6.55 HISTORY: A 50-year-old woman status postlumpectomy and radiation therapy for breast cancer.
MAMMOGRAPHY: Left CC magnification view shows multiple eggshell (arrows) and lucent-centered calcifications at the lumpectomy site, which is indicated by a wire marker. These are normal posttreatment findings.
IMPRESSION: Eggshell, lucent-centered, and dystrophic calcifications of fat necrosis at the lumpectomy site.
Figure 6.56 HISTORY: A 41-year-old for screening mammography.
MAMMOGRAPHY: Bilateral MLO (A) and CC (B) views show fatty-replaced breasts. There are extensive lucent-centered calcifications bilaterally. On the enlarged image (C), the calcifications are very well demonstrated and thin rimmed.
IMPRESSION: Lucent-centered calcifications of fat necrosis.
Figure 6.57 HISTORY: A 33-year-old gravida 1, para 1 woman who has had bilateral reduction mammoplasties.
MAMMOGRAPHY: Left magnified MLO view. The breast shows fatty replacement. There are three ringlike eggshell calcifications in the area of a surgical scar. These are typical of oil cysts secondary to reduction mammoplasty.
IMPRESSION: Fat necrosis.
Figure 6.58 HISTORY: A 72-year-old for screening mammography.
MAMMOGRAPHY: Bilateral CC views (A) show heterogeneously dense breasts with diffuse vascular (arrow) and lucent-centered calcifications. There are two groups of coarse pleomorphic calcifications (arrowheads) in the left breast, which are better seen on the enlarged CC view (B). The more medial group of microcalcifications has a more suspicious appearance; however, on the prior mammogram (C), the medial group was a single, round, dense lucent-centered calcification. In the process of disappearance, the calcification has become more fragmented and irregular in appearance.
IMPRESSION: Bilateral benign vascular and lucent calcifications; evolution of a calcified oil cyst to more dystrophic-appearing microcalcifications, BI-RADS® 2.
Figure 6.59 SUTURAL CALCIFICATION: Knot-shaped calcification at the site of a prior lumpectomy for breast cancer.
The irregular or indistinct contour of the individual calcifications is related to their location within the terminal duct rather than the lobule in most cases. The calcifications are actively secreted as salts of either calcium phosphate or calcium oxalate by the epithelial cells that line the small ducts. Because the hyperplastic duct lining is associated with the calcifications, their morphology is irregular, reflecting the internal duct lumen. Calcium phosphate stains readily as purple with the routine hematoxylin and eosin stain. However, calcium oxalate is pale pink or invisible on H&E stain and often requires the use of polarized light to be evident at microscopic analysis.
The etiologies of the amorphous pattern of calcifications include the following: DCIS, atypical ductal hyperplasia, epithelial hyperplasia of the ordinary type, papillomatosis, and sclerosing adenosis (Figs. 6.75,Figs. 6.76,Figs. 6.77,Figs. 6.78,Figs. 6.79,Figs. 6.80,Figs. 6.81,Figs. 6.82,Figs. 6.83,Figs. 6.84,Figs. 6.85,6.86).
Rare causes of amorphous-appearing calcifications are the formation of osteoid in carcinosarcomas or osteosarcoma metastatic to the breast or in the formation of psammomatous calcifications in mucin-producing tumors (Figs. 6.87 and 6.88). The presence of amorphous calcifications usually requires biopsy unless they are diffusely scattered bilaterally or clearly stable for 2 years or more. In a study (104) of 150 cases of biopsied amorphous calcifications, 30 (20%) were malignant, 30 (20%) were high-risk lesions, and the remainder were benign.
Suspicious Patterns of Microcalcifications
Pleomorphic Calcifications
The presence of pleomorphism in grouped linear, segmental, or regional microcalcifications—particularly when there is variability of size and density as well as shape—is a very worrisome feature. Pleomorphic microcalcifications have a high predictive value of being associated with malignancy.
In the second edition of the BI-RADS® lexicon (105), pleomorphic calcifications have been divided into two groups, namely coarse or fine pleomorphic. The coarse pleomorphic calcifications are those also described as “dystrophic” because they are a bit larger and more smoothly marginated than the fine pleomorphic group. Coarse pleomorphic calcifications are stromal in location and occur primarily in fibrosis and degenerated fibroadenomas and in resolving fat necrosis (Figs. 6.89 and 6.90). The fine pleomorphic microcalcifications are ductal in location and occur in ductal carcinomas and in ductal hyperplasia. The distinction between these two groups on mammography may be difficult, and reliance on other factors, such as distribution and interval stability, are important in the final assessment of the lesion. Biopsy of these two patterns of calcifications is often necessary for confirmation of their etiology.
Like amorphous microcalcifications, those that are pleomorphic are typically located in the terminal ducts. These may be associated with duct hyperplasias or atypical hyperplasias (Fig. 6.91) or with DCIS. Because the malignant cells producing them create a thickening of the duct epithelium in papillary projections, the shape of the calcifications may be quite jagged or irregular. Typically pleomorphic calcifications are larger and more
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dense than amorphous calcifications and may be produced by active cellular secretion of calcium salts as well as by the dystrophic calcification of necrotic debris in comedocarcinoma.
Figure 6.60 HISTORY: A 56-year-old woman with a history of surgical biopsy in left breast for benign disease.
MAMMOGRAPHY: Left MLO (A) and BB (B) views show a surgical site marked with BBs. There is a somewhat coarse calcification located centrally. On the enlarged MLO image (C), the knotlike shape of this sutural calcification is evident.
IMPRESSION: Sutural calcification.
Figure 6.61 HISTORY: A 42-year-old woman recalled from screening mammography.
MAMMOGRAPHY: Left ML (A) and left CC (B) magnification views show regional microcalcifications. On the CC view (B), the microcalcifications appear rounded and smudged. On the magnification ML view (A), the calcifications appear crescentic, which is typical of milk of calcium.
IMPRESSION: Milk of calcium in areas of cystic hyperplasia.
Figure 6.62 HISTORY: A 35-year-old recalled from screening for microcalcification.
MAMMOGRAPHY: Left CC (A) and ML (B) views. There are regional microcalcifications in the central aspect of the left breast. These appear rounded on the CC view but on the ML are more dense and visible, and many have crescentic shapes.
IMPRESSION: Milk of calcium in microcysts, BI-RADS® 2.
A mixture of shapes—including amorphous, punctate, linear, Y-shaped, and teardrop—are seen in groups of pleomorphic calcifications (Figs. 6.92,Figs. 6.93,Figs. 6.94,Figs. 6.95,Figs. 6.96,Figs. 6.97,Figs. 6.98,Figs. 6.99,Figs. 6.100,Figs. 6.101,Figs. 6.102,Figs. 6.103,6.104). The pattern is sometimes described as having the appearance of broken glass or broken stone because of the clean, sharp edges of the individual calcifications (78). The greater the degree of pleomorphism and the sharper the edges of calcifications, the more likely malignant is their etiology.
Fine Linear/Linear Branching
The presence of fine linear or branching microcalcifications is a highly suspicious finding and is associated with a high positive predictive value for malignancy. These calcifications represent casts of the ducts in which they lie. The calcifications are often associated with the comedo subtype of intraductal carcinoma, and they represent the dystrophic calcification of necrotic debris in the duct lumen. Because these microcalcifications are casts of the internal lumen of the duct, their forms reflect their surrounding environment. Clumps and craters created by malignant cells contain the calcium deposits, so the edges of the individual calcifications are irregular, variable, and jagged (Figs. 6.105,Figs. 6.106,Figs. 6.107,Figs. 6.108,Figs. 6.109,Figs. 6.110,Figs. 6.111,Figs. 6.112,Figs. 6.113,Figs. 6.114,6.115). The presence of fine linear microcalcifications, also described as casting calcifications, is often indicative of a high grade or poorly differentiated ductal malignancy. This finding has been associated with a poor prognosis in women with T1 invasive breast cancer. Tabar et al. (64) found that the 20-year survival for women with 1- to 9-mm invasive cancers and casting type calcifications was 55%; for women with 1- to 9-mm invasive tumors and no calcifications, the 20-year survival was 95%.
Figure 6.63 HISTORY: A 42-year-old woman for screening mammography.
MAMMOGRAPHY: Magnification CC (A) and ML (B) views show calcifications that are diffuse, and a mixture of punctate and milk-of-calcium forms are present. On the ML (B), typical meniscoid shapes of layering calcifications in areas of cystic hyperplasia are seen.
IMPRESSION: Diffuse fibrocystic changes, milk of calcium in areas of cystic hyperplasia, BI-RADS® 2.
Unusual Calcific Densities
The presence of vermiform macrocalcifications, particularly in patients who have lived in endemic areas, may suggest the diagnosis of Loa Loa. Loiasis is an parasitic disease caused by a filaria, Loa Loa, and is a disease seen
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in subtropical Africa. The adult parasite is found preferentially in the subcutaneous tissues. Because this is a systemic infestation, the calcified parasites may be present bilaterally on mammography (106,107) (Fig. 6.116).
Figure 6.64 HISTORY: Screening mammogram.
MAMMOGRAPHY: Left MLO (A) and ML (B) views show extensive microcalcifications in the left breast. None were present on the right. The morphology of these is mixed (C), with some being crescentic or milk of calcium and others being amorphous and pleomorphic. The unilateral distribution and mixed morphology is suspicious, even though milk of calcium is present.
IMPRESSION: Highly suspicious for malignancy.
HISTOPATHOLOGY: Apocrine carcinoma.
NOTE: This type of malignancy may produce milk of calcium in the cystic spaces around the malignant cells. The pattern, however, is highly pleomorphic and extensive, much different from benign milk of calcium in fibrocystic changes.
Figure 6.65 HISTORY: A 42-year-old woman for screening.
MAMMOGRAPHY: Left MLO view (A) shows heterogeneously dense tissue and an obscured mass in the supra-areolar area. On the magnification CC (B) and ML (C) views, the mass is found to be circumscribed and round. There are microcalcifications associated with it, which are rounded on the CC view but crescentic on the ML view, typical of milk of calcium in a cyst. Ultrasound confirmed a cyst.
IMPRESSION: Milk of calcium in a cyst.
Figure 6.66 HISTORY: An 83-year-old nulliparous woman with a pleural effusion and no palpable breast abnormalities.
MAMMOGRAPHY: Bilateral oblique views (A) and magnification image of the right breast (B). The breasts are dense and diffusely nodular, as may be seen in an elderly nulliparous woman. The “snowflake” pattern of nodularity suggests fibrocystic changes with adenosis. There are also innumerable round pearllike microcalcifications distributed evenly throughout both breasts. The smooth-bordered, rounded shapes of the microcalcifications and the similarity in appearance suggest a lobular origin and are consistent with adenosis.
IMPRESSION: Diffuse fibrocystic changes with round lobular calcifications, BI-RADS® 2.
Figure 6.67 HISTORY: A 42-year-old woman status postreduction mammoplasty.
MAMMOGRAPHY: Right CC view (A) shows wires marking the surgical scars from the reduction. There are extensive round calcifications distributed primarily over the medial aspect of the breast in the orientation of the scar. On the enlarged image (B), the very-well-defined morphology of these calcifications is seen, indicating a benign etiology.
IMPRESSION: Extensive round and dystrophic calcifications from breast reduction.
Figure 6.68 HISTORY: Screening mammogram in a patient with no history of trauma to the breast.
MAMMOGRAPHY: Left MLO (A) and CC (B) views show segmental calcifications in the 2 o’clock position. These are associated with an area of prominent ducts, and they had increased from the prior mammogram. On the enlarged CC image (C), the smooth round morphology of these is seen. Because of their distribution and interval change, they were biopsied.
IMPRESSION: Segmental round microcalcifications, BI-RADS® 4.
HISTOPATHOLOGY: Comedocarcinoma.
NOTE: Morphologically, these are benign. However, the associated dilated ducts, the segmental distribution, and the interval increase were suspicious and therefore should prompt biopsy.
Figure 6.69 HISTORY: A 64-year-old woman for screening.
MAMMOGRAPHY: Left ML (A) and magnification ML (B) views demonstrate a cluster of punctuate microcalcifications. On the magnification view (B), slight variability in size and shape is noted; however, because of the smooth margins, these are likely benign. The calcifications were new since the prior studies and were therefore biopsied.
IMPRESSION: New microcalcifications likely fibrocystic. Recommend biopsy BI-RADS® 4.
HISTOPATHOLOGY: Adenosis.
Figure 6.70 HISTORY: Screening mammography.
MAMMOGRAPHY: Bilateral MLO views (A) show extremely dense breast tissue and extensive bilateral microcalcifications. On enlarged MLO images (B, C), the microcalcifications are noted to be diffuse, amorphous, and punctuate. These are most consistent with a lobular process, such as adenosis or sclerosing adenosis.
HISTOPATHOLOGY: Diffuse lobular microcalcifications consistent with fibrocystic changes.
Figure 6.71 HISTORY: A 43-year-old woman for screening mammography.
MAMMOGRAPHY: Right CC (A) and ML (B) views show diffuse punctuate, round, and amorphous microcalcifications. The pattern of calcifications was bilateral, as was the dense breast parenchyma.
IMPRESSION: Diffusely scattered punctuate microcalcifications of fibrocystic change, BI-RADS® 2.
Figure 6.72 HISTORY: A 54-year-old woman for screening mammography.
MAMMOGRAPHY: Bilateral CC views (A) show diffuse bilateral microcalcifications. On an enlarged image (B), these are uniform and punctuate, suggesting a benign lobular etiology. This pattern of calcifications is usually associated with fibrocystic changes or adenosis because of their lobular origin.
IMPRESSION: Diffuse punctuate microcalcifications of fibrocystic change.
Figure 6.73 HISTORY: A 49-year-old woman with a positive family history of breast cancer, for routine screening.
MAMMOGRAPHY: Left CC magnification view. There are punctuate, smooth, and round microcalcifications with little variability, suggesting a lobular origin. The findings are nonspecific and may be seen in adenosis, lobular hyperplasia, and LCIS. A needle localization–directed biopsy was performed.
HISTOPATHOLOGY: Fibrocystic changes with epithelial hyperplasia.
Figure 6.74 HISTORY: An 80-year-old woman with a history of lymphoma, for screening mammography.
MAMMOGRAPHY: Left ML (A) and magnification (B) views and histopathology (C). There is focal asymmetry in the lower inner quadrant, containing variably shaped microcalcifications and macrocalcifications. Many of these are smooth and round, suggesting a lobular origin, but histologic examination is necessary to confirm the diagnosis.
IMPRESSION: Microcalcification, BI-RADS® 4. Recommend biopsy.
HISTOPATHOLOGY: Sclerosing adenosis with focal LCIS. On histology (C), the distended lobules are filled by a monomorphic cell population diagnostic of LCIS. Rounded microcalcifications are present within the abnormal lobules.
Figure 6.75 HISTORY: A 40-year-old woman with an abnormal screening mammogram.
MAMMOGRAPHY: Left CC (A) and ML (B) spot magnification views show clustered microcalcifications within dense parenchyma. The morphology of the calcifications is punctuate and somewhat amorphous, suggesting most likely a lobular origin.
IMPRESSION: Punctuate and amorphous microcalcification. Recommend biopsy.
HISTOPATHOLOGY: Nonproliferative fibrocystic change.
Figure 6.76 HISTORY: A 60-year-old woman with a history of benign right breast biopsy, for routine screening.
MAMMOGRAPHY: Right CC view (A) shows a faint cluster of microcalcifications located anteriorly at 2 o’clock (arrow). Magnification CC (B) and MLO (C) views show the microcalcifications to be clustered and amorphous.
IMPRESSION: Suspicious microcalcifications. Recommend biopsy.
HISTOPATHOLOGY: Benign breast tissue, intraductal hyperplasia, adenosis, apocrine metaplasia with microcalcifications.
NOTE: The morphology of the calcifications suggests a lobular origin, and fibrocystic etiology most likely. However, biopsy is necessary to confirm this.
Figure 6.77 HISTORY: A 41-year-old for screening mammography.
MAMMOGRAPHY: Right MLO view (A) shows dense parenchyma and a region of faint amorphous microcalcifications (arrow) centrally. On the magnified view (B), the fine amorphous pattern is seen. Core needle biopsy was performed showing radial scar. Excision was performed, and the specimen radiography (C) shows the extent of calcifications.
IMPRESSION: Amorphous microcalcifications, BI-RADS® 4.
HISTOPATHOLOGY: Radial scar.
Figure 6.78 HISTORY: A 62-year-old woman for screening mammography.
MAMMOGRAPHY: Right MLO view (A) shows scattered fibroglandular densities and a small cluster of microcalcifications located superiorly (arrow). On the magnification ML (B) and CC (C) views, the amorphous grouped microcalcifications are evident. Core needle biopsy was performed.
IMPRESSION: Amorphous microcalcifications, BI-RADS® 4.
HISTOPATHOLOGY: Fibrocystic change with calcifications.
Figure 6.79 HISTORY: A 35-year-old woman for screening mammography.
MAMMOGRAPHY: Left ML (A) and CC (B) views show a focal asymmetric density with associated faint calcifications in the 3 o’clock position (arrows). On the enlarged image (C), the calcifications are better visualized as being uniform and punctuate, suggesting a lobular location.
IMPRESSION: Asymmetry with microcalcifications, probably of fibrocystic origin. Recommend biopsy.
HISTOPATHOLOGY: Sclerosing adenosis, hyperplasia, micropapillomas, LCIS, radial scars.
Figure 6.80 HISTORY: A 58-year-old woman for screening mammography.
MAMMOGRAPHY: Right ML (A) shows dense parenchymal clustered microcalcifications (arrow) superiorly. On the ML (B) and CC (C) magnification views, the microcalcifications are clustered and amorphous, and somewhat uniform in size and shape. This pattern suggests a lobular origin.
IMPRESSION: BI-RADS® 4 microcalcifications. Recommend biopsy.
HISTOPATHOLOGY: Atypical lobular hyperplastica on core biopsy and LCIS on excision.
Figure 6.81 HISTORY: A 61-year-old woman for screening.
MAMMOGRAPHY: Left MLO view (A) shows two clusters of microcalcification located posteriorly (arrows). On the magnified view (B), the microcalcifications appear to be punctuate, amorphous, and tightly clustered, suggesting most likely a lobular origin.
IMPRESSION: Suspicious microcalcifications, BI-RADS® 4, most likely fibrocystic change.
HISTOPATHOLOGY: LCIS.
Figure 6.82 Clustered amorphous and slightly pleomorphic microcalcifications (A, B); DCIS with invasion.
Figure 6.83 HISTORY: A 79-year-old woman for screening mammography.
MAMMOGRAPHY: Left CC magnification view shows amorphous grouped microcalcifications adjacent to benign vascular calcifications.
IMPRESSION: Amorphous microcalcifications, suspicious. Recommend biopsy.
HISTOPATHOLOGY: Invasive ductal carcinoma, with DCIS.
Figure 6.84 HISTORY: Screening mammogram.
MAMMOGRAPHY: Left CC view (A) shows a cluster of very faint microcalcifications (arrow) located far posteriorly. On the CC magnification view (B), the clustered microcalcifications are amorphous and slightly variable in size. The most likely diagnosis is fibrocystic change.
IMPRESSION: Clustered amorphous microcalcifications, BI-RADS® 4.
HISTOPATHOLOGY: DCIS.
Figure 6.85 HISTORY: Screening mammogram.
MAMMOGRAPHY: Left MLO view (A) shows dense parenchyma and a faint cluster of microcalcifications posteriorly. On the CC magnification view (B), the few, faint, amorphous microcalcifications are present.
IMPRESSION: Amorphous microcalcifications, BI-RADS® 4.
HISTOPATHOLOGY: DCIS, intermediate grade with comedonecrosis.
Figure 6.86 HISTORY: A 76-year-old woman with a palpable carcinoma in the right breast.
MAMMOGRAPHY: Left CC (A) and magnification (B) views. There are fine granular microcalcifications extending throughout the subareolar ducts of the left breast. These are of variable morphology, suggesting a suspicious etiology.
IMPRESSION: Microcalcifications suspicious for ductal carcinoma.
HISTOPATHOLOGY: Extensive intraductal carcinoma.
Figure 6.87 HISTORY: Elderly patient with a palpable left breast mass.
MAMMOGRAPHY: Left ML view (A) shows an indistinct, high-density round mass with associated microcalcifications. The magnification CC (B) shows that the mass contains unusual dense amorphous calcifications.
IMPRESSION: Highly suspicious for malignancy.
HISTOPATHOLOGY: Carcinosarcoma with osteoid matrix.
Figure 6.88 HISTORY: An 80-year-old with a palpable right axillary mass.
MAMMOGRAPHY: Right MLO view (A) shows a large, lobulated, high-density mass in the axilla. Faint microcalcifications having a powdery appearance are within the mass on the magnified image (B). The differential includes a primary breast cancer versus one metastatic node.
IMPRESSION: Axillary mass, highly suspicious for neoplasm.
HISTOPATHOLOGY: Metastatic mucinous carcinoma from the umbilicus.
NOTE: The psammomatous calcifications are amorphous and are associated with mucin-producing tumors.
Figure 6.89 HISTORY: A 68-year-old woman for screening mammography.
MAMMOGRAPHY: Right MLO view (A) and magnified image (B). In the upper outer quadrant of the right breast, showing otherwise fatty replacement, are clustered amorphous microcalcifications (arrow) in an area of low-density soft tissue (A). The magnified image (B) shows the irregularity of borders of the calcifications, but no branching or linear forms are noted.
IMPRESSION: Cluster of calcifications of mild to moderate suspicion, favoring fibrocystic changes.
HISTOPATHOLOGY: Fibroadenoma with calcifications.
NOTE: Occasionally, a small fibroadenoma may degenerate, and the soft tissue mass decreases in size, leaving only calcifications visible. Although calcifications in fibroadenomas are generally coarse, microcalcifications may be seen, particularly early in the degenerative process.
Figure 6.90 HISTORY: A 57-year-old woman for screening mammography.
MAMMOGRAPHY: Right CC view (A) shows scattered fibroglandular densities and clustered microcalcifications medially (arrow). On the magnification and CC view (B), the somewhat pleomorphic, faint microcalcifications are evident.
IMPRESSION: Microcalcifications, BI-RADS® 4. Recommend biopsy.
PATHOLOGY: Periductal and stromal fibrosis with microcalcifications.
NOTE: Fibrosis with associated microcalcifications is a striking mimicker of DCIS.
Figure 6.91 HISTORY: A 58-year-old woman with a strong family history of breast cancer, for routine screening.
MAMMOGRAPHY: Bilateral MLO views (A) and magnification images of the left (B) and right (C) upper outer quadrants and histopathology section (D). There are areas of focally clustered microcalcifications in the right upper-outer quadrant (A and C) that are punctuate, relatively smooth bordered, and similar is size and shape. These have an appearance suggesting a lobular origin, such as is found in adenosis or sclerosing adenosis. In the left upper-outer quadrant, there is a cluster of pleomorphic microcalcifications (A and B) associated with a soft tissue density. Because of the jagged edges of these calcifications, they are of moderate suspicion for malignancy, particularly an intraductal lesion.
IMPRESSION: Right: Lobular type of calcifications, favoring fibrocystic changes. Left: Moderately suspicious calcifications, possible intraductal carcinoma. Recommend bilateral biopsy.
HISTOPATHOLOGY: Right: Adenosis, fibrocystic changes. Left: severely atypical intraductal hyperplasia. An enlarged duct (D) is filled with hyperplasia with architectural atypia, forming cribriform structures (arrow). Irregular intraductal calcifications (arrowhead) are present in the adjacent ducts.
Figure 6.92 HISTORY: A 63-year-old woman recalled from screening mammography for microcalcifications.
MAMMOGRAPHY: Left CC magnification (A) and ML magnification (B) views show segmental pleomorphic microcalcifications in the central aspect of the breast. The ductal distribution is very suspicious for malignancy.
IMPRESSION: Highly suspicious for carcinoma (BI-RADS® 5).
HISTOPATHOLOGY: DCIS with comedonecrosis. This is shown on the histologic section (C), where the duct is filled with a malignant cell population. There is central calcification of the necrotic material, better seen on the high-power image (D).
Figure 6.93 HISTORY: Screening mammogram.
MAMMOGRAPHY: Right CC view (A) and enlarged CC image (B) show two clusters of fine pleomorphic and linear microcalcifications in the central aspect of the breast. The morphology is highly suspicious for malignancy.
IMPRESSION: Multifocal carcinoma.
HISTOPATHOLOGY: Invasive ductal carcinoma and DCIS, multifocal.
Figure 6.94 HISTORY: A 40-year-old with thickening in the left breast.
MAMMOGRAPHY: Left CC view (A) shows extremely dense parenchyma with regional microcalcifications located laterally. On the magnified CC view (B), the highly pleomorphic, jagged irregular pattern of these microcalcifications is better seen.
IMPRESSION: Highly suspicious for carcinoma, BI-RADS® 5.
HISTOPATHOLOGY: DCIS with foci of invasion.
Figure 6.95 HISTORY: A 27-year-old woman with a history of surgical excision of a left breast fibroadenoma, who now presents with a new palpable mass on the right.
MAMMOGRAPHY: Right MLO view (A) shows extremely dense breast tissue. There are clustered microcalcifications inferiorly at the site of the palpable lump (arrow). There are also faint microcalcifications located in the supra-areolar and posterior central areas (arrowheads). Magnification (B) of the palpable lump (B) shows the highly pleomorphic nature of the calcifications, some of which extend into the ducts in a more linear pattern. Magnification (C) of the superior microcalcifications shows that they are fine and linear and distributed segmentally.
IMPRESSION: Highly suspicious for multicentric ductal carcinoma, BI-RADS® 5.
HISTOPATHOLOGY: Multicentric DCIS with comedonecrosis and foci of invasion.
Figure 6.96 HISTORY: A 47-year-old woman for screening.
MAMMOGRAPHY: Right MLO (A) shows dense parenchyma and a lobulated circumscribed calcified mass located posteriorly (arrow). On the magnification MLO view (B), the highly pleomorphic nature of the microcalcification is noted.
IMPRESSION: Highly suspicious for malignancy, BI-RADS® 5.
HISTOPATHOLOGY: Invasive ductal carcinoma and DCIS.
Figure 6.97 HISTORY: A 48-year-old woman with a palpable left breast mass.
MAMMOGRAPHY: Left CC (A) and MLO (B) views show dense parenchyma and regional microcalcifications within focal asymmetry posteriorly and marked by BBs. On the magnified MLO view (C), the highly pleomorphic, granular appearance of the microcalcifications is noted.
IMPRESSION: Highly suspicious for ductal carcinoma.
HISTOPATHOLOGY: Invasive ductal carcinoma and DCIS.
Figure 6.98 HISTORY: A 78-year-old woman for screening mammography.
MAMMOGRAPHY: Right MLO (A) and CC (B) views show two clusters of microcalcifications. The more lateral group is coarse and dystrophic, suggesting a fibroadenoma. The more medial group (arrow) (C) is fine and pleomorphic, therefore suspicious in nature. Core needle biopsy of the medial group was performed.
IMPRESSION: Clustered benign and clustered suspicious microcalcifications.
HISTOPATHOLOGY: DCIS low grade (medial group).
Figure 6.99 HISTORY: A 33-year-old woman who presents with palpable thickening and a serous nipple discharge.
MAMMOGRAPHY: Left MLO (A) and CC (B) views show dense parenchyma and regional microcalcifications laterally. On the magnified CC (C) view, the highly pleomorphic nature of the microcalcifications in a segmental distribution is seen.
IMPRESSION: Segmental microcalcification, highly suspicious for malignancy.
HISTOPATHOLOGY: DCIS with comedonecrosis, intermediate nuclear grade, solid and cribiform type.
Figure 6.100 HISTORY: A 38-year-old woman who is 1 year postpartum and who presents with diffuse heaviness of the right breast. She was not lactating.
MAMMOGRAPHY: Right MLO view (A) shows extremely dense parenchyma with diffuse scattered microcalcifications. No calcifications were present on the left. On the magnification ML view (B), the calcifications are fine and pleomorphic but diffusely scattered.
IMPRESSION: Suspicious microcalcifications, BI-RADS® 4. Recommend biopsy.
HISTOPATHOLOGY: DCIS with comedonecrosis, diffusely involving the breast.
Figure 6.101 HISTORY: A 54-year-old woman with an abnormal screening mammogram.
MAMMOGRAPHY: Left CC magnification view (A) and specimen radiograph (B). There are markedly pleomorphic, heterogeneous microcalcifications in a segmental distribution in the left breast. The calcifications are jagged, simulating the appearance of slivers of broken glass. The appearance is highly consistent with that of DCIS.
IMPRESSION: Highly suspicious microcalcifications.
HISTOPATHOLOGY: Intraductal carcinoma, comedo subtype.
Figure 6.102 HISTORY: A 48-year-old woman for screening mammography.
MAMMOGRAPHY: Left MLO (A) and CC (B) views show segmental microcalcifications in the 8 o’clock position (arrow). On the enlarged image (C), the pleomorphic nature of the calcifications is evident.
IMPRESSION: Highly suspicious for carcinoma, BI-RADS® 5.
HISTOPATHOLOGY: Infiltrating ductal carcinoma and DCIS.
Figure 6.103 HISTORY: A 50-year-old woman with microcalcifications identified on screening, for additional views.
MAMMOGRAPHY: Right CC magnification (A) and MLO magnification (B) views demonstrate grouped pleomorphic microcalcifications within dense tissue located in the axillary tail. On the enlarged image (C), the variable morphology and sharp edges of the microcalcifications are seen, which are highly malignant features.
IMPRESSION: Highly suspicious for ductal carcinoma.
HISTOPATHOLOGY: DCIS, intermediate grade, solid type with comedonecrosis extending into the adjacent lobules.
In patients infected with Trichinella spiralis, fine microcalcifications may be evident in the pectoralis major muscle. These appear finely stippled and diffuse (108) and represent calcified parasite larvae within the muscle (Fig. 6.117).
Calcifications Following Breast Conservation Therapy
Following lumpectomy and breast irradiation, mammography may reveal various types of calcifications. Normal changes following breast conservation therapy include the formation of dystrophic, lucent-centered, eggshell, and sutural calcifications (Fig. 6.118). The dystrophic and lucent-centered calcifications are secondary to fat necrosis and often appear at least a year or more following treatment (Fig. 6.119). Dershaw et al. (109) found that benign coarse calcifications formed in about one fourth of women treated conservatively.
Figure 6.104 HISTORY: A 50-year-old woman with a palpable left breast mass.
MAMMOGRAPHY: Left CC view (A) shows dense parenchyma and a BB marking the palpable lump laterally. Numerous microcalcifications are grouped in the palpable area. On magnification ML (B) and CC (C) views, the fine pleomorphic and linear calcifications are noted.
IMPRESSION: Highly suspicious for ductal carcinoma, BI-RADS® 5.
HISTOPATHOLOGY: DCIS with invasion.
The development of pleomorphic amorphous or linear microcalcifications is of concern for recurrence of carcinoma (Figs. 6.120,Figs. 6.121,Figs. 6.122,6.123). These may occur at the tumor bed or elsewhere in the treated breast, and their presence
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necessitates biopsy. In a study of patients treated with breast conservation therapy, Rebner et al. (110) found that 10 of 152 (7%) developed suspicious microcalcifications in the tumor bed and that 4 of 10 (40%) of these had recurrent malignancies. The mammographic features of the microcalcifications were not specific enough to differentiate benign disease from recurrent carcinoma (110). Vora et al. (111) found that various types of benign-appearing calcifications, including punctuate microcalcifications, developed at the lumpectomy sites. The authors recommended conservative management with follow-up mammography of patients with the benign-appearing calcifications. Dershaw et al. (112) found that recurrent tumors were associated with >10 calcifications in 77% of cases. Recurrences presented as linear calcifications in 68% and pleomorphic calcifications in 77% (111).
Figure 6.105 HISTORY: A 57-year-old woman with an abnormal screening mammogram.
MAMMOGRAPHY: Left CC (A) and ML (B) magnified views demonstrate segmental fine linear and branching microcalcifications. The morphology and distribution are highly suspicious for DCIS.
IMPRESSION: Microcalcifications highly suspicious for malignancy, BI-RADS® 5.
HISTOPATHOLOGY: DCIS, comedo subtype.
Figure 6.106 HISTORY: Screening mammogram.
MAMMOGRAPHY: Left CC view (A) shows dense parenchyma. There are extensive granular and fine linear calcifications throughout the medial and central aspect of the breast. Many of the calcifications appear to be in linear structures, as they fill the abnormal ducts on the magnified CC view (B).
IMPRESSION: BI-RADS® 5, highly suspicious for malignancy.
HISTOPATHOLOGY: DCIS, with comedonecrosis.
Figure 6.107 HISTORY: Screening mammogram on a 75-year-old woman.
MAMMOGRAPHY: Right MLO (A) and CC (B) views show a small, dense indistinct mass with adjacent linear microcalcifications. The microcalcifications are better demonstrated on the enlarged image (C). The finding suggests the appearance of an invasive cancer with intraductal extension.
IMPRESSION: Highly suspicious for carcinoma.
HISTOPATHOLOGY: Invasive ductal carcinoma with DCIS.
Figure 6.108 HISTORY: An 85-year-old woman who presents with a scaling nipple.
MAMMOGRAPHY: Left MLO (A) and CC (B) views show multiple clusters of pleomorphic and linear microcalcifications. In particular, there are fine linear microcalcifications (C) in the left subareolar area, extending to the nipple. This spectrum of clinical and mammographic findings is consistent with Paget disease with intraductal extension.
IMPRESSION: Paget disease.
HISTOPATHOLOGY: Paget carcinoma with multicentric DCIS on mastectomy.
Figure 6.109 HISTORY: A 68-year-old woman for screening mammography.
MAMMOGRAPHY: Left CC (A) and coned-down MLO (B) views show a small cluster of microcalcifications centrally (arrow). On spot-compression magnification (C), the calcifications (arrow) are fine, linear in shape, and are located in a linear distribution. Just posterior to these is a small indistinct mass with associated amorphous calcifications.
IMPRESSION: Calcifications suspicious for ductal carcinoma.
HISTOPATHOLOGY: DCIS and invasive ductal carcinoma.
Figure 6.110 HISTORY: A 45-year-old woman with an abnormal screening mammogram.
MAMMOGRAPHY: Left CC magnification (A) and ML (B) views show scattered fibroglandular densities and a single microcalcification (arrows). On the enlarged image (C), the single fine linear microcalcification is seen. This was new in comparison with the prior mammogram and was biopsied.
IMPRESSION: New linear microcalcification, suspicious for DCIS, BI-RADS® 4.
HISTOPATHOLOGY: Invasive ductal carcinoma and DCIS.
Figure 6.111 HISTORY: A 55-year-old woman for screening mammography.
MAMMOGRAPHY: Right MLO view (A) and enlarged ML (B) show segmentally distributed, fine linear microcalcifications in the upper aspect of the breast. The pattern is highly suggestive of malignancy. Core needle biopsy was performed, and specimen radiography (C) demonstrates numerous microcalcifications to be included in the cores. Pathology of the cores showed atypical ductal hyperplasia. Because of the presence of atypia, surgical excision was recommend and performed.
IMPRESSION: Microcalcifications, highly suspicious for malignancy, BI-RADS® 5.
HISTOPATHOLOGY: A typical ductal hyperplasia on core. Ductal carcinoma in situ on excision.
Figure 6.112 HISTORY: A 56-year-old woman who is status post–left breast cancer, for screening of the right breast.
MAMMOGRAPHY: Right MLO view (A) shows a small cluster of fine microcalcifications centrally (arrow). On the enlarged MLO (B), the linear calcifications are better seen. The magnification view (C) demonstrates the malignant appearance of these microcalcifications that are in a linear distribution.
IMPRESSION: Highly suspicious calcifications.
HISTOPATHOLOGY: DCIS, comedo type.
Figure 6.113 HISTORY: A 58-year-old woman for screening mammography.
MAMMOGRAPHY: Right MLO (A) and CC (B) views show segmental microcalcification in the right breast at 5 o’clock. An enlarged image (C) shows the calcifications to be fine, linear, and branching.
IMPRESSION: Linear microcalcifications, highly suspicious for malignancy.
HISTOPATHOLOGY: DCIS, with comedonecrosis.
Figure 6.114 HISTORY: A 61-year-old woman with a palpable mass in the left subareolar area.
MAMMOGRAPHY: Left MLO (A) and CC (B) views and magnified image (C). There are linear ductal calcifications of varying sizes extending back from a retracted nipple-areolar complex to a spiculated mass (straight arrow). A second mass (curved arrow) is present in the upper outer quadrant (A). A magnified image (C) of the subareolar area shows the pleomorphism of the linear casting calcifications that have a highly malignant appearance.
IMPRESSION: Multicentric carcinoma with intraductal extension to the nipple.
HISTOPATHOLOGY: Infiltrating ductal and intraductal carcinoma in two sites, with 2 of 25 lymph nodes positive for tumor.
Figure 6.115 HISTORY: A 48-year-old woman with a palpable mass in the medial aspect of the right breast.
MAMMOGRAPHY: Right CC view (A) shows a lobular, slightly indistinct, dense mass in the inner aspect of the breast, corresponding to the palpable finding. In addition, there are extensive segmentally distributed microcalcifications located laterally. On the enlarged CC image (B), the fine pleomorphic and fine linear microcalcifications are better seen.
IMPRESSION: Multicentric carcinoma.
HISTOPATHOLOGY: Invasive ductal carcinoma (medial mass) and invasive ductal with comedocarcinoma (lateral calcifications).
In summary, patients who have undergone breast conservation therapy often develop calcifications. Many of these are clearly benign and are posttraumatic or sutural in origin. Careful attention to the mammogram is important to detect amorphous or pleomorphic microcalcifications that may indicate recurrent carcinoma.
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Figure 6.116 HISTORY: A 50-year-old Nigerian woman who presents for screening mammography.
MAMMOGRAPHY: Left CC view (A) shows a group of serpiginous calcifications in the lateral aspect of the breast. On magnification (B), these are dense, curvilinear calcifications not corresponding to a vessel or duct. The pattern is typical of parasitic calcification.
IMPRESSION: Calcified worms, likely Loiasis. (Case courtesy of Dr. Lindsay Cheng, Sacramento, California.)
Figure 6.117 HISTORY: Screening mammography performed on an immigrant from Central America.
MAMMOGRAPHY: Bilateral MLO views (A) and magnified MLO views (B) of the axillary region show innumerable stippled calcifications overlying the pectoralis major muscles bilaterally. The pattern is associated with calcified intramuscular parasites in Trichinella.
IMPRESSION: Trichinosis with calcified parasites in the pectoralis muscle. (Case courtesy of Dr. Jan Walecki, Washington, DC.)
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Figure 6.118 HISTORY: Patient is status posttreatment of right breast cancer with lumpectomy and radiation therapy.
MAMMOGRAPHY: Right MLO (A) and CC (B) views show a wire marking the lumpectomy site inferiorly. In this area are somewhat coarse curvilinear calcifications. On the MLO magnification view (C), the knot-shaped calcifications are seen.
IMPRESSION: Sutural calcifications at the lumpectomy site, BI-RADS® 2.
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Figure 6.119 HISTORY: Patient is status postlumpectomy and radiation therapy for right breast cancer.
MAMMOGRAPHY: Right MLO (A) view shows a scar mark the lumpectomy site. There are round and lucent calcifications present both centrally in the breast as well as at the tumor bed, seen on the magnification view (B).
IMPRESSION: Normal posttreatment changes with dystrophic calcifications of fat necrosis.
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Figure 6.120 HISTORY: A 44-year-old woman who was 3 years status posttreatment of right breast cancer with lumpectomy and radiation therapy.
MAMMOGRAPHY: Right MLO (A) and CC (B) views show distortion at the lumpectomy site consistent with postsurgical scar. In the medial aspect of the breast are faint microcalcifications (arrow). On spot CC magnification (C), the microcalcifications are amorphous and linearly arranged, which is a suspicious distribution pattern.
IMPRESSION: Microcalcifications, suspicious for recurrence of carcinoma.
HISTOPATHOLOGY: DCIS, high grade, cribriform and solid types with comedonecrosis.
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Figure 6.121 HISTORY: A 51-year-old woman who is 5 years status post–right lumpectomy and radiation therapy for DCIS.
MAMMOGRAPHY: Bilateral MLO (A) and CC (B) views show the paucity of parenchyma in the right upper-outer quadrant, secondary to the lumpectomy, as indicated by the wire marker. At the posterior margin of the lumpectomy site on the right CC view (arrow) is a small cluster of microcalcifications. On magnification exaggerated CC lateral view (C), the calcifications are pleomorphic and suspicious for malignancy. On the left MLO view (D), two groups of amorphous calcifications are seen. On the magnification view (E), these faint amorphous microcalcifications are also suspicious for malignancy.
IMPRESSION: Highly suspicious for recurrent right breast carcinoma and possible carcinoma in the left breast.
HISTOPATHOLOGY: DCIS, multifocal in the left breast; DCIS recurrent, right breast.
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Figure 6.122 HISTORY: A 76-year-old woman with prior history of right breast cancer treated with lumpectomy and radiation therapy.
MAMMOGRAPHY: Right CC view (A) and enlarged MLO view (B) demonstrate an irregular mass at the lumpectomy site consistent with the postsurgical scar. Within the scar are faint amorphous microcalcifications that had developed from an earlier postoperative study.
IMPRESSION: New microcalcifications in the tumor bed suspicious for recurrence of carcinoma.
HISTOPATHOLOGY: DCIS.
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Figure 6.123 HISTORY: A 61-year-old woman who is status posttreatment of left breast cancer with lumpectomy and radiation therapy.
MAMMOGRAPHY: Left ML (A) and magnification (B) views show the lumpectomy site indicated by wire markers. The scar was stable in comparison with prior examinations. However, faint amorphous microcalcifications are in the inferior aspect of the tumor bed and are suspicious in appearance.
IMPRESSION: Postsurgical changes with adjacent microcalcifications, suspicious for malignancy, BI-RADS® 4.
HISTOPATHOLOGY: Recurrent DCIS.
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