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BREAST RADIOLOGY Table of Contents   
Year : 2009  |  Volume : 19  |  Issue : 4  |  Page : 282-286
Evaluation of breast calcifications


Asian institute of Oncology and S. L. Raheja Hospital, Nutan mammography Centre, 2- A Manubharti, Azad lane. S. V. Road, Andheri West, Mumbai, India

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Date of Web Publication24-Oct-2009
 

   Abstract 

Various patterns of calcifications occur in the breast; some benign, some malignant. A knowledge of these patterns on mammography helps in accurate interpretation and management.

Keywords: Benign calcifications; microcalcifications; wire localization; malignant calcifications

How to cite this article:
Nalawade YV. Evaluation of breast calcifications. Indian J Radiol Imaging 2009;19:282-6

How to cite this URL:
Nalawade YV. Evaluation of breast calcifications. Indian J Radiol Imaging [serial online] 2009 [cited 2019 Jul 21];19:282-6. Available from: http://www.ijri.org/text.asp?2009/19/4/282/57208

   Introduction Top


Microcalcifications can be the early and only presenting sign of breast cancer. Mammography is used worldwide to detect microcalcifications. Hence, with the help of mammography, we can not only diagnose cancer in a nonpalpable stage but can also detect the extent of the disease. It is very essential to perform a proper evaluation of various calcifications to decide whether they are benign or malignant. A biopsy can be avoided if the calcifications appear absolutely benign on mammography and the patient can be followed-up with annual screening mammography.

In 1913, a German surgeon, Solomon, reported the presence of microcalcifications in the radiographic examination of a mastectomy specimen. In 1949, Leborgne, a radiologist, postulated that the presence of microcalcifications may be the only mammographic manifestation of a carcinoma. [1] Since then, all radiologists have made active efforts to look for microcalcifications in mammograms and this in turn over the years has resulted in a significant improvement in the resolution and performance of the mammography machines.

To detect microcalcifications efficiently, a good mammography machine should have:

  1. dedicated mammography grids,
  2. a small focal spot and
  3. a proper source image distance


In addition, the following are necessary:

  1. Magnification. Every area of microcalcifications should be magnified.
  2. Proper processing of the mammography films should be performed, with longer processing times as compared to conventional radiography.
  3. The use of a magnifying glass, which helps in better visualization, is a must.
  4. A dedicated mammography viewing box (more than 3000 nit) should be used.
  5. There should be very little (<50 lux) ambient light in the room.
  6. A computed-aided diagnosis (CAD) system is useful when evaluating a large volume of examinations, although CAD systems may sometimes fail to pick up amorphous calcifications. [2]


Full-field digital mammography machines are better than film-screen mammography machines for diagnosing microcalcifications. High-resolution computer radiography (CR) machines cannot detect microcalcifications efficiently. [3]

Once calcifications are detected, they have to be described and categorized according to the lexicon mentioned in BI-RADS (Breast Imaging Reporting And Data System) so that the radiologist, the surgeon and the pathologist share a common language. BI-RADS, developed by the American college of Radiology, is followed worldwide to describe and categorize breast abnormalities.

In the chapter titled 'Lexicons' in the official BI-RADS publication, calcifications are described according to their appearance and distribution.

According to appearance

Calcifications that are typically benign are described as follows: [5]

Eggshell or rim-like calcifications:
These are thin, round, rim-like calcifications often seen in the walls of cysts or in fat necrosis [Figure 1].

Coarse and popcorn-like calcifications: These are calcifications seen within degenerating fibroadenomas [Figure 2]A and B.

Vascular calcifications: These are also described as railroad track calcifications, showing a linear configuration, either singly or in parallel pairs [Figure 3]. When small, single and linear, these calcifications should be differentiated from malignant calcifications.

Large, rod-like calcifications or secretory deposits: These are due to secretory disease. The calcific foci are thick and follow the ducts, toward the nipple [Figure 4].

Milk of calcium: These are seen as tiny, teacup-shaped calcifications, situated within small cysts on the lateral view [Figure 5]. Sometimes, the small, rounded soft-tissue shadow of the cyst itself is also appreciated.

Lucent-centered calcifications: These are rounded calcifications with a lucent center usually representing dermal calcifications [Figure 6]A. Larger calcifications with lucent centers may be due to oil cysts/fat necrosis and may follow surgery or trauma [Figure 6]B.

Calcifications that are of intermediate concern

Amorphous calcifications:
These are very tiny, hazy calcifications [Figure 7] and are often difficult to pick up on CR machines.

Calcifications that are highly suspicious for malignancy

Fine, linear, branching or casting calcifications:
These are linear, rod-like calcifications and are typically seen in malignancy [Figure 8].

Pleomorphic calcifications: These are microcalcifications of varying shapes and sizes [Figure 9].

According to distribution

Grouped or clustered: These are five or more than five calcifications seen in a small area of 1 cm 3 [Figure 10] and may be seen in benign or malignant conditions. If the cluster is a loose cluster (<10/cm 2 ), it is more likely to represent a benign condition, whereas a compact cluster (>20/cm 2 ) is more likely to be due to malignant disease. [6]

Linear, segmental: These are suspicious calcifications arranged in a line or showing a branching pattern, suggesting deposits in a duct [Figure 11]. They tend to be distributed in a linear manner because most common malignancies are ductal, beginning in the terminal ducts.

Regional: Calcifications are seen in a large volume, not necessarily conforming to a duct; more likely to be benign.

Diffuse or scattered: These calcifications are seen all over the breast and may be bilateral [Figure 12]. They are almost always benign.

In conclusion, with the help of morphology and distribution, calcifications can be categorized into benign, of intermediate-concern, and malignant types. It would be more appropriate to categorize them with the help of BI-RADS into 2, 3, 4 and 5. [7] The egg shell, popcorn, lucent-centered, dermal, vascular calcifications, milk of calcium and scattered calcifications are definitely benign and can be categorized as BI-RADS 2. They do not need biopsy or follow-up.

Those of intermediate concern can be categorized into 3 and should be closely monitored. Pleomorphic and casting-type calcifications are categorized as BI-RADS 4 or 5 and a biopsy is recommended. In case follow-up is advised, it should be kept in mind that some microcalcifications, sometimes even of DCIS , can remain unchanged for years. Some calcifications are even known to resolve. [8]

 
   References Top

1.Leborgne R. Diagnosis of tumours of breast by simple roentgenography: Calcifications in carcinoma. AJR 1951:65:1-11.  Back to cited text no. 1      
2.Soo MS, Rosen EL, Xia JQ, Ghate S, Baker JA. Computer aided detection of amorphous calcifications. AJR Am J Roentgenol 2005;184:887-92.  Back to cited text no. 2      
3.Rong XJ, Shaw CC, Johnston DA, Lemacks MR, Liu X, Whitman GJ, et al. Microcalcificationdetectibility for four mammographic detectors: Flat panel, CCD, CR and screen film. Med Phys 2002;29:2052-61.  Back to cited text no. 3      
4.Gülsün M, Demirkazik FB, Ariyürek M. Evaluation of breast microcalcifications according to breast imaging reporting and data system criteria and Le Gal's classification. Eur J Radiol 2003;47:227-31.  Back to cited text no. 4      
5.Monsees BS. Evaluation of breast microcalcifications. Radiol Clin North Am 1995;33:1109-21.  Back to cited text no. 5      
6.Park JM, Choi HK, Bae SJ, Lee MS, Ahn SH, Gong G. Clustering of breast microcalcifications: revisited. Clin Radiol 2000;55:114-8.  Back to cited text no. 6      
7.Seymour H, Given-Wilson R, Wilkinson L, Cooke J. Resolving breast microcalcifications. Radiographics 2000:20:307-8.  Back to cited text no. 7      
8.Burnside ES, Ochsner JE, Fowler KJ, Fine JP, Salkowski LR, Rubin DL, et al. Use of Microcalcification Descriptors in BI-RADS 4 th edition to stratify risk of malignancy. Radiology 2007;242:388-95.  Back to cited text no. 8      

Top
Correspondence Address:
Yojana V Nalawade
Asian institute of Oncology and S.L.Raheja Hospital, Nutan mammography Centre, 2- A Manubharti, Azad lane. S.V. road, Andheri West, Mumbai
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-3026.57208

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12]

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