Discussion
A short review of CALCIFICATIONS OF BREAST will show that they are the smallest structures identified on a mammogram, extremely common and usually benign, they might be located anywhere within a breast and their frequency increases with age. Cell secretion, necrotic debris, inflammation, foreign body reaction, trauma and radiation might trigger their formation. Their chemical composition while extremely diverse, is nonspecific. High-resolution imaging techniques, vigorous compression and radiographic magnification should be employed for complete characterization. <<>> Analyzing calcifications by their morphology might prove to be an extremely laborious, painful and costly process, unless certain patterns are recognized and classified. <> Within the wide range of calcifications present in a breast, there are some, that are characteristic of certain abnormalities and might be included in certain BIRADS categories. For a short BIRADS category assessment, see (http://www.breastbiopsy.com/birads.html). Recognizing calcifications as a pattern and eliminating or marking them with a red flag may ease the diagnostic process. SKIN – sebaceous glands calcifications are geometrically shaped with a lucent center and should always be inferred when seen in only one projection. When seen in two projections or in doubtful cases, tangential views or stereotactic localization should be employed to solve the problem. BIRADS category 2. – VASCULAR – arterial calcifications, usually associated with a vessel running through the breast. They show the well-known pattern of parallel, and/or serpentine deposits attached to the edge of the vessel. Early in the process, when only one side of the vessel is calcified, there might be problems in diagnosis. They may be solved by magnification projections showing the vessel. BIRADS category 2. – COARSE – popcorn-like, are typical of involuting fibroadenomas. The calcification process may start in the center of the fibroadenoma but also may originate from the periphery. In the early stages of the process, the calcifications are small and irregular, resembling microcalcifications associated with a malignant process. Biopsy may be indicated in these cases. A calcified involuting fibroadenoma does not require biopsy. BIRADS category 2 if mature; BIRADS category 3 or 4 while in early stages. – LARGE ROD LIKE – secretory calcifications are stick-like, continuous, solid or hollow, sometimes branching. They are the result of inflammatory changes within breast tissue. Sometimes association with a palpable thickening of the breast might be caused by plasma cell mastitis. More than 0.5 mm thick, these calcifications may be as long as 10-15 mm and are usually seen bilaterally. Although benign, a thorough search of the entire breast should always be adopted, in order to detect suspicious microcalcifications which may be obscured by the benign looking general appearance of the process. BIRADS category 2. – ROUND – showing breast tissue involution, represent concretions formed within acini of dilated lobules. They are smooth, round, regular, larger than 0.5 mm. BIRADS category 2. – SPHERICAL or LUCENT CENTERED – calcifications are invariably the result of benign processes like fat necrosis, calcified ductal debris or small fibroadenomas. They may be included within a malignant process in the region, but may be traced back on previous mammograms, years before the onset of the cancer. In their early stages of formation, they may raise some diagnostic problems. Short-term follow-up should be employed as the first method for disclosing their real nature. BIRADS category 2 if mature, otherwise category 3 or 4. – EGGSHELL or RIM SHAPED – calcifications, are thin calcified capsules of spherical benign lesions in the breast. Eggshell calcifications are associated with cysts but fibroadenomas may sometimes calcify in a fine, rim like fashion. The calcified shell surrounding a cyst is usually delicate, sometimes lace-like, in contrast with shells of fat necrosis that look denser and thicker. Calcifications may surround oil cysts but in contrast to fluid filled cysts that are isodense or hyperdense compared with breast tissue, oil cysts are always hypodense. A calcified rim may compromise the effectiveness of an ultrasound examination in assessing the composition of the mass, therefore aspiration of the cyst may be sometimes indicated to complete the diagnosis. BIRADS category 2. – MILK OF CALCIUM – represents precipitated, amorphous calcium particles, floating within small cysts of cystic hyperplasia. Their unique characteristic is the different appearance they take in two orthogonal projections. On the cranio-caudal projection they show a mottled pattern of small, faint, grains changing position even between two identical projections. On the lateral view, they sediment onto the bottom of the cyst, and may show the so called “tea pot” pattern. BIRADS category 2 or 3. – SUTURE – calcifications are the result of calcium deposits on suture material. They are most frequently seen in post-irradiated breast or following extensive surgery. BIRADS category 2 or 3. – DYSTROPHIC – calcifications are irregular, dense, sometimes inhomogeneous, appear in post-irradiated breast or following trauma, including surgery. They may appear in 30% of the women even up to 4 years following the procedure. Again, a very high index of suspicion should be exercised. Any change in position of known dystrophic calcifications, following local resection and/or irradiation, should be regarded as an incipient local recurrence. BIRADS category 2 if mature, otherwise category 3 or 4. – PUNCTATE – calcifications are very small, less than 5 mm. regular, dense, pinpoint, round or oval deposits. Their etiology is benign, representing involuting breast structures. A careful search should rule-out any associated concentration of suspicious microcalcifications. BIRADS category 2. – AMORPHOUS or INDISTINCT – Round, flake-shaped, small and hazy, calcifications that do not change position should cause concern. Magnification views may show them to be formed by innumerable small particles glued together. Intracystic calcifications and adenosis may display this appearance, but occasionally breast cancer may also generate these types of calcifications. BIRADS category 3 or 4. – HETEROGENEOUS or PLEOMORPHIC – These calcifications include granular, comma-shaped, pointed, fine linear interrupted or branching types, which can be irregular in shape and of different size. They should be carefully analyzed and regarded as highly suspicious. BIRADS category 4 or 5. – CASTING – type calcifications, formed also by innumerable small particles bound together. These are the result of irregular patterns of tissue necrosis within a ductal cancer. Their distribution is guided by the course of the duct, giving a very distinctive fine, linear, branching pattern. BIRADS category 5. – ARTIFACTS – including skin contaminants can be misinterpreted as microcalcifications. Scratches on the film or screen dust particles, nail polish, air bubbles during developing process or dirt on the rollers of the developing machine may all produce artifacts. Skin ointments, talc or other powders, dry deodorants, tattoos, or rubber adhesive on the skin, all cause artifacts that may be mistaken for intramammary calcifications. BIRADS category 1. – CHANGING – calcifications are always worrisome. The new appearance of calcifications in a place where there were none previously, or as an addition to an already known calcification or cluster, should raise suspicion. Definite benign morphology need only follow-up, while suspicious morphology calcifications should be biopsied, even if stable for two or more years. BIRADS category 3 or 4. <<>> Calcifications in the breast are an important sign of benign, as well as of malignant changes. Analyzing their morphology with care will warrant correct management of the lesion in question. Recognizing certain “classic” patterns, as described above, might ease the diagnostic process, avoiding needless emotions and invasive diagnostic procedures, without jeopardizing patient’s health. Relying only on calcification morphology, follow-up or percutaneous core biopsy should be recommended for any calcifications that do not conform to the “classic” patterns. <> A variety of calcifications may sometimes be seen simultaneously within the same breast. There may be only few of them but they may be also seen in large numbers, in a diversity of shapes and sizes. Some of them may be certainly benign, some of them probably benign and some suspicious. All calcifications have to be evaluated, but the management of the case should be in accordance with the most suspicious intramammary calcifications seen.
