Pictorial Essay Singapore Med J 2009; 50(9) : 907
CME Article
Breast calcifications: which are malignant?
Muttarak M, Kongmebhol P, Sukhamwang N
ABSTRACT
1a
Most calcifications depicted on mammograms
are benign. However, calcifications are important
because they can be the first and earliest sign
of malignancy. For detection and analysis of
microcalcifications, high-quality images and
magnification views are required. The American
College of Radiology (ACR) Breast Imaging
Reporting and Data System (BI-RADS) classifies
calcif ications on mammograms into three
categories: typical benign, intermediate concern
and higher probability of malignancy, according
to types and distribution of calcifications. Benign
calcifications are typically larger, coarser, round
with smooth margins and have a scattered or
diffuse distribution. Malignant calcifications are
typically grouped or clustered, pleomorphic,
fine and with linear branching. It is important 1b
for radiologists to detect, evaluate, classify
and provide appropriate recommendations for
calcifications perceived on mammograms to
provide proper management.
Key words : breast cancer, Breast imaging
Repor ting and Data System ( BI - R ADS ) ,
calcifications, mammography
Singapore Med J 2009; 50(9): 907-914 Fig.1 Skin calcifications. (a) Left mediolateral oblique mammogram
shows scattered, round, radiolucent-centred calcifications (arrows).
(b) A tangential view shows multiple round calcifications in the
Introduction skin.
Most calcifications depicted on mammograms are benign.
However, 90% of nonpalpable ductal carcinoma in situ
(DCIS), and 20% of minimal cancer (infiltrating carcinoma be described as grouped or clustered, linear, segmental, Department of
Radiology,
< 0.5 cm and all DCIS) were diagnosed on the basis of regional, and diffuse or scattered. Benign calcifications Chiang Mai
University,
microcalcifications alone. (1)
A high-quality image and tend to be regional, with a diffuse or scattered distribution 110 Intavaroros
Road,
magnification view are required for detection and analysis and are often bilateral, even if asymmetric. Grouped or Chiang Mai 50200,
of microcalcifications. The American College of Radiology clustered, linear and segmental distributions are considered Thailand
(ACR) Breast Imaging Reporting and Data System (BI- important as the likelihood of malignancy is increased. It is Muttarak M, MD
Professor
RADS) classifies calcifications on mammograms into important for radiologists to detect, evaluate, classify and
three categories: typical benign, intermediate concern, provide appropriate recommendations for calcifications Kongmebhol P, MD
Instructor
and higher probability of malignancy, according to perceived on mammograms, in order to provide proper
Department of
the types and distribution of calcifications. (2)
Benign management. Pathology
calcifications are typically larger, coarser and round Sukhamwang N, MD
with smooth margins, while malignant calcifications are Typical benign calcifications Instructor
usually smaller and are often called microcalcifications. The first step in evaluating breast calcifications is to Correspondence to:
Prof Malai Muttarak
These microcalcifications are often harder to perceive identify those that have a typical benign appearance, Tel: (66) 5394 5450
and usually require a magnification view and magnifying because they do not need further investigation or close Fax: (66) 5394 6136
Email: mmuttara@
glass to be seen clearly. Distribution of calcifications can follow-up. These typical benign calcifications include: skin mail.med.cmu.ac.th
Singapore Med J 2009; 50(9) : 908
Fig. 2 Left craniocaudal mammogram shows typical parallel Fig. 5 Bilateral craniocaudal mammograms show scattered, round
lines or railroad track calcifications along arteial walls. calcifications in both breasts.
Fig. 3 Bilateral craniocaudal mammograms show calcified Fig. 6 Spot magnification view shows a group of punctate
degenerating fibroadenoma in varying stages, including early calcifications which proved to be a fibrocystic change.
peripheral calcifications (arrow) and late popcorn-like calcification
(arrowheads) without the soft tissue component.
or dermal, vascular, coarse or popcorn-like, large rod-like,
round, lucent-centred, eggshell or rim, milk of calcium,
suture, and dystrophic calcifications. Skin or dermal
calcifications often occur in the sebaceous glands, in the
inferior and medial aspect of the breasts. They usually
appear as spherical or polygonal with a lucent centre, and
can be clustered or diffuse with a regional distribution (Fig.
1a). Calcifications may be projected peripherally on one
or more mammographic views, or they may appear to be
within the breast parenchyma. A tangential view can be
used to confirm calcifications within the dermis (Fig. 1b).
Vascular calcifications identified on mammograms
are atherosclerotic, arterial calcifications. They are
typically seen as two parallel lines or have a railroad
Fig. 4 Right mediolateral oblique mammogram shows secretory
track appearance (Fig. 2). These calcifications often
calcifications, both rod-like calcifications (arrows) and hollow
cylinders (arrowhead). Vascular and rim calcifications are also occur in postmenopausal women with atherosclerotic
seen.
Singapore Med J 2009; 50(9) : 909
7a
7b
Fig. 8 Bilateral craniocaudal mammograms shows multiple lucent
calcifications of fat necrosis.
9a
9b
Fig. 7 (a) and (b) Mammograms of different patients show eggshell
or rim calcifications of calcified lipid cysts.
heart disease and may be related to coronary heart
disease.(3) Early calcifications in one wall may simulate
linear calcifications in DCIS. Spot magnification view
can help identify the uncalcified vessel coming in and Fig. 9 Milk of calcium in a cyst. (a) Craniocaudal magnification
view shows a circumscribed mass (arrowheads) with faint
going out of the calcified area. Coarse or popcorn-like
clustered calcifications (arrow). (b) Lateral magnification view
calcifications represent involuting fibroadenomas. After shows layering of calcium at the bottom of the cyst (arrows).
menopause, fibroadenomas undergo degeneration and
calcify. Calcifications usually begin at the periphery
of the mass, and become larger and denser. Finally, the disease, which is also known as duct ectasia or plasma cell
soft tissue component is no longer seen, leaving only the mastitis. The disease often occurs in perimenopausal or
characteristic coarse or popcorn-like calcifications postmenopausal women. The cause of the duct ectasia is
(Fig. 3). uncertain, but may be due to obstruction from thickened
Large rod-like calcifications are due to secretory secretions leading to ductal dilatation. Secretory material
Singapore Med J 2009; 50(9) : 910
12a
12b
Fig. 10 Left mediolateral oblique mammogram shows the knots in
the calcified suture material (arrow).
Fig. 12 (a) Magnification view shows a group of amorphous
calcifications (arrow). (b) Photomicrograph shows fibrocystic
change with calcifications in the lumen (arrows) (Haematoxylin
& eosin, × 40).
lobules due to adenosis. They can be considered benign
when scattered or diffuse (Fig. 5). An isolated cluster of
punctate calcifications may warrant close follow-up or even
a biopsy (Fig. 6).
Lucent-centred and eggshell or rim calcifications are
Fig. 11 Right mediolateral oblique mammogram of a patient, round calcifications with a radiolucent centre. Eggshell or
who had been treated with lumpectomy and radiation for breast
carcinoma, shows large, irregular, bizarre calcifications. rim calcifications (Fig. 7) are thinner than lucent-centred
calcifications (Fig. 8). They represent calcifications
in the wall of a cyst, lipid cyst or fat necrosis. Milk of
may burst through the distended duct wall producing calcium in cysts represent calcium that sediments in the
periductal inflammation. Intraductal calcifications appear dependent portion of the cysts. They are seen as poorly-
as a smooth, marginated solid, with a large rod-like defined smudges on the craniocaudal view, and linear or
appearance or a thinner, needle-like-shaped appearance. curvilinear on the lateral view (Fig. 9). Suture calcifications
Periductal calcifications appear as hollow cylinders. These represent calcium deposited on suture materials. They have
calcifications are usually seen in the subareolar area, a characteristic linear or tubular appearance where the knots
and branch out along the ductal system (Fig. 4). Round are frequently visible (Fig. 10). Dystrophic calcifications
calcifications may vary in size from 2 to 4 mm. The term resulting from surgery or radiation are coarse and irregular
“punctate” can be used when calcifications are less than and have a bizarre or plaque-like shape (Fig.11). They often
0.5 mm in size. They are frequently formed in the acini of have lucent centres.
Singapore Med J 2009; 50(9) : 911
15a
Fig. 13 Right mediolateral oblique mammogram shows a group of
coarse, heterogeneous calcifications, which proved to be calcified
degenerating fibroadenoma. 15b
Fig. 15 (a) Magnification view shows fine, linear, branching
calcifications of comedocarcinoma (arrow). (b) Photomicrograph
shows a distended duct lined with high-nuclear-grade tumour
cells and necrotic debris with calcification (arrow) in the lumen
(Haematoxylin & eosin, × 200).
Fig. 14 Left mediolateral oblique mammogram shows an ill-
defined mass (arrows) with coarse, heterogeneous calcifications,
which proved to be invasive ductal carcinoma. Associated large Higher probability of malignancy
calcifications of degenerating fibroadenoma (arrowhead) are also
seen. Calcifications suggestive of malignancy are typically
grouped/clustered, fine, linear, branching, pleomorphic
(varying in size and shape), and numerous. These types
Intermediate-concern calcifications of calcifications are only rarely associated with benign
These calcifications are not typically benign nor higher conditions, and biopsy is indicated. Malignant calcifications
probability of malignancy. They are amorphous or indistinct may occur alone or may be associated with a tumour mass
(Fig. 12), and coarsely heterogeneous (Figs. 13 & 14). or parenchymal distortion. These calcifications may occur
Management of these calcifications may be periodic short- from necrotic debris in the ducts in comedocarcinoma
term mammographic follow-up or investigative via a biopsy. or from stagnation of secretion within the cystic spaces
Diffuse, scattered, amorphous calcifications are usually and cleft-like openings or within the interstices in
benign, while clustered, regional, linearly or segmentally noncomedocarcinoma.(4,5) Comedocarcinoma is a high-
distributed, amorphous calcifications may warrant a biopsy. nuclear-grade DCIS and noncomedocarcinoma is a low- to
Coarsely heterogeneous calcifications are irregular, usually intermediate-nuclear-grade DCIS. Comedocarcinoma
larger than 0.5 mm in size and tend to coalesce, but not is characterised by proliferation of high-nuclear-grade
to the size of irregular dystrophic calcifications. They may tumour cells that undergo necrosis, forming necrotic debris
represent malignancy or areas of fibrosis, fibroadenomas, or in the duct lumen. Calcifications developing in the necrotic
trauma representing evolving dystrophic calcifications. debris are typically fine, linear, branching, conforming to
Singapore Med J 2009; 50(9) : 912
Fig. 16 Magnification view shows a segmental distribution of fine,
linear, branching calcifications and two groups of pleomorphic
calcifications (arrows). Diagnosis was invasive ductal carcinoma
with extensive intraductal component.
Fig. 18 Right mediolateral oblique mammogram shows a dense
breast with diffuse punctate calcifications. Diagnosis was invasive
ductal carcinoma with an extensive intraductal component.
Fig. 17 Magnification view shows a cluster of mixed round and
amorphous calcifications (arrows). Diagnosis was ductal carcinoma
in situ, mixed comedo- and noncomedocarcinoma.
Fig. 19 Magnification view shows two groups of pleomorphic
calcifications (arrows). Diagnosis was ductal carcinoma in situ,
the linear shape and distribution of the ducts. They may mixed comedo- and noncomedocarcinoma.
also have segmental or regional distribution (Figs. 15 &
16). These types of calcifications are highly specific for
malignancy. Mammography fairly accurately estimates (Figs. 17 & 18). A mixture of different types of calcifications
the extent of the disease. Where the mammographers results in a pleomorphic pattern (Figs. 19 & 20). These types
see calcifications is where the pathologists find DCIS. of calcifications are less specific for malignancy. They can
In noncomedocarcinoma, calcifications occurring from be found in fibroadenoma, papilloma or fibrocystic change.
stagnation of secretion are punctate, round or amorphous Mammography tends to underestimate the extent of the
with variable densities within a cluster and among clusters disease because the calcifications we see may be in areas of
Singapore Med J 2009; 50(9) : 913
Fig. 20 Magnification view shows a cluster of pleomorphic
calcifications. Diagnosis was fibrocystic change.
Fig. 22 Right mediolateral oblique mammogram shows multiple
white spots simulating microcalcifications (arrows) from dust and
dirt in the intensifying screen.
evaluation of breast calcifications. The ACR BI-RADS
classifies calcifications on mammograms into three
categories: typical benign, intermediate concern, and higher
probability of malignancy, according to the types and
distribution of calcifications. Typical benign calcifications
Fig. 21 Craniocaudal magnification view shows an artifact from
fingerprint-simulating calcifications. need no further investigation, but the higher probability of
malignant calcifications require a biopsy. Intermediate-
concern calcifications are not typically benign or malignant,
hyperplasia or atypical hyperplasia that are next to an area
and require either a periodic short-term mammographic
of noncomedo DCIS that had no associated calcifications.
follow-up or a biopsy.
Pseudocalcifications
References
Many artifacts may simulate breast calcifications.(6) Such
1. Feig SA. Mammographic evaluation of calcifications. In: Kopans
artifacts include a scratch or “pick-off” of film emulsion, DB, Mendelson EB, eds. Syllabus: A Categorical Course in Breast
deodorant, talcum powder, tattoos, hair, fingerprints (Fig. Imaging. Oak Brook: Radiological Society of North America
21), dust and dirt (Fig. 22). Meticulous attention to detail Publications, 1995: 93-105.
2. American College of Radiology: Breast Imaging Reporting and
during handling, loading, processing of films and strict
Data System (BI-RADS). 4th ed. Reston: American College of
adherence to all steps in quality control can minimise the Radiology, 2003.
occurrence of artifacts. 3. Moshyedi AC, Puthawala AH, Kurland RJ, O’Leary DH. Breast
arterial calcification: association with coronary artery disease.
Conclusion Work in progress. Radiology 1995; 194:181-3.
4. Bassett LW. Mammographic analysis of calcifications. Radiol
Detection and evaluation of calcifications from
Clin North Am 1992; 30:93-105.
mammography are crucial because they can be the sole 5. Cardenosa G. Breast calcifications. In: Feig SA, ed. 2005
manifestation of breast carcinoma. However, most Syllabus: Categorical Course in Diagnostic Radiology--Breast
mammographic calcifications are benign. Therefore, it Imaging. Oak Brook: Radiological Society of North America
Publications, 2005: 31-41.
is important for radiologists to provide more sensitive
6. Chaloeykitti L, Muttarak M, Ng KH. Artifacts in mammography:
and specific interpretation. High-quality image and ways to identify and overcome them. Singapore Med J 2006;
magnification views are essential for the detection and 47:634-40.
Singapore Med J 2009; 50(9) : 914
SINGAPORE MEDICAL COUNCIL CATEGORY 3B CME PROGRAMME
Multiple Choice Questions (Code SMJ 200909B)
True False
Question 1. Typical benign calcifications include:
(a) Popcorn-like calcifications. ☐ ☐
(b) Large rod-like calcifications. ☐ ☐
(c) Clustered punctate calcifications. ☐ ☐
(d) Dystrophic calcifications. ☐ ☐
Question 2. Concerning benign calcifications:
(a) A tangential view is used to confirm milk of calcium calcifications. ☐ ☐
(b) Early vascular calcifications may mimic calcifications seen in DCIS. ☐ ☐
(c) Dystrophic calcifications represent secretory disease. ☐ ☐
(d) Scattered round calcifications are found in adenosis. ☐ ☐
Question 3. Concerning intermediate-concern calcifications:
(a) They can be amorphous in appearance. ☐ ☐
(b) They can be coarsely heterogeneous. ☐ ☐
(c) They can be linear branching. ☐ ☐
(d) A biopsy is the treatment of choice. ☐ ☐
Question 4. Concerning higher probability of malignant calcifications:
(a) They are typically seen as grouped or clustered calcifications that vary in size ☐ ☐
and shape.
(b) Calcifications found in comedocarcinoma are usually punctuate, round or ☐ ☐
amorphous with variable densities.
(c) Calcifications found in noncomedocarcinoma are typically fine, linear and branching. ☐ ☐
(d) Pleomorphic calcifications can either be benign or malignant. ☐ ☐
Question 5. Concerning management of calcifications found on mammography:
(a) Hollow cylinder calcifications need no further investigation. ☐ ☐
(b) Eggshell calcifications need short interval follow-ups. ☐ ☐
(c) Pleomorphic calcifications should be managed by biopsy. ☐ ☐
(d) Fine, linear and branching calcifications require biopsy. ☐ ☐
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