Atoosa Adibi MD.
Isfahan University Of Medical Scienses
Ductal carcinoma-in-situ (DCIS)
represents 25-30% of all reported breast
cancers.
Approximately 95% of all DCIS is
diagnosed because of mammographically
detected microcalcifications.
The basic functional
unit in the breast is the
lobule, also called the
terminal ductal lobular
unit (TDLU).
The TDLU consists of
10-100 acini, that drain
into the terminal duct.
Most invasive cancers arise from the TDLU.
It also is the site of origin of ductal carcinoma in situ
(DCIS), lobular carcinoma in situ, fibroadenoma and
fibrocystic disease, like cysts, apocine metaplasia,
adenosis and epitheliosis.
Most calcifications in
the breast form
either within the
terminal ducts
(intraductal
calcifications) or
within the acini
(lobular
calcifications).
LEFT: Lobular calcifications: punctate,
round or 'milk of calcium'
RIGHT: Intraductal calcifications:
pleomorph and form casts in a linear or
branching distribution.
These calcifications fill the acini, which are often
dilated.
This results in uniform, homogeneous and sharply
outlined calcifications, that are often punctate or
round.
When the acini become very large, as in cystic
hyperplasia, 'milk of calcium' may fill these cavities.
However when there is more fibrosis, as in sclerosing
adenosis, the calcifications are usually smaller and
less uniform.
In these cases it can be difficult to differentiate them
from intraductal calcifications.
Lobular calcifications usually have a diffuse or
scattered distribution, since most of the breast is
involved in the process that forms the calcifications.
Lobular calcifications are almost always benign.
These calcifications are calcified cellular debris or
secretions within the intraductal lumen.
The uneven calcification of the cellular debris
explains the fragmentation and irregular contours of
the calcifications.
These calcifications are extremely variable in size,
density and form (i.e. pleomorphic).
Sometimes they form a complete cast of the ductal
lumen.
This explains why they often have a fine linear or
branching form and distribution.
Intraductal calcifications are suspicious of
malignancy and are classified as BI-RADS 4 or 5.
The diagnostic approach to breast calcifications is to
analyze the morphology, distribution and
sometimes change over time.
The form or morphology of calcifications is the
most important factor in deciding whether
calcifications are typically benign or not.
If not, they are either suspicious (intermediate
concern) or of a high probability of malignancy.
Usually biopsy in these cases is needed to
determine the etiology of these
calcifications.
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Diffuse or Scattered: diffuse calcifications may be
scattered calcifications or multiple similar
appearing clusters of calcifications throughout the
whole breast.
Regional: scattered in a larger volume (> 2 cc) of
breast tissue and not in the expected ductal
distribution.
Clustered : at least 5 calcifications occupy a small
volume of tissue (< 1 cc).
Linear: calcifications arrayed in a line, which
suggests deposits in a duct.
Segmental: calcium deposits in ducts and branches
of a segment or lobe.
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Diffuse or scattered distribution is typically seen
in benign entities.
Even when clusters of calcifications are scattered
throughout the breast, this favors a benign entity.
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Regional distribution according to the BI-RADS
atlas would favor a non-ductal distribution (i.e.
benignity), while
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Segmental distribution would favor a ductal
distribution (i.e. malignancy).
Sometimes this differentiation can be made, but in
many cases the differentiation between 'regional' and
'segmental' is problematic, because it is not clear on a
mammogram or MRI where the boundaries of a
segment (or a lobe) exactly are.
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Clustered calcifications are both seen in
benign and malignant disease and are of
intermediate concern.
When clusters are scattered throughout the
breast, this favors a benign entity.
A single cluster of calcification favors a
malignant entity.
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Linear distribution is typically seen when
DCIS fills the entire duct and its branches with
calcifications.
There are conflicting data concerning the
value of absence of change over time.
It is said that the absence of interval
change in microcalcifications that are
probably benign on the basis of
morphologic criteria is a reassuring sign
and an indication for continued
mammographic follow-up .
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On the other hand in a retrospective study that
included indeterminate and suspicious clusters
of microcalcifications, stability could not be
relied on as a reassuring sign of benignancy
In group of patients with biopsy proven
malignancy, 25% of patients had stable
microcalcifications for 8-63 months.
It seems that the morphology of calcifications
is far more important than stability and
stability can only be relied on if the
calcifications have a probably benign form.
The odds for invasive carcinoma versus
DCIS are statistically significantly
higher among patients with increasing
or new microcalcifications.
The likelihood that carcinoma will be
invasive increases significantly when a
suspicious or indeterminate cluster of
calcifications is new or increasing.
At six month follow up they had increased
in number and DCIS was found at biopsy
Benign Calcifications
Skin Calcifications
These are usually lucent-centered deposits.
Atypical forms may be confirmed by tangential
views to be in the skin.
Usually they are located along the inframammary
fold parasternally and in the axilla and areola.
This cluster calcifications was presented for biopsy.
When you look at the oblique and craniocaudal
view, notice that the calcifications look exactly
the same in configuration.
This is called the tattoo sign .
Spot views subsequently proved that these were
dermal calcifications.
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These are linear or form parallel tracks, that are usually
clearly associated with blood vessels.
Vascular calcifications noted in women < 50 years
suggest potential risk of coronary artery disease.
On the left typical vascular calcifications.
If only one side of a vessel is calcified (arrow), the
calcification may simulate intraductal calcification, but
usually the diagnosis is straight forward
The classic large 'popcorn-like' calcifications are
produced by involuting fibroadenomas.
When the calcifications in an fibroadenoma are
small and numerous, they may resemble
malignant-type calcifications and need a
biopsy.
These benign calcifications form continuous rods that
may occasionally be branching.
They are different from malignant-type fine
branching calcifications, because they are usually >
1 mm in diameter.
They may have lucent centers if the calcium is in
the wall of the duct.
These calcifications follow a ductal distribution,
radiating toward the nipple and are usually
bilateral.
These secretory calcifications are most often seen in
women older than 60 years.
Sometimes it is difficult to differentiate these from
linear calcifications as seen in DCIS.
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Round calcifications are 0.5-1 mm in size and
frequently form in the acini of the terminal duct
lobular unit.
When smaller than 0.5 mm, the term 'punctate' is
used.
Round and punctate calcifications can be seen in
fibrocystic changes or adenosis, skin calcifications,
skin talc and rarely in DCIS.
Suspect DCIS when the calcifications are small, i.e.
punctate , and show some heterogeneity especially
when in cluster, linear or segmental distribution.
Round and punctate calcifications are
classified as:
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Bi-RADS 2: when scattered round
calcifications.
Bi-RADS 3 or 4: when in isolated cluster or if
new or ipsilateral to a cancer.
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These are round or oval calcifications that
range from under 1 mm to over a centimeter.
They are the result of fat necrosis, calcified
debris in ducts, and occasional fibroadenomas
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These are very thin benign calcifications that
appear as calcium is deposited on the surface of
a sphere.
These deposits are usually under 1 mm in
thickness when viewed on edge.
Although fat necrosis can produce these thin
deposits, calcifications in the wall of cysts are the
most common 'rim' calcifications.
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The most important feature of these
calcifications is the apparent change in shape of
the calcific particles on different
mammographic projections (craniocaudal
versus oblique or 90° lateral)
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They are typically linear or tubular in
appearance and knots are sometimes visible
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These are coarse irregular 'lava-shaped' calcifications.
These calcifications are larger than 0.5 mm and often
have a lucent center.
They are seen in irradiated breast or following trauma.
They develop 3-5 years after treatment in about 30% of
women.
These calcifications are also described as fat necrosis
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These calcifications have either an
amorphous or coarse heterogeneous
form.
Usually these calcifications are
biopsied to determine their exact
nature.
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Amorphous or indistinct calcifications are
defined as 'without a clearly defined shape or
form'.
These calcifications are usually so small or
hazy in appearance, that a more specific
morphologic classification cannot be
determined.
About 20% of amorphous calcifications turn
out to be malignant.
Usually it is low grade DCIS.
Based on the morphology these calcifications
were classified as BI-RADS 4.
Biopsy revealed fibrocystic changes (FCC)
Amorphous calcifications
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BI-RADS 2: when diffuse and bilateral
BI-RADS 3: when multiple bilateral
clustered
BI-RADS 4: when unilateral clustered or
new on follow up or in a patient with a
cancer in the contralateral breast
This was classified as Bi-RADS 4 (3-95% chance of
malignancy).
Biopsy revealed DCIS with invasive ductal carcinoma
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larger than 0.5 mm.
They are considered to be of intermediate
concern,
They have to be differentiated from fine
pleomorphic microcalcifications, formerly
called fine granular, that vary in size and shape,
are usually less than 0.5 mm in diameter and
are considered to be of higher probability of
malignancy, along with the fine linear
microcalcifications .
coarse heterogeneous calcifications
They were classified as Bi-RADS 4.
Biopsy revealed DCIS.
The differential diagnosis of coarse
heterogeneous calcifications includes:
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Fibroadenoma
Fibrosis
Post-traumic representing evolving
dystrophic calcifications (fat necrosis)
DCIS.
Multiplicity and bilaterality of such
calcifications favors a benign etiology.
DCIS is considered when these calcifications
have a clustered, linear or segmental
distribution.
a patient in whom new calcifications were detected during follow up
for breast cancer in the contralateral breast:
coarse heterogeneous calcifications in a segmented
distribution.
These calcifications were classified as Bi-RADS 4.
Biopsy showed calcifications within fibrous stroma.
There was no sign of malignancy
Calcifications with a higher
probability of malignancy are fine
pleomorphic and fine linear or fine
linear branching.
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These calcifications vary in size and shapes and
are usually < 0.5 mm in diameter.
They are more conspicuous than the amorphic
calcifications.
There is a 25-40% risk of malignancy.
fine pleomorphic calcifications in a segmental and
linear distribution.
These were classified as BI-RADS 5.
Biopsy revealed high grade DCIS.
There are some round typically benign
calcifications.
The most conspicious calcifications however
are the fine pleomorphic calcifications.
They have a segmental distribution.
Amorphous and fine pleomorphic calcifications
(Bi-RADS 4)
Biopsy: fibrocystic changes
New calcifications were detected during follow up in a
screening program.
These are fine pleomorphic calcifications in a cluster.
These calcifications were classified as Bi-RADS 4.This
proved to be DCIS.
The message is that with these
calcifications you cannot tell
whether they are malignant or not
and they have to be biopsied.
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These are thin, linear or curvilinear irregular
calcifications.
They may be discontinuous.
Usually they are < 0.5 mm in width.
Their appearance suggests filling of the lumen
of a duct, i.e. 'casting' calcifications.
These calcifications are classified as Bi-RADS 5.
calcifications in a segmental distribution.
Some have a linear distribution and some have a branching morphology.
This is highly suggestive of malignancy (Bi-RADS 5).
fine linear and branching calcifications in a
segmental distribution highly suggestive of
malignancy (Bi-RADS 5). Extensive high grade
DCIS was found at biopsy.
The morphology and distribution these calcifications were
classified as BI-RADS 5.
At biopsy this was high grade DCIS
The image on the left shows the same
artifacts.
On the image on the right DCIS.
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Central lucent
Rod like
Skin
Coarse
Chunky
Vascular
Punctate
Round