Assessing and demonstrating clearly an area of concern on our images is a long way from diagnosing disease. What is missed or obscured on our clinical images is not analyzed by the Radiologist. Therefore it is essential that we recognize a possible concern and know how to demonstrate it clearly.
Calcifications arise in the breast as a natural process of aging and can be grossly benign. Calcifications can also gather in the ductal paths of the breast parenchyma due to an atypical proliferation of dead or dying cells caused by the presence of some active pathology. To demonstrate breast calcification we first must appreciate their presence and then comprehend their characteristics.
Characteristics of Benign Breast Calcifications:
Usually @ .5mm and Larger
Uniform highly dense
Dense with Lucent Areas of Fat
Scattered, Surrounding a Smooth Mass,
Following a vessel
or Embedded in the Skin
Smooth, Rounded, Easily Seen and Followed
Number of Calcifications
Usually not more than 5 in a Group
Always separate and easily Counted
Position in Relation to Mass
Either centered in the Core of a Smooth Mass
Gathering Around its Edge
Benign breast Calcifications Include:
1. Blunt Duct Adenosis
2. Sclerosing Adenosis
4. Arterial Calcification
5. Intra/Peri Ductal Plasma Cell Mastitis
6. Sebaceous, Skin Calcifications
7. Benign Papilloma
8. Eggshell Calcified Galactocele or Oil Cysts
9. Calcified Fibroadenomas
BLUNT DUCT ADENOSIS: Shows a fat for-shortened Terminal Duct Lobular Unit with clusters of calcifications at the base of the ductules
SCLEROSING ADENOSIS: Shows a long spidery elongated TLDU with rows of calcifications strewn along the length of the ductules
FIBROSIS: Shows a fat swollen badly misshapen TLDU with large smooth calcifications filling the distal ends of the ductules
2. Calcified Internal Arterial Walls
INTERDUCTAL PLASMA CELL MASTITIS:
1. Terminal Duct Lobular Units
2. Branching Ducts
3. Intraductal Calcifications Stretching through the Length of the Ducts
PERIDUCTAL PLASMA CELL MASTITIS:
1. Branching Ducts
2. Periductal Calcifications Coating the walls of the Duct
1. Skin Pore or Sebaceous Gland
2. Tiny Smooth Calcification
1. Epithial Cell Layer
2. Interductal Papilloma
3. Scattered inter-lesion calcifications
4. Main or Large Branching duct
EGGSHELL TYPE CALCIFICATIONS: Very dense calcifications surrounding a central core mass. If the central core is OPAQUE, the mass very likely is a cyst with a calcified wall, a fibroadenoma or a Phase 1 galactocele. If the central core is RADIOLUCENT, the mass very likely is a calcified lipoma, an oil cyst, fat necrosis or a Phase 3 galactocele.
CALCIFIED FIBROADENOMA: Benign fibroadenoma can calcify in several ways.
Sub capsular calcifications are very dense inside layer of calcification coating the edge of the mass. These can appear linear or eggshell like. Fibroadenomas calcifying with central dense or mixed fat/calcified centers very often appear like pieces of sponge toffee or popcorn.
All calcifications seen on our breast images should be noted, located and well demonstrated by today’s Mammographer. We should be well versed in the procedures of clarification and follow-up for such abnormalities. Tangential views will easily and efficiently locate calcifications for the Radiologist. Magnification and coned compression are the primary techniques used to further analyze calcifications. These views afford a clearer appreciation of the morphology and distribution of the calcifications thus allowing the Radiologist to make informed diagnostic decisions.The Mammographer within today’s modern team oriented department must have the advanced positioning and clinical skills to ensure the area of concern is appropriately imaged, clearly seen and able to be characterized by the Radiologist.