Breast Calcifications: What’s Good, What’s Bad and What’s What! (Malignant Breast Calcification)

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 Malignant Breast Calcifications:

CHARACTERISTIC	PROPERTIES
Form	Irregular Rod-Like Powdery
Size	Small to Tiny Usually < .5mm
Density	Varied Densities Light to Darker Densities inside
Distribution	Clusters of Tiny Groups Rod-Like Indian Lines All Within one Lobe Following a Duct
Margins	Irregular Edges Border Not easily Identified Indistinct Edges
Number of Calcifications	Many in a Group Overlapping and Not easily Counted
Position in Relation to Mass	Scattered all through the Mass Intruding into Surrounding Parenchyma

Malignant Calcifications:

Malignant Breast Calcifications Include:

1. Small Irregular Clusters Confined to a Lobe
2. Granular Clusters Following a Ductal Path from Nipple to Chest Wall
3. Fine Powdery Clusters of Barely Perceptible Specks Confined to One or Two Areas
4. Casting, Branching or Rod Shaped Following the Duct
5. Irregular, varied, indistinct associated with a ill-defined mass or spiculation
6. Malignant Fibroadenoma
7. Malignant Papilloma

Small clusters of irregular calcifications confined to one area, lobe or segment. The calcifications are of variable densities, sizes and shapes.

Granular, rod like or irregular clusters of numerous calcifications of varying densities, sizes and shapes following along one ductal path from the chest wall edge toward the nipple.

Fine powdery calcifications that are confined to a small section, lobe or lobule; they are usually difficult to perceive without magnification.

Irregular, casting, Indian-line or rod-like calcifications which branch through the ductal system from chest wall to nipple; these are of various sizes, forms, contours and densities.

Indistinct, irregular calcifications associated with a dense, asymmetrical, ill defined mass or a white-star spiculation. These calcifications may invade the tissue outside the mass as well as concentrating themselves in rough dense clusters within the lesion.

Malignant fibroadenoma are very rare. Most fibroadenoma are profoundly benign. Cancerous fibroadenoma contain clustered irregular or branching calcifications. Malignant fibroadenoma will appear atypical on mammography and on U/S.

Malignant Papilloma:

1. Main Duct

2. A interductal Papilloma with dense branching calcifications

3. Papilloma accompanied by a spontaneous bloody discharge

SUMMARY

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.