Imaging of Benign Breast Calcifications
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Radiologists who interpret mammograms encounter calcifications on a daily basis (see the images below). Most of the breast calcifications encountered by radiologists are benign. Radiologists must be able to identify typically benign breast calcifications that do not require biopsy to prevent unnecessary procedures and to reduce patient anxiety. [1, 2, 3, 4, 5, 6]
Typically, benign calcifications that do not require biopsy are skin or dermal calcifications, vascular calcifications, lucent-centered calcifications, eggshell or rim calcifications, coarse or popcornlike calcifications, large rodlike calcifications, round and punctuate calcifications, milk of calcium calcifications, suture calcifications, and dystrophic calcifications. [7, 8]
Breast calcifications are described in terms of type and distribution and categorized according to the Breast Imaging Reporting and Data System (BI-RADS) of the American College of Radiology (ACR). [9, 10, 11, 12, 13, 14]
Distribution modifiers (grouped or clustered, linear, segmental, regional, diffuse) are used to describe the arrangement of the calcifications. Historically, the terms grouped or clustered were used to describe suspicious calcification. Now, these terms are neutral and may be used to describe benign or malignant processes. Grouped or clustered should be used to describe calcifications that occupy a small volume (< 2 µL) of tissue. [15]
Calcifications that are linearly distributed are arranged in a line and may have branch points.
Segmentally distributed calcifications suggest deposition of calcification in a duct and its branches. This type of calcification may be secondary to benign or malignant processes.
Regionally distributed calcifications are most likely due to benign processes. These calcifications are scattered in a large volume of the breast and do not necessarily conform to a ductal distribution.
Diffusely distributed calcifications are scattered randomly throughout the breast.
The ACR BI-RADS lexicon enables radiologists to use similar terminology to describe mammography findings. This lexicon facilitates data tracking and provides clear management and follow-up recommendations to referring physicians, allied healthcare providers, and patients.
There are 7 ACR BI-RADS standardized categories [10, 11] :
Category 0, or “need additional imaging evaluation,” is used if additional imaging is needed (this category is almost always used in a screening situation and should be used only rarely after a full imaging workup; additional imaging evaluation includes the use of spot compression and magnification views, along with other tailored mammographic views and ultrasonography)
Category 1, or “negative,” is used if there are no findings to comment on; for example, the breasts are symmetrical, and no masses, architectural disturbances, or suspicious calcifications are present
Category 2, or “benign finding(s),” is used if the radiologist wishes to describe a benign finding while still concluding that there is no mammographic evidence of malignancy
Category 3, or “probably benign finding–initial short-interval follow-up suggested,” is used when a noted finding has a very high probability of being benign; the finding is not expected to change over the follow-up interval, but the radiologist prefers to establish its stability over time
Category 4, or “suspicious abnormality–biopsy should be considered,” is used when a finding has a definite probability of being malignant
Category 5, or “highly suggestive of malignancy–appropriate action should be taken,” is used when a finding has a high probability of being cancerous
Category 6, or “known biopsy-proven malignancy-appropriate action should be taken,” is “reserved for lesions identified on imaging study with biopsy proof of malignancy prior to definitive therapy”
Typically, benign calcifications will be placed in ACR BI-RADS categories 1 and 2. Sometimes, these calcifications are initially placed in ACR BI-RADS category 0 and, after additional imaging evaluation, are found to have benign features. Early in their development, calcifications (eg, vascular, dystrophic, or lucent centered calcifications) may be indeterminate; these are often followed at short intervals to establish or confirm their etiology (ie, BI-RADS category 3).
High-quality mammography is the best diagnostic tool for the identification of breast calcifications. Accredited, dedicated mammographic equipment should be used to obtain high-quality images. Mammography technologists must be well trained and skilled in the proper positioning and compression of the breast. [16, 17, 18, 19, 20, 21]
Mammograms should always be interpreted on dedicated high-luminance mammographic view boxes or viewers, and a magnifying glass should be used routinely. Extraneous light and glare should be eliminated for optimal viewing conditions. Mammograms should be arranged in the same manner at each interpretation session to minimize left-right confusion.
Routine mammograms should include craniocaudal (CC) and mediolateral oblique (MLO) views. That is, the 2 mammographic views usually obtained first for screening or diagnostic evaluations are the MLO view and the CC view. Magnification images of calcifications should be obtained in the CC and mediolateral (ML) or lateromedial (LM) views, also known as true lateral views. Tangential views are useful for verification of the intradermal location of calcifications. [22]
Comparing current mammograms with prior mammograms is essential to determine the stability of any calcifications detected. Finally, on the basis of the interpretation, the radiologist can make an informed decision about whether the calcifications identified are benign and do not require biopsy or whether the appearance of the calcifications warrants biopsy.
Mammography is limited in evaluating benign calcifications when benign calcifications morphologically overlap with indeterminate or malignant calcifications. These calcifications may be observed for a short period (ACR BI-RADS category 3), or biopsy may be performed (ACR BI-RADS categories 4 and 5).
For patient education information, see the Imaging Center, Cancer and Tumors Center, and Women’s Health Center, as well as Mammogram, Breast Lumps and Pain, and Breast Self-Exam.
Skin or dermal calcifications (see the image below) are usually identified as spherical, lucent-centered calcifications at the periphery of the breast, especially in the inferior, posterior, and medial aspects. [23, 24] Skin calcifications may develop from a degenerative metaplastic process. Usually, skin calcifications are readily distinguished as benign findings. However, in some cases, additional imaging is needed to differentiate skin calcifications from more worrisome calcifications.
When mammograms are compared, calcifications that maintain a fixed relationship to one another are suggestive of a dermal location. Magnification views may be used to demonstrate the lucent centers characteristic of skin calcifications. In some cases, a skin localization procedure may be needed to prove that the calcifications are in the skin.
When performing a skin localization procedure, the radiologist should determine if the calcifications are more likely to be in the upper or the lower portion of the breast. Thereafter, the patient’s breast is placed in the mammographic unit by using a fenestrated compression device. For calcifications presumed to be in the upper part of the breast, a CC approach is used with the fenestration device in the region of the calcifications. For calcifications thought to be in the inferior part of the breast, a caudocranial approach is used. A metal marker is then placed over the calcifications, and a tangential view is obtained to show the dermal calcifications in the skin.
Vascular calcifications (shown below) are commonly identified on mammography, especially in older women. Vascular calcifications, which are usually secondary to medial atherosclerosis, often demonstrate a characteristic train tracklike configuration. In some cases, it may be difficult to distinguish vascular calcifications from ductal calcifications (including calcifications representing ductal carcinoma in situ). Arterial calcification in the breasts may be associated with diabetes and hyperparathyroidism.
The presence of mammary vascular calcifications may allow for the detection of women with elevated cardiovascular disease risk profiles. [25, 26, 27, 28] Researchers in the Netherlands examined 12,239 women in a population-based breast cancer screening program. The study showed a significant correlation between vascular calcifications identified on mammography and myocardial infarction, transient ischemic attacks, and hypertension. Additional studies are needed to validate the potential role for screening mammography in the early detection of women at risk for cardiovascular disease.
In a systematic review and meta-analysis, breast arterial calcifications (BAC) were found in 12.7% of women in breast cancer screening programs. Increasing age, diabetes, and parity (as opposed to nulliparity) were associated with a higher prevalence of BAC. The authors concluded that medial arterial calcification might contribute to cardiovascular disease through a pathway distinct from the intimal atherosclerotic process. [29]
Screening mammograpms in women with a history of warfarin use found that the prevalence of breast arterial calcification is increased in women with current or past warfarin use independent of other risk factors and conditions predating warfarin use. According to the study, this effect appears to be cumulative and may be irreversible. The increased prevalence varied depending on duration of treatment, from 25% for use less than one year to 74.4% for use more than 5 years. [30]
Lucent-centered calcifications, as depicted below, which are round or oval, are almost always benign and they have thicker walls than those of rim or eggshell calcifications. Skin calcifications are often lucent-centered, and lucent-centered calcifications may form around benign debris in the ducts. Other entities that may appear as lucent-centered calcifications on mammography include silicone granulomas and fat necrosis.
Fat necrosis results from several causes including trauma, surgery, and radiation therapy. Fat necrosis occurs most often in fatty pendulous breasts of middle-aged women. Lucent-centered calcifications may result from fat necrosis, and the thickness of the calcified wall around the lucent area is variable and probably related to the amount of desmoplastic reaction.
Eggshell or rim calcifications, shown below, are thin and appear as calcium deposited on the surface of a sphere. The walls of eggshell or rim calcifications are thinner than the walls of lucent-centered calcifications.
The entire circumference of an eggshell calcification does not need to be completely calcified to represent a benign finding. Although fat necrosis can result in eggshell calcifications, calcification in the walls of cysts is the most common cause of eggshell or rim calcifications.
Coarse or popcornlike calcifications, as shown below, are associated with the involution and hyaline degeneration of fibroadenomas. Fibroadenomas are the most common breast masses seen in women younger than 35 years of age.
Calcifications in fibroadenomas usually begin at the periphery and then involve the central portion of the fibroadenoma. Fibroadenomas may be completely replaced by calcification without a mass discernible by mammography.
Large rodlike or secretory calcifications (see below) are oriented along the axes of the ductal system. These calcifications result from calcification of ductal secretions.
Large rodlike calcifications may have lucent centers if the ductal secretions undergo peripheral calcification. In general, these calcifications are coarser and larger (usually > 1 mm in diameter) than malignant calcifications. Large rodlike calcifications are commonly bilateral and diffuse. These calcifications are associated with secretory disease, plasma cell mastitis, and duct ectasia.
Punctate calcifications, like in the image below, are spherical calcifications that have well-defined margins.
Punctate calcifications usually measure less than 0.5 mm in diameter. Round calcifications are benign spherical calcifications that may vary in size. When less than 1 mm, round calcifications are frequently formed in the acini of the lobules.
Milk of calcium (see below) is a benign process that can be diagnosed readily during mammography, especially with magnification views in the CC and the true lateral (ML or LM) projections. [31]
When milk of calcium is imaged with a vertical x-ray beam on the CC view, the calcifications appear poorly defined and smudgy. When imaged with a horizontal x-ray beam on the ML or the LM view, the calcifications are seen as sharply defined, crescent-shaped, semilunar, curvilinear (concave up), or linear arrangements. The characteristic appearance of the calcifications on the magnification views helps to establish the correct diagnosis of milk of calcium.
Suture material (see the image below) may become calcified, resulting in suture calcifications. [32, 33] Suture calcifications are usually seen at a known surgical site, and the calcifications may be linear or tubular. Knots may be demonstrated. Suture calcifications are likely due to delayed resorption of catgut sutures, which can provide a matrix on which calcium can precipitate.
Suture calcifications are more common in women who have undergone radiation therapy compared with those who have had benign breast biopsy. Radiation therapy results in delayed tissue healing, and it is likely that suture resorption is also delayed in the radiated breast, allowing for the precipitation of calcium in the catgut sutures. The earliest time at which calcified suture material may become evident on mammography is within 2 years of surgery.
Dystrophic calcifications, as shown in the image below, may form secondary to trauma, surgery, or irradiation.
Most often irregular, dystrophic calcifications are usually larger than 0.5 mm, and they may have lucent centers.
Borecky N, Rickard M. Preoperative diagnosis of carcinoma within fibroadenoma on screening mammograms. J Med Imaging Radiat Oncol. 2008 Feb. 52(1):64-7. [Medline].
Lehman CD, Rutter CM, Eby PR, White E, Buist DS, Taplin SH. Lesion and patient characteristics associated with malignancy after a probably benign finding on community practice mammography. AJR Am J Roentgenol. 2008 Feb. 190(2):511-5. [Medline].
Rosenberg RD, Yankaskas BC, Abraham LA, Sickles EA, Lehman CD, Geller BM, et al. Performance benchmarks for screening mammography. Radiology. 2006 Oct. 241(1):55-66. [Medline].
Sickles EA, Miglioretti DL, Ballard-Barbash R, Geller BM, Leung JW, Rosenberg RD, et al. Performance benchmarks for diagnostic mammography. Radiology. 2005 Jun. 235(3):775-90. [Medline].
Stephens TW, Whitman GJ, Stelling CB. Typical benign calcifications of the breast that do not require biopsy. The Radiologist. 2003. 10:1-9.
Whitman GJ, Stephens TW, Hopkins K. Benign and malignant breast calcifications. Contemporary Diagnostic Radiology. 2002. 25:1-6.
Choi YJ, Ko EY, Kook S. Diagnosis of pseudoangiomatous stromal hyperplasia of the breast: ultrasonography findings and different biopsy methods. Yonsei Med J. 2008 Oct 31. 49(5):757-64. [Medline].
Shin JH, Han BK, Ko EY, Choe YH, Nam SJ. Probably benign breast masses diagnosed by sonography: is there a difference in the cancer rate according to palpability?. AJR Am J Roentgenol. 2009 Apr. 192(4):W187-91. [Medline].
Masroor I. Effectiveness of assigning BI-RADS category-3 to breast lesion with respect to follow-up. J Coll Physicians Surg Pak. 2008 Apr. 18(4):209-12. [Medline].
American College of Radiology BI-RADS ATLAS and MQSA: Frequently Asked Questions. American College of Radiology BI-RADS ATLAS and MQSA. Available at http://www.acr.org/~/media/ACR/Documents/PDF/QualitySafety/Resources/BIRADS/BIRADSFAQs.pdf. Accessed: May 12, 2009.
D’Orsi CJ, Bassett LW, Berg WA, et al. Breast Imaging Reporting and Data System: ACR BI-RADS-Mammography (ed 4). 4th. Reston, Virginia: American College of Radiology; 2003.
ACR. American College of Radiology: Illustrated Breast Imaging Reporting and Data System (BI-RADS). 3rd ed. Reston, VA: American College of Radiology. 1998.
Cardenosa G, Mendelson E, Bassett L, et al. Appropriate imaging work-up of breast microcalcifications. American College of Radiology. ACR Appropriateness Criteria. Radiology. 2000 Jun. 215 Suppl:973-80. [Medline].
Homer MJ, Marchant DJ, Smith TJ. The geographic cluster of microcalcifications of the breast. Surg Gynecol Obstet. 1985 Dec. 161(6):532-4. [Medline].
Sitzman SB. A useful sign for distinguishing clustered skin calcifications from calcifications within the breast on mammograms. AJR Am J Roentgenol. 1992 Jun. 158(6):1407-8. [Medline].
Bassett LW. Mammographic analysis of calcifications. Radiol Clin North Am. 1992 Jan. 30(1):93-105. [Medline].
D”Orsi CJ, Kopans DB. Mammographic feature analysis. Semin Roentgenol. 1993 Jul. 28(3):204-30. [Medline].
Hoeffken W, Lanyi M. Mammography: Technique, Diagnosis, Differential Diagnosis, Results. Philadelphia:. WB Saunders Co. 1977:261.
Linden SS, Sickles EA. Sedimented calcium in benign breast cysts: the full spectrum of mammographic presentations. AJR Am J Roentgenol. 1989 May. 152(5):967-71. [Medline].
Sickles EA. Breast calcifications: mammographic evaluation. Radiology. 1986 Aug. 160(2):289-93. [Medline].
Baldwin P. Breast calcification imaging. Radiol Technol. 2013 Mar-Apr. 84(4):383M-404M; quiz 405M-408M. [Medline].
Craft M, Bicknell AM, Hazan GJ, Flegg KM. Microcalcifications Detected as an Abnormality on Screening Mammography: Outcomes and Followup over a Five-Year Period. Int J Breast Cancer. 2013. 2013:458540. [Medline].
Berkowitz JE, Gatewood OM, Donovan GB, Gayler BW. Dermal breast calcifications: localization with template-guided placement of skin marker. Radiology. 1987 Apr. 163(1):282. [Medline].
Kopans DB, Meyer JE, Homer MJ, Grabbe J. Dermal deposits mistaken for breast calcifications. Radiology. 1983 Nov. 149(2):592-4. [Medline].
Molloi S, Xu T, Ducote J, Iribarren C. Quantification of breast arterial calcification using full field digital mammography. Med Phys. 2008 Apr. 35(4):1428-39. [Medline].
Kataoka M, Warren R, Luben R, Camus J, Denton E, Sala E, et al. How predictive is breast arterial calcification of cardiovascular disease and risk factors when found at screening mammography?. AJR Am J Roentgenol. 2006 Jul. 187(1):73-80. [Medline].
Rotter MA, Schnatz PF, Currier AA Jr, O’Sullivan DM. Breast arterial calcifications (BACs) found on screening mammography and their association with cardiovascular disease. Menopause. 2008 Mar-Apr. 15(2):276-81. [Medline].
Maas AH, van der Schouw YT, Atsma F, Beijerinck D, Deurenberg JJ, Mali WP, et al. Breast arterial calcifications are correlated with subsequent development of coronary artery calcifications, but their aetiology is predominantly different. Eur J Radiol. 2007 Sep. 63(3):396-400. [Medline].
Hendriks EJ, de Jong PA, van der Graaf Y, Mali WP, van der Schouw YT, Beulens JW. Breast arterial calcifications: a systematic review and meta-analysis of their determinants and their association with cardiovascular events. Atherosclerosis. 2015 Mar. 239 (1):11-20. [Medline].
Tantisattamo E, Han KH, O’Neill WC. Increased vascular calcification in patients receiving warfarin. Arterioscler Thromb Vasc Biol. 2015 Jan. 35 (1):237-42. [Medline].
Sickles EA, Abele JS. Milk of calcium within tiny benign breast cysts. Radiology. 1981 Dec. 141(3):655-8. [Medline].
Davis SP, Stomper PC, Weidner N, Meyer JE. Suture calcification mimicking recurrence in the irradiated breast: a potential pitfall in mammographic evaluation. Radiology. 1989 Jul. 172(1):247-8. [Medline].
Stacey-Clear A, McCarthy KA, Hall DA, et al. Calcified suture material in the breast after radiation therapy. Radiology. 1992 Apr. 183(1):207-8. [Medline].
Tanya Washington Stephens, MD Assistant Professor of Diagnostic Imaging, Associate Professor of Diagnostic Radiology, Section of Breast Imaging, University of Texas MD Anderson Cancer Center
Tanya Washington Stephens, MD is a member of the following medical societies: American College of Radiology
Disclosure: Nothing to disclose.
Gary J Whitman, MD Associate Professor, Department of Radiology, University of Texas MD Anderson Cancer Center
Gary J Whitman, MD is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society
Disclosure: Nothing to disclose.
Bernard D Coombs, MB, ChB, PhD Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.
Edward Azavedo, MD, PhD Director of Clinical Breast Imaging Services, Associate Professor, Department of Radiology, Karolinska University Hospital, Sweden
Edward Azavedo, MD, PhD is a member of the following medical societies: Radiological Society of North America, Swedish Medical Association, Swedish Society of Medicine
Disclosure: Nothing to disclose.
Eugene C Lin, MD Attending Radiologist, Teaching Coordinator for Cardiac Imaging, Radiology Residency Program, Virginia Mason Medical Center; Clinical Assistant Professor of Radiology, University of Washington School of Medicine
Eugene C Lin, MD is a member of the following medical societies: American College of Nuclear Medicine, American College of Radiology, Radiological Society of North America, Society of Nuclear Medicine and Molecular Imaging
Disclosure: Nothing to disclose.
Imaging of Benign Breast Calcifications
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