Breast calcifications

Benign calcifications and artifacts

Benign calcium deposits are very common in clinical practice and, as a rule, have recognizable radiological patterns that allow them to be distinguished from dangerous pathologies.

• Duct ectasia (duct ectasia): This condition is characterized by the appearance of deposits resembling the broken-needle sign (broken-needle appearance). If the deposits become thicker and concentrate in a single zone, radiologists describe this as the lead-pipe sign (lead-pipe appearance).
• Fibrocystic changes (fibrocystic change): This pathology is frequently associated with the teacup sign (teacups). This visual phenomenon occurs due to the settling and stratification of calcified material in the lowest (dependent) parts of microcysts. To reliably visualize this sign, magnification views with a lateral beam are required. However, the picture does not always look classic. If there is any doubt about the benign nature of the process, the patient may be recommended for an x-ray guided biopsy.
• Skin calcifications (skin calcifications): They have a specific appearance—rounded, with extremely sharp margins and a characteristic radiolucent center (lucent centre). In most cases, such deposits are located symmetrically and are detected bilaterally.

Physicians also need to remember artifacts that can mimic microcalcifications on images. Most often, a false picture is created by deodorants applied to the skin, talcum powder, and tattoo pigments introduced under the skin.

Malignant microcalcifications

The presence of specific microcalcifications is closely associated with the development of ductal carcinoma in situ (DCIS) and invasive breast cancer. Malignant deposits have a number of characteristic features: they are clustered (clustered) rather than scattered randomly throughout the breast tissue, differ from each other in shape and size (pleomorphic — pleomorphic), and frequently demonstrate a linear (linear) or ductal (ductal) distribution.

Of particular clinical significance is the association with high-grade DCIS (high-grade DCIS):

• Necrotic debris accumulates within the affected ducts and subsequently calcifies.
• Due to this pathogenesis, the calcifications take the shape of the ducts themselves, becoming branching and rod-shaped (rod-shaped).
• In terminology, they are known as casting (casting) or comedo microcalcifications (comedo microcalcifications).
• The detection of these structures during screening mammography plays a critical role, as it allows for the diagnosis of aggressive cancers at a small stage.

Unlike high-grade forms, microcalcifications are much less common in low-grade DCIS (low-grade DCIS). This is because intraductal necrosis generally does not occur in this form. If deposits do form, they cluster together, but appear non-specific.

Assessment of invasion risk: Surgical excision of areas containing clusters of malignant microcalcifications reveals a focus of invasive growth in approximately one-third of cases. There is a direct correlation: the more individual microcalcification flecks (flecks) present in the DCIS zone, the higher the probability of invasive disease.

Role of ultrasound imaging

Ultrasound (US) examination occupies an important, yet strictly defined role in the evaluation of calcifications.

1. Limitations in screening: The sensitivity of ultrasound in detecting ductal carcinoma in situ (DCIS) is significantly lower than that of conventional mammography. For this exact reason, ultrasound is not considered or used as an effective standalone screening test for breast cancer.
2. Practical application (guidance): The main strength of ultrasound in the context of microcalcifications is realized after their detection on a mammogram. Ultrasound is extremely useful for the precise spatial identification of these suspicious areas. Real-time visualization greatly facilitates and makes percutaneous biopsy (percutaneous biopsy) safer, allowing the physician to accurately sample tissue from the desired area for histological examination.

Class and exam questions

What else to study on this topic

• Technique for performing magnification mammography with a lateral beam.
• Histological picture of intraductal necrosis (comedo necrosis).
• Technique for ultrasound-guided percutaneous biopsy.
• Specific features of x-ray guided biopsy.
• Scales and triage algorithms for patients with non-specific calcification clusters.

Other topics in the "Diagnostic Radiology in Oncology" section

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.