CALCIFICATIONS

GENERAL

Management is based on the most worrisome features
- Suspicious morphology trumps benign distribution
- Suspicious distribution trumps benign calc morphology.
Macrocalcifications are >5 mm on mammography and appear echogenic w/ posterior shadowing
- Often represent dystrophic calcs in an area of fat necrosis or w/n FA
- Microcalcs have no shadowing on mammography
If you can easily see the calcs they are probably benign. If you have difficulty seeing them then they are probably malignant.
Typically benign calc morphology: skin, vascular, coarse/popcorn-like, large rod-like, round, rim, dystrophic, milk of Ca, suture
Suspicious calc morphology: amorphous, coarse heterogeneous, fine pleomorphic, fine linear and fine linear branching

Perfectly round, very small.
Considered benign if diffuse and small <1 mm.
Frequently formed in the acini of lobules.
Things that are round tend to be noninvasive. Think of pushing instead of invading.
Termined punctate when < 0.5 mm

Oval, smooth, lucent center; represents oil cysts / fat necrosis
When you get fat necrosis, fat liquifies at areas of trauma. then the body walls of fat and wall begins to calcify.
Thin benign calcs that appear as Ca deposited on the surface of a sphere.

Large rod-like calcs radiating from the nipple on mammography
Typically bilateral and cased by a dystrophic or degenerative process
- Can be 2/2 plasma cell mastitis (premenopauseal, prior pregnancy) or more typically from mammary duct ectasia (post menopausal, unrelated to pregnancy)
- Usually seen after age 60 yo.
Must distinguish from fine linear calcifications bc they represent very different pathologic processes and implications. Distribution is a key distinguishing feature
- Large rod-like - larger, denser, smoother, usually bilateral and diffuse or scattered = BIRADS 2
- Fine linear - smaller in caliber, fainter, more discontinuous (dot-dash) in linear / segmental distribution = BIRADS 4 or 5

Parallel tracks or linear tubular calcs that are clearly associated with blood vessels.
If unsure get mag views

Often associated with a calcified fibroadenoma or sequelae of fat necrosis
Classic large calcs (>2-3 mm at the greatest diameter)
Fibroadenomas are estrogen dependent tumors that involute and infarct in menopause.
More dense than coarse heterogeneous calcs (look similar to coarse salt/sea salt).

Irregular calcs of varying size and shape that tend to coalesce
- Denser and more conspicuous than amorphous calcs
- Heterogeneous, granular and/or shard-like
Judge if they're fine or coarse based on non-mag views.
BR4
DDX
- Fibroadenoma/fibroadenomatoid change
- Stromal fibrosis
- Fat necrosis
- Ductal carcinoma in situ (usually linear or segmental distribution)
- Invasive ductal carcinoma

Tiny fuzzy hazy indistinct calcs that are sufficiently small enough that a more specific morphologic classification cannot be assigned.
Magnification CC and 90 degree lateral views are required for full characterization.
Distribution guides management
- Diffuse and bilateral = benign (BR2)
- Clustered or regional = suspicious (BR4B)
  - 20% malignant, 20% atypical hyperplasia, 60% fibrocystic change
- Linear or segmental = moderately suspicious (BR4C)
Can be stable over multiple years and still be due to malignant or high-risk lesion
DDX
- Fibrocystic change (MC)
- Sclerosing adenosis
- Columnar cell change
- DCIS (low grade)

Discontinuous fine linear calcs are suspicious for DCIS and warrants bx
- Extent of carcinoma correlates closely w/ calcification extent on mammography.
- 70% likelihood of malignancy.
Individually linear with irregular branching often conforming to a ductal pattern
Moderately to highly suspicious (BR 4c or 5; >50% to <95%)
Stereotactic bx should be performed unless there are patient factors precluding successful stereo such as...
- Pt unable to lie prone
- Thin breast compressing to <2 cm
- Location not amenable to stero
If unable to use stereotactic approach, then mammographic wire localization for surgical excision is required.
Post-excision (pre-radiation) magnification mammography should be performed to exclude residual malignant calcifications if...
- there is any question about close margins
- there is a large area of calcs (>3 cm) on initial mammography.

Looks like broken shards of glass w/ calcs of varying sizes and shapes.
- Look like punctuation marks or shrapnel of all different shapes. Best judged on non-mag views.
- More dense than amorphous calcs with defined shapes
Most are the result of comedonecrosis, necrosis calcifying as cancer is stripped of its blood supply.
Typically BR 4B w/ 30% chance of malignancy
- Concerning for DCIS
Typically warrant bx independent of distribution
- Bx anterior and posterior aspects of distribution.
DDX
- FA (less likely)
- Papilloma (less likely)
- Fibrocystic change
- DCIS (high grade)

DR SLuG

Scatterred random distribution
DIffuse punctate and amorphous calcs are almost always benign (especially if bilateral)
0% likelihood of malignancy

Numerous calcs occupying a large part of the breast BUT not conforming to a ductal distribution
Calcs spanning >2 cm and not thought to conform to a duct and its branches
May involve 1 or more quadrants.
26% likelihood of malignancy