All About Calcification

All About Calcification
Fine pleomorphic calcifications, resembling “broken glass:” BI-RADS 5, “highly suspicious of malignancy”

Key Points

  • A majority of women have some form of calcifications in their breasts.
  • Calcifications come in various shapes, sizes, and distribution, reflecting their many causes.
  • Most calcifications sampled by biopsies pose no health threat.
  • Mammography saves lives through the early detection of breast cancer.
  •  What are they?
  •  How common are they?
  •  What are the various kinds of calcifications?
  •  What causes them?
  •  What does it mean if my doctor says I have breast calcifications?
  •  To what degree has radiology of the breast evolved since the discovery of calcifications, and what does this mean for my annual mammogram?

There are two main ways in which breast calcifications are formed.  Active secretion of calcium salts by cells lining the ducts and glands of the breast is a common cause. Also, the calcification of necrotic debris (or dead cancer cells inside the ducts) causes fine linear microcalcifications on mammography and is a sign of ductal carcinoma.

Benign causes of calcifications include fibrocystic changes, benign tumors, and breast trauma. Pleomorphic calcifications, which look like broken glass, are suggestive of cancer. Amorphous calcifications, which often appear like “gunpowder,” are inconclusive and may be completely benign or indicative of cancer, depending upon their distribution. They require additional mammographic magnification views to observe more closely their shape and distribution.  High dietary and supplementary calcium does not increase the probability of having breast calcifications, unless the patient has an impaired ability to process the calcium such as in patients with kidney disease.

The radiologists will evaluate calcifications on mammography based on their shape, distribution, number, size, variability, stability across time, and associated findings. Screening mammography shows the calcium deposits, but additional views with diagnostic mammography (magnification views) is necessary to completely analyze the shapes of very small calcifications. This evaluation leads to a variety of assessments based on the Breast Imaging Reporting and Data System (BI-RADS®). Radiologists assign a number, one through five, to each case, with five characterized as “highly suspicious of malignancy” and one as “normal mammogram.” If the radiologist deems the diagnostic mammogram suspicious, she will recommend a breast needle biopsy. A pathologist will analyze the tissue and make a diagnosis.  For every four to five women who have a breast biopsy of microcalcifications, the pathologist will diagnose only one with cancer.  The remaining three cases usually represent fibrocystic change, a common benign condition. In some cases the tiny groups of calcifications are caused by abnormal cells or pre-cancers that have not yet progressed enough to be called cancer. With routine screening mammograms, radiologists and patients are catching breast cancers caused by calcifications earlier, allowing for prompt and aggressive treatment.

Researchers first discovered breast calcifications in 1951, and for years radiologists had little success in detecting them in pre and peri-menopausal women. It was also difficult to find calcifications in women under 50, especially in those with dense breasts. In the last thirty years, the evolution of breast imaging technology, particularly with the advent of digital mammography, has allowed radiologists to identify tiny areas of micro-calcifications associated with pre-cancers years before an actual cancer forms. Because the five-year survival rates for patients with breast cancer detected early approaches 100%, it is essential to visit a breast imaging radiologist routinely and according to the screening guidelines established by the American Cancer Society.

By Jordan McKittrick and Ellen Shaw de Paredes, MD, FACR

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