Discussion Author: Albert V Porambo
Typically benign appearing calcifications have a wide variety of appearances.
They can be lucent centered, as in skin calcifications.
Vascular calcifications in the breast look the same as in other parts of the body, demonstrating the parallel, serpentine deposits along the edge of a vessel.
Coarse or popcorn-like calcifications are typical of involuting fibroadenomas.
Large (>0.5 mm across) rod-like calcifications that only occasionally branch and are solid or have lucent centers are the kinds of calcifications found in secretory disease. These calcifications form in debris that collects in the duct lumen or causes an inflammatory reaction around a duct. The latter can result in lucent-centered rods. These benign calcifications are frequently bilateral, as in this case.
Other calcifications that are typically associated with benign processes include smooth, round calcifications 0.5 mm or larger. These deposits are probably concretions formed in the acini of microcystically dilated lobules.
Rim or eggshell calcifications are very thin, benign calcifications that appear as calcium deposited on the surface of a sphere. These deposits are usually under one millimeter in thickness when viewed on edge. Although fat necrosis can produce these thin deposits, fat necrosis usually results in thicker calcium deposition. Calcifications in the wall of cysts are the most common rim calcifications.
Because they represent solid particles, most calcifications have a similar appearance when viewed on orthogonal projections. Calcium that has precipitated in cysts is influenced by gravity and has a different morphology in the CC projection than on the lateral view. Calcifications that appear round and amorphous on the CC projection and are curvilinear or linear in the lateral projection are almost always due to milk of calcium. On the CC image the x-ray beam passes through a thin layer of the powdery particles, and they often appear as indistinct and fuzzy, round, amorphous deposits because they form in a pool in the dependent portion of the cyst. The same deposits appear as sharply defined, semilunar, crescent-shaped, curvilinear (concave up), or linear calcifications in the horizontal beam lateral because the photons pass through a thicker layer of calcium that is precipitated in and defines the dependent portion of a cyst. Milk of calcium is felt by virtually all experts to be formed by a benign process. Calcifications that form in the wall of a cyst may have a similar appearance, as would concretions in cysts that have solidified in the same orientation as free-flowing milk of calcium. It would be extremely unusual for the calcifications of breast cancer to form this pattern.
Suture calcifications probably represent calcium deposited on the gut matrix of suture material. These are relatively common in the postirradiated breast, and, on occasion, when extensive surgery (such as reduction mammoplasty) has been performed. They are probably the result of delayed resorption of the resorbable suture material that permits the calcium to form. They are typically linear or tubular in appearance and knots are frequently visible.
Large (>0.5 mm), irregular calcifications may have no apparent underlying cause and are termed dystrophic. Dystrophic calcifications usually form in the irradiated breast or in the breast after trauma (perhaps due to fat necrosis). Although irregular in shape, they are usually >0.5 mm in size. They may have lucent centers. Benign, dystrophic calcifications frequently have an appearance that resembles crushed lava.
Punctate calcifications are round or oval and very small (<0.5 mm) but very sharply defined, pinpoint deposits. Very round, regular, punctate calcifications are rarely associated with breast cancer, but if they include or are associated with calcifications whose shapes are not round or smooth but heterogeneous, they should be viewed with suspicion. Punctate calcifications are frequently found in the fibrous stroma with no apparent etiology. They may have formed in the remnants of burned-out lobules.
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