Frequently Asked Questions - Breast calcifications

1. What are breast calcifications?
2. What microcalcifications are suspicious and what might they suggest?
3. Are microcalcifications visible in ultrasonography?
4. What do we do in case microcalcifications appear in the mammography?
5. How is biopsy of microcalcifications performed ?
6. Could follow up be as an alternative to biopsy for suspicious microcalcifications?
 
1. What are breast calcifications?

Breast calcifications are depositions of calcium inside the breast tissue. They are visible in mammography as white marks of various shapes and sizes. According to their size, they are distinguished in macrocalcifications and microcalcifications. Macrocalcifications are large, coarse depositions of calcium that are almost never associated with the development of a malignancy and they need no more follow-up and treatment. Microcalcifications are tiny calcium foci and in some cases they might be linked to the development of a malignancy, which is why they need further evaluation.

Their existence might be due to some previous procedure or trauma (lipodystrophy), to calcification of benign lesions (cysts, fibroadenomas etc.), to calcification of breast vessels, to calcification of sebaceous glands of the skin etc. As mentioned, in some cases they might be produced by malignant lesion (carcinoma in situ or invasive breast carcinoma).

In most cases, calcifications are innocent and very common, especially in women over 50.

 
2. What microcalcifications are suspicious and what might they suggest?

Microcalcifications are characterized based on certain of their features. The morphology (linear, finely granular, ring-like, worm-like, amorphous, coarse, pleomorphic, punctate, irregularly-shaped, crushed stone-like, clustered etc.), the size (small, large or of various sizes if clustered), the density (high, medium or low density or varying if clustered) and the distribution (in one or both breasts, diffuse/scattered or localized, regional or segmental, distributed in a lactiferous duct or lobule, linearly distributed etc.).

The classification of microcalcifications as innocent or suspicious requires knowledge and experience and takes all of the above-mentioned features into account. So, microcalcifications may be classified as suspicious (possibility of malignancy 2-95%), intermediate (possibility of malignancy <2%) or innocent (without any possibility of malignancy). The presence of suspicious microcalcifications usually means the development of  ductal carcinoma in situ or lobular carcinoma in situ and in some cases the development of invasive cancer. The presence of an invasive cancer is more possible if the microcalcifications are coupled with other imaging-based findings too (presence of a mass, disruption of the normal architecture of the breast).

Malignant microcalcifications

1. Ductal carcinoma in situ 2. Multicentric ductal carcinoma in situ 3. Microinvasive ductal carcinoma in situ 4. Invasive ductal carcinoma

 
3. Are microcalcifications visible in ultrasonography?

Ultrasonography as an imaging method is not highly sensitive in detecting microcalcifications, therefore the mammography remains the main test for finding and studying them. In some cases, imaging of microcalcifications is possible if an experienced examiner uses high-resolution ultrasounds, especially if microcalcifications have previously been localized through a mammography.

Malignant microcalcifications (images from ultrasonographies)

1. Ductal carcinoma in situ 2. In situ and invasive ductal carcinoma 3. Invasive ductal carcinoma 4. Invasive papillary carcinoma

 
4. What do we do in case microcalcifications appear in the mammography?

When microcalcifications are obviously innocent, no follow-up is required; instead, regular screening is recommended. In case microcalcifications are characterized as intermediate or suspicious, a targeted, thorough ultrasonography test and special mammography views (magnification/spot compression views) are next. If microcalcifications are characterized as intermediate and there are no ultrasonography-based findings, doctors recommend follow-up every 6 months for 1-2 years or biopsy, depending on the case. In cases of intermediate microcalcifications with ultrasonography findings (e.g. a tumor) as well as in cases of suspicious microcalcifications, biopsy is necessary.

 
5. How is biopsy of microcalcifications performed ?

Microcalcifications can be biopsied in three ways:

  • Ultrasonography-guided percutaneous core needle biopsy, if there is a finding in the ultrasonography.
     
  • Mammography-guided (stereotactic) percutaneous  core needle biopsy. In this case a vacuum-assisted system (Mammotome®) can be used to obtain more tissue.
     
  • Open surgical biopsy. Mammography-guided hook wire localization of the calcifications is previously performed, so that they can be fully removed without removing extra, healthy tissue.
 
6. Could follow up be as an alternative to biopsy for suspicious microcalcifications?

Prior to the mass implementation of screening, our experience with microcalcifications and carcinoma in situ was very limited. So, if microcalcifications were detected by the mammography, physicians used to recommend monitoring. This turned out to be an incorrect approach for the following reasons:

  • Ductal carcinoma in situ, which is identified in the mammography due to the presence of microcalcifications, might remain stable for years or even decades before evolving to invasive cancer. For how long should then the woman have a mammography once in 6 months in order for the benign nature of the lesion to be confirmed?
     
  • A change in the imaging of suspicious microcalcifications most of the times means that a carcinoma in situ has changed into an invasive cancer. In this case, the woman is eventually treated for an invasive cancer and faces the consequences of that (possible life threat, possible need for painful treatments such as chemotherapy, emotional pressure etc.).

Following up on suspicious imaging-based lesions is risky and dangerous. Imaging "stability" in itself is not a proof of benignity.

 
 
 
 
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