BI-RADS AND CALCIFICATION(FIGURES)

Distribution
In the BI-RADS atlas the following descriptions are given for the distribution of calcifications (1) :
Diffuse or Scattered: diffuse calcifications may be scattered calcifications or multiple similar appearing clusters of calcifications throughout the whole breast.
Regional: scattered in a larger volume (> 2 cc) of breast tissue and not in the expected ductal distribution.
Clustered : at least 5 calcifications occupy a small volume of tissue (<>



Diffuse or scattered distribution is typically seen in benign entities.Even when clusters of calcifications are scattered throughout the breast, this favors a benign entity.
Regional distribution according to the BI-RADS atlas would favor a non-ductal distribution (i.e. benignity), whileSegmental distribution would favor a ductal distribution (i.e. malignancy).Sometimes this differentiation can be made, but in many cases the differentiation between 'regional' and 'segmental' is problematic, because it is not clear on a mammogram or MRI where the bounderies of a segment (or a lobe) exactly are.
Change over time
There are conflicting data concerning the value of absence of change over time. It is said that the absence of interval change in microcalcifications that are probably benign on the basis of morphologic criteria is a reassuring sign and an indication for continued mammographic follow-up (2). On the other hand in a retrospective study that included indeterminate and suspicious clusters of microcalcifications, stability could not be relied on as a reassuring sign of benignancy (3). In this group of patients with biopsy proven malignancy, 25% of patients had stable microcalcifications for 8-63 months.It seems that the morphology of calcifications is far more important than stability and stability can only be relied on if the calcifications have a probably benign form.



Vascular Calcifications These are linear or form parallel tracks, that are usually clearly associated with blood vessels. Vascular calcifications noted in women <> Coarse or 'Popcorn-like' The classic large 'popcorn-like' calcifications are produced by involuting fibroadenomas.These calcifications usually do not cause a diagnostic problem.When the calcifications in an fibroadenoma are small and numerous, they may resemble malignant-type calcifications and need a biopsy.





Eggshell or Rim Calcifications These are very thin benign calcifications that appear as calcium is deposited on the surface of a sphere. These deposits are usually under 1 mm in thickness when viewed on edge. Although fat necrosis can produce these thin deposits, calcifications in the wall of cysts are the most common 'rim' calcifications.

Round and amorphous calcifications
Round calcifications are 0.5-1 mm in size and frequently form in the acini of the terminal duct lobular unit.When smaller than 0.5 mm, the term amorphous is used.
Round and amorphous calcifications can be seen in fibrocystic changes or adenosis, skin calcifications, skin talc and rarely in DCIS.Suspect DCIS when the calcifications are small, i.e.amorphous , and show some heterogeneity especially when in cluster, linear or segmental distribution. Coarse and heterogenous calcification

coarse heterogeneous calcificationsThey were classified as Bi-RADS 4. Biopsy revealed DCIS. amorphous and pleomorphic calcifications.Based on the morphology these calcifications were classified as BI-RADS 4.Biopsy revealed fibrocystic changes (FCC)

amorphous calcifications within a denser area of the breast.This was classified as Bi-RADS 4 (3-95% chance of malignancy). Biopsy revealed DCIS with invasive ductal carcinoma.

There is a cluster of amorphous and fine pleomorphic calcifications.These calcifications were classified as BI-RADS 4.A biopsy was performed and only fibrocystic changes were found.

LEFT: cluster of pleiomorphic calcifications on oblique viewRIGHT: milk of calcium (teacups) on lateral view with horizontal beam

a mammogram demonstrating two forms of calcifications.There are some round typically benign calcifications.The most conspicious calcifications however are the fine pleomorphic calcifications. They have a segmental distribution.Even without the presence of the mass these calcifications would be classified as Bi-RADS 5.Biopsy demonstrated an extensive high grade DCIS with an invasive carcinoma.

a patient with new calcifications detected in a screening program.These are fine pleomorphic and fine linear calcifications.The distribution is linear.On the basis of the morphology and distribution these calcifications were classified as BI-RADS 5.At biopsy this was high grade DCIS.

fine linear and branching calcifications in a segmental distribution highly suggestive of malignancy (Bi-RADS 5). Extensive high grade DCIS was found at biopsy.

Fine Linear or Fine Linear Branching
These are thin, linear or curvilinear irregular calcifications.They may be discontinuous.Usually they are <>