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Fibrocystic disease

Microcalcifications of breast


Reviewer: Hind Nassar, MD, Johns Hopkins Medical Institute

Revised: 6 October 2012, last major update June 2010

Copyright: (c) 2002-2010, PathologyOutlines.com, Inc.




● Deposits of calcium in breast tissue visible on mammographic imaging




● Microcalcifications are either calcium phosphate (basophilic, nonbirefringent) or calcium oxalate (seen with polarized microscopy, not H&E, Am J Surg Pathol 1990;14:961, Archives 1989;113:1367, Mod Pathol 1992;5:146)




● Can occur at any age but more common after menopause




● Can be associated with both benign and malignant lesions


Clinical features


● Presence of microcalcifications on mammography has led to detection of breast tumors as small as 1-2 mm

● Microcalcifications are present in 50% of carcinomas versus 20% of benign breast disease, but only 20% of “suspicious” microcalcifications are actually part of a malignant process




● Suspicious microcalcifications are irregular and fine; non-suspicious are coarse and chunky

● Pathologists must detect microcalcifications in glass slides that correspond to those in radiographs - if not present, submit additional tissue, obtain additional levels or use polarized microscopy to look for calcium oxalate (Pathologica 2007;99:5)

● Exhaustive searching for microcalcifications yields a small increase in specific diagnostic information but with a high technical cost (Mod Pathol 2001;14:350)

Note: microcalcifications may be missing from biopsy due to retrieval failure (Radiology 2006;239:61)

Note: recommended to examine all vacuum assisted breast biopsy specimens histologically, even those without microcalcifications (Eur Radiol 2008;18:925)

● Detection of calcium phosphate microcalcifications is reduced with glyoxal fixative (Hum Pathol 2004;35:1058)


Radiologic BI-RADS (Breast Imaging Reporting and Data System of American College of Radiology) classification:

● Category 0 - need additional imaging evaluation

● Category 1 - negative

● Category 2 - benign finding

● Category 3 - probably benign finding-short term interval follow up suggested

● Category 4 - suspicious abnormality-biopsy should be considered

● Category 5 - highly suggestive of malignancy-appropriate action should be taken

References: American College of Radiology


Suggested that radiologists subcategorize BI-RADS 4 as 4A (low suspicion for malignancy), 4B (intermediate suspicion of malignancy), and 4C (moderate concern, but not classic for malignancy), Breast J 2010;16:28


LeGal classification of microcalcifications

● Type 1 - annular

● Type 2 - regularly punctiform

● Type 3 - too fine for precizing the shape

● Type 4 - irregularly punctiform

● Type 5 - vermicular (Bull Cancer 1984;71:57)


Xray images






Other images: The Radiology Assistant


Case reports


● 61 year old woman with suspicious mammographic calcifications (Case of the Week #25)

● Gold salts within intramammary nodes may simulate microcalcifications (Hum Pathol 1988;19:992)


Micro description (Histopathology)


● Calcium phosphate microcalcifications are associated with benign and malignant disease; are blue/purple psammoma like chunks

● Calcium oxalate crystals are typically within benign cysts or terminal ductules that are histologically apocrine or GCDFP-15 positive; are associated with LCIS, but only rarely with invasive carcinoma (Am J Surg Pathol 1991;15:586)

● Calcium oxalate crystals may be present in centrifuged fixative (Am J Surg Pathol 1997;21:255)


Micro images



Calcium oxalate calcifications


With polarized light                                            Without polarized light



Benign lesions with microcalcifications


Fibrocystic disease           Sclerosing adenosis




ADH                                        Sclerosing adenosis                                         Mucocele-like lesion




Columnar cell change #1;  #2                          Cystically dilated ducts



Malignant lesions with microcalcifications


Cribriform DCIS      LCIS involving adenosis


Virtual Slides



Microglandular adenosis with microcalcifications


Positive stains


● Von Kossa for calcium phosphate


Differential Diagnosis


● FloSeal hemostatic sealant (AJR Am J Roentgenol 2008;191:1371): mimics malignant calcifications


Additional references




End of Breast-nonmalignant > Fibrocystic disease > Microcalcifications of breast



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