CASE 18548 Published on 03.05.2024
0

An unusual malignant manifestation of breast milk of calcium calcifications

Section

Breast imaging

Case Type

Clinical Case

Authors

Sofía Ventura-Díaz 1, Pooja Vasudev 2, Abdullah Alabousi 3, Colm Boylan 3, Faten Al-Douri 3

1 McMaster University, Hamilton, Canada

2 Pathology Department, Saint Joseph’s Hospital Healthcare, Hamilton, Canada

3 Radiology Department, Saint Joseph’s Hospital Healthcare, Hamilton, Canada

Connected authors
Patient

43 years, female

Categories
Area of Interest Breast ; Imaging Technique Mammography, Ultrasound, Ultrasound-Power Doppler
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Clinical History

A 43-year-old female presented with a palpable lump within the right breast for 1 month.

Imaging Findings

On ultrasound, the palpable lump corresponded to a lobulated complex cystic mass, measuring 5.1 x 1.1 cm (Figure 1a). It demonstrated multiple cystic spaces and a solid component with intrinsic vascularity (Figure 1b).

Mammographic projections (Figures 2a, 2b and 2c) revealed a heterogeneous mass with internal dependent calcifications. On the mediolateral oblique and mediolateral views (Figures 2b and 2c), the calcifications appeared as semilunar, crescent-shaped or teacups, typical of milk of calcium.

On the recombined images of the contrast-enhanced mammogram (Figures 3a, 3b and 3c), the mass showed heterogeneous enhancement with multiple tiny non-enhancing components corresponding to the sonographic internal cystic spaces. There was a washout on the delayed mediolateral view (Figure 3c), a finding that should raise concern for malignancy.

Ultrasound-guided biopsy (Figure 1c) and surgical pathology revealed high-grade ductal carcinoma in situ with cribriform architecture associated with comedonecrosis and teacup calcifications (Figures 4a, 4b and 4c). Note Figures 5a, 5b and 5c, where the radio-pathological correlation of the layering calcifications is put in perspective.

Discussion

Milk of calcium calcifications are found in 4–6% of diagnostic mammograms [1]. As a general rule, they are considered typically benign by the BI-RADS lexicon [2] and usually represent sedimented calcifications within benign cystic lesions or fibrocystic changes [3,4]. Its appearance of dense, linear and curvilinear “teacup” layering is considered pathognomonic in the mediolateral (ML) and mediolateral oblique (MLO) views. On the craniocaudal (CC) projection, they should have a “cloudlike” or smudgy appearance, like tea leaves in the bottom of a teacup, whereas ductal carcinoma in situ (DCIS) retains a linear shape [3].

Although uncommon, milk of calcium calcifications can be associated to malignancy. In the review by Linden and Sickles [1], 4% of cancers were associated with milk of calcium calcifications. However, malignancies related to milk of calcium were described near or adjacent, not within them [1,5].

The interesting fact about this case is that the teacup calcifications were located not in the periphery, but within the cystic spaces generated by a high-grade DCIS with comedonecrosis (Figures 4a, 4b and 4c). The surgical piece was reviewed, and there were no fibrocystic changes associated that could contribute to the appearance of milk of calcium. Incidentally, there was a small focus of invasive carcinoma in situ (not shown).

The teaching point is that not all milk of calcium calcifications are benign. It is necessary to evaluate ancillary findings associated to the calcifications. In this case, the presence of milk of calcium within a complex cystic mass should always prompt a biopsy in order to rule out malignancy. Although debatable, one could say that there were also linear and pleomorphic calcifications within the mass, which is very challenging to assess given the extensive component of milk of calcium.

All patient data have been completely anonymised throughout the entire manuscript and related files.

Differential Diagnosis List
High-grade ductal carcinoma in situ (DCIS)
Fibrocystic changes
Atypical ductal hyperplasia
Papilloma
Mucocele-like lesions
Final Diagnosis
High-grade ductal carcinoma in situ (DCIS)
Case information
URL: https://eurorad.org/case/18548
DOI: 10.35100/eurorad/case.18548
ISSN: 1563-4086
License

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.

Figure 1

Ultrasound findings in the right breast

Ultrasound findings of the palpable lump within the right breast. a: Lobulated mass with solid and cystic components. b: Power colour Doppler demonstrates intrinsic vascularity of the solid component. c: 14 G core-needle ultrasound-guided biopsy performed of the mass.
Ultrasound findings of the palpable lump within the right breast. a: Lobulated mass with solid and cystic components. b: Power colour Doppler demonstrates intrinsic vascularity of the solid component. c: 14 G core-needle ultrasound-guided biopsy performed of the mass.
Ultrasound findings of the palpable lump within the right breast. a: Lobulated mass with solid and cystic components. b: Power colour Doppler demonstrates intrinsic vascularity of the solid component. c: 14 G core-needle ultrasound-guided biopsy performed of the mass.
Ultrasound findings of the palpable lump within the right breast. a: Lobulated mass with solid and cystic components. b: Power colour Doppler demonstrates intrinsic vascularity of the solid component. c: 14 G core-needle ultrasound-guided biopsy performed of the mass.
Ultrasound findings of the palpable lump within the right breast. a: Lobulated mass with solid and cystic components. b: Power colour Doppler demonstrates intrinsic vascularity of the solid component. c: 14 G core-needle ultrasound-guided biopsy performed of the mass.
Ultrasound findings of the palpable lump within the right breast. a: Lobulated mass with solid and cystic components. b: Power colour Doppler demonstrates intrinsic vascularity of the solid component. c: 14 G core-needle ultrasound-guided biopsy performed of the mass.
Figure 2

Mammographic views of the right breast

Mammographic views of the right breast. a: Extended craniocaudal view, demonstrating a heterogenous mass with a “cloudlike” appearance within the axillary tail.
Mammographic views of the right breast. a: Extended craniocaudal view, demonstrating a heterogenous mass with a “cloudlike” appearance within the axillary tail.
Mammographic views of the right breast. b: Mediolateral oblique view, demonstrating some layering of the calcifications within the mass.
Mammographic views of the right breast. b: Mediolateral oblique view, demonstrating some layering of the calcifications within the mass.
Mammographic views of the right breast. c: Mediolateral view, showing more clearly the crescent-shaped or semilunar teacups, typical of milk of calcium.
Mammographic views of the right breast. c: Mediolateral view, showing more clearly the crescent-shaped or semilunar teacups, typical of milk of calcium.
Figure 3

Recombined views of contrast-enhanced mammogram

Recombined views of contrast-enhanced mammogram. a: Extended craniocaudal view, first image acquired; the mass demonstrates heterogenous early enhancement with multiple tiny non-enhancing components.
Recombined views of contrast-enhanced mammogram. a: Extended craniocaudal view, first image acquired; the mass demonstrates heterogenous early enhancement with multiple tiny non-enhancing components.
Recombined views of contrast-enhanced mammogram. b: Mediolateral oblique view, showing the maximum peak of enhancement.
Recombined views of contrast-enhanced mammogram. b: Mediolateral oblique view, showing the maximum peak of enhancement.
Recombined views of contrast-enhanced mammogram. c: Delayed mediolateral view demonstrating washout.
Recombined views of contrast-enhanced mammogram. c: Delayed mediolateral view demonstrating washout.
Figure 4

Histological specimen

Histological specimen showing high-grade ductal carcinoma in situ, cribriform pattern. The yellow arrows demonstrate the calcifications (blue, glassy appearing), most times layering or admixed with necrosis (pink, friable). The black arrows point to the high-grade pleomorphic cells within duct spaces with central comedonecrosis. a: Hematoxylin & Eosin staining; magnification, ×20.
Histological specimen showing high-grade ductal carcinoma in situ, cribriform pattern. The yellow arrows demonstrate the calcifications (blue, glassy appearing), most times layering or admixed with necrosis (pink, friable). The black arrows point to the high-grade pleomorphic cells within duct spaces with central comedonecrosis. a: Hematoxylin & Eosin staining; magnification, ×20.
Histological specimen showing high-grade ductal carcinoma in situ, cribriform pattern. The yellow arrows demonstrate the calcifications (blue, glassy appearing), most times layering or admixed with necrosis (pink, friable). The black arrows point to the high-grade pleomorphic cells within duct spaces with central comedonecrosis. b: Hematoxylin & Eosin staining; magnification, ×40.
Histological specimen showing high-grade ductal carcinoma in situ, cribriform pattern. The yellow arrows demonstrate the calcifications (blue, glassy appearing), most times layering or admixed with necrosis (pink, friable). The black arrows point to the high-grade pleomorphic cells within duct spaces with central comedonecrosis. b: Hematoxylin & Eosin staining; magnification, ×40.
Histological specimen showing high-grade ductal carcinoma in situ, cribriform pattern. The yellow arrows demonstrate the calcifications (blue, glassy appearing), most times layering or admixed with necrosis (pink, friable). The black arrows point to the high-grade pleomorphic cells within duct spaces with central comedonecrosis. c: Hematoxylin & Eosin staining; magnification, ×100.
Histological specimen showing high-grade ductal carcinoma in situ, cribriform pattern. The yellow arrows demonstrate the calcifications (blue, glassy appearing), most times layering or admixed with necrosis (pink, friable). The black arrows point to the high-grade pleomorphic cells within duct spaces with central comedonecrosis. c: Hematoxylin & Eosin staining; magnification, ×100.
Figure 5

Radio-pathological correlation

Radio-pathological correlation. a: Ultrasound, transverse view of the lesion; redemonstration of the complex cystic mass, with solid component (*), internal hyperechogenic foci (solid arrow) and possible layering within the cystic space (dashed arrow).
Radio-pathological correlation. a: Ultrasound, transverse view of the lesion; redemonstration of the complex cystic mass, with solid component (*), internal hyperechogenic foci (solid arrow) and possible layering within the cystic space (dashed arrow).
Radio-pathological correlation. b: Amplification image of the mediolateral mammographic view; note the crescent-shaped teacups, typical of milk of calcium, likely corresponding to the sonographic cystic spaces (solid arrow); the solid component of the mass is dense (*).
Radio-pathological correlation. b: Amplification image of the mediolateral mammographic view; note the crescent-shaped teacups, typical of milk of calcium, likely corresponding to the sonographic cystic spaces (solid arrow); the solid component of the mass is dense (*).
Radio-pathological correlation. c: Hematoxylin & Eosin staining; magnification, ×20; note the cribriform pattern of the ductal carcinoma in situ representing the solid component (*) and the cystic spaces containing layering of milk of calcium (solid arrow).
Radio-pathological correlation. c: Hematoxylin & Eosin staining; magnification, ×20; note the cribriform pattern of the ductal carcinoma in situ representing the solid component (*) and the cystic spaces containing layering of milk of calcium (solid arrow).