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Combined morphology and distribution features for risk stratification in pathology-enriched BI-RADS 4A/4B microcalcifications
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DOI：10.1186/s12885-026-16577-z.png)
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Abstract
En 中文
Breast microcalcifications are a common indication for biopsy in breast cancer screening and often represent the earliest mammographic manifestation of malignancy. However, substantial heterogeneity within BI-RADS 4 A lesions presents challenges for clinical interpretation. This study aimed to evaluate the association of microcalcification morphology and distribution with pathological outcomes and to explore their potential role in characterizing heterogeneity within BI-RADS 4 A lesions. A total of 327 patients with 356 pathologically confirmed microcalcification-positive breast lesions detected on digital mammography were retrospectively analyzed on a lesion-based basis. Calcification morphology and distribution were classified according to the BI-RADS 5th Edition. Associations with pathological outcomes were assessed using chi-square or Fisher’s exact tests. Multivariable logistic regression was performed to identify independent factors associated with malignancy. Receiver operating characteristic (ROC) curve analysis was used to evaluate diagnostic performance at BI-RADS thresholds ≥4 A and ≥4B. Among the 327 patients, 205 (62.7%) had malignant disease and 122 (37.3%) had benign disease. Fine pleomorphic (80.2%), amorphous (66.2%), and fine linear or branching (100%) morphologies, as well as clustered (71.2%), regional (96.6%), and linear (100%) distribution patterns, were significantly associated with malignancy (P < 0.001). Multivariable analysis demonstrated that morphology and distribution remained independently associated with malignancy. Among lesions initially categorized as BI-RADS 4 A in institutional practice (n = 58), substantial heterogeneity was observed. Lesions with high-risk morphology and distribution patterns were more frequently malignant, whereas punctate calcifications with scattered distribution showed a lower malignancy proportion. In this pathology-confirmed cohort, BI-RADS ≥4B showed higher specificity than BI-RADS ≥4 A, although this category-level finding should be interpreted descriptively. In this retrospective cohort of biopsied BI-RADS 4 A/4B microcalcification-positive lesions, combined morphology and distribution features provided supplementary information for imaging–pathology correlation and helped illustrate risk heterogeneity within institutionally assigned BI-RADS 4 A lesions. These findings should be interpreted as confirmatory observations within a selected biopsy cohort rather than population-level malignancy estimates, and they are not intended to replace established BI-RADS-based management principles. These findings should be interpreted with caution due to the pathology-enriched design and should not be considered population-level risk estimates. They may provide supplementary information for understanding lesion heterogeneity but are not intended to replace established BI-RADS-based clinical decision-making. This retrospective study analyzed 356 pathologically confirmed microcalcification-positive breast lesions detected on digital mammography. Fine pleomorphic and fine linear or branching microcalcification morphologies showed the strongest association with malignancy. Clustered, regional, and linear distribution patterns were significantly correlated with higher malignancy rates. BI-RADS 4 A lesions exhibited substantial internal heterogeneity in this pathology-enriched cohort. Morphology and distribution together may provide supplementary information for interpreting lesions initially categorized as BI-RADS 4 A.
Keywords:
Breast cancer
Digital mammography
Microcalcifications
BI-RADS
Morphology
Distribution
Diagnostic accuracy
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