Fine-Needle Aspiration Cytologyof the Breast in a Case WithAbundant Acellular CalcificMaterial Indicative of Soft-TissueCalcinosisRaj K. Gupta, M.D., F.I.A.C.,1,2* Sarla Naran, B.Sc., C.M.I.A.C.,1Sharda Lallu, B.Sc., C.M.I.A.C.,1 Robert Fauck, C.T. (I.A.C.),1and David Gaskell, M.B., Ch.B., F.R.C.S., F.R.A.C.S.1

Since calcific deposits in soft tissue may clinically resemble atumor, it is feasible to investigate them by fine-needle aspiration(FNA) cytology. In this presentation we describe a case in thebreast with extensive accumulation of acellular liquid calcificmaterial which was sampled by the noninvasive technique of FNA,and which was indicative of nonfamilial soft-tissue calcinosis. A48-yr-old, perimenopausal woman on a routine mammogramshowed a well-defined, 1-cm partially cystic opacity in the leftupper quadrant of the breast. All other investigations were normal,and no significant family or medical history was present. Underultrasound guidance FNA was done, and about 1 ml of thickwhitish fluid was obtained. Cytopreparations only showed abun-dant acellular calcium. The patient refused any further treatmentand elected to be under the care of her family physician, accordingto whom she was clinically well with no changes in mammogramsfor the last 2 yr. The case is interesting, since the cytohistologic findingsin aspirate sample appeared to be strongly indicative of soft-tissuecalcinosis, which to our knowledge has not been previouslyreported. Diagn. Cytopathol. 2000;22:30–32.r 2000 Wiley-Liss, Inc.

Key Words:calcinosis; breast; fine-needle aspiration cytology

Calcific deposits in tissue, termed as tumoral calcinosis, area rare disorder and have generally been seen in patients inend-stage renal failure. Such deposits are now seldom seendue to improvement in management. Since calcific depositsmay resemble a tumor, it is feasible to investigate them bythe noninvasive method of fine-needle aspiration (FNA)cytology, which seems to have been only rarely used in viewof the few reports in the literature.1–4 In this communication,

we present a female patient with a partially cystic mammo-graphic opacity in the breast in which FNA yielded abundantacellular liquid calcific material indicative of soft-tissuecalcinosis. To our knowledge, such a finding in the breasthas not been previously reported. The case was also shownto Dr. Tilde S. Kline of Philadelphia, Pennsylvania duringher visit to our laboratory in January 1998.

Case ReportA 48-yr-old, perimenopausal woman on a routine mammo-gram showed a well-defined, partially cystic 1-cm opacity inthe left upper quadrant of the breast. Physical examinationand all investigations were normal, and no significant familyor medical history was present. Under ultrasound guidanceFNA was done, and about 1 ml of thick whitish fluid wasobtained. The patient refused any further treatment, andaccording to her family physician was clinically well withno changes for the last 2 yr.

Materials and MethodsThe aspirate was obtained using a disposable 10-ml syringeand 22-gauge disposable needle, using multiple passes in thebreast abnormality, and maintaining negative pressure. Nosmears were made, and the aspirated material in the syringewas collected as needle and syringe washings in a cytologycontainer in which 30% ethyl alcohol in physiologic salinewas present. This was accomplished by withdrawing thecontents of the container in the syringe barrel and, afterreattaching the needle, gently expelling the contents into thecontainer and repeating the procedure at least three times toensure maximum recovery of material. From about half ofthis material, filter preparations were made on size 3 micronGelman filters using the cytosieve method and stained by the

1Departments of Cytology and Surgery, Wellington Hospital and Schoolof Medicine, Wellington, New Zealand

2Valley Diagnostic Laboratory Ltd., Lower Hutt, New Zealand*Correspondence to: Raj K. Gupta, M.D., F.I.A.C., Cytology Unit,

Wellington Hospital, Wellington, New Zealand.Received 10 May 1999; Accepted 28 July 1999

30 Diagnostic Cytopathology, Vol 22, No 1 r 2000 WILEY-LISS, INC.

Papanicolaou method. The remainder of the aspirate samplewas spun and from the sediment a cell block was made, andsections were cut and stained with hematoxylin-eosin stain.

ResultsPapanicolaou-stained filter preparations and hematoxylin-eosin-stained sections of the cell block showed numerousamorphous, basophilic, deeply stained fragments of refrac-tile material and some fragmented bodies and concentriclamellations which were diagnosed as calcium (Figs. 1, 2).Despite a careful search, no normal breast elements ormalignant cells were identified.

DiscussionSoft-tissue calcification in various body sites has alwaysbeen a focus of attention clinically and radiologically, andthe presence of calcium in breast tissue in particular hasalways been of concern, despite the fact that such a findingcan be ascribed to both benign and malignant lesions. In thecase presented here, in our opinion the abundant acellular

calcium most likely indicated features mimicking soft-tissuecacinosis. However, this diagnosis could be questioned bysome, due to the fact that calcium in fibrocystic process andother pathological lesions such as fibroadenoma are rarelypresent. We did not feel that this was entirely convincing inthe case described here, since despite multiple passes in thebreast abnormality and vigorous aspiration,3 only acellularliquid calcific material was obtained. However, the possibil-ity of abundantly accumulated calcium as a precipitate ofunknown cause within a cystic lesion in the breast could notbe totally excluded. Also, the opacity was partially cystic onmammography.

Soft-tissue calcium deposits as a complication have beenknown to occur in patients with end-stage renal disease dueto altered calcium and phosphorus,5–7 although recent im-provements in management have resulted in a lower inci-dence of these deposits. Hypercalcemia may be due toparathyroid neoplasm, hypervitaminosis D, or destruction ofbones in such conditions as osteomyelitis. Hyperphospha-temia may occur as a result of chronic renal disease,secondary hyperparathyroidism, and demineralizaion ofbones. Also, soft-tissue calcium deposits may occur inpatients without any altered calcium and phosphorus, asappeared to be true in the case presented here.

Calcium may also deposit in organs in which cells excreteacid and, therefore, have low carbon dioxide tension, due towhich calcium becomes less soluble and precipitates. In onestudy,8 it was stated that regression of soft-tissue calcifica-tions can be dependent on the lowering of plasma phosphatelevel, which may be accomplished through dietary mea-sures, phosphate binding medications, renal transplantation,and parathyroidectomy. In some cases a wide local excisionmay be necessary. Based on radiological observations,soft-tissue calcifications have been described in various sitessuch as skin, blood vessels, eye, periarticular areas, viscera,and the temporomandibular joint.8,9

The presence of abundant calcium in a fine-needleaspiration cytology (FNAC) sample from a space-occupyinglesion (mass) warrants consideration of certain conditions inthe differential diagnosis. Examples include calcifying fi-brous pseudotumor, sarcoid, lymphoepithelial lesion, oste-itis fibrosa cystica, pilomatrixoma, and infection with Asper-gillus.10–16Cases of calcifying fibrous pseudotumor show theabundant hyalinized collagen, lymphoplasmacytic infiltrate,and entrapped structures such as skeletal muscle, adiposetissue, and neurovascular bundles apart from calcification.10

In lymphoepithelial lesions, a polymorphous lymphoidpopulation, histiocytes, myoepithelial cells, and calcifiedbodies have been described,11 while in sarcoidosis the mainfindings (apart from calcium crystals) are of noncaseatinggranulomas, multinucleated giant cells, and lymphocytes.12

Osteitis fibrosa cystica (brown tumor), attributed toprimary or secondary hyperparathyroidism, is seldom seennow due to early parathyroid surgery: a case report of FNAC

Fig. 1. Papanicolaou-stained filter preparation, showing abundant acellularcalcium (3450).

Fig. 2. Hematoxylin-eosin-stained section of cell block of aspirate, show-ing abundant calcium (3450).

SOFT-TISSUE CALCINOSIS OF BREAST

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findings in the literature13 emphasized the presence ofmultinucleate osteoclast-like giant cells and mononuclearstromal cells apart from calcium. In pilomatrixoma (calcify-ing epithelioma of Malherbe), the major cytologic findingsapart from calcium are of basaloid cells, multinucleatedgiant cells, and acellular masses suggestive of ghost cells.14

In the case described here, the cytohistologic findings didnot appear to indicate the above conditions.10–14Likewise, acareful search of the FNAC sample failed to reveal Aspergil-lus fungal elements, which have been described withcalcium crystals.15,16In addition, the patient had no evidenceof respiratory pathology.

In conclusion, we feel that the case described here, withaspiration of extensive acellular liquid calcific material, isinteresting and in our opinion is strongly indicative ofsoft-tissue calcinosis of the breast, which to our knowledgehas not been previously described.

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13. Gupta RK, Voss DM , McHutchison AG, Hatfield PJ. Osteitis fibrosacystica (brown tumour) in a patient with renal transplantation. report ofa case with aspiration cytodiagnosis. Acta Cytol 1992;36:555–558.

14. Unger P, Watson C, Phelps RG, Danque P, Bernard P. Fine needleaspiration cytology of pilomatrixoma (calcifying epithelioma of Mal-herbe): report of a case. Acta Cytol 1990;34:847–850.

15. Reyes CV, Kathuria S, Macglashan A. Diagnostic value of calciumoxalate crystals in respiratory and pleural fluid cytology: a case report.Acta Cytol 1979;23:65–68.

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