The Relationship Between Mammographic Features of BI-RADS 4 and 5 Calcifications and Pathological Diagnoses

Objective: To evaluate the relationship between mammographic features of BI-RADS category 4 and 5 breast calcifications and their corresponding pathological diagnoses, and to determine whether specific morphological or distribution patterns are predictive of malignancy. Methods: This retrospective study included 54 patients who underwent biopsy for suspicious breast calcifications between August 2021 and March 2024. Among these patients, 30 underwent stereotactic vacuum-assisted biopsy, and 24 underwent wire-guided localization followed by excisional biopsy. The mammographic morphology and distribution patterns of the calcifications were assessed using the BI-RADS lexicon, and the corresponding histopathological diagnoses were recorded. The association between mammographic features and pathological outcomes was subsequently analyzed. Results: Fine pleomorphic calcifications were the most common morphology (40.7%). A grouped distribution was the predominant pattern (61.1%). Benign lesions were mostly categorized as BI-RADS 4A, B3 lesions as BI-RADS 4B, and DCIS cases as BI-RADS 4C (P = 0.03). The Grouped distribution was more frequent among benign and B3 lesions, whereas DCIS exhibited more frequent linear and segmental patterns (P = 0.01). Malignancy rates were highest for fine linear/branching and fine pleomorphic morphologies. Conclusion: A significant association exists between the mammographic characteristics of BI-RADS 4 and 5 calcifications and their pathological outcomes. In our study, fine pleomorphic morphology and linear or segmental distribution patterns consistently indicated a increased likelihood of malignancy, particularly ductal carcinoma in situ, whereas benign and B3 lesions were more commonly associated with grouped distribution patterns. These results highlight that detailed evaluation of calcification morphology and distribution on mammography can improve diagnostic confidence, aid in distinguishing higher-risk lesions, and contribute to more informed biopsy decision-making.