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the crainocaudal and mediolateral oblique views divulged a cluster of microcalcifications in the right upper inner quadrant .
subsequent magnification mammograms revealed the poorly defined smudges on a craniocaudal projection , and the typical crescent - shaped sedimented calcium on a mediolateral projection , also known as the " teacup sign " , suggestive of milk of calcium ( 4 ) .
however , among the milk of calcium clusters , several fine pleomorphic microcalcifications , which are distinct in appearance from sedimented calcium , were observed ( figs .
1a , b ) . and a mammography - guided wire localization a surgical excision was performed , followed by a specimen radiography , confirmed the excision of the calcifications ( fig .
1c ) . a histological assessment revealed a ductal carcinoma in situ , with a comedo type and a low nuclear grade among the cystically dilatated acini .
milk of calcium has been found in a variety of cystic structures elsewhere in the body , particularly in the renal collecting systems and the gallbladder .
the pathophysiology of milk of calcium formation is poorly understood ; however , lanyi ( 4 ) and sickles and abele ( 1 ) initially identified and explained the mammographic findings of milk of calcium in benign breast cysts . because of its tendency to sediment out of cyst fluid , the diagnosis of milk of calcium diagnosis depended upon the demonstration of a poorly defined smudgelike density on a craniocaudal mammography as well as a fluid - calcium level on a true lateral view ( 1 ) .
its recognition is important since this characteristic calcification has no known precedence as a malignant potential and a follow - up or biopsy has been typically deemed unnecessary ( 1 ) .
however , as shown in our case , it may incidentally coexist with other types of calcifications , including malignant calcifications . in 1989 ,
linden and sickles ( 2 ) described eight patients with carcinoma presented as clustered microcalcifications in a breast , which incidentally contained typical sedimented calcifications .
the described cases revealed calcifications which were associated with carcinomas , were distinct in appearance from the sedimented calcium , but located near or adjacent to them however , not within them . in the present case study , malignant microcalcifications were found to be located within the milk of calcium cluster .
the histology revealed that almost all calcifications were associated with malignant cells , but adjacent cystically dilated acini contained little calcific debris .
from the mammographies , the calcific debris was identified as milk of calcium and hence , escaped the benign cyst lumen during the sectioning , as well as the transfer to glass slides , and staining .
( 5 ) described 10 cases of typically benign calcifications associated with malignant cells , including milk of calcium layering in the dependent portion of cystically dilated acini lined with malignant cells .
even so , the classic crescent - shaped calcium precipitated in the cysts , and the spherical centrally lucent calcium deposits are almost always associated with the benign processes . the authors also believe that it was the malignant calcifications seen at histology that were the fine pleomorphic calcifications seen mammographically , and not milk of calcium . as a result of this case study , radiologists should be aware of the possible association between milk of calcium and other types of calcifications , including malignant calcifications .
a more careful analysis of the characteristics of all calcific particles and correlation with craniocaudal mammograms with true lateral views is essential .
unless all calcific particles are characteristic of a benign entity , the consideration of a biopsy would be a prudent approach .
milk of calcium located in the breast is typically a benign entity . 
 however , carcinoma may incidentally arise adjacent to or even within milk of calcium . 
 consequently , the characteristics of all observed calcific particles should be carefully analyzed . in this study , we report a case of carcinoma presented as malignant microcalcifications mixed within milk of calcium in a breast .