ACR Appropriateness Criteria®
Clinical Condition: Calcifications
Variant 1: Pleomorphic, fine, linear, branching in any distribution.
Radiologic Exam Procedure |
Appropriateness Rating |
Comments |
X-ray, breast, mammography, magnification views |
9 |
CC and 90° lateral views preferred. |
INV, breast, biopsy, core |
9 |
|
X-ray, breast, mammography, orthogonal views (90o lateral and CC views if not readily available) |
7 |
Orthogonal views may be useful in positioning for the spot compression magnification views to be sure to include the calcifications. They will also be useful for pre-stereotactic localization or localization procedure. |
INV, breast, biopsy, excisional |
6 |
If discordant needle biopsy results or concerned about sampling error. If image guided percutaneous biopsy not available. |
US, breast |
4 |
May be useful in dense breast to look for mass component in lesion. |
MRI, breast |
3 |
Specific indications are still being investigated. |
Physical examination |
2 |
Physical examination does not play a role in the evaluation of calcifications. |
6-month follow-up |
2 |
|
INV, breast, fine needle aspiration (FNA) |
2 |
|
NUC, breast, sestamibi |
1 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 2: Documentation of skin calcification.
Radiologic Exam Procedure |
Appropriateness Rating |
Comments |
X-ray, breast, mammography, tangential views, dermal localization exam |
8 |
Only if calcifications are not typically dermal in appearance. |
Physical examination |
2 |
Physical examination does not play a role in the evaluation of calcifications. |
X-ray, breast, mammography, magnification views |
1 |
|
US, breast |
1 |
|
6-month follow-up |
1 |
|
INV, breast, fine needle aspiration (FNA) |
1 |
|
INV, breast, biopsy, core |
1 |
|
INV, breast, fine needle aspiration (FNA) |
1 |
|
MRI, breast |
1 |
|
NUC, breast, sestamibi |
1 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 3: Milk of calcium, any distribution.
Radiologic Exam Procedure |
Appropriateness Rating |
Comments |
X-ray, breast, mammography, magnification views |
8 |
CC and 90o lateral views preferred. |
X-ray, breast, mammography, orthogonal views (90o lateral and CC views if not readily available) |
7 |
Orthogonal views may be useful in positioning for the spot compression magnification views to be sure to include the calcifications. |
US, breast |
2 |
|
6-month follow-up |
2 |
|
INV, breast, fine needle aspiration (FNA) |
2 |
|
INV, breast, biopsy, core |
2 |
|
INV, breast, biopsy, excisional |
2 |
|
Physical examination |
1 |
Physical examination does not play a role in the evaluation of calcifications. |
MRI, breast |
1 |
|
NUC, breast, sestamibi |
1 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 4: Amorphous, single cluster.
Radiologic Exam Procedure |
Appropriateness Rating |
Comments |
X-ray, breast, mammography, magnification views |
9 |
CC and 90° lateral views preferred. |
INV, breast, biopsy, core |
8 |
|
X-ray, breast, mammography, orthogonal views (90o lateral and CC views if not readily available) |
7 |
Orthogonal views may be useful in positioning for the spot compression magnification views to be sure to include the calcifications. They will also be useful for pre-stereotactic localization or localization procedure. |
INV, breast, biopsy, excisional |
6 |
If discordant needle biopsy results or concerned about sampling error. If image guided percutaneous biopsy not available. |
6-month follow-up |
3 |
If present in retrospect and stable, 6-month follow-up can be considered. |
US, breast |
2 |
|
Physical examination |
3 |
Physical examination does not play a role in the evaluation of calcifications. |
INV, breast, fine needle aspiration (FNA) |
2 |
|
MRI, breast |
2 |
Specific indications are still being investigated. |
NUC, breast, sestamibi |
1 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 5: Amorphous, multiple cluster, one breast.
Radiologic Exam Procedure |
Appropriateness Rating |
Comments |
X-ray, breast, mammography, magnification views |
9 |
CC and 90° lateral views preferred. |
X-ray, breast, mammography, orthogonal views (90o lateral and CC views if not readily available) |
7 |
Orthogonal views may be useful in positioning for the spot compression magnification views to be sure to include the calcifications. They will also be useful for pre-stereotactic localization or localization procedure. |
INV, breast, biopsy, core |
7 |
Sampling of representative grouping is recommended with further management dependent on histology. |
6-month follow-up |
No Consensus |
Some would only follow-up after work-up complete and biopsy of dominant cluster benign. Others would be more conservative. If no dominant cluster, they would do 6-month follow-up. |
INV, breast, biopsy, excisional |
3 |
|
US, breast |
2 |
|
Physical examination |
2 |
Physical examination does not play a role in the evaluation of calcifications. |
INV, breast, fine needle aspiration (FNA) |
2 |
|
MRI, breast |
2 |
Specific indications are still being investigated. |
NUC, breast, sestamibi |
1 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 6: Amorphous, multiple bilateral clusters.
Radiologic Exam Procedure |
Appropriateness Rating |
Comments |
X-ray, breast, mammography, magnification views |
8 |
CC and 90° lateral views preferred. |
X-ray, breast, mammography, orthogonal views (90° lateral and CC views if not readily available) |
7 |
Orthogonal views may be useful in positioning for the spot compression magnification views to be sure to include the calcifications. |
6-month follow-up |
7 |
Once work-up demonstrates uniform, probably benign appearance of all calcifications. |
US, breast |
2 |
|
Physical examination |
2 |
Physical examination does not play a role in the evaluation of calcifications. |
INV, breast, fine needle aspiration (FNA) |
2 |
|
INV, breast, biopsy, core |
2 |
|
INV, breast, biopsy, excisional |
2 |
|
MRI, breast |
2 |
Specific indications are still being investigated. |
NUC, breast, sestamibi |
1 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 7: Amorphous in a regional distribution.
Radiologic Exam Procedure |
Appropriateness Rating |
Comments |
X-ray, breast, mammography, magnification views |
8 |
CC and 90° lateral views preferred. |
X-ray, breast, mammography, orthogonal views (90o lateral and CC views if not readily available) |
7 |
Orthogonal views may be useful in positioning for the spot compression magnification views to be sure to include the calcifications. They will also be useful for pre-stereotactic localization or localization procedure. |
INV, breast, biopsy, core |
6 |
|
US, breast |
2 |
|
Physical examination |
2 |
Physical examination does not play a role in the evaluation of calcifications. |
6-month follow-up |
2 |
|
INV, breast, fine needle aspiration (FNA) |
2 |
|
INV, breast, biopsy, excisional |
2 |
|
MRI, breast |
2 |
Specific indications are still being investigated. |
NUC, breast, sestamibi |
1 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 8: Amorphous in a linear or segmental distribution.
Radiologic Exam Procedure |
Appropriateness Rating |
Comments |
X-ray, breast, mammography, magnification views |
9 |
CC and 90° lateral views preferred. |
INV, breast, biopsy, core |
8 |
|
X-ray, breast, mammography, orthogonal views (90o lateral and CC views if not readily available) |
7 |
Orthogonal views may be useful in positioning for the spot compression magnification views to be sure to include the calcifications. They will also be useful for pre-stereotactic localization or localization procedure. |
INV, breast, biopsy, excisional |
6 |
If discordant needle biopsy results or concerned about sampling error. If image guided percutaneous biopsy not available. |
US, breast |
4 |
May be useful in dense breast to look for mass component in lesion. |
Physical examination |
2 |
Physical examination does not play a role in the evaluation of calcifications. |
6-month follow-up |
2 |
|
INV, breast, fine needle aspiration (FNA) |
2 |
|
MRI, breast |
2 |
Specific indications are still being investigated. |
NUC, breast, sestamibi |
1 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 9: Course (popcorn), large rod-like, dystrophic, suture, lucent-centered, egg shell rim.
Radiologic Exam Procedure |
Appropriateness Rating |
Comments |
X-ray, breast, mammography, magnification views |
2 |
|
X-ray, breast, mammography, orthogonal views |
2 |
|
US, breast |
2 |
|
Physical examination |
2 |
Physical examination does not play a role in the evaluation of calcifications. |
6-month follow-up |
2 |
|
INV, breast, fine needle aspiration (FNA) |
2 |
|
INV, breast, biopsy, core |
2 |
|
INV, breast, biopsy, excisional |
2 |
|
MRI, breast |
2 |
Specific indications are still being investigated. |
NUC, breast, sestamibi |
1 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 10: Round or punctate, clustered.
Radiologic Exam Procedure |
Appropriateness Rating |
Comments |
X-ray, breast, mammography, magnification views |
8 |
CC and 90° lateral views preferred. |
6-month follow-up |
8 |
Biopsy if increasing |
X-ray, breast, mammography, orthogonal views (90o lateral and CC views if not readily available) |
7 |
Orthogonal views may be useful in positioning for the spot compression magnification views to be sure to include the calcifications. |
INV, breast, biopsy, core |
4 |
Only if increasing. |
US, breast |
2 |
|
Physical examination |
2 |
Physical examination does not play a role in the evaluation of calcifications. |
INV, breast, fine needle aspiration (FNA) |
2 |
|
INV, breast, biopsy, excisional |
3 |
|
MRI, breast |
2 |
Specific indications are still being investigated. |
NUC, breast, sestamibi |
1 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 11: Round or punctate, regional.
Radiologic Exam Procedure |
Appropriateness Rating |
Comments |
X-ray, breast, mammography, magnification views |
8 |
CC and 90° lateral views preferred. |
X-ray, breast, mammography, orthogonal views (90o lateral and CC views if not readily available) |
7 |
Orthogonal views may be useful in positioning for the spot compression magnification views to be sure to include the calcifications. |
6-month follow-up |
6 |
If magnification views show calcifications that are probably benign. |
US, breast |
2 |
|
Physical examination |
2 |
Physical examination does not play a role in the evaluation of calcifications. |
INV, breast, fine needle aspiration (FNA) |
2 |
|
INV, breast, biopsy, core |
2 |
|
INV, breast, biopsy, excisional |
2 |
|
MRI, breast |
2 |
Specific indications are still being investigated. |
NUC, breast, sestamibi |
1 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 12: Punctate calcifications in a linear or segmental distribution.
Radiologic Exam Procedure |
Appropriateness Rating |
Comments |
X-ray, breast, mammography, magnification views |
8 |
CC and 90° lateral views preferred. |
INV, breast, biopsy, core |
8 |
|
X-ray, breast, mammography, orthogonal views (90o lateral and CC views if not readily available) |
7 |
Orthogonal views may be useful in positioning for the spot compression magnification views to be sure to include the calcifications. They will also be useful for pre-stereotactic localization or localization procedure. |
INV, breast, biopsy, excisional |
6 |
If discordant needle biopsy results or concerned about sampling error. If image guided percutaneous biopsy not available. |
US, breast |
4 |
May be useful in dense breast to look for mass component in lesion. |
Physical examination |
2 |
Physical examination does not play a role in the evaluation of calcifications. |
6-month follow-up |
2 |
|
INV, breast, fine needle aspiration (FNA) |
2 |
|
MRI, breast |
2 |
Specific indications are still being investigated. |
NUC, breast, sestamibi |
1 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 13: Punctate and amorphous, diffuse, bilateral.
Radiologic Exam Procedure |
Appropriateness Rating |
Comments |
X-ray, breast, mammography, magnification views |
2 |
|
X-ray, breast, mammography, orthogonal views |
2 |
|
6-month follow-up |
2 |
|
US, breast |
2 |
|
Physical examination |
2 |
Physical examination does not play a role in the evaluation of calcifications. |
INV, breast, fine needle aspiration (FNA) |
2 |
|
Core biopsy |
2 |
|
INV, breast, biopsy, excisional |
2 |
|
MRI, breast |
2 |
Specific indications are still being investigated. |
NUC, breast, sestamibi |
1 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 14: Course heterogeneous, single cluster.
Radiologic Exam Procedure |
Appropriateness Rating |
Comments |
X-ray, breast, mammography, magnification views (2 projections) |
8 |
CC and 90° lateral views preferred. |
X-ray, breast, mammography, orthogonal views (90o lateral and CC views if not readily available) |
7 |
Orthogonal views may be useful in positioning for the spot compression magnification views to be sure to include the calcifications. They will also be useful for pre-stereotactic localization or localization procedure. |
INV, breast, biopsy, core |
6 |
If new or increasing. |
6-month follow-up |
5 |
If magnification views demonstrate the calcifications to be probably benign. |
INV, breast, biopsy, excisional |
4 |
If suspicious and core not available. |
US, breast |
2 |
|
Physical examination |
2 |
Physical examination does not play a role in the evaluation of calcifications. |
INV, breast, fine needle aspiration (FNA) |
2 |
|
MRI, breast |
2 |
Specific indications are still being investigated. |
NUC, breast, sestamibi |
1 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 15: Course heterogeneous, multiple clusters, one breast.
Radiologic Exam Procedure |
Appropriateness Rating |
Comments |
X-ray, breast, mammography, magnification views |
8 |
CC and 90° lateral views preferred. |
X-ray, breast, mammography, orthogonal views (90° lateral and CC views if not readily available) |
7 |
Orthogonal views may be useful in positioning for the spot compression magnification views to be sure to include the calcifications. |
6-month follow-up |
7 |
If magnification views demonstrate the calcifications to be probably benign. |
US, breast |
2 |
|
Physical examination |
2 |
Physical examination does not play a role in the evaluation of calcifications. |
INV, breast, fine needle aspiration (FNA) |
2 |
|
INV, breast, biopsy, core |
2 |
|
INV, breast, biopsy, excisional |
2 |
|
MRI, breast |
2 |
Specific indications are still being investigated. |
NUC, breast, sestamibi |
1 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 16: Course heterogeneous, multiple bilateral clusters.
Radiologic Exam Procedure |
Appropriateness Rating |
Comments |
X-ray, breast, mammography, magnification views |
2 |
|
X-ray, breast, mammography, orthogonal views |
2 |
|
US, breast |
2 |
|
Physical examination |
2 |
Physical examination does not play a role in the evaluation of calcifications. |
6-month follow-up |
2 |
|
INV, breast, fine needle aspiration (FNA) |
2 |
|
INV, breast, biopsy, core |
2 |
|
INV, breast, biopsy, excisional |
2 |
|
MRI, breast |
2 |
Specific indications are still being investigated. |
NUC, breast, sestamibi |
1 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 17: Course heterogeneous, in regional distribution.
Radiologic Exam Procedure |
Appropriateness Rating |
Comments |
X-ray, breast, mammography, magnification views |
8 |
CC and 90° lateral views preferred. |
X-ray, breast, mammography, orthogonal views (90o lateral and CC views if not readily available) |
7 |
Orthogonal views may be useful in positioning for the spot compression magnification views to be sure to include the calcifications. |
6-month follow-up |
7 |
If magnification views demonstrate the calcifications to be probably benign. |
INV, breast, biopsy, core |
4 |
If new or increasing. |
US, breast |
3 |
If biopsy is contemplated and tissue is dense, may be useful to look for mass component in lesion. |
Physical examination |
2 |
Physical examination does not play a role in the evaluation of calcifications. |
INV, breast, fine needle aspiration (FNA) |
2 |
|
INV, breast, biopsy, excisional |
2 |
|
MRI, breast |
2 |
Specific indications are still being investigated. |
NUC, breast, sestamibi |
1 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 18: Course heterogeneous, in linear or segmental distribution.
Radiologic Exam Procedure |
Appropriateness Rating |
Comments |
X-ray, breast, mammography, magnification views |
8 |
CC and 90° lateral views preferred. |
INV, breast, biopsy, core |
8 |
|
X-ray, breast, mammography, orthogonal views (90o lateral and CC views if not readily available) |
7 |
Orthogonal views may be useful in positioning for the spot compression magnification views to be sure to include the calcifications. They will also be useful for pre-stereotactic localization or localization procedure. |
US, breast |
4 |
May be useful in dense breast to look for mass component in lesion. |
Physical examination |
2 |
Physical examination does not play a role in the evaluation of calcifications. |
6-month follow-up |
2 |
|
INV, breast, fine needle aspiration (FNA) |
2 |
|
INV, breast, biopsy, excisional |
2 |
|
MRI, breast |
2 |
Specific indications are still being investigated. |
NUC, breast, sestamibi |
1 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Currently, ductal carcinoma-in-situ (DCIS) represents 25%-30% of all reported breast cancers. Approximately 95% of all DCIS is diagnosed because of mammographically detected microcalcifications. Prior to the widespread use of screening mammography, DCIS, detected as a mass on physical examination, was an uncommon disease representing less than 3% of all breast cancers. Screening mammography is the only reliable tool available for the detection of breast microcalcifications and DCIS.
Breast microcalcifications are detected commonly on screening mammograms. Most breast calcifications are benign and can be classified accordingly without any additional work-up. In women with indeterminate or malignant calcifications on screening studies, micro-focus (0.1 mm focal spot) magnification views in orthogonal projections are useful.
On magnification images, additional calcifications may be apparent, the morphology of individual calcifications can be characterized, and the distribution of calcifications can be better determined. In women with malignant calcifications, magnification images may be helpful in establishing the extent of disease.
Currently, the role for computer-aided detection (CAD) of calcifications has not yet been determined. However, recent studies indicate that computer-aided detection can be clinically useful to avoid false negatives when used properly.
Stereotactically guided core biopsy using a variety of devices can sample areas of microcalcifications. Stereotactically guided FNA of microcalcifications has been shown to be inaccurate. Core biopsy specimen radiographs should be done to establish the presence of calcifications in the core, as is done with surgically excised specimens.
Abbreviations
- CC, cranial-caudal
- FNA, fine needle aspiration
- INV, invasive
- MRI, magnetic resonance imaging
- NUC, nuclear medicine
- US, ultrasound