ACR Appropriateness Criteria®
Clinical Condition: Breast Calcifications
Variant 1: Pleomorphic, fine, linear, branching in any distribution.
Radiologic Procedure |
Rating |
Comments |
RRL* |
X-ray mammography magnification views |
9 |
CC and 90° lateral views preferred. |
Low |
INV core biopsy breast |
9 |
|
IP |
X-ray 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. |
Low |
Excisional biopsy breast |
6 |
If discordant needle biopsy results or concerned about sampling error. If image guided percutaneous biopsy not available. |
None |
US breast |
4 |
May be useful in dense breast to look for mass component in lesion. |
None |
MRI breast |
3 |
Specific indications are still being investigated. |
None |
X-ray diagnostic mammography 6-month follow-up |
2 |
|
Low |
INV fine needle aspiration breast |
2 |
|
IP |
NUC sestamibi scan breast |
1 |
|
High |
Rating Scale: 1=Least appropriate, 9=Most appropriate |
*Relative Radiation Level |
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 2: Documentation of skin calcification.
Radiologic Procedure |
Rating |
Comments |
RRL* |
X-ray mammography tangential views dermal localization exam |
8 |
Only if calcifications are not typically dermal in appearance. |
Low |
INV fine needle aspiration breast |
1 |
|
IP |
INV core biopsy breast |
1 |
|
IP |
Excisional biopsy breast |
1 |
|
None |
MRI breast |
1 |
|
None |
NUC sestamibi scan breast |
1 |
|
High |
X-ray mammography magnification views |
1 |
|
Low |
US breast |
1 |
|
None |
X-ray diagnostic mammography 6-month follow-up |
1 |
|
Low |
Rating Scale: 1=Least appropriate, 9=Most appropriate |
*Relative Radiation Level |
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 3: Milk of calcium, any distribution.
Radiologic Procedure |
Rating |
Comments |
RRL* |
X-ray mammography magnification views |
8 |
CC and 90° lateral views preferred. |
Low |
X-ray 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. |
Low |
X-ray diagnostic mammography 6-month follow-up |
2 |
|
Low |
INV fine needle aspiration breast |
2 |
|
IP |
Excisional biopsy breast |
2 |
|
None |
INV core biopsy breast |
2 |
|
IP |
US breast |
2 |
|
None |
MRI breast |
1 |
|
None |
NUC sestamibi scan breast |
1 |
|
High |
Rating Scale: 1=Least appropriate, 9=Most appropriate |
*Relative Radiation Level |
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 4: Amorphous, single cluster.
Radiologic Procedure |
Rating |
Comments |
RRL* |
X-ray mammography magnification views |
9 |
CC and 90° lateral views preferred. |
Low |
INV core biopsy breast |
8 |
|
IP |
X-ray 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. They will also be useful for pre-stereotactic localization or localization procedure. |
Low |
Excisional breast biopsy |
6 |
If discordant needle biopsy results or concerned about sampling error. If image guided percutaneous biopsy not available. |
None |
X-ray diagnostic mammography 6-month follow-up |
3 |
If present in retrospect and stable, 6-month follow-up can be considered. |
Low |
MRI breast |
2 |
Specific indications are still being investigated. |
None |
US breast |
2 |
|
None |
INV fine needle aspiration breast |
2 |
|
IP |
NUC sestamibi scan breast |
1 |
|
High |
Rating Scale: 1=Least appropriate, 9=Most appropriate |
*Relative Radiation Level |
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 5: Amorphous, multiple cluster, one breast.
Radiologic Procedure |
Rating |
Comments |
RRL* |
X-ray mammography magnification views |
9 |
CC and 90° lateral views preferred. |
Low |
X-ray 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. They will also be useful for pre-stereotactic localization or localization procedure. |
Low |
INV core biopsy breast |
7 |
Sampling of representative grouping is recommended with further management dependent on histology. |
IP |
Excisional biopsy breast |
3 |
|
None |
MRI breast |
2 |
Specific indications are still being investigated. |
None |
INV fine needle aspiration breast |
2 |
|
IP |
US breast |
2 |
|
None |
NUC sestamibi scan breast |
1 |
|
High |
X-ray diagnostic mammography 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. |
Low |
Rating Scale: 1=Least appropriate, 9=Most appropriate |
*Relative Radiation Level |
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 6: Amorphous, multiple bilateral clusters.
Radiologic Procedure |
Rating |
Comments |
RRL* |
X-ray mammography magnification views |
8 |
CC and 90° lateral views preferred. |
Low |
X-ray 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. |
Low |
X-ray diagnostic mammography 6-month follow-up |
7 |
Once work-up demonstrates uniform, probably benign appearance of all calcifications. |
Low |
MRI breast |
2 |
Specific indications are still being investigated. |
None |
Excisional biopsy breast |
2 |
|
None |
INV fine needle aspiration breast |
2 |
|
IP |
US breast |
2 |
|
None |
INV core biopsy breast |
2 |
|
IP |
NUC sestamibi scan breast |
1 |
|
High |
Rating Scale: 1=Least appropriate, 9=Most appropriate |
*Relative Radiation Level |
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 7: Amorphous in a regional distribution.
Radiologic Procedure |
Rating |
Comments |
RRL* |
X-ray mammography magnification views |
8 |
CC and 90° lateral views preferred. |
Low |
X-ray 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. They will also be useful for pre-stereotactic localization or localization procedure. |
Low |
INV core biopsy breast |
6 |
|
IP |
MRI breast |
2 |
Specific indications are still being investigated. |
None |
INV fine needle aspiration breast |
2 |
|
IP |
Excisional biopsy breast |
2 |
|
None |
X-ray diagnostic mammography 6-month follow-up |
2 |
|
Low |
US breast |
2 |
|
None |
NUC sestamibi scan breast |
1 |
|
High |
Rating Scale: 1=Least appropriate, 9=Most appropriate |
*Relative Radiation Level |
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 Procedure |
Rating |
Comments |
RRL* |
X-ray mammography magnification views |
9 |
CC and 90° lateral views preferred. |
Low |
INV core biopsy breast |
8 |
|
IP |
X-ray 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. They will also be useful for pre-stereotactic localization or localization procedure. |
Low |
Excisional breast biopsy |
6 |
If discordant needle biopsy results or concerned about sampling error. If image guided percutaneous biopsy not available. |
None |
US breast |
4 |
May be useful in dense breast to look for mass component in lesion. |
None |
X-ray diagnostic mammography 6-month follow-up |
2 |
|
Low |
INV fine needle aspiration breast |
2 |
|
IP |
MRI breast |
2 |
Specific indications are still being investigated. |
None |
NUC sestamibi scan breast |
1 |
|
High |
Rating Scale: 1=Least appropriate, 9=Most appropriate |
*Relative Radiation Level |
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 Procedure |
Rating |
Comments |
RRL* |
X-ray mammography magnification views |
2 |
|
Low |
X-ray mammography orthogonal views |
2 |
|
Low |
US breast |
2 |
|
None |
X-ray diagnostic mammography 6-month follow-up |
2 |
|
Low |
INV fine needle aspiration breast |
2 |
|
IP |
INV core biopsy breast |
2 |
|
IP |
Excisional breast biopsy |
2 |
|
None |
MRI breast |
2 |
Specific indications are still being investigated. |
None |
NUC sestamibi scan breast |
1 |
|
High |
Rating Scale: 1=Least appropriate, 9=Most appropriate |
*Relative Radiation Level |
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 10: Round or punctate, clustered.
Radiologic Procedure |
Rating |
Comments |
RRL* |
X-ray mammography magnification views |
8 |
CC and 90° lateral views preferred. |
Low |
X-ray diagnostic mammography 6-month follow-up |
8 |
Biopsy if increasing |
Low |
X-ray 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. |
Low |
INV core biopsy breast |
4 |
Only if increasing. |
IP |
Excisional biopsy breast |
3 |
|
None |
INV fine needle aspiration breast |
2 |
|
IP |
US breast |
2 |
|
None |
MRI breast |
2 |
Specific indications are still being investigated. |
None |
NUC sestamibi scan breast |
1 |
|
High |
Rating Scale: 1=Least appropriate, 9=Most appropriate |
*Relative Radiation Level |
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 11: Round or punctate, regional.
Radiologic Procedure |
Rating |
Comments |
RRL* |
X-ray mammography magnification views |
8 |
CC and 90° lateral views preferred. |
Low |
X-ray 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. |
Low |
X-ray diagnostic mammography 6-month follow-up |
6 |
If magnification views show calcifications that are probably benign. |
Low |
Excisional biopsy breast |
2 |
|
None |
US breast |
2 |
|
None |
INV fine needle aspiration breast |
2 |
|
IP |
INV core biopsy breast |
2 |
|
IP |
MRI breast |
2 |
Specific indications are still being investigated. |
None |
NUC sestamibi scan breast |
1 |
|
High |
Rating Scale: 1=Least appropriate, 9=Most appropriate |
*Relative Radiation Level |
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 Procedure |
Rating |
Comments |
RRL* |
X-ray mammography magnification views |
8 |
CC and 90° lateral views preferred. |
Low |
INV core biopsy breast |
8 |
|
IP |
X-ray 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. They will also be useful for pre-stereotactic localization or localization procedure. |
Low |
Excisional biopsy breast |
6 |
If discordant needle biopsy results or concerned about sampling error. If image guided percutaneous biopsy not available. |
None |
US breast |
4 |
May be useful in dense breast to look for mass component in lesion. |
None |
X-ray diagnostic mammography 6-month follow-up |
2 |
|
Low |
INV fine needle aspiration breast |
2 |
|
IP |
MRI breast |
2 |
Specific indications are still being investigated. |
None |
NUC sestamibi scan breast |
1 |
|
High |
Rating Scale: 1=Least appropriate, 9=Most appropriate |
*Relative Radiation Level |
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 13: Punctate and amorphous, diffuse, bilateral.
Radiologic Procedure |
Rating |
Comments |
RRL* |
INV fine needle aspiration breast |
2 |
|
IP |
INV core biopsy breast |
2 |
|
IP |
Excisional biopsy breast |
2 |
|
None |
MRI breast |
2 |
Specific indications are still being investigated. |
None |
X-ray mammography magnification views |
2 |
|
Low |
X-ray mammography orthogonal views |
2 |
|
Low |
X-ray diagnostic mammography 6-month follow-up |
2 |
|
Low |
US breast |
2 |
|
None |
NUC sestamibi scan breast |
1 |
|
High |
Rating Scale: 1=Least appropriate, 9=Most appropriate |
*Relative Radiation Level |
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 14: Course heterogeneous, single cluster.
Radiologic Procedure |
Rating |
Comments |
RRL* |
X-ray mammography magnification views |
8 |
CC and 90° lateral views preferred. |
Low |
X-ray 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. They will also be useful for pre-stereotactic localization or localization procedure. |
Low |
INV core biopsy breast |
6 |
If new or increasing. |
IP |
X-ray diagnostic mammography 6-month follow-up |
5 |
If magnification views demonstrate the calcifications to be probably benign. |
Low |
Excisional biopsy breast |
4 |
If suspicious and core not available. |
None |
INV fine needle aspiration breast |
2 |
|
IP |
MRI breast |
2 |
Specific indications are still being investigated. |
None |
US breast |
2 |
|
None |
NUC sestamibi scan breast |
1 |
|
High |
Rating Scale: 1=Least appropriate, 9=Most appropriate |
*Relative Radiation Level |
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 Procedure |
Rating |
Comments |
RRL* |
X-ray mammography magnification views |
8 |
CC and 90° lateral views preferred. |
Low |
X-ray 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. |
Low |
X-ray diagnostic mammography 6-month follow-up |
7 |
If magnification views demonstrate the calcifications to be probably benign. |
Low |
Excisional biopsy breast |
2 |
|
None |
MRI breast |
2 |
Specific indications are still being investigated. |
None |
US breast |
2 |
|
None |
INV fine needle aspiration breast |
2 |
|
IP |
INV core biopsy breast |
2 |
|
IP |
NUC sestamibi scan breast |
1 |
|
High |
Rating Scale: 1=Least appropriate, 9=Most appropriate |
*Relative Radiation Level |
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 16: Course heterogeneous, multiple bilateral clusters.
Radiologic Procedure |
Rating |
Comments |
RRL* |
X-ray mammography magnification views |
2 |
|
Low |
X-ray mammography orthogonal views |
2 |
|
Low |
US breast |
2 |
|
None |
X-ray diagnostic mammography 6-month follow-up |
2 |
|
Low |
INV fine needle aspiration breast |
2 |
|
IP |
INV core biopsy breast |
2 |
|
IP |
Excisional biopsy breast |
2 |
|
None |
MRI breast |
2 |
Specific indications are still being investigated. |
None |
NUC sestamibi scan breast |
1 |
|
High |
Rating Scale: 1=Least appropriate, 9=Most appropriate |
*Relative Radiation Level |
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 17: Course heterogeneous, in regional distribution.
Radiologic Procedure |
Rating |
Comments |
RRL* |
X-ray mammography magnification views |
8 |
CC and 90° lateral views preferred. |
Low |
X-ray 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. |
Low |
X-ray diagnostic mammography 6-month follow-up |
7 |
If magnification views demonstrate the calcifications to be probably benign. |
Low |
INV core biopsy breast |
4 |
If new or increasing. |
IP |
US breast |
3 |
If biopsy is contemplated and tissue is dense, may be useful to look for mass component in lesion. |
None |
INV fine needle aspiration breast |
2 |
|
IP |
Excisional biopsy breast |
2 |
|
None |
MRI breast |
2 |
Specific indications are still being investigated. |
None |
NUC sestamibi scan breast |
1 |
|
High |
Rating Scale: 1=Least appropriate, 9=Most appropriate |
*Relative Radiation Level |
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 Procedure |
Appropriateness Rating |
Comments |
RRL* |
X-ray mammography magnification views |
8 |
CC and 90° lateral views preferred. |
Low |
INV core biopsy breast |
8 |
|
IP |
X-ray 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. They will also be useful for pre-stereotactic localization or localization procedure. |
Low |
US breast |
4 |
May be useful in dense breast to look for mass component in lesion. |
None |
X-ray diagnostic mammography 6-month follow-up |
2 |
|
Low |
INV fine needle aspiration breast |
2 |
|
IP |
Excisional biopsy breast |
2 |
|
None |
MRI breast |
2 |
Specific indications are still being investigated. |
None |
NUC sestamibi scan breast |
1 |
|
High |
Rating Scale: 1=Least appropriate, 9=Most appropriate |
*Relative Radiation Level |
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
- IP, in progress
- MRI, magnetic resonance imaging
- NUC, nuclear medicine
- US, ultrasound
Relative Radiation Level |
Effective Dose Estimated Range |
None |
0 |
Minimal |
<0.1 mSv |
Low |
0.1-1 mSv |
Medium |
1-10 mSv |
High |
10-100 mSv |