• D'Orsi C, Bassett LW, Berg WA, Bohm-Velez M, Evans WP III, Farria DM, Lee C, Mendelson E, Goldstein S, Expert Panel on Women's Imaging. Breast microcalcifications. [online publication]. Reston (VA): American College of Radiology (ACR); 2005. 12 p. [17 references]

This is the current release of the guideline.

It updates a previously published version: Cardenosa G, Mendelson E, Bassett L, Bohm-Velez M, D'Orsi C, Evans WP 3rd, Monsees B, Thurmond A, Goldstein S. Appropriate imaging work-up of breast microcalcifications. American College of Radiology. ACR Appropriateness Criteria. Radiology. 2000 Jun;215 Suppl:973-80.

The appropriateness criteria are reviewed annually and updated by the panels as needed, depending on introduction of new and highly significant scientific evidence.

Breast microcalcifications

Diagnosis
Evaluation

Family Practice
Internal Medicine
Nuclear Medicine
Obstetrics and Gynecology
Oncology
Radiology

Health Plans
Hospitals
Managed Care Organizations
Physicians
Utilization Management

To evaluate the appropriateness of radiologic procedures for patients with breast microcalcifications

Women with breast microcalcifications

1. X-ray (mammography)
   • Magnification views & magnification views with 2 projections
   • Orthogonal views (90^o lateral and cranial-caudal [CC] views if not readily available)
   • Tangential views, dermal localization exam
2. Invasive procedures
   • Core biopsy
   • Excisional biopsy
   • Fine needle aspiration (FNA)
3. Ultrasound (US)
4. Magnetic resonance imaging (MRI)
5. Physical examination
6. Six month follow-up
7. Nuclear medicine (NUC), sestamibi

Utility of radiologic examinations in differential diagnosis

Searches of Electronic Databases

The guideline developer performed literature searches of peer-reviewed medical journals, and the major applicable articles were identified and collected.

The total number of source documents identified as the result of the literature search is not known.

Weighting According to a Rating Scheme (Scheme Not Given)

Not stated

Systematic Review with Evidence Tables

One or two topic leaders within a panel assume the responsibility of developing an evidence table for each clinical condition, based on analysis of the current literature. These tables serve as a basis for developing a narrative specific to each clinical condition.

Expert Consensus (Delphi)

Since data available from existing scientific studies are usually insufficient for meta-analysis, broad-based consensus techniques are needed for reaching agreement in the formulation of the appropriateness criteria. The American College of Radiology (ACR) Appropriateness Criteria panels use a modified Delphi technique to arrive at consensus. Serial surveys are conducted by distributing questionnaires to consolidate expert opinions within each panel. These questionnaires are distributed to the participants along with the evidence table and narrative as developed by the topic leader(s). Questionnaires are completed by the participants in their own professional setting without influence of the other members. Voting is conducted using a scoring system from 1 to 9, indicating the least to the most appropriate imaging examination or therapeutic procedure. The survey results are collected, tabulated in anonymous fashion, and redistributed after each round. A maximum of three rounds is conducted and opinions are unified to the highest degree possible. Eighty percent agreement is considered a consensus. This modified Delphi technique enables individual, unbiased expression, is economical, easy to understand, and relatively simple to conduct.

If consensus cannot be reached by this Delphi technique, the panel is convened and group consensus techniques are utilized. The strengths and weaknesses of each test or procedure are discussed and consensus reached whenever possible. If "No consensus" appears in the rating column, reasons for this decision are added to the comment sections.

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

Internal Peer Review

Criteria developed by the Expert Panels are reviewed by the American College of Radiology (ACR) Committee on Appropriateness Criteria.

ACR Appropriateness Criteria®

Clinical Condition: Breast Calcifications

Variant 1: Pleomorphic, fine, linear, branching in any distribution.

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 2: Documentation of skin calcification.

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 3: Milk of calcium, any distribution.

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 4: Amorphous, single cluster.

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 5: Amorphous, multiple cluster, one breast.

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 6: Amorphous, multiple bilateral clusters.

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 7: Amorphous in a regional distribution.

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.

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.

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 10: Round or punctate, clustered.

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 11: Round or punctate, regional.

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.

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 13: Punctate and amorphous, diffuse, bilateral.

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 14: Course heterogeneous, single cluster.

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 15: Course heterogeneous, multiple clusters, one breast.

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 16: Course heterogeneous, multiple bilateral clusters.

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 17: Course heterogeneous, in regional distribution.

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.

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

Algorithms were not developed from criteria guidelines.

The recommendations are based on analysis of the current literature and expert panel consensus.

Selection of appropriate radiologic imaging procedures for the evaluation of patients with breast microcalcifications

Relative Radiation Level (RRL)

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Additional information regarding radiation dose assessment for imaging examinations can be found in the American College of Radiology (ACR) Appropriateness Criteria® Radiation Dose Assessment Introduction document (see "Availability of Companion Documents" field).

An American College of Radiology (ACR) Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists, and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient's clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those exams generally used for evaluation of the patient's condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the U.S. Food and Drug Administration (FDA) have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.

An implementation strategy was not provided.

Getting Better
Staying Healthy

Effectiveness

• D'Orsi C, Bassett LW, Berg WA, Bohm-Velez M, Evans WP III, Farria DM, Lee C, Mendelson E, Goldstein S, Expert Panel on Women's Imaging. Breast microcalcifications. [online publication]. Reston (VA): American College of Radiology (ACR); 2005. 12 p. [17 references]

Not applicable: The guideline was not adapted from another source.

1996 (revised 2005)

American College of Radiology - Medical Specialty Society

The American College of Radiology (ACR) provided the funding and the resources for these ACR Appropriateness Criteria®.

Committee on Appropriateness Criteria, Expert Panel on Women's Imaging--Breast Work Group

Panel Members: Carl D'Orsi, MD; Lawrence W. Bassett, MD; Wendie A. Berg, MD, PhD; Marcela Bohm-Velez, MD; W. Phil Evans III, MD; Dione Marie Farria, MD, MPH; Carol Lee, MD; Ellen Mendelson, MD; Steven Goldstein, MD

Not stated

This is the current release of the guideline.

It updates a previously published version: Cardenosa G, Mendelson E, Bassett L, Bohm-Velez M, D'Orsi C, Evans WP 3rd, Monsees B, Thurmond A, Goldstein S. Appropriate imaging work-up of breast microcalcifications. American College of Radiology. ACR Appropriateness Criteria. Radiology. 2000 Jun;215 Suppl:973-80.

The appropriateness criteria are reviewed annually and updated by the panels as needed, depending on introduction of new and highly significant scientific evidence.

None available

This NGC summary was completed by ECRI on February 13, 2006.