Is breast arterial calcification associated with coronary artery disease?-A systematic review and meta-analysis

Mammographic breast features and risk of cardiovascular diseases in korean women

BACKGROUND

There is a growing amount of evidence on the association between cardiovascular diseases (CVDs) and breast calcification. Thus, mammographic breast features have recently gained attention as CVD predictors.

OBJECTIVE

This study assessed the association of mammographic features, including benign calcification, microcalcification, and breast density, with cardiovascular diseases.

METHODS

This study comprised 6,878,686 women aged ≥40 who underwent mammographic screening between 2009 and 2012 with follow-up until 2020. The mammographic features included benign calcification, microcalcification, and breast density. The cardiovascular diseases associated with the mammographic features were assessed using logistic regression.

RESULTS

The prevalence of benign calcification, microcalcification, and dense breasts were 9.6 %, 0.9 % and 47.3 % at baseline, respectively. Over a median follow-up of 10 years, benign calcification and microcalcification were positively associated with an increased risk of chronic ischaemic heart disease whereas breast density was inversely associated with it; the corresponding aOR (95 % CI) was 1.14 (1.10-1.17), 1.19 (1.03-1.15), and 0.88 (0.85-0.90), respectively. A significantly increased risk of chronic ischaemic heart disease (IHD) was observed among women with benign calcifications (aHR, 1.14; 95 % CI 1.10-1.17) and microcalcifications (aOR, 1.19; 95 % CI 1.06-1.33). Women with microcalcifications had a 1.16-fold (95 % CI 1.03-1.30) increased risk of heart failure.

CONCLUSIONS

Mammographic calcifications were associated with an increased risk of chronic ischaemic heart diseases, whereas dense breast was associated with a decreased risk of cardiovascular disease. Thus, the mammographic features identified on breast cancer screening may provide an opportunity for cardiovascular disease risk identification and prevention.

Deep transfer learning for detection of breast arterial calcifications on mammograms: a comparative study

INTRODUCTION

Breast arterial calcifications (BAC) are common incidental findings on routine mammograms, which have been suggested as a sex-specific biomarker of cardiovascular disease (CVD) risk. Previous work showed the efficacy of a pretrained convolutional network (CNN), VCG16, for automatic BAC detection. In this study, we further tested the method by a comparative analysis with other ten CNNs.

MATERIAL AND METHODS

Four-view standard mammography exams from 1,493 women were included in this retrospective study and labeled as BAC or non-BAC by experts. The comparative study was conducted using eleven pretrained convolutional networks (CNNs) with varying depths from five architectures including Xception, VGG, ResNetV2, MobileNet, and DenseNet, fine-tuned for the binary BAC classification task. Performance evaluation involved area under the receiver operating characteristics curve (AUC-ROC) analysis, F1-score (harmonic mean of precision and recall), and generalized gradient-weighted class activation mapping (Grad-CAM++) for visual explanations.

RESULTS

The dataset exhibited a BAC prevalence of 194/1,493 women (13.0%) and 581/5,972 images (9.7%). Among the retrained models, VGG, MobileNet, and DenseNet demonstrated the most promising results, achieving AUC-ROCs > 0.70 in both training and independent testing subsets. In terms of testing F1-score, VGG16 ranked first, higher than MobileNet (0.51) and VGG19 (0.46). Qualitative analysis showed that the Grad-CAM++ heatmaps generated by VGG16 consistently outperformed those produced by others, offering a finer-grained and discriminative localization of calcified regions within images.

CONCLUSION

Deep transfer learning showed promise in automated BAC detection on mammograms, where relatively shallow networks demonstrated superior performances requiring shorter training times and reduced resources.

RELEVANCE STATEMENT

Deep transfer learning is a promising approach to enhance reporting BAC on mammograms and facilitate developing efficient tools for cardiovascular risk stratification in women, leveraging large-scale mammographic screening programs.

KEY POINTS

• We tested different pretrained convolutional networks (CNNs) for BAC detection on mammograms. • VGG and MobileNet demonstrated promising performances, outperforming their deeper, more complex counterparts. • Visual explanations using Grad-CAM++ highlighted VGG16's superior performance in localizing BAC.

Assessing breast arterial calcification in mammograms and its implications for atherosclerotic cardiovascular disease risk

PURPOSE

Breast arterial calcifications (BAC) are incidentally observed on mammograms, yet their implications remain unclear. We investigated lifestyle, reproductive, and cardiovascular determinants of BAC in women undergoing mammography screening. Further, we investigated the relationship between BAC, coronary arterial calcifications (CAC) and estimated 10-year atherosclerotic cardiovascular (ASCVD) risk.

METHODS

In this cross-sectional study, we obtained reproductive history and CVD risk factors from 215 women aged 18 or older who underwent mammography and cardiac computed tomographic angiography (CCTA) within a 2-year period between 2007 and 2017 at hospital. BAC was categorized as binary (present/absent) and semi-quantitatively (mild, moderate, severe). CAC was determined using the Agatston method and recorded as binary (present/absent). Adjusted odds ratios (ORs) and 95 % confidence intervals (CIs) were calculated, accounting for age as a confounding factor. ASCVD risk over a 10-year period was calculated using the Pooled Cohort Risk Equations.

RESULTS

Older age, systolic and diastolic blood pressures, higher parity, and younger age at first birth (≤28 years) were significantly associated with greater odds of BAC. Women with both BAC and CAC had the highest estimated 10-year risk of ASCVD (13.30 %). Those with only BAC (8.80 %), only CAC (5.80 %), and no BAC or CAC (4.40 %) had lower estimated 10-year risks of ASCVD. No association was detected between presence of BAC and CAC.

CONCLUSIONS

These findings support the hypothesis that BAC on a screening mammogram may help to identify women at potentially increased risk of future cardiovascular disease without additional cost and radiation exposure.

Patient Notification About Breast Arterial Calcification on Mammography: Empowering Women With Information About Cardiovascular Risk

OBJECTIVE

To assess the impact of informing women about the presence of breast arterial calcification (BAC) on mammography by determining whether those notified about the presence of BAC would seek cardiovascular evaluation.

METHODS

This IRB-approved prospective study included 494 patients who underwent screening mammography between June 8, 2021, and April 22, 2022. Mammograms were reviewed by a radiologist, and patients were notified via e-mail about the presence or absence of BAC. Patients with BAC were advised to discuss the results with their physicians and were surveyed 3 months later. Frequencies and proportions were calculated for study participation, presence of BAC, survey participation, health actions, and perceptions. Confidence intervals were calculated for proportions of health actions and perceptions.

RESULTS

Of 494 study participants, 68/494 (13.8%; 95% CI: 10.9%-17.1%) had BAC detected on mammography and 42/68 (61.8%; 95% CI: 61.1%-62.1%) with BAC completed the follow-up survey at 3 months. Of these 42 survey respondents, 24/42 (57.1%; 95% CI: 41.1%-72.3%) reported discussing results with their primary care physician (PCP) or a cardiologist. In addition, 34/42 (81.0%; 95% CI: 65.9%-91.4%) reported finding it helpful to receive information about BAC and 32/42 (76.2%; 95% CI: 60.6%-88.0%) believed all women should be informed about BAC after mammography.

CONCLUSION

After notification about the presence of BAC on screening mammography, the majority (57.1%) of survey respondents reported discussing the results with a PCP or cardiologist. These results suggest that providing mammography patients with information about BAC may promote preventive cardiovascular health.

Opportunistic screening at chest computed tomography: literature review of cardiovascular significance of incidental findings

Background and Objective

Several incidental cardiovascular findings are present in a routine chest computed tomography (CT) scan, many of which do not make it to the final radiology report. However, these findings have important clinical implications, particularly providing prognosis and risk-stratification for future cardiovascular events. The purpose of this article is to review the literature on these incidental cardiovascular findings in a routine chest CT and inform the radiologist on their clinical relevance.

Methods

A time unlimited review of PubMed and Web of Science was performed by using relevant keywords. Articles in English that involved adults were included.

Key Content and Findings

Coronary artery calcification (CAC) is the most common incidental cardiac finding detected in a routine chest CT and is a significant predictor of cardiovascular events. Noncoronary vascular calcifications in chest CT include aortic valve, mitral annulus, and thoracic aortic calcifications (TAC). Among these, aortic valve calcification (AVC) has the strongest association with coronary artery disease and cardiovascular events. Additional cardiac findings such as myocardial scar and left ventricular size and noncardiac findings such as thoracic fat, bone density, hepatic steatosis, and breast artery calcifications can also help in risk stratification and patient management.

Conclusions

The radiologist interpreting a routine chest CT should be cognizant of the incidental cardiovascular findings, which helps in the diagnosis and risk-stratification of cardiovascular disease. This will guide appropriate referral and management.

Associations of Breast Arterial Calcifications with Cardiovascular Disease

Cardiovascular diseases (CVD), including coronary artery disease (CAD), continue to be the leading cause of global mortality among women. While traditional CVD/CAD prevention tools play a significant role in reducing morbidity and mortality among both men and women, current tools for preventing CVD/CAD rely on traditional risk factor-based algorithms that often underestimate CVD/CAD risk in women compared with men. In recent years, some studies have suggested that breast arterial calcifications (BAC), which are benign calcifications seen in mammograms, may be linked to CVD/CAD. Considering that millions of women older than 40 years undergo annual screening mammography for breast cancer as a regular activity, innovative risk prediction factors for CVD/CAD involving mammographic data could offer a gender-specific and convenient solution. Such factors that may be independent of, or complementary to, current risk models without extra cost or radiation exposure are worthy of detailed investigation. This review aims to discuss relevant studies examining the association between BAC and CVD/CAD and highlights some of the issues related to previous studies' design such as sample size, population types, method of assessing BAC and CVD/CAD, definition of cardiovascular events, and other confounding factors. The work may also offer insights for future CVD risk prediction research directions using routine mammograms and radiomic features other than BAC such as breast density and macrocalcifications.

The association between breast arterial calcification and atherosclerotic cardiovascular disease in an Australian population-based breast cancer case-control study

PURPOSE

Atherosclerotic cardiovascular disease (ASCVD) is a major cause of morbidity and mortality. Breast arterial calcification (BAC) on mammograms is not associated with breast cancer risk. However, there is increasing evidence supporting its association with cardiovascular disease (CVD). This study examines the association between BAC and ASCVD and their risk factors within an Australian population-based breast cancer study.

MATERIALS AND METHODS

Data from the controls who participated in the breast cancer environment and employment study (BCEES) were linked with the Western Australian Department of Health Hospital Morbidity database and Mortality Registry to obtain ASCVD outcomes and related risk factor data. Mammograms from participants with no prior history of ASCVD were assessed for BAC by a radiologist. Cox proportional hazards regression was used to examine the association between BAC and later occurrence of an ASCVD event. Logistic regression was used to investigate the factors associated with BAC.

RESULTS

A total of 1020 women with a mean age of 60 (sd = 7.0 years) were included and BAC found in 184 (18.0%). Eighty (7.8%) of the 1020 participants developed ASCVD, with an average time to event of 6.2 years (sd = 4.6) from baseline. In univariate analysis, participants with BAC were more likely to have an ASCVD event (HR = 1.96 95% CI 1.29-2.99). However, after adjusting for other risk factors, this association attenuated (HR = 1.37 95% CI 0.88-2.14). Increasing age (OR = 1.15, 95% CI 1.12-1.19) and parity (p_LRT < 0.001) were associated with BAC.

CONCLUSION

BAC is associated with increased ASCVD risk, but this is not independent of cardiovascular risk factors.

The association between incidentally found breast arterial calcification on routine screening mammography and the development of coronary artery disease and stroke: results of a 10-year prospective study

OBJECTIVE

The objective of this study is to assess whether the presence of breast arterial calcifications (BACs) found on routine mammography is prospectively associated with the development of cardiovascular disease (CVD) events after 10 years of follow-up.

METHODS

Women presenting for screening mammography were enrolled in this prospective cohort. Baseline data were collected including history of CVD and CVD risk factors. Mammograms were assessed for the presence or absence of BAC. Participants completed questionnaires 10 years after baseline that assessed the development of CVD (coronary artery disease [CAD] and stroke) and CVD risk factors.

RESULTS

Of the 1,995 participants who enrolled at baseline, complete 10-year follow-up data were available for 1,039; of those, 114 (11.0%) were BAC-positive and 925 (89.0%) were BAC-negative at baseline. After controlling for age, BAC-positive women were more likely to develop CAD (odds ratio, 3.14; 95% confidence interval, 1.86-5.27; P < 0.001) compared with BAC-negative women after 10 years of follow-up. After controlling for age, BAC-positive women were more likely to have had a stroke (odds ratio, 5.10; 95% CI, 1.82-14.30) compared with BAC-negative women after 10 years.

CONCLUSIONS

The presence of BAC on routine screening mammography was associated with a significantly increased risk of developing CAD and stroke after 10 years of follow-up. Additional large prospective, population-based studies are needed to confirm BAC as a predictor of future CVD events and its utility in stratifying a woman's risk of CVD.

Association Between Breast Arterial Calcification on Mammography and Coronary Artery Disease: A Systematic Review and Meta-Analysis

Background: Breast arterial calcification (BAC), which may be detected during screening mammography, is hypothesized to be a noninvasive imaging marker that may enhance cardiovascular risk assessment. Materials and Methods: In this systematic review and meta-analysis, we sought to assess the association between BAC and coronary artery disease (CAD) by conducting a meta-analysis. We conducted a literature search of PubMed, Scopus, Cochrane library, ClinicalTrials.gov, and conference proceedings, from inception through December 24, 2019. The outcome of interest was the presence of CAD in patients with BAC. This was reported as crude and adjusted odds ratio (OR). Results: A total of 18 studies comprising 33,494 women (mean age of 60.8 ± 3.7 years, 25% with diabetes, 57% with hypertension, and 21% with history of tobacco smoking) were included in the current meta-analysis. The prevalence of BAC among study participants was 10%. There was a statistically significant association between BAC and CAD (unadjusted OR 2.14; 95% confidence interval [CI] 1.63-2.81, p < 0.001, I2 = 76.5%). Moreover, adjusted estimates were available from 10 studies and BAC was an independent predictor of CAD (OR 2.39; 95% CI 1.68-3.41, p < 0.001, I2 = 61.7%). In the meta-regression analysis, covariates included year of publication, age, hypertension, diabetes mellitus, and history of tobacco smoking. None of these study covariates explained the heterogeneity across studies. Conclusions: BAC detected as part of screening mammography is a promising noninvasive imaging marker that may enhance CAD risk prediction in women. The clinical value of BAC for cardiovascular risk stratification merits further evaluation in large prospective studies.

Prevalence and Severity of Breast Arterial Calcification on Routine Mammography

Aim. To determine the frequency of detection and severity of breast arterial calcification (BAC) among women undergoing mammography on the basis of medical institutions in Moscow.Material and methods. The analysis included 4274 digital mammograms of women aged 40-93 who underwent preventive or diagnostic mammography. Standard full-format digital mammograms were performed in craniocaudal and mediolateral oblique projections. In addition to the standard diagnosis of breast disease, all mammograms were evaluated for the presence of BAC. The severity of BAC was assessed on a 12-point scale: mild 3-4 points, moderate 5-6 points, severe 7-12 points.Results. The average frequency of BAC was 10.1%, in the middle age group 50-59 years – 6.0%. The incidence of BAC increased with age, from 0.4% to 0.6% in women <50 years of age to >50% in women ≥80 years of age. A statistically significant and pronounced correlation was found between the woman's age and the presence of BAC r Pearson =0.769 (p<0.001). There was also a less noticeable but statistically significant correlation between age and severity of BAC r Spearman =0.319 (p<0.001). Regression analysis made it possible to estimate the probability of CAD depending on age. In women <50 years of age, only mild to moderate calcification occurred, while those ≥65 years of age had a significant increase in the incidence of severe CAD.Conclusion. There was an expected increase with age in both prevalence and severity of BAC. Cases of severe BAC in women younger than 65 years of age and any BAC in women younger than 50 years of age are atypical and require clarification of their association with cardiovascular and other diseases.

Breast arterial calcification and epicardial adipose tissue volume, but not density are independently associated with cardiovascular risk

BACKGROUND

Mammographically detected breast arterial calcification (BAC) has been proposed as surrogate marker for coronary artery disease (CAD) in women. Epicardial adipose tissue (EAT) and peri-coronary adipose tissue (PCAT) are inflammatory fat depots linked to atherogenesis. BAC has demonstrated association with inflammation, therefore we aimed to determine the association between BAC, EAT and PCAT.

METHODS

Single-centre, retrospective, cross-sectional study of women with digital mammography and coronary computed tomography angiography (CCTA). EAT and PCAT were quantitively assessed using semi-automated software. Patient demographics and cardiovascular risk factors were obtained from medical records and mammograms reviewed for BAC. Pre-test cardiovascular risk was determined with CAD Consortium Score. Chi-square, t-test and Mann-Whitney U tests were used to assess between group differences. Multivariable linear and logistic regression modelling was conducted to adjust for confounders.

RESULTS

Among 153 patients (age 61, SD 11) included in this study, BAC was present in 37 (24%) patients. BAC-positive patients had higher EAT volume (EATv) (110.2 mL, SD 41 mL vs 94.4 mL, SD 41 mL, p = 0.02) but this association was not significant after adjusting for cardiovascular risk factors (p = 0.26). BAC did not associate with EAT density or PCAT. BAC and EATv were strongly associated with cardiovascular risk and CAD independent of each other: CV risk (BAC OR 7.55 (3.26-18.49), p < 0.001, EATv OR 1.02 (1.01-1.03), p < 0.001), CAD presence (BAC OR 4.26 (1.39-13), p = 0.01; EATv OR 1.01 (1.0-1.03), p = 0.04).

CONCLUSION

BAC and EATv are independent predictors of CV risk and CAD, but don't independently associate with each other, the relationship confounded by shared cardiovascular risk factors. BAC doesn't appear to associate with adipose tissue density and its presence may be cumulative result of long-term exposure to CV risk factors.

Next Generation Risk Markers in Preventive Cardio-oncology

PURPOSE OF REVIEW

Cardiovascular disease (CVD) and cancer are the first and second most common causes of death within the USA. It is well established that a diagnosis of cancer increases risk and predisposes the patient to CVD, and vice versa. Despite these associations, cancer is not yet incorporated into current CVD risk calculators, necessitating additional CV risk markers for improved stratification in this at-risk population. In this review, we consider the utility of breast arterial calcification (BAC), coronary artery calcification (CAC), clonal hematopoiesis of indeterminate potential (CHIP), and cancer and cancer treatment in CVD risk assessment.

RECENT FINDINGS

There is evidence supporting the use of BAC, CAC, CHIP, and cancer and cancer treatment for improved CV risk stratification in patients with cancer and those who are being screened for cancer. BAC has been shown to predict CAC, coronary atherosclerotic plaque on coronary CTA, coronary artery stenosis on coronary angiography, and CVD events and accordingly enhances CVD risk stratification beyond the atherosclerotic CVD (ASCVD) risk pooled cohort equation. Additionally, CAC visualized on CT utilized for lung cancer screening, radiation planning, and cancer staging is predictive of coronary artery disease (CAD). Furthermore, CHIP can also be utilized in risk stratification, as the presence of CHIP carries a 40% increase in CV risk independent of traditional CV risk factors. Finally, cancer and many oncologic therapies confer a lifelong increased risk of CVD. We propose an emerging set of tools to be incorporated into the routine continuum of CVD risk assessment in individuals who have been treated for cancer or who are being screened for cancer development. In this review, we discuss BAC, CAC, CHIP, and cancer and cancer treatment as emerging risk markers in cardiovascular health assessment. Their effectiveness in predicting and influencing the burden of CVD will be discussed, along with suggestions on their incorporation into preventive cardio-oncology practice. Future research will focus on short- and long-term CVD outcomes in these populations.

2022 Prevention of chronic non-communicable diseases in Of the Russian Federation. National guidelines

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Breast arterial calcifications on mammography: a new marker of cardiovascular risk in asymptomatic middle age women?

OBJECTIVES

To determine whether breast arterial calcification (BAC) detected on mammography can predict the presence of coronary artery calcification (CAC) on CT in women.

METHODS

Women explored with both mammography and thoracic CT from 2009 to 2018 were retrospectively included. Women were separated in 3 categories (no BAC, few BAC, and marked BAC) using a specific 12-point scale. Similar scale was used to evaluate the amount of CAC on CT. The mean sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy of BAC for the detection of CAC were calculated. Statistical significance was assessed with Pearson's chi-squared test and Fisher's exact test as appropriate.

RESULTS

A total of 507 women (mean age: 62 years ± 16) were included. Patients with high amount of BAC were older (72 ± 11 vs. 59 ± 15 years old; p < .0001), were more frequently hypertensive (66% vs. 31%; p < .0001), and had more frequently renal failure (21% vs. 6%; p < .0003) than patients without BAC. The sensitivity, specificity, PPV, NPV, and diagnostic accuracy of BAC for the detection of women with marked CAC were 53.1%, 87.6%, 55.0%, 86.7%, and 79.9%, respectively. The highest diagnostic accuracy was obtained in patients under 60 years: 84.2% for detection of CAC and 93.2% for detection of women with marked CAC.

CONCLUSION

The presence of BAC on mammography was linked to the presence of CAC and may be used as a cardiovascular marker in patient less than 60 years.

KEY POINTS

• The diagnostic accuracy of breast arterial calcification (BAC) to detect the presence of coronary artery calcification (CAC) was 70.4% and reached to 79.9% to detect women with high amount of CAC. • Highest diagnostic accuracy of BAC to detect CAC (93.2%) was noticed in women under 60 years. • The presence of BAC on mammography may be used as a cardiovascular risk marker in women, especially under 60 years.

Reporting and Perceptions of Breast Arterial Calcification on Mammography: A Survey of ACR Radiologists

RATIONALE AND OBJECTIVES

The ACR Breast Commission conducted a member survey to evaluate current practices of reporting breast arterial calcification (BAC) on mammography and to determine perceptions about the value of BAC communication and follow-up recommendations among radiologists.

MATERIALS AND METHODS

In September 2020, an 18-item online survey was emailed to radiologist members of the American College of Radiology (ACR). Questions included radiologist demographics, current BAC reporting practices, follow-up recommendations, and perceptions about BAC. Five-point Likert scales were used and multivariate analysis was performed.

RESULTS

Of 598 completed survey responses, up to 87% (522/598) of ACR radiologist members include BAC in mammogram reports. However, only 41% (212/522) of respondents report BAC 'always' or 'most of the time'. Radiologist factors significantly associated with BAC reporting include years in practice and fellowship training with those in practice longer more likely to report BAC (OR 1.10, 95% CI, [1.01-1.20], p = 0.023) and those with fellowship training less likely to report BAC (OR 0.63, 95% CI, [0.42-0.94], p = 0.024). When BAC is reported, 69% (360/522) simply indicate the presence of BAC, 23% (121/522) provide a subjective grading of BAC burden, and 1% (6/522) calculate a BAC score. Among the radiologists reporting BAC, 58% (301/522) make no subsequent recommendations, while the remainder recommend primary care follow-up (39%; 204/522), cardiology evaluation (13%; 68/522), and/or coronary calcium scoring CT (11%; 59/522). Overall, there was agreement from 66% (392/598) of respondents that BAC is a cardiovascular risk factor. However, there was no consensus on whether patients and/or providers should be informed about BAC or whether reporting of BAC should become a standardized practice in breast imaging. Older and more experienced radiologists are more likely to agree that BAC is a cardiovascular risk factor (p = 0.022), providers should be informed about BAC (p = 0.002 and 0.006), BAC reporting should be a standardized practice (p = 0.004 and 0.001), and feel more comfortable informing patients about BAC (p = 0.001 and 0.003).

CONCLUSION

Radiologists' reporting practices and perceptions regarding BAC are not homogeneous. Although many radiologists report BAC to varying degrees, it is not routinely reported or recommended for follow-up in mammogram reports. Experienced radiologists are more likely to include and value BAC in their breast imaging practice.

Multimodality imaging review of breast vascular lesions

Breast vasculature is visualised on all screening and diagnostic imaging of the breast. Various vascular breast lesions exist, spanning from chronic systemic processes, congenital malformations, post-traumatic sequela, benign masses, to malignant tumours. Accurate diagnosis of vascular lesions on breast imaging can be difficult due to overlapping characteristics. Radiologists should be aware of key multi-technique imaging features to make an accurate diagnosis and to avoid unnecessary biopsies. This article reviews the normal vascular anatomy of the breast, commonly used imaging techniques to diagnose vascular lesions, and an in-depth review of various vascular breast lesions. Finally, management recommendations and clinical guidance are discussed so that the radiologist can appropriately triage these patients.

Breast Arterial Calcifications: Reporting Preferences and Impact on Screening for Coronary Artery Disease

OBJECTIVE

Breast arterial calcifications (BAC) have been shown to correlate with measures of coronary artery disease risk stratification, although reporting of BAC is optional by BI-RADS guidelines. The purpose of this study is to determine referring provider preferences in BAC reporting on mammography reports and if such reporting has any impact on patient management.

METHODS

This study was approved by the local institutional review board. A voluntary eight-question survey regarding the preferences and outcomes of BAC reporting on mammography was distributed to 1085 primary care physicians, obstetrics and gynecologists, medical oncologists, and breast and general surgeons in our health system via a secure online platform. Data analysis including Pearson chi-square was performed with a P-value of <0.05 for significance.

RESULTS

A response rate of 19.1% (207/1085) was attained, with 21/207 (10.1%) of respondents indicating they do not routinely order mammograms excluded from further analysis. A total of 62.4% (116/186) of ordering physicians indicated a preference for reporting of BAC in both the body and impression of the radiology report, with 82.3% (153/186) of respondents placing importance on the quantity of atherosclerotic calcifications. Most participants (148/186, 79.6%) reported that the presence of BAC would prompt further investigation for coronary artery disease and associated risk factors.

CONCLUSION

The majority of responding physicians indicated a preference for detailed reporting of BAC and that such reporting would impact patient care. Understanding referring provider preferences regarding ancillary findings of BAC will allow for improved communication and value in mammography.

Reproductive factors and breast arterial calcification: a systematic review and meta-analysis

BACKGROUND

Breast arterial calcification (BAC) is a common incidental finding on screening mammography. Recent evidence suggests that BAC is associated with cardiovascular disease (CVD). We systematically reviewed the associations between BAC and reproductive factors (menopausal status, hormone replacement therapy [HRT] use, oral contraceptive [OC] use and parity).

METHODS

MEDLINE and EMBASE databases, references of relevant papers and Web of Science were searched up to February 2020 for English-language studies that evaluated these associations. Study quality were determined and a random effects model was used to assess these associations.

RESULTS

Nineteen observational studies (n = 47,249; three cohort studies, seven case-control studies, nine cross-sectional studies) were included. BAC was associated with menopause (nine studies; n = 15,870; odds ratio [OR] 2.67; 95% confidence interval [CI] 1.50-4.77) and parity (seven studies; n = 27,728; OR 2.50; 95% CI 1.68-3.71) and inversely with HRT use (10 studies; n = 33,156; OR 0.57; 95% CI 0.40-0.80). No association was found with OC use. Eleven studies were considered good in quality. Marked heterogeneity existed across all analyses.

CONCLUSIONS

BAC is associated with HRT use, menopause and parity. However, careful interpretation is required as marked heterogeneity existed across all analyses. Traditional cardiovascular risk factors may need to be taken into account in future investigations of associations between BAC and reproductive factors.

PROSPERO

CRD42020141644.

Breast Arterial Calcifications on Mammography: A Survey of Practicing Radiologists

OBJECTIVE

To explore current practice patterns of reporting and issuing recommendations based on the presence of breast arterial calcifications on mammography and existing knowledge of their prevalence and associated factors.

METHODS

An online anonymous 19-question survey was distributed to 2583 practicing radiologists who were members of the Society of Breast Imaging. Questions covered demographics, breast imaging training, practice type, and knowledge regarding the epidemiology and potential clinical significance of breast arterial calcifications detected on mammograms. Differences between groups were calculated using the chi-square test or Fisher exact test. An α level of 0.05 was used to determine statistical significance.

RESULTS

Response rate was 22% (364/1662). The median age of respondents was 51 years (range: 29-76) and most were female (248/323, 77%). The most prevalent characteristics among respondents were as follows: 69% (223/323) had completed a breast imaging fellowship, 55% (179/323) were in private practice, 49% (158/323) practiced dedicated breast imaging, and 38% (124/323) had been in practice for more than 20 years. The prevalence of breast arterial calcifications was correctly estimated to be 1%-30% by 39% (125/323) of respondents. Most respondents correctly recognized the growing evidence of an association between breast arterial calcifications and coronary artery disease (275/323, 85%). However, only 15% (48/323) always reported the presence of these calcifications, and of those who report them at any time, only 0.7% (2/274) always issued recommendations.

CONCLUSION

There are differences in both knowledge of the epidemiology of breast arterial calcifications and practices around their reporting amongst breast radiologists.

Semiquantitative score of breast arterial calcifications on mammography (BAC-SS): intra- and inter-reader reproducibility

Background

Breast arterial calcifications (BAC), representing Mönckeberg's sclerosis of the tunica media of breast arteries, are an imaging biomarker for cardiovascular risk stratification in the female population. Our aim was to estimate the intra- and inter-reader reproducibility of a semiquantitative score for BAC assessment (BAC-SS).

Methods

Consecutive women who underwent screening mammography at our center from January 1^st to January 31^st, 2018 were retrieved and included according to BAC presence. Two readers (R1 and R2) independently applied the BAC-SS to medio-lateral oblique views, obtaining a BAC score by summing: (I) number of calcified vessels (from 0 to n); (II) vessel opacification, i.e., the degree of artery coverage by calcium bright pixels (0 or 1); and (III) length class of calcified vessels (from 0 to 4). R1 repeated the assessment 2 weeks later. Scoring time was recorded. Cohen's κ statistics and Bland-Altman analysis were used.

Results

Among 408 women, 57 (14%) had BAC; 114 medio-lateral oblique views were assessed. Median BAC score was 4 [interquartile range (IQR): 3-6] for R1 and 4 (IQR: 2-6) for R2 (P=0.417) while median scoring time was 156 s (IQR: 99-314 s) for R1 and 191 s (IQR: 137-292 s) for R2 (P=0.743). Bland-Altman analysis showed a 77% intra-reader reproducibility [bias: 0.193, coefficient of repeatability (CoR): 0.955] and a 64% inter-reader reproducibility (bias: 0.211, CoR: 1.516). Cohen's κ for BAC presence was 0.968 for intra-reader agreement and 0.937 for inter-reader agreement.

Conclusions

Our BAC-SS has a good intra- and inter-reader reproducibility, within acceptable scoring times. A large-scale study is warranted to test its ability to stratify cardiovascular risk in women.

Breast Arterial Calcification: A Potential Biomarker for Atherosclerotic Cardiovascular Disease Risk?

PURPOSE OF REVIEW

We aimed to summarize the current evidence regarding the association between breast arterial calcification (BAC) and atherosclerotic cardiovascular disease (ASCVD) in women and discuss the potential role of BAC in the risk stratification and preventive approaches for ASCVD.

RECENT FINDINGS

BAC has emerged as a potential women-specific risk marker for ASCVD. Although BAC presents as a medial calcification of the arteries, notably different from the intimal atherosclerotic process, current evidence supports a correlation between BAC and ASCVD risk factors or subclinical and clinical ASCVD, such as coronary artery disease or stroke. As millions of women undergo mammograms each year, the potential clinical application of BAC in enhanced ASCVD risk estimation, with no additional cost or radiation, has tremendous appeal. Although further research regarding optimal risk assessment and management in women with BAC is required, the presence of BAC should prompt healthy cardiovascular lifestyle modifications.

Systemic diseases affecting the breast: Imaging, diagnosis, and management

Various systemic diseases of benign or malignant etiologies can clinically manifest in the breast. Some imaging findings of breast lesions can be pathognomonic for a given condition, while others are non-specific, mimicking primary breast carcinoma and requiring tissue biopsy for definitive diagnosis. In addition to obtaining a detailed clinical history, radiologists should be familiar with the diverse clinical and imaging characteristics of these conditions to help exclude primary breast cancer and avoid unnecessary interventions. This review aims to discuss the clinical presentations, imaging features, pathologic findings, and management of systemic conditions that may affect the breast.