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## Complete Summary

#### GUIDELINE TITLE

Breast microcalcifications.

#### BIBLIOGRAPHIC SOURCE(S)

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. \[17 references\]

#### GUIDELINE STATUS

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.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Breast microcalcifications

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation

#### CLINICAL SPECIALTY

Family Practice\
Internal Medicine\
Nuclear Medicine\
Obstetrics and Gynecology\
Oncology\
Radiology

#### INTENDED USERS

Health Plans\
Hospitals\
Managed Care Organizations\
Physicians\
Utilization Management

#### GUIDELINE OBJECTIVE(S)

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

#### TARGET POPULATION

Women with breast microcalcifications

#### INTERVENTIONS AND PRACTICES CONSIDERED

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

#### MAJOR OUTCOMES CONSIDERED

Utility of radiologic examinations in differential diagnosis

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

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

#### NUMBER OF SOURCE DOCUMENTS

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

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Not Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not stated

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

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.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus (Delphi)

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

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.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

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

#### METHOD OF GUIDELINE VALIDATION

Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

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

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**ACR Appropriateness Criteria®**

**Clinical Condition: Calcifications**

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

  ---------------------------------------------------------------------------
  **Radiologic Exam    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  X-ray, breast,       9                   CC and 90° lateral views
  mammography,                             preferred.
  magnification views                      

  INV, breast, biopsy, 9                    
  core                                     

  X-ray, breast,       7                   Orthogonal views may be useful in
  mammography,                             positioning for the spot
  orthogonal views                         compression magnification views to
  (90^o^ lateral and                       be sure to include the
  CC views if not                          calcifications. They will also be
  readily available)                       useful for pre-stereotactic
                                           localization or localization
                                           procedure.

  INV, breast, biopsy, 6                   If discordant needle biopsy
  excisional                               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    2                    
  needle aspiration                        
  (FNA)                                    

  NUC, breast,         1                    
  sestamibi                                

  ***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    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  X-ray, breast,       8                   Only if calcifications are not
  mammography,                             typically dermal in appearance.
  tangential views,                        
  dermal localization                      
  exam                                     

  Physical examination 2                   Physical examination does not play
                                           a role in the evaluation of
                                           calcifications.

  X-ray, breast,       1                    
  mammography,                             
  magnification views                      

  US, breast           1                    

  6-month follow-up    1                    

  INV, breast, fine    1                    
  needle aspiration                        
  (FNA)                                    

  INV, breast, biopsy, 1                    
  core                                     

  INV, breast, fine    1                    
  needle aspiration                        
  (FNA)                                    

  MRI, breast          1                    

  NUC, breast,         1                    
  sestamibi                                

  ***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    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  X-ray, breast,       8                   CC and 90^o^ lateral views
  mammography,                             preferred.
  magnification views                      

  X-ray, breast,       7                   Orthogonal views may be useful in
  mammography,                             positioning for the spot
  orthogonal views                         compression magnification views to
  (90^o^ lateral and                       be sure to include the
  CC views if not                          calcifications.
  readily available)                       

  US, breast           2                    

  6-month follow-up    2                    

  INV, breast, fine    2                    
  needle aspiration                        
  (FNA)                                    

  INV, breast, biopsy, 2                    
  core                                     

  INV, breast, biopsy, 2                    
  excisional                               

  Physical examination 1                   Physical examination does not play
                                           a role in the evaluation of
                                           calcifications.

  MRI, breast          1                    

  NUC, breast,         1                    
  sestamibi                                

  ***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    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  X-ray, breast,       9                   CC and 90° lateral views
  mammography,                             preferred.
  magnification views                      

  INV, breast, biopsy, 8                    
  core                                     

  X-ray, breast,       7                   Orthogonal views may be useful in
  mammography,                             positioning for the spot
  orthogonal views                         compression magnification views to
  (90^o^ lateral and                       be sure to include the
  CC views if not                          calcifications. They will also be
  readily available)                       useful for pre-stereotactic
                                           localization or localization
                                           procedure.

  INV, breast, biopsy, 6                   If discordant needle biopsy
  excisional                               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    2                    
  needle aspiration                        
  (FNA)                                    

  MRI, breast          2                   Specific indications are still
                                           being investigated.

  NUC, breast,         1                    
  sestamibi                                

  ***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    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  X-ray, breast,       9                   CC and 90° lateral views
  mammography,                             preferred.
  magnification views                      

  X-ray, breast,       7                   Orthogonal views may be useful in
  mammography,                             positioning for the spot
  orthogonal views                         compression magnification views to
  (90^o^ lateral and                       be sure to include the
  CC views if not                          calcifications. They will also be
  readily available)                       useful for pre-stereotactic
                                           localization or localization
                                           procedure.

  INV, breast, biopsy, 7                   Sampling of representative
  core                                     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, 3                    
  excisional                               

  US, breast           2                    

  Physical examination 2                   Physical examination does not play
                                           a role in the evaluation of
                                           calcifications.

  INV, breast, fine    2                    
  needle aspiration                        
  (FNA)                                    

  MRI, breast          2                   Specific indications are still
                                           being investigated.

  NUC, breast,         1                    
  sestamibi                                

  ***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    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  X-ray, breast,       8                   CC and 90° lateral views
  mammography,                             preferred.
  magnification views                      

  X-ray, breast,       7                   Orthogonal views may be useful in
  mammography,                             positioning for the spot
  orthogonal views                         compression magnification views to
  (90° lateral and CC                      be sure to include the
  views if not readily                     calcifications.
  available)                               

  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    2                    
  needle aspiration                        
  (FNA)                                    

  INV, breast, biopsy, 2                    
  core                                     

  INV, breast, biopsy, 2                    
  excisional                               

  MRI, breast          2                   Specific indications are still
                                           being investigated.

  NUC, breast,         1                    
  sestamibi                                

  ***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    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  X-ray, breast,       8                   CC and 90° lateral views
  mammography,                             preferred.
  magnification views                      

  X-ray, breast,       7                   Orthogonal views may be useful in
  mammography,                             positioning for the spot
  orthogonal views                         compression magnification views to
  (90^o^ lateral and                       be sure to include the
  CC views if not                          calcifications. They will also be
  readily available)                       useful for pre-stereotactic
                                           localization or localization
                                           procedure.

  INV, breast, biopsy, 6                    
  core                                     

  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    2                    
  needle aspiration                        
  (FNA)                                    

  INV, breast, biopsy, 2                    
  excisional                               

  MRI, breast          2                   Specific indications are still
                                           being investigated.

  NUC, breast,         1                    
  sestamibi                                

  ***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    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  X-ray, breast,       9                   CC and 90° lateral views
  mammography,                             preferred.
  magnification views                      

  INV, breast, biopsy, 8                    
  core                                     

  X-ray, breast,       7                   Orthogonal views may be useful in
  mammography,                             positioning for the spot
  orthogonal views                         compression magnification views to
  (90^o^ lateral and                       be sure to include the
  CC views if not                          calcifications. They will also be
  readily available)                       useful for pre-stereotactic
                                           localization or localization
                                           procedure.

  INV, breast, biopsy, 6                   If discordant needle biopsy
  excisional                               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    2                    
  needle aspiration                        
  (FNA)                                    

  MRI, breast          2                   Specific indications are still
                                           being investigated.

  NUC, breast,         1                    
  sestamibi                                

  ***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    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  X-ray, breast,       2                    
  mammography,                             
  magnification views                      

  X-ray, breast,       2                    
  mammography,                             
  orthogonal views                         

  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    2                    
  needle aspiration                        
  (FNA)                                    

  INV, breast, biopsy, 2                    
  core                                     

  INV, breast, biopsy, 2                    
  excisional                               

  MRI, breast          2                   Specific indications are still
                                           being investigated.

  NUC, breast,         1                    
  sestamibi                                

  ***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    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  X-ray, breast,       8                   CC and 90° lateral views
  mammography,                             preferred.
  magnification views                      

  6-month follow-up    8                   Biopsy if increasing

  X-ray, breast,       7                   Orthogonal views may be useful in
  mammography,                             positioning for the spot
  orthogonal views                         compression magnification views to
  (90^o^ lateral and                       be sure to include the
  CC views if not                          calcifications.
  readily available)                       

  INV, breast, biopsy, 4                   Only if increasing.
  core                                     

  US, breast           2                    

  Physical examination 2                   Physical examination does not play
                                           a role in the evaluation of
                                           calcifications.

  INV, breast, fine    2                    
  needle aspiration                        
  (FNA)                                    

  INV, breast, biopsy, 3                    
  excisional                               

  MRI, breast          2                   Specific indications are still
                                           being investigated.

  NUC, breast,         1                    
  sestamibi                                

  ***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    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  X-ray, breast,       8                   CC and 90° lateral views
  mammography,                             preferred.
  magnification views                      

  X-ray, breast,       7                   Orthogonal views may be useful in
  mammography,                             positioning for the spot
  orthogonal views                         compression magnification views to
  (90^o^ lateral and                       be sure to include the
  CC views if not                          calcifications.
  readily available)                       

  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    2                    
  needle aspiration                        
  (FNA)                                    

  INV, breast, biopsy, 2                    
  core                                     

  INV, breast, biopsy, 2                    
  excisional                               

  MRI, breast          2                   Specific indications are still
                                           being investigated.

  NUC, breast,         1                    
  sestamibi                                

  ***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    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  X-ray, breast,       8                   CC and 90° lateral views
  mammography,                             preferred.
  magnification views                      

  INV, breast, biopsy, 8                    
  core                                     

  X-ray, breast,       7                   Orthogonal views may be useful in
  mammography,                             positioning for the spot
  orthogonal views                         compression magnification views to
  (90^o^ lateral and                       be sure to include the
  CC views if not                          calcifications. They will also be
  readily available)                       useful for pre-stereotactic
                                           localization or localization
                                           procedure.

  INV, breast, biopsy, 6                   If discordant needle biopsy
  excisional                               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    2                    
  needle aspiration                        
  (FNA)                                    

  MRI, breast          2                   Specific indications are still
                                           being investigated.

  NUC, breast,         1                    
  sestamibi                                

  ***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    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  X-ray, breast,       2                    
  mammography,                             
  magnification views                      

  X-ray, breast,       2                    
  mammography,                             
  orthogonal views                         

  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    2                    
  needle aspiration                        
  (FNA)                                    

  Core biopsy          2                    

  INV, breast, biopsy, 2                    
  excisional                               

  MRI, breast          2                   Specific indications are still
                                           being investigated.

  NUC, breast,         1                    
  sestamibi                                

  ***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    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  X-ray, breast,       8                   CC and 90° lateral views
  mammography,                             preferred.
  magnification views                      
  (2 projections)                          

  X-ray, breast,       7                   Orthogonal views may be useful in
  mammography,                             positioning for the spot
  orthogonal views                         compression magnification views to
  (90^o^ lateral and                       be sure to include the
  CC views if not                          calcifications. They will also be
  readily available)                       useful for pre-stereotactic
                                           localization or localization
                                           procedure.

  INV, breast, biopsy, 6                   If new or increasing.
  core                                     

  6-month follow-up    5                   If magnification views demonstrate
                                           the calcifications to be probably
                                           benign.

  INV, breast, biopsy, 4                   If suspicious and core not
  excisional                               available.

  US, breast           2                    

  Physical examination 2                   Physical examination does not play
                                           a role in the evaluation of
                                           calcifications.

  INV, breast, fine    2                    
  needle aspiration                        
  (FNA)                                    

  MRI, breast          2                   Specific indications are still
                                           being investigated.

  NUC, breast,         1                    
  sestamibi                                

  ***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    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  X-ray, breast,       8                   CC and 90° lateral views
  mammography,                             preferred.
  magnification views                      

  X-ray, breast,       7                   Orthogonal views may be useful in
  mammography,                             positioning for the spot
  orthogonal views                         compression magnification views to
  (90° lateral and CC                      be sure to include the
  views if not readily                     calcifications.
  available)                               

  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    2                    
  needle aspiration                        
  (FNA)                                    

  INV, breast, biopsy, 2                    
  core                                     

  INV, breast, biopsy, 2                    
  excisional                               

  MRI, breast          2                   Specific indications are still
                                           being investigated.

  NUC, breast,         1                    
  sestamibi                                

  ***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    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  X-ray, breast,       2                    
  mammography,                             
  magnification views                      

  X-ray, breast,       2                    
  mammography,                             
  orthogonal views                         

  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    2                    
  needle aspiration                        
  (FNA)                                    

  INV, breast, biopsy, 2                    
  core                                     

  INV, breast, biopsy, 2                    
  excisional                               

  MRI, breast          2                   Specific indications are still
                                           being investigated.

  NUC, breast,         1                    
  sestamibi                                

  ***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    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  X-ray, breast,       8                   CC and 90° lateral views
  mammography,                             preferred.
  magnification views                      

  X-ray, breast,       7                   Orthogonal views may be useful in
  mammography,                             positioning for the spot
  orthogonal views                         compression magnification views to
  (90^o^ lateral and                       be sure to include the
  CC views if not                          calcifications.
  readily available)                       

  6-month follow-up    7                   If magnification views demonstrate
                                           the calcifications to be probably
                                           benign.

  INV, breast, biopsy, 4                   If new or increasing.
  core                                     

  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    2                    
  needle aspiration                        
  (FNA)                                    

  INV, breast, biopsy, 2                    
  excisional                               

  MRI, breast          2                   Specific indications are still
                                           being investigated.

  NUC, breast,         1                    
  sestamibi                                

  ***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    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  X-ray, breast,       8                   CC and 90° lateral views
  mammography,                             preferred.
  magnification views                      

  INV, breast, biopsy, 8                    
  core                                     

  X-ray, breast,       7                   Orthogonal views may be useful in
  mammography,                             positioning for the spot
  orthogonal views                         compression magnification views to
  (90^o^ lateral and                       be sure to include the
  CC views if not                          calcifications. They will also be
  readily available)                       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    2                    
  needle aspiration                        
  (FNA)                                    

  INV, breast, biopsy, 2                    
  excisional                               

  MRI, breast          2                   Specific indications are still
                                           being investigated.

  NUC, breast,         1                    
  sestamibi                                

  ***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

#### CLINICAL ALGORITHM(S)

Algorithms were not developed from criteria guidelines.

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

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

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

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

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

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.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Personal Digital Assistant (PDA) Downloads

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Staying Healthy

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

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. \[17 references\]

#### ADAPTATION

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

#### DATE RELEASED

1996 (revised 2005)

#### GUIDELINE DEVELOPER(S)

American College of Radiology - Medical Specialty Society

#### SOURCE(S) OF FUNDING

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

#### GUIDELINE COMMITTEE

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

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*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

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

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.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[American College of Radiology (ACR) Web
site](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonWomensImagingBreastWorkGroup/BreastMicrocalcificationsDoc1.aspx).

ACR Appropriateness Criteria® *Anytime*, *Anywhere*™ (PDA application).
Available from the [ACR Web
site](http://www.acr.org/SecondaryMainMenuCategories/ACRStore/FeaturedCategories/QualityandSafety/ac_pda.aspx).

Print copies: Available from the American College of Radiology, 1891
Preston White Drive, Reston, VA 20191. Telephone: (703) 648-8900.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   ACR Appropriateness Criteria®. Background and development. Reston
    (VA): American College of Radiology; 2 p. Electronic copies:
    Available in Portable Document Format (PDF) from the [American
    College of Radiology (ACR) Web
    site](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/background_dev.aspx).

#### PATIENT RESOURCES

None available

#### NGC STATUS

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

#### COPYRIGHT STATEMENT

Instructions for downloading, use, and reproduction of the American
College of Radiology (ACR) Appropriateness Criteria® may be found on the
[ACR Web
site.](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/ACRAppropriatenessCriteriaTermsandConditionsDoc1.aspx)

### DISCLAIMER

#### NGC DISCLAIMER

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Date Modified: 11/3/2008