La radiologia medica

, Volume 123, Issue 3, pp 168–173 | Cite as

Breast arterial calcifications on mammography: intra- and inter-observer reproducibility of a semi-automatic quantification tool

  • Rubina Manuela Trimboli
  • Marina Codari
  • Alberto Bert
  • Luca Alessandro Carbonaro
  • Sara Maccagnoni
  • Dario Raciti
  • Daniela Bernardi
  • Paola Clauser
  • Claudio Losio
  • Alberto Tagliafico
  • Francesco Sardanelli



A strong association between breast arterial calcifications (BAC) and cardiovascular disease has been demonstrated. However, BAC quantification tools are lacking. We evaluated the intra- and inter-observer reproducibility of a semi-automatic tool for BAC quantification on digital mammograms.

Materials and methods

A multivendor image dataset of 212 mammographic views, 106 cranio-caudal (CC) and 106 medio-lateral oblique (MLO), were retrospectively selected from 53 subjects if BAC were seen in at least one view. Images were segmented twice by two intensively trained residents in Radiodiagnostics with > 6-month experience in mammography using a semi-automatic software. The two observers (O1, O2) independently positioned rectangular ROIs where they recognized BAC on both CC and MLO views, separately. The adaptive thresholding algorithm automatically provided the BAC amount in mm2. Number, size, and position of the ROIs were observer-dependent. Total BAC amount was calculated for each patient. Bland–Altman analysis was used.


Total BAC amount was 56.6 (IQR 18.1–91.1) and 41.0 (IQR 18.8–90.9) for O1 and O2, respectively. Intra-observer Bland–Altman analysis showed a bias of 11.9 mm2, a coefficient of repeatability of 32.7 mm2, an average measurement of 72.8 mm2, for a 55% reproducibility; the same data were − 7.0, 61.4, 63.4 mm2, and only 3%, respectively, for the inter-observer analysis.


Our semi-automatic tool for BAC quantification showed a poor reproducibility. These results pointed out that the human identification of BAC represents the main source of variability. Further research is needed to translate BAC quantification into clinical practice.


Breast arterial calcifications (BAC) Cardiovascular risk Mammography Reproducibility 



The authors thank the Italian College of Breast Radiologists by SIRM for the financial support for the development of the segmentation software used for this work.

Compliance with ethical standards

Conflict of interest

Authors declared they have no competing interests.

Ethical approval

The work has been approved by the Local Ethical Committee on December 15, 2016 (no. 176/int/2016).


  1. 1.
    Degrell P, Sorbets E, Feldman LJ et al (2015) Screening for coronary artery disease in asymptomatic individuals: why and how? Arch Cardiovasc Dis 108:675–682CrossRefPubMedGoogle Scholar
  2. 2.
    Kotseva K, De Bacquer D, De Backer G, On Behalf Of The Euroaspire Investigators (2016) Lifestyle and risk factor management in people at high risk of cardiovascular disease. A report from the European Society of Cardiology European Action on Secondary and Primary Prevention by Intervention to Reduce Events (EUROASPIRE) IV cross-sectional survey in 14 European regions. Eur J Prev Cardiol. doi: 10.1177/2047487316667784 Google Scholar
  3. 3.
    Grundy SM, Pasternak R, Greenland P et al (1999) Assessment of cardiovascular risk by use of multiple-risk-factor assessment equations: a statement for healthcare professionals from the American Heart Association and the American College of Cardiology. Circulation 100:1481–1492CrossRefPubMedGoogle Scholar
  4. 4.
    Conroy RM, Pyorala K, Fitzgerald AP et al (2003) Estimation of ten-year risk of fatal cardiovascular disease in Europe: the SCORE project. Eur Heart J 24:987–990CrossRefPubMedGoogle Scholar
  5. 5.
    Tehrani DM, Wong ND (2015) Cardiovascular disease risk assessment: review of established and newer modalities. Curr Treat Options Cardiovasc Med 17:57CrossRefPubMedGoogle Scholar
  6. 6.
    Hendriks EJ, de Jong PA, van der Graaf Y et al (2015) Breast arterial calcifications: a systematic review and meta-analysis of their determinants and their association with cardiovascular events. Atherosclerosis 239:11–20CrossRefPubMedGoogle Scholar
  7. 7.
    Jiang X, Clark M, Singh RK et al (2015) Association of breast arterial calcification with stroke and angiographically proven coronary artery disease: a meta-analysis. Menopause 22:136–143CrossRefPubMedGoogle Scholar
  8. 8.
    Margolies L, Salvatore M, Hecht HS et al (2016) Digital mammography and screening for coronary artery disease. JACC Cardiovasc Imaging 9:350–360CrossRefPubMedGoogle Scholar
  9. 9.
    Yushkevich PA, Piven J, Hazlett HC et al (2006) User-guided 3D active contour segmentation of anatomical structures: significantly improved efficiency and reliability. Neuroimage 31:1116–1128CrossRefPubMedGoogle Scholar
  10. 10.
    American College of Radiology (ACR) Breast Imaging Reporting and Data System Atlas (BI-RADS Atlas) (2013) Reston, Va, USA: American College of Radiology At: Accessed on July 2017
  11. 11.
    Duhn V, D’Orsi ET, Johnson S et al (2011) Breast arterial calcification: a marker of medial vascular calcification in chronic kidney disease. Clin J Am Soc Nephrol 6:377–382CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Fishbein GA, Fishbein MC (2009) Arteriosclerosis: rethinking the current classification. Arch Pathol Lab Med 133:1309–1316PubMedGoogle Scholar
  13. 13.
    Lauby-Secretan B, Loomis D, Straif K (2015) Breast-cancer screening-viewpoint of the IARC Working Group. N Engl J Med 373:1479PubMedGoogle Scholar
  14. 14.
    Bae MJ, Lee SY, Kim YJ et al (2013) Association of breast arterial calcifications, metabolic syndrome, and the 10-year coronary heart disease risk: a cross-sectional case-control study. J Womens Health (Larchmt) 22:625–630CrossRefGoogle Scholar
  15. 15.
    Maas AH, van der Schouw YT, Mali WP, van der Graaf Y (2004) Prevalence and determinants of breast arterial calcium in women at high risk of cardiovascular disease. Am J Cardiol 94:655–659CrossRefPubMedGoogle Scholar
  16. 16.
    Loberant N, Salamon V, Carmi N, Chernihovsky A (2013) Prevalence and degree of breast arterial calcifications on mammography: a cross-sectional analysis. J Clin Imaging Sci 3:36CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Reddy J, Son H, Smith SJ et al (2005) Prevalence of breast arterial calcifications in an ethnically diverse population of women. Ann Epidemiol 15:344–350CrossRefPubMedGoogle Scholar
  18. 18.
    Evans AJ, Cohen ME, Cohen GF (1992) Patterns of breast calcification in patients on renal dialysis. Clin Radiol 45:343–344CrossRefPubMedGoogle Scholar
  19. 19.
    Wang J, Ding H, Bidgoli FA et al (2017) Detecting cardiovascular disease from mammograms with deep learning. IEEE Trans Med Imaging 36:1172–1181CrossRefPubMedGoogle Scholar
  20. 20.
    Molloi S, Mehraien T, Iribarren C et al (2009) Reproducibility of breast arterial calcium mass quantification using digital mammography. Acad Radiol 16:275–282CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Cheng JZ, Chen CM, Cole EB et al (2012) Automated delineation of calcified vessels in mammography by tracking with uncertainty and graphical linking techniques. IEEE Trans Med Imaging 31:2143–2155CrossRefPubMedGoogle Scholar

Copyright information

© Italian Society of Medical Radiology 2017

Authors and Affiliations

  • Rubina Manuela Trimboli
    • 1
  • Marina Codari
    • 2
  • Alberto Bert
    • 3
  • Luca Alessandro Carbonaro
    • 2
  • Sara Maccagnoni
    • 4
  • Dario Raciti
    • 4
  • Daniela Bernardi
    • 5
  • Paola Clauser
    • 6
  • Claudio Losio
    • 7
  • Alberto Tagliafico
    • 8
  • Francesco Sardanelli
    • 2
    • 9
  1. 1.Integrative Biomedical Research PhD Program, Department of Biomedical Sciences for HealthUniversità degli Studi di MilanoMilanItaly
  2. 2.Unit of RadiologyIRCCS Policlinico San DonatoSan Donato MilaneseItaly
  3. 3.Kiwifarm S.r.l.Frazione Rivalta 69, 12064 La MorraItaly
  4. 4.Postgraduate School in RadiodiagnosticsUniversità degli Studi di MilanoMilanItaly
  5. 5.U.O. Senologia Clinica e Screening Mammografico, Dipartimento di RadiologiaAPSS, Centro per i Servizi SanitariTrentoItaly
  6. 6.Division of Molecular and Gender Imaging, Department of Biomedical Imaging and Image-guided TherapyMedical University of Vienna/General Hospital ViennaViennaAustria
  7. 7.U.O. Radiologia SenologicaIRCCS Ospedale San RaffaeleMilanItaly
  8. 8.Department of Experimental Medicine, DIMES, Institute of AnatomyUniversity of GenoaGenoaItaly
  9. 9.Department of Biomedical Sciences for HealthUniversità degli Studi di MilanoSan Donato MilaneseItaly

Personalised recommendations