European Journal of Radiology Thesis


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European Journal of Radiology

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Screening mammography beyond breast cancer: breast arterial calcifications as a sex-specific biomarker of cardiovascular risk

Rubina Manuela Trimbolia, Marina Codarib,⁎, Marco Guazzic,d, Francesco Sardanellic,e

a Department of Biomedical Sciences for Health, Università degli Studi di Milano, Via Mangiagalli 31, 20133 Milan, Italy b Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Via Ponzio 34/5, 20133 Milan, Italy c Department of Biomedical Sciences for Health, Università degli Studi di Milano, Via Morandi 30, 20097 San Donato Milanese, Milan, Italy d Heart Failure Unit, IRCCS Policlinico San Donato, Via Morandi 30, 20097 San Donato Milanese, Milan, Italy e Unit of Radiology, IRCCS Policlinico San Donato, Via Morandi 30, 20097 San Donato Milanese, Milan, Italy


Keywords: Cardiovascular diseases Mammography Mass screening Monckeberg Medial calcific sclerosis Risk assessment


Purpose: To highlight the importance of quantitative breast arterial calcifications (BAC) assessment for an ef- fective stratification of cardiovascular (CV) risk in women, for whom current preventive strategies are in- adequate. BAC, easily detectable on mammograms, are associated with CV disease and represent a potential imaging biomarker for CV disease prevention in women. Method: We summarized the available evidence on this topic. Results: Age, parity, diabetes, and hyperlipidemia were found to positively correlate with BAC. Women with BAC have a higher CV risk than those without BAC: the relative risk was reported to be 1.4 for transient ischemic attack/stroke, 1.5 for thrombosis, 1.8 for myocardial infarction; the reported hazard ratio was 1.32 for coronary artery disease (CAD), 1.52 for heart failure, 1.29 for CV death, 1.44 for death from CAD. However, BAC do not alarm radiologists; when reported, they are commonly mentioned as “present”, not impacting on CV decision- making. Of 18 published studies, 9 reported only presence/absence of BAC, 4 used a semi-quantitative scale, and 5 a continuous scale (with manual, automatic or semiautomatic segmentation). Various appearance, topological complexity, and vessels overlap make BAC quantification difficult to standardize. Nevertheless, machine learning approaches showed promising results in BAC quantification on mammograms. Conclusions: There is a strong rationale for mammography to become a dual test for breast cancer screening and CV disease prevention. However, robust and automated quantification methods are needed for a deeper insight on the association between BAC and CV disease, to stratifying CV risk and define personalized preventive ac- tions.

1. Introduction

Cardiovascular (CV) disease represents a major public health issue and the first cause of death for men and women, accounting for more than 30% of cases worldwide [1]. Over the last fifty years, increasing attention has been paid to primary prevention, through the identifica- tion and control of risk factors and a progressive improvement in phenotyping CV risk. The complex biological pathway leading to CV events encompasses functional and structural changes of heart and vessels that develop over the years with a variable progression rate. Hence, there is a chance for these changes to be identified long before CV events occur and for a preventive strategy to be effective. In the last years, several attempts have been made for improving the performance

of traditional CV risk scores with the help of improved algorithms in- cluding alternative blood-based risk markers and also imaging bio- markers [2] such as the coronary artery calcium score in asymptomatic individuals at intermediate-risk [3].

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