Increased Breast Calcifications in Women With ESRD on Dialysis: Implications for Breast Cancer Screening

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<ul><li><p>Increased Breast Calcifications in Women With ESRD on Dialysis:st C</p><p>M thleeAngSuza</p><p> B cationma cificatimo ce ofco mmogwo rmalcas screeag andomexa ast caof , andde nts ledcal antlyof tics. Nbe wever,an ater foan eral btha a slical ater prKid 2</p><p>IND seasema</p><p>CURRENTLY IN THE United States, 431,284patients are being treated for end-stageren</p><p>43Acca</p><p>theun</p><p>scrpamabreofcretieintiooldrepquDacadean</p><p>ited, although thousands of women with ESRDare eligible for mammogram screening. This data</p><p>Amal disease (ESRD). Females account for about%, with the majority older than 45 years.1,2cording to current recommendations for breast</p><p>ncer screening, most of these patients are inage range in which patients are encouraged to</p><p>dergo screening mammography.Breast calcification is an important finding oneening mammography; the appearance andttern may be specific, reflecting a benign,lignant, or indeterminate pattern. Patterns ofast calcification in renal dialysis patients areparticular interest because there is an in-ased incidence of breast calcification in pa-nts with renal disease.3-10 There were attemptsthe past to describe patterns of breast calcifica-ns in renal patients, but these included only 2</p><p>small studies5,11 and a few scattered caseorts,4,9,12 significantly limited by the poor</p><p>ality of mammogram resolution of that period.ta for morphological characteristics of breast</p><p>lcification associated with renal disease, inci-nce of benign versus malignant calcifications,d their clinical consequences clearly are lim-</p><p>is important to aid in management and avoidunnecessary costly erroneous workups and psy-chological stress for the patient.</p><p>In this study, we compare mammograms ofwomen with ESRD on long-term dialysis therapywith those of women with normal renal function.We describe morphological characteristics ofbreast calcifications in each group and compare</p><p>From the Departments of Medicine and Radiology, StatenIsland University Hospital; and Regional Radiology, StVincents Medical Center of Richmond, Staten Island, NY.</p><p>Received October 21, 2005; accepted in revised form May4, 2006.</p><p>Originally published online as doi:10.1053/j.ajkd.2006.05.001on June 30, 2006.</p><p>Support: None. Potential conflicts of interest: None.Address reprint requests to Mario Castellanos, MD,</p><p>Director of Medical Womens Health Division, AssociateDirector of Research, Department of Medicine, 401 SeaviewAve, Staten Island, NY 10305. E-mail: mario_castellanos@siuh.edu</p><p> 2006 by the National Kidney Foundation, Inc.0272-6386/06/4802-0015$32.00/0doi:10.1053/j.ajkd.2006.05.001</p><p>erican Journal of Kidney Diseases, Vol 48, No 2 (August), 2006: pp 301-306 301Implications for Breaario Castellanos, MD, Seema Varma, MD, Ka</p><p>Shalom Buchbinder, MD, Denis DMorton Kleiner, MD, and</p><p>ackground: Different appearances of breast calcifilignant disease. An increased incidence of breast calrphological characteristics in renal patients, inciden</p><p>nsequences are limited. In this study, we compare mamen on hemodialysis with that of women with noe-control study; 45 women on hemodialysis had their</p><p>e-matched women with normal renal function was rmined and the recommended workup was traced. Bre</p><p>benign versus malignant calcifications, callback ratetermine whether breast calcifications in renal patiecifications in the renal group were statistically significseveral benign-appearing morphological characteristween the 2 groups with respect to callback rates. Hod hence biopsy recommendation rate were slightly greincrease in breast calcification, mostly caused by sevn that in the general population. However, there iscifications; hence, once called back, they have a greney Dis 48:301-306.006 by the National Kidney Foundation, Inc.</p><p>EX WORDS: Breast calcification; end-stage renal dimmography.ancer Screeningn Ahern, PhD, RN, Sue-Jane Grosso, MD,elo, MD, Carolyn Raia, MD,nne Elsayegh, MD</p><p>on mammography can differentiate benign fromons in dialysis patients is established, but data forbenign and malignant calcifications, and clinicalrams and the workup of abnormal calcifications ofrenal function. Methods: This is a retrospectivening mammograms reviewed. A control group of 86ly obtained for comparison. Mammograms were</p><p>lcification morphological characteristics, incidencebiopsy recommendation rates were compared to</p><p>to excessive workups. Results: Overall, breastincreased compared with controls, mostly becauseo statistically significant difference was presentincidences of malignancy-associated calcificationr the renal group. Conclusion: Renal patients have</p><p>enign calcifications. The callback rate is no greaterghtly greater incidence of malignancy-associatedobability of being recommended for biopsy. Am J</p><p>(ESRD); chronic kidney disease (CKD); screening</p></li><li><p>canaciorat</p><p>StuW</p><p>Aftfrocen</p><p>sishadwe</p><p>inswe</p><p>witingcalhadgroagebreage</p><p>MaM</p><p>grousimo</p><p>enc</p><p>andree</p><p>Cacc</p><p>Imacom</p><p>ogyuse</p><p>scr</p><p>tiesstagroaftepattionnee</p><p>thetionopsnum</p><p>aga</p><p>StaN</p><p>exa</p><p>use</p><p>un</p><p>Co</p><p>CASTELLANOS ET AL302llback rates, incidences of benign and malig-nt calcifications, diagnostic workups for suspi-us calcifications, and biopsy recommendationes for each group.</p><p>METHODS</p><p>dy Populatione performed a retrospective case-control study in 2001.</p><p>er institutional review board approval, medical recordsm 3 dialysis units from a university-affiliated medicalter were reviewed. All women who were on hemodialy-therapy were considered. From this cohort, patients whoa previous mammogram performed at the medical center</p><p>re assigned to the study group. Women attending thetitutions medical clinics who had normal renal functionre randomly selected to form the control group. Patientsh normal renal function were obtained by randomly select-</p><p>patients with normal creatinine clearance and serumcium levels. Patients were screened to ensure that each</p><p>a mammogram at the institution. Patients in the controlup were age matched to the renal group to create a similardistribution to the study group because the incidence of</p><p>ast calcification is influenced by age.5 Figure 1 shows thedistribution of renal patients.</p><p>mmographyammograms of patients from both the renal and control</p><p>ups were reviewed. Mammograms were obtained byng a standard 4-view examination with Lorad MIII mam-graphy units (Trex Medical, Danbury, CT). Three experi-ed mammographers reviewed the films (S.-J.G., D.D.,C.R.). They were blinded to patient renal function and</p><p>xamined the mammograms independently (Fig 2).alcifications were described, categorized, and reported</p><p>ording to the American College of Radiology Breastging Reporting and Data Systems (BIRADS)13 (Table 1).Aponent of the BIRADS is that it gives standard terminol-for describing findings seen on mammography that are</p><p>d to provide consistency among radiologists. Using thistem, breast calcifications can be grouped as being associ-d with benign (9 calcification patterns), malignant (3cification patterns), and indeterminate breast pathologicaltes (2 calcification patterns).</p><p>he final diagnosis of mammograms was reported byng the BIRADS final assessment categories. Negative/mal studies are placed into category 1; benign lesions,egory 2; probably benign lesions, category 3; suspi-us lesions, category 4; and highly suspicious lesions,egory 5. Incomplete screening that requires additionalrkup is placed in category 0. BIRADS 1, 2, and 3 werearded as negative studies and BIRADS 4 and 5 werearded as positive studies for malignancy.</p><p>llow-Upatients were called back for abnormal findings on initial</p><p>eening mammogram, such as a mass, asymmetric densi-, and suspicious breast calcifications. The callback rate, a</p><p>ndard mammography measure, was examined in bothups. The callback rate is the number of cases called backr initial screening mammography of the total number of</p><p>ients screened. Additional workup included magnifica-views of the breast with or without breast ultrasound, as</p><p>ded. Patients who had a final BIRADS description afteradditional workup consistent with suspicious calcifica-s for malignancy were recommended to undergo a bi-y. Biopsy recommendation rates were calculated as totalber of patients recommended for biopsy in each group</p><p>inst the total number of patients screened.</p><p>tistical Analysesonparametric statistics were used. Chi-square and Fisher</p><p>ct tests were performed as appropriate, with Fisher exactd in all instances in which cell sizes were less than 5.</p><p>RESULTSForty-five renal patients from the 3 dialysisits had mammograms at the medical center.ntrols consisted of 86 age-matched patients.</p><p>Fig 1. Age distribution ofrenal patients.sysatecalsta</p><p>Tusinor</p><p>catciocatwo</p><p>regreg</p><p>FoP</p></li><li><p>havetio</p><p>Fing</p><p>MaIPA</p><p>BeSVLESSDPM</p><p>IndCR</p><p>BREAST CALCIFICATIONS IN RENAL DISEASE 303From the renal group, 38 of 45 patients (84.4%)d calcifications on their mammograms. Con-rsely, 51 of 86 controls (59.3%) had calcifica-ns on their mammograms. The incidence of</p><p>ig 2. Mammogram show-vascular calcifications.</p><p>Table 1. Abbreviations of BreastCalcification Categories</p><p>Pattern Abbreviation</p><p>lignant associationnterrupted, fine, linear, or branching ICleomorphic heterogeneous HCmorphous AC</p><p>nign associationkin SCascular VCarge rod-like LGggshell ECpherical or lucent center OCuture SC1ystrophic DCunctate (0.5 mm) PCilk of calcium MC</p><p>eterminateoarse CCound (0.5-1 mm) RClcifications in the renal group versus the con-l group was statistically significant (P 0.003;ble 2).The frequency of each category is listed inble 3. Most of the increase in incidence oflcifications in the renal group appears to beused by several benign calcification patternsig 3; Table 3). Comparing categories of benigncifications, vascular calcification was the mostmmon pattern seen in both groups, with notistical difference between groups (P 0.46).e benign pattern that differed between groupss parenchymal spherical or lucent calcifica-n pattern. Renal patients were significantlyre likely to have this calcification pattern than</p><p>ntrols (P 0.0004; Table 3).Comparing only incidence of calcificationsmmonly considered to be associated with ma-nancy (BIRADS 4 and 5), amorphous, pleo-rphic heterogeneous, and interrupted, fine,ear, or branching, no statistically significantference was identified between the renal andntrol groups for the incidence of each indi-ca</p><p>troTa</p><p>Taca</p><p>ca</p><p>(Fcalco</p><p>staThwa</p><p>tiomo</p><p>co</p><p>co</p><p>ligmo</p><p>lindifco</p></li><li><p>vidgroateda(4tie</p><p>4 cgrosu86baforTh</p><p>scrwawh</p><p>Table 2. Results of Mammogram Review</p><p>NoNoCaFin</p><p>c</p><p>N*</p><p>(1.</p><p>tics ofol Gro</p><p>requencPatter</p><p>G</p><p>MaIPA</p><p>BeSVLESSDPM</p><p>BeCR</p><p>Nverno</p><p>*</p><p>CASTELLANOS ET AL304ual calcification (Table 3). However, as aup, the final diagnosis of malignancy-associ-d calcifications provoking a biopsy recommen-tion was significantly greater in the renal groupof 45 patients) versus controls (1 of 86 pa-nts; P 0.047; Tables 2 and 4).On initial screening mammography, there wereases with suspicious calcifications in the renalup of 45 patients screened and 3 cases with</p><p>spicious calcifications in the control group ofpatients screened (Table 2). Therefore, call-</p><p>ck rates for abnormal calcifications were 8.8%the renal group versus 3.48% for controls.</p><p>is was not statistically significant (P 0.23).</p><p>. of patients</p><p>. of cases with calcificationsllback rate for suspicious calcificationsal BIRADS description consistent with malignancy-associaalcification and cases sent for biopsy</p><p>OTE. Values expressed as number (percent).As a group, malignancy-associated calcifications were s16%), and biopsy recommendation rates were significantly</p><p>Table 3. Frequencies of Morphological Characterisand Contr</p><p>Morphological Characteristics ofCalcification Abbreviation</p><p>F</p><p>lignantnterrupted, fine, linear, or branching ICleomorphic heterogeneous HCmorphous AC</p><p>nignkin SCascular VCarge rod-like LGggshell ECpherical or lucent center OCuture SC1ystrophic DCunctate (0.5 mm) PCilk of calcium MC</p><p>nign or malignantoarse CCound (0.5-1 mm) RC</p><p>OTE. As a group, malignancy-associated calcifications wsus controls (1 of 86 patients; P 0.047). Vascular calcificstatistical difference between groups.Categories are statistically significant.Upon further workup of patients called backsuspicious calcifications, all 4 cases in the</p><p>al group, but only 1 case of the 3 callback casesthe control group, had a final BIRADS descrip-n consistent with a malignancy-associated cal-cation pattern, and biopsy was recommended.erefore, the incidence of final radiologicalgnosis of malignant-associated calcifications,ecting the biopsy recommendation rate, was</p><p>lculated as the total number of patients recom-nded for biopsy of the total number of patientseened in each group. In the renal group, thiss 8.8%, and in controls, 1.16% (P 0.047,ich is statistically significant; Tables 2 and 4).</p><p>Renal Patients Controls P</p><p>45 8638 (84.4) 51 (59.3) 0.003</p><p>4/45 (8.8) 3/86 (3.48) 0.23</p><p>4/45 (8.8) 1/86 (1.16) 0.047*</p><p>ntly greater in the renal group (8.8%) versus controlsnt (P 0.047).</p><p>Calcifications on Mammograms of the Renalups</p><p>y of Calcificationn in the Renalroup (%)</p><p>Frequency of CalcificationPattern in the Control</p><p>Group (%) P</p><p>7.8 0 0.072.06 1.9 0.10 0 0</p><p>2.6 7.8 0.3855 45 0.467.8 13.7 0.5</p><p>10.5 11.7 0.150 13.7 0.0004*0 0 00 0 05.2 13.7 0.130 0 0</p><p>21 17.6 0.5115.7 21.5 0.37</p><p>gnificantly greater in the renal group (4 of 45 patients)as the most common pattern seen in both groups, withere siation wforrenintiocifiThdiareflcame</p><p>ted</p><p>ignificadiffere</p></li><li><p>forHointbetisficroiwedeunsevpa</p><p>ofthethitoactielimresmoouteringbeRama</p><p>renangroFrcifidisthocalfreanfic</p><p>Fanmatrocaltergro</p><p>BREAST CALCIFICATIONS IN RENAL DISEASE 305DISCUSSIONThousands of patients with ESRD are eligiblebreast cancer screening with mammography.wever, there is a concern that mammographicerpretation in this population may be difficultcause of the increased incidence of breastsue calcification. Metastatic soft-tissue calci-ation as a result of secondary hyperparathy-dism in patients with chronic renal disease isll described.5,7,8,10 In 1987, Sommer et al5scribed breast calcifications in 68% of patientsdergoing dialysis. Since then, there have beeneral reports describing breast calcifications in</p><p>tients with renal disease.3,4,6,9There is concern that the increased incidencebreast calcifications in patients on dialysisrapy may pose a diagnostic dilemma. Despites possibility, only 2 old studies5,11 attempteddescribe and categorize morphological char-teristics of breast calcifications in dialysis pa-nts. These studies were small and significantlyited by the unavailability of current high-olution mammography techniques. Further-re, investigators of these studies5,11 and previ-</p><p>s case reports4,9,12 did not have uniformminology available for categorizing and report-</p><p>breast calcifications because they were donefore institution of the American College ofdiology BIRADS. Sommer et al5 comparedmmograms of 15 patients with compensated</p><p>ig 3. Frequencies of benignd malignant calcifications onmmograms of the renal and con-l groups. The frequency of spheri-or lucent (OC) calcification pat-</p><p>n was more common in the renalup, P 0.0004.al insufficiency, 22 on hemodialysis therapyd 14 who had renal transplants, with a controlup of 100 who had normal kidney function.</p><p>equenc...</p></li></ul>

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