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

Background: Breast arterial calcifications (BAC), representing Monckeberg'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 1st to January 31st, 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. 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. 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.