BI RADS ANALISIS

of 44

Tracks to face a breast imaging and succeed

Poster No.: C-1089Congress: ECR 2013Type: Educational ExhibitAuthors: V. Mayoral Campos1, J. M. Sainz Martinez1, C. Bonnet Carron1,

J. A. GUIROLA2, J. A. Fernandez Gomez1, J. Sancho Prez1;1Zaragoza/ES, 2ZARAGOZA, ZA/ES

Keywords: Breast, Management, Mammography, Ultrasound, MR, Screening,Diagnostic procedure, Biopsy, Education and training, Cancer

DOI: 10.1594/ecr2013/C-1089

Any information contained in this pdf file is automatically generated from digital materialsubmitted to EPOS by third parties in the form of scientific presentations. Referencesto any names, marks, products, or services of third parties or hypertext links to third-party sites or information are provided solely as a convenience to you and do not inany way constitute or imply ECR's endorsement, sponsorship or recommendation of thethird party, information, product or service. ECR is not responsible for the content ofthese pages and does not make any representations regarding the content or accuracyof material in this file.As per copyright regulations, any unauthorised use of the material or parts thereof aswell as commercial reproduction or multiple distribution by any traditional or electronicallybased reproduction/publication method ist strictly prohibited.You agree to defend, indemnify, and hold ECR harmless from and against any and allclaims, damages, costs, and expenses, including attorneys' fees, arising from or relatedto your use of these pages.Please note: Links to movies, ppt slideshows and any other multimedia files are notavailable in the pdf version of presentations.www.myESR.org

of 44

Learning objectives

In this e-poster we are willing to remark the following key points:

To review and illustrate the BI-RADS mammogram and ultrasound system.

To describe what to look for in the breast imaging studies in order to helpresidents and non-specialized radiologists to lose their fear to the breastinterpretation.

To illustrate with examples all the explanations.

Background

Breast Imaging Reporting and Data System (BI-RADS) was created for the ACR(American Journal of Radiology) and it is considered the standard for reporting andassessing the relative malignancy of breast abnormalities. The BI-RADS system wascreated in 1992 with the next objetives:

of 44

Fig. 2: BI-RADS ObjetivesReferences: Department of Radiology, Hospital Clinico Lozano Blesa. Zaragoza/Spain2012

It contains a lexicon for standardized terminology (descriptors) for mammography, breastUS and MRI, as well as standard reporting with final assessment categories andguidelines for follow-up and outcome monitoring. It is considered the main system ofcommunication among physicians, as it tells you the next steps to do.

of 44

Fig. 1: BI_RADS system (Breast Imaging Report and Data System)References: - Zaragoza/ES

When a physician suspect a breast abnormality due to a symptom or a screening test,women will typically be referred for additional breast imaging such as mammogram,ultrasound, or MRI. Depending on the results of these imaging tests, they may be referredfor a breast biopsy.

Imaging findings OR Procedure details

Imaging techniques:

Each technique used in breast imaging has a principal role in the diagnoses of breastcancer. The principal indications are:

Mammography:

of 44

Screening of breast cancer Palpable mass Abnormality of skin or nipple Search of unknown primary cancer Follow-up study of probably benign lesion or calcifications

Ultrasound:

Inconclusive findings in mammography (specially palpable lesion not visibleat mammography)

Screening of high breast density. Differenciate cystic from solid lesions. Pregnant or lactant women US-guided biopsy

MRI:

Inconclusive findings in conventional imaging Preoperative staging (screening of contralateral breast cancer) Unknown primary carcinoma The evaluation of therapy response in the neoadjuvant chemotherapy setting Imaging of the breast after conservative therapy (exclusion of local recurrence) Screening in patients with gene mutations (lifetime risk of 20% or more) Prosthesis imaging MR-guided biopsy and lesion localization in lesions that are neither palpable

nor visible on conventional imaging techniques

DESCRIPTORS

Mammography:

First of all, it is important to identifie the mammographic pattern. It is namedas the principal breast tissue:

1. Predominant fat (less 25% fibroglandular densities)2. Heterogeneous ( 25-50% fibroglandular densities)3. Heterogeneously dense (51-75%)4. Extremely dense (more than 75 %)

of 44

1.

Fig. 3: Breast CompositionReferences: Department of Radiology, Hospital Clinico Lozano Blesa.Zaragoza/Spain 2012

of 44

Fig. 4: Breast CompositionReferences: Department of Radiology, Hospital Clinico Lozano Blesa. Zaragoza/Spain2012

What to look for in mammography:

1. Nodule: It is a space occupying lesion seen in two different projections. It isimportant to describe:

-Location

of 44

Fig. 5: Lesion location: it describes the different breast planes and how to locate thelesion using a clock disposition.References: R. Rostagmo. El informe imagenolgico de mama. 1998

-Size

-Morfology: Round, oval, lobulated, irregular or architectural distortion.

Fig. 6: Nodule MorfologyReferences: Department of Radiology, HCU Lozano Blesa, Zaragoza, Spain, 2013.

of 44

-Margin:Circumscribed, partially obscured, micro-lobulated, ill-defined, spiculated

Fig. 7: Nodule MarginsReferences: Department of Radiology, HCU Lozano Blesa, Zaeagoza, Spain 2012-Density: isodense, hyperdense, hypodense with fat, hypodense without fat

Depends on the nodule characteristics radiologists should give a BI-RADScategorisation.

of 44

Fig. 8: BI-RADS ASSESSMENTS for NodulesReferences: - Zaragoza/ES

It is important to determinate if the lesion is in the breast parenchyma or in the skin.Cutaneous benign masses can be projected as intramammary. Normally, skin lesionshave air rounding the nodule.

2. Calcification: It is the most common finding in mammography but also the mostdifficult to identify. The mammography is the election technique to visualize calcifications.Radiologists can find the calcification in lobules, ducts, interlobular tissue, vessels, skin,or soft tissues.

It is important to see distribution, morfology, size and number of calcifications to give aBI-RADS categorization.

Morfology

Fig. 12: BI-RADS ASSESSMENTS for Calcifications

of 44

References: - Zaragoza/ES

Distribution

Fig. 17: Calcification DistributionReferences: Department of Radiology, Hospital Clinico Lozano Blesa.Zaragoza/Spain 2012

Size:

- 2mm: benign

3. Architectural Distortion: The normal architecture is distorted and there is no definitemass visible.

of 44

This finding includes fine lines or spiculations radiating from a point, focal retraction ordistortion of the edge of the parenchyma. If there is no traumatic or surgery history, biopsyis always indicated.

4. Associated findings: they are not specific when they are alone, but in association withother findings they are suggestive of malignancy.

Skin retraction Nipple retraction Axilar adenopathies Trabecular thickening Skin thickening

Ultrasound:

BI-RADS assessments for US are based on an analysis of six morphologic features ofsolid masses. Whenever possible, the US lexicon uses terms similar to those used inthe mammography lexicon, with the primary overlap related to the shape and marginsof a mass.

of 44

Fig. 20: US DescriptorsReferences: Raza S et AL. BI-RADS 3, 4, and 5 lesions: value of US in management--follow-up and outcome. Radiology. 2008 Sep;248(3):773-81.

of 44

Fig. 21: US DescriptorsReferences: Raza S et AL. BI-RADS 3, 4, and 5 lesions: value of US in management--follow-up and outcome. Radiology. 2008 Sep;248(3):773-81.Final assessment-recommendation is based on the most suspicious finding.

Special cases:

1. Intramammary lymph nodes : BI-RADS 1 or 22. Complicated cyst: BI-RADS 33. Complex cyst: BI-RADS 44. Group of microcyst: BI-RADS 25. Abscess: BI-RADS 4A6. Hematoma: BI-RADS 3

MRI:

MR imaging improves the detection and characterization of primary and recurrent breastcancers. The assessment categories are based on BI-RADS categories developed

of 44

for mammography. The breast imaging lexicon allows a standardized and consistentdescription of the morphologic and kinetic characteristics of breast lesions. The margincharacteristics of a lesion and the intensity of its enhancement at MR imaging 2 minutes orless after contrast material injection are currently considered the most important featuresfor breast lesion diagnosis.

FINAL ASSESSMENT CATEGORIES

Fig. 26: FINAL ASSESSMENT CATEGORIESReferences: Department of Radiology, Hospital Clinico Lozano Blesa. Zaragoza/Spain2012

If a lesion is palpable, the BI-RADS final categorie is one point higher.

Example: a palpable fibroadenoma (usually a BI-RADS 2) is a BI-RADS 3If more than one imaging modality is performed, an integrated report with assessmentbased on the highest level of suspicion must be used.

of 44

TESTING YOURSELF:

In the next cases, which BI-RADS final categorie do you report and whichare your management recommendations?

CASE 1

Fig. 37: Case 1References: Department of Radiology, Hospital Clinico Lozano Blesa. Zaragoza/Spain2012

CASE 2

of 44


CASE 3

of 44


CASE 4

of 44


SOLUTIONS:

- Case 1: BI-RADS 2, normal follow-up

Mammography shows a round, circunscribed, isodense mass categorizated as BI-RADS 3. In US, oval, circumscribed anechoic mass with horizontal orientation andposterior enhancement, typical appearance of a cyst: BI-RADS 2. In this case the typicalappearance of the cyst give the final assessment categorie.

-Case 2: BI-RADS 5, biopsy

Fine linear branching calcifications with focal distribution.

-Case 3: BI-RADS 2, normal follow-up.

of 44

Multiple coarse calcifications, all of them with morphologies that are high suggestive ofbenignity. The calcifications have a diffuse distribution.

-Case 4: BI-RADS 5, biopsy.

Multiple round, hyperdense nodules, some of them spiculated. In US, solid, roundcomplex nodule with indistinct margins, horizontal orientation and no shape. This is anatypical case in mammography because this case was a patient with lymphoma andbreast metastases.

Images for this section:

Fig. 9: Nodules Morfology

of 44

Fig. 10: Nodules margins

of 44

Fig. 11: Nodules density

of 44

Fig. 13: Skin nodule: air interface round the nodule indicating that the lesion is locatedin the skin.

of 44

Fig. 14: Examples of Benign Calcifications

of 44

Fig. 15: Calcifications with low-medium suspicion. Management recommendations: shortfollow-up or Biopsy.

of 44

Fig. 16: Calcifications with high suspicion. Management recommendation: Biopsy

of 44

Fig. 18: Examples of architectural distortion. It is important to know if there is traumaticor surgery history.

of 44

Fig. 19: Associated findings

of 44

Fig. 22: Examples of US descriptors

of 44

Fig. 23: Examples of US descriptors

of 44

Fig. 24: Examples of special cases

of 44

Fig. 25: Enhancement kinetics curves in MRI. There is 3 different types. Type I is apattern of progressive enhancement, with a continuous increase in signal intensity oneach successive contrast-enhanced image. Type II is a plateau pattern, in which an initialincrease in signal intensity is followed by a flattening of the enhancement curve. TypeIII is a washout enhancement pattern, in which there is initial increase and subsequentdecrease in signal intensity

of 44

Fig. 27: BI-RADS 0: You need additional imaging evaluation to give a final assessment.

of 44

Fig. 28: BI-RADS 1: predominant fat pattern. There is nothing to comment on.

of 44

Fig. 30: Dense lobulated nodule with coarse calcifications. These are typical offibroadenoma. In this case it is not necessary any subsequent conduct. Therecommendation is normal follow-up.

of 44

Fig. 29: BI-RADS 2: benign nodule. In mammogrphy, we can see an isodense nodule,with oval morfology and with partially indistinct margin. In ultrosund, it is oval, parallel tothe skin, anechoic, circunscribed with posterior enhancement, compatible with a cyst.

of 44

Fig. 31: Mammogrphy shows an isodense nodule, with oval morfology and with partiallyindistinct margin. In ultrosund, the nodule is oval, parallel to the skin, hypoechoic andcircunscribed. Bi-RADS 3, probably benign, 6 months follow-up.

of 44

Fig. 32: Mammogrphy shows a dense nodule, with oval morfology and with partiallyindistinct margin (arrow in mammography). Ultrasound shows a large cyst with posteriorechogenic components (arrows). BI-RADS 4, Biopsy is recommended.

of 44

Fig. 33: Mammography shows a dense, lobulated nodule, with microlobulated margins.Ultrasound demostrate an oval hypoechoic nodule, not parallel to the skin,withmicrolobulated margins, echogenic halo and posterior shadowing. This lesion is probablymalign, so biopsy is recommended.

of 44

Fig. 34: Mammography shows a hyperdense nodule, with spiculated margins(shortarrows). There is also skin and nipple retraction (long arrow). Highly suggestive ofmalignancy. Biopsy and treatment are recommended.

of 44

Fig. 35: Mammography shows a pleomorphic segmentary gruop of calcifications(arrows), highly suggestive of malignancy. Ultrasound demostrates a hypoechoic,irregular mass, with spiculated margins and posterior shadowing, categorized as BI-RADS 5.

of 44

Fig. 36: In mammography, spiculated hyperdense lesion (arrows in mammography)and skin thickennig categorizated as BI-RADS 5. The ultrasound demostrates an oval,spiculated, hypoechoic nodule with vertical orientation and echogenic halo (arrow in US),categorizated also as BI-RADS 5 because it is highly suggestive of malignancy. Biopsyand treatment are recommended.

of 44

Conclusion

Some things that all radiologists should know to read breast imaging easily:

Make sure that you are looking a breast lesion. Use standard BI-RADS descriptors for Mammography, Ultrasound and MRI. Your final assessment has always to be based on the most worrisome

finding. Make sure that you are looking the same lesion with all the imaging

modalities.

References

1- American College of Radiology. BI-RADS-Mamography. 4th ed. In: Breast ImagingReporting and Data System (BI-RADS) atlas. 4th ed. Reston, Va: American College ofRadiology, 2003.

2- American College of Radiology. BI-RADS-Ultrasound. 1st ed. In: Breast ImagingReporting and Data System (BI-RADS) atlas. 4th ed. Reston, Va: American College ofRadiology, 2003.

3- American College of Radiology. BI-RADS-MRI. 41st ed. In: Breast Imaging Reportingand Data System (BI-RADS) atlas. 4th ed. Reston, Va: American College of Radiology,2003.

4- Harvey JA, Nicholson BT, Cohen MA. Finding early invasive breast cancers: a practicalapproach. Radiology. 2008 Jul;248(1):61-76.

5- Raza S, Goldkamp AL, Chikarmane SA, Birdwell RL. US of breast masses categorizedas BI-RADS 3, 4, and 5: pictorial review of factors influencing clinical management.Radiographics. 2010 Sep;30(5):1199-213

6- Raza S, Chikarmane SA, Neilsen SS, Zorn LM, Birdwell RL. BI-RADS 3, 4, and5 lesions: value of US in management--follow-up and outcome. Radiology. 2008Sep;248(3):773-81.

of 44

7- Mann RM, Kuhl CK, Kinkel K, Boetes C. Breast MRI: guidelines from the EuropeanSociety of Breast Imaging. Eur Radiol. 2008 Jul;18(7):1307-18.

8- Macura KJ, Ouwerkerk R, Jacobs MA, Bluemke DA. Patterns of enhancementon breast MR images: interpretation and imaging pitfalls. Radiographics. 2006 Nov-Dec;26(6):1719-34;

Personal Information

Documents

BI RADS ANALISIS