The Radiology Assistant _ Bi-RADS for Mammography and Ultrasound 2013

8/11/2019 The Radiology Assistant _ Bi-RADS for Mammography and Ultrasound 2013

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10/10/2014 The Radiology Assistant : Bi-RADS for Mammography and Ultrasound 2013

http://www.radiologyassistant.nl/en/p53b4082c92130/bi-rads-for-mammography-and-ultrasound-2013.html 1

The ACR BI-RADS Atlas 2013 (4) is thupdated version of the 2003 Atlas.

BI-RADS is designed to standardize breaimaging reporting and to reduce confusion breast imaging interpretations.It also facilitates outcome monitoring anquality assessment.

It contains a lexicon for standardizeterminology (descriptors) for mammographbreast US and MRI, as well as chapters oReport Organization and Guidance Chaptefor use in daily practice.

Publicationdate October 8, 2014

This article is a summary of the BI-RADS Atla2013 for mammography and ultrasound.It is an updated version of the 2005 article.

Since 2000 BI-RADS is required in thNetherlands, as described in the updateGuideline breast cancer 2012 (6).The application of BI-RADS is part of thnational quality assessment program.

We encourage anyone who is involved breast imaging to order the illustrated atlas tget a full knowledge of BI-RADS edition 2013

Bi-RADS for Mammography and Ultrasound 2013Updated version

Harmien Zonderland and Robin Smithuis

Radiology department of the Academical Medical Centre in Amsterdam and the Rijnlandhospital in Leiderdorp, the Netherlands

Introductio
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Standard Reporting

1. Describe the indication for the study.Screening, diagnostic or follow-up.Mention the patient's history.If Ultrasound is performed, mention ifthe US is targeted to a specific locationor supplementary screening.

2. Describe the breast composition.

3. Describe any significant finding usingstandardized terminology.Use the morphological descriptors:mass, asymmetry, architecturaldistortion and calcifications.These findings may have associatedfeatures, like for instance a mass can baccompanied with skin thickening, nippretraction, calcifications etc.Correlate these findings with the clinicainformation, mammography, US or MRI

Integrate mammography and US-findings in a single report.

4. Compare to previous studies.Awaiting previous examinations forcomparison should only take place ifthey are required to make a finalassessment

5. Conclude to a final assessment categoryUse BI-RADS categories 0-6 and thephrase associated with them.If Mammography and US are performed

overall assessment should be based onthe most abnormal of the two breasts,based on the highest likelihood ofmalignancy.

6. Give management recommendations.7. Communicate unsuspected findings with

the referring clinician.Verbal discussions between radiologist,patient or referring clinician should bedocumented in the report.
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Mammography and UltrasoundLexicon

The table shows a summary of thmammography and ultrasound lexicon.Enlarge the table by clicking on the image.

First describe the breast composition.When there is a significant finding use thdescriptors in the table.

The ultrasound lexicon has many similaritieto the mammography lexicon, but there arsome descriptors that are specific fultrasound.

We will discuss the lexicon in more detail in moment.

BI-RADS Assessment Categories

The table shows the final assessmecategories.

We will first discuss the breast imaging lexicoof mammography and ultrasound and thediscuss in more detail the final assessmecategories and the do's and don'ts in thescategories.
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Breast Composition

In the BI-RADS edition 2003 the assignmen

of the breast composition was based on thoverall density resulting in ACR catergory 175%).

In BI-RADS 2013 the use of percentages discouraged, because in individual cases it more important to take into account thchance that a mass can be obscured bfibroglandular tissue than the percentage

breast density as an indicator for breacancer risk.

In the BI-RADS edition 2013 the assignmenof the breast composition is changed into a, c and d-categories followed by a description:

a- The breast are almost entirely fatty.Mammography is highly sensitive in thissetting.b- There are scattered areas offibroglandular density.

The term density describes the degree x-ray attenuation of breast tissue butnot discrete mammographic findings.c- The breasts are heterogeneouslydense, which may obscure small masseSome areas in the breasts aresufficiently dense to obscure smallmasses.d- The breasts are extremely dense,which lowers the sensitivity ofmammography.

Mammography - Breast Imaging Lexico
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Notice in the left example the composition is- heterogeneously dense, although the volumof fibroglandular tissue is less than 50%.

The fibroglandular tissue in the upper part sufficiently dense to obscure small masses.So it is called c, because small masses can bobscured.

Historically this would have been called aACR 2: 25-50% density.

The example on the right has more than 50%glandular tissue and is also called compositioc.

Mass

A 'Mass' is a space occupying 3D lesion seein two different projections.If a potential mass is seen in only a singprojection it should be called a 'asymmetruntil its three-dimensionality is confirmed.

1. Shape: oval (may include 2 or 3lobulations), round or irregular

2. Margins: circumscribed, obscured,microlobulated, indistinct, spiculated

3. Density: high, equal, low or fat-containing.

The images show a fat-containing lesion wia popcorn-like calcification.All fat-containing lesions are typically benignThese image-findings are diagnostic for hamartoma - also known as fibroadenolipoma
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The density of a mass is related to thexpected attenuation of an equal volume fibroglandular tissue.High density is associated with malignancy.It is extremely rare for breast cancer to blow density.

The shape of a mass is either round, oval oirregular.

Always make sure that a mass that is founon physical examination is the same as thmass that is found with mammography oultrasound.Location and size should be applied in anlesion, that must undergo biopsy.

The margin of a lesion can be:

Circumscribed (historically well-definedThis is a benign finding.Obscured or partially obscured, when thmargin is hidden by superimposedfibroglandular tissue. Ultrasound can behelpful to define the margin better.Microlobulated. This implies a suspicioufinding.Indistinct (historically ill-defined).This is also a suspicious finding.Spiculated with radiating lines from themass is a very suspicious finding.
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Here multiple round circumscribed low densimasses in the right breast.These were the result of lipofilling, which transplantation of body fat to the breast.

Here a hyperdense mass with an irregulashape and a spiculated margin.Notice the focal skin retraction.

This was reported as BI-RADS 5 and proved tbe an invasive ductal carcinoma.

Architectural distortion

The term architectural distortion is usewhen the normal architecture is distorted witno definite mass visible.This includes thin straight lines or spiculation

radiating from a point, and focal retractiodistortion or straightening at the edges of thparenchyma.The differential diagnosis is scar tissue carcinoma.

Architectural distortion can also be seen as aassociated feature.For instance if there is a mass that causearchitectural distortion, the likelihood malignancy is greater than in the case of
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Here an example of a focal asymmetry seeon MLO and CC-view.

Local compression views and ultrasound dnot show any mass.

mass without distortion.

Notice the distortion of the normal breaarchitecture on oblique view (yellow circleand magnification view.A resection was performed and only sctissue was found in the specimen.

Asymmetries

Findings that represent unilateral deposits fibroglandulair tissue not conforming to thdefinition of a mass.

Asymmetryas an area offibroglandulair tissue visible on only onmammographic projection, mostlycaused by superimposition of normalbreast tissue.Focal asymmetryvisible on two

projections, hence a real finding ratherthan superposition.This has to be differentiated from amass.Global asymmetryconsisting of anasymmetry over at least one quarter ofthe breast and is usually a normalvariant.Developing asymmetrynew, largerand more conspicuous than on aprevious examination.
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Here an example of global asymmetry.In this patient this is not a normal variansince there are associated features, thindicate the possibility of malignancy like sk

thickening, thickened septa and subtle nippretraction.

Ultrasound (not shown) detected multipsmall masses that proved to badenocarcinoma.The PET-CT shows diffuse infiltratincarcinoma.

Asymmetry versus Mass

All types of asymmmetry have differenborder contours than true masses and alslack the conspicuity of masses.Asymmetries appear similar to other discreareas of fibroglandulair tissue except that theare unitaleral, with no mirror-image correlatin the opposite breast.

An asymmetry demonstrates concave outwaborders and usually is interspersed with fawhereas a mass demonstrates conveoutward borders and appears denser in th

center than at the periphery.The use of the term "density" is confusing, athe term "density" should only be used tdescribe the x-ray attenuation of a mascompared to an equal volume fibroglandular tissue.
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Calcifications

In the 2003 atlas calcifications were classifie

by morphology and distribution either abenign, intermediate concern or higprobability of malignancy.

In the 2013 version the approach hachanged.Since calcifications of intermediate conceand of high probability of malignancy all abeing treated the same way, which usualmeans biopsy, it is logic to group thetogether.Calcifications are now either typically benig

or of suspicious morphology.

Within this last group the chances malignancy are different depending on themorphology (BI-RADS 4B or 4C) and alsdepending on their distribution.
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Typically benign

Skin, vascular, coarse, large rodlike, round punctate (< 1mm), rim, dystrophic, milk calcium and suture calcifications are typicalbenign.

There is one exception of the rule: an isolategroup of punctuate calcifications that is newincreasing, linear, or segmental distribution, or adjacent to a known canccan be assigned as probably benign osuspicious.

Suspicious morphology

Amorphous(BI-RADS 4B)So small and/or hazy in appearance thaa more specific particle shape cannot bedetermined.Coarse heterogeneous(BI-RADS 4B)Irregular, conspicuous calcifications thaare generally between 0,5 mm and 1mm and tend to coalesce but are smallethan dystrophic calcifications.Fine pleomorphic(BI-RADS 4C)

Usually more conspicuous thanamorphous forms and are seen to havediscrete shapes, without fine linear andlinear branching forms, usually < 0,5mm.Fine linear or fine-linear branching(BI-RADS 4C)Thin, linear irregular calcifications, maybe discontinuous, occasionally branchinforms can be seen, usually < 0,5 mm.

Amorphous, indistinct microcalcifications
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Read more on breast calcifications.

Distribution of calcifications

The arrangement of calcifications, thdistribution, is at least as important amorphology.These descriptors are arranged according

the risk of malignancy:

1. Diffuse: distributed randomly throughouthe breast.

2. Regional: occupying a large portion ofbreast tissue > 2 cm greatest dimensio

3. Grouped (historically cluster): fewcalcifications occupying a small portionof breast tissue: lower limit 5calcifications within 1 cm and upper lima larger number of calcifications within

cm.4. Linear: arranged in a line, whichsuggests deposits in a duct.

5. Segmental: suggests deposits in a ductor ducts and their branches.

The 2013 edition refines the upper limit in sizfor grouped distribution as 2 cm (historically cm) while retaining > 2 cm as the lower limfor regional distribution.

Study the images and describe thcalcifications.Then continue reading.

The findings are:

Morphology: some are coarseheterogenous and some look more likefine pleomorphic.Distribution: Some calcifications are in group ( 2cm), but not ina segmental or linear arrangement.

This proved to be multifocal DCIS with areaof invasive carcinoma.
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Associated features

Associated features are things that are seen association with suspicious findings likmasses, asymmetries and calcifications.

Associated features play a role in the finassessment.For instance a BI-RADS 4-mass could get BI-RADS 5 assessment if seen in associatiowith skin retraction.

Many descriptors for ultrasound are the samas for mammography.For instance when we describe the shape omargin of a mass.

Here we will focus on findings that are speciffor ultrasound:

Breast Composition:

Homogeneous echotexture-fatHomogeneous echotexture-

fibroglandularHeterogeneous echotexture

Mass:

Orientation: unique to US-imaging, andefined as parallel (benign) or notparallel (suspicious finding) to the skin.

Special cases

Special cases are findings with features stypical that you do not need to describe thein detail, like for instance an intramammarlymph node or a wart on the skin.

Ultrasound - Breast Imaging Lexico
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Echo pattern: anechoic, hypoechoic,complex cystic and solid, isoechoic,hyperechoic, heterogeneous.Echogenicity can contribute to theassessment of a lesion, together withother feature categories. Alone it haslittle specificity.Posterior features: enhancement,shadowing.Posterior features represent theattenuation characteristics of a masswith respect to its acoustic transmissionalso of additional value. Alone it haslittle specificity.

Calcifications:

On US poorly characterized comparedwith mammography, but can be

recognized as echogenic foci, particularwhen in a mass.

Associated features:

Architectural distortionDuct changesSkin changesEdemaVascularityElasticity assessment

Special cases- cases with a unique diagnosor pathognomonic ultrasound appearance:

Simple cystComplicated cystClustered microcystsMass in or on skinForeign body including implantsLympnodes- intramammaryLymph nodes- axillaryVascular abnormalitiesPostsurgical fluid collectionFat necrosis

Final Assessment Categorie


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BI-RADS 0

Need Additional Imaging Evaluatioand/or Prior Mammograms Fo

Comparison:Category 0 or BI-RADS 0 is utilized whefurther imaging evaluation (e.g. additionviews or ultrasound) or retrieval of prioexaminations is required.When additional imaging studies acompleted, a final assessment is made.Always try to avoid this category bimmediately doing additional imaging oretrieving old films before reporting.Even better to have the old examination

before starting the examination.

This patient presented with a mass on thmammogram at screening, which waassigned as BI-RADS 0 (needs additionimaging evaluation).

Additional ultrasound demonstrated that thmass was caused by an intramammary lympnode.

The final assessment is BI-RADS 2 (benigfinding).

Don't forget to mention in the report that thlymph node on US corresponds with thnoncalcified mass on mammography.In the paragraph on location we will discushow we can be sure that the lymph node thawe found with ultrasound is indeed the samas the mammographic mass.

DO

1. Use if additional mammographic imaginis needed: additional mammographicviews, spot compression

2. Use if additional US or (complete)mammography is needed ONLY ifequipment or personnel is not availableor patient is unable to wait

3. Use if prior mammography or US arerequired to make a final assessment an
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BI-RADS 1

DO

1. Use BI-RADS 1 if there are no abnormimaging findings in a patient with

palpable abnormality, possible palpable cancer, BUT add a sentencrecommending surgical consultation otissue diagnosis if clinically indicated.

issue an addendum including a revisedassessment

DON'T

1. Don't use if prior mammography or USare not available, however NOT requireto make a final assessment.

2. Don't use if prior mammography or US

are irrelevant, because the finding isalready suspicious.

3. Don't use for findings that warrantfurther evaluation with MRI, but make areport before the MRI is performed.

BI-RADS 1

Negative:

There is nothing to comment on.

The breasts are symmetric and no massearchitectural distortion or suspicioucalcifications are present.

BI-RADS 2

Benign Finding:

Like BI-RADS 1, this is a normal assessmenbut here, the interpreter chooses to describebenign finding in the mammography reporlike:

Follow up after breast conservativesurgery

BI-RADS 1 (normal). There is nothing to commenton.
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Involuting, calcified fibroadenomasMultiple large, rod-like calcificationsIntramammary lymph nodesVascular calcificationsImplantsArchitectural distortion clearly related toprior surgery.Fat-containing lesions such as oil cysts,lipomas, galactoceles and mixed-densithamartomas. They all havecharacteristically benign appearances,and may be labeled with confidence.

BI-RADS 2

DO

1. Agree in a group practice on whetherand when to describe benign findings in

a report2. Use in screening or in diagnostic imaginwhen a benign finding is present

3. Use in the presence of bilaterallymphadenopathy, probably reactive orinfectious in origin

4. Use in diagnostic imaging andrecommend management if appropriate

5. - as in abscess or hematoma6. - as in implant rupture and other foreig

bodies

DON'T

1. Don't use when a benign finding ispresent but not described in the report,then use Category 1.

2. Don't recommend MRI to furtherevaluate a benign finding.

BI-RADS 3

Probably Benign Finding

Initial Short-Interval Follow-USuggested:

A finding placed in this category should havless than a 2% risk of malignancy.

It is not expected to change over the followup interval, but the radiologist would prefer testablish its stability.Lesions appropriately placed in this categoinclude:

BI-RADS Category 2: Mass seen on mammogramproved to be a cyst.
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Here a non-palpable sharply defined maswith a group of punctate calcifications.The mass was categorized as BI-RADS 3.Continue with follow up images.

Nonpalpable, circumscribed mass on abaseline mammogram (unless it can beshown to be a cyst, an intramammarylymph node, or another benign finding)Focal asymmetry which becomes lessdense on spot compression viewSolitary group of punctate calcifications

The initial short-term follow-up of a BI-RADS 3 lesion is a unilateralmammogram at 6 months, then abilateral follow-up examination at 12months. Assuming stability perform afollow-up after one year and optionallyafter another year.If the findings shows no change in thefollow up the final assessment ischanged to BI-RADS 2 (benign) and nofurther follow up is needed.

Follow-up at 6, 12 and 24 months showed nchange and the final assessment was changeinto a Category 2.Nevertheless the patient and the cliniciapreferred removal, because the radiologiwas not able to present a clear differentidiagnosis.

So add the following sentence in your report:

BI-RADS 2 (benign finding).

Instead of stopping the follow-up, tissudiagnosis will be performed, due topatient and referring clinician concern.

PA: benign vascular malformation.

Final assessment was changed to a Category 2
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If a BI-RADS 3 lesion shows any changduring follow up, it will change into a BI-RAD

4 or 5 and biopsy should be performed.

The upper image shows a few amorphoucalcifications initially classified as BI-RADS 3At 12 month follow up more than fivcalcifications were noted in a group.The findings were now classified as BI-RAD4.This proved to be DCIS with invasivcarcinoma.

BI-RADS 3

DO

1. Do perform initial short term follow-upafter 6 months. Assuming stabilityperform a second short term follow-upafter 6 months (With mammography:image both breasts). Assuming stabilityperform a follow-up after one year andoptionally another year. Then use

Category 2.2. Do realize, that a benign evaluation ma

always be rendered before completion othe Category 3 analysis, if in the opinioof the radiologist the finding has nochance of malignancy and thus isCategory 2.

3. Use in findings on mammography like- Noncalcified circumscribed solid mass- Focal asymmetry- Solitary group of punctuate

calcifications4. Use in findings on US with robust

evidence to suggest- Typical fibroadenoma- Isolated complicated cyst- Clustered microcysts

5. Use in a probably benign finding, whilethe patient or referring clinician stillprefers biopsy. Then add sentence:'Instead of follow-up tissue diagnosis wbe performed, due to patient or referrin


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clinician concern'.

DON'T

1. Don't use if unsure whether to render abenign (Category 2) or suspicious(Category 4) assessment. Then useCategory 4.

2. Don't use in a screening examination

3. Don't use in a diagnostic examination ifadditional imaging is required to make afinal assessment

4. Don't use if a lesion, previously assesseas Category 3 has increased in size orextent, like a mass on US with anincrease of 20% or more of longestdimension. Then use category 4.

5. Don't recommend MRI to furtherevaluate a probably benign finding

BI-RADS 4

Suspicious Abnormality - Biopsy ShoulBe Considered:

This category is reserved for findings that dnot have the classic appearance of malignancbut are sufficiently suspicious to justify recommendation for biopsy.BI-RADS 4 has a wide range of probability malignancy (2 - 95%).

By subdividing Category 4 into 4A, 4B and 4, it is encouraged that relevant probabilitiefor malignancy be indicated within thcategory so the patient and her physician camake an informed decision on the ultimatcourse of action.

DO

1. Use for findings sufficiently suspicious t

justify biopsy2. Use for findings sufficiently suspicious tjustify biopsy and the patient orreferring clinician refrain from biopsybecause of contraindications. Then addsentence: "Biopsy should be performedin the absence of clinicalcontraindications".

3. Use in the presence of suspiciousunilateral lymphadenopathy withoutabnormalities in the breast
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Here another BI-RADS 4 abnormality.The pathologist could report to you that it sclerosing adenosis or ductal carcinoma situ.Both diagnoses are concordant with thmammographic findings.

4. Do use Category 4ain findings as:- Partially circumscribed mass,suggestive of (atypical) fibroadenoma- Palpable, solitary, complex cystic andsolid cyst- Probable abscess

5. Do use Category 4bin findings as:- Group amorphous or fine pleomorphiccalcifications- Nondescript solid mass with indistinctmargins

6. Do use Category 4c in findings as:- New group of fine linear calcifications- New indistinct, irregular solitary mass

The CC mammographic image shows finding, not reproducible on the MLO view.

This finding is sufficiently suspicious to justibiopsy.

A benign lesion, although unlikely, is possibility.This could be for instance ectopic glandultissue within a heterogeneously dense breastThis lesion is categorized as BI-RADS 4.

BI-RADS 5

Highly Suggestive of Malignancy.Appropriate Action Should Be Taken:BI-RADS 5 must be reserved for findings thare classic breast cancers, with a >95%

likelihood of malignancy.

The current rationale for using category 5 that if the percutaneous tissue diagnosis nonmalignant, this automatically should bconsidered as discordant.

Spiculated, irregular highdensity mass.Segmental or linear arrangement of finelinear calcifications.Irregular spiculated mass withassociated pleomorphic calcifications.
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First study the images and describe thfindings.Then continue reading.

The findings are:

Mass with irregular shape.

Spiculated margin.High density.Ultrasound also shows irregular shapewith indistinct margin.

This mass is categorized as BI-RADS 5.

BI-RADS 5

DO

1. Use if a combination of highly suspicioufindings are present:

Spiculated, irregular mass + high-density.Fine linear calcifications +segmental or linear arrangement Irregular spiculated mass +

associated pleomorphiccalcifications.2. Use in findings for which any

nonmalignant percutaneous tissuediagnosis is automatically considereddiscordant

3. Use in findings sufficiently suspicious tojustify Category 5 and the patient orreferring clinician refrain from biopsybecause of contraindications or otherconcerns.Then add sentence: "Biopsy should beperformed in the absence of clinicalcontraindications".

DON'T

1. Don't use if only one highly suspiciousfinding is present.Then use Category 4c.

High density mass with spiculated margin
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Here images of a biopsy proven malignancy.On the initial mammogram a marker is placein the palpable tumor.Due to the dense fibroglandular tissue thtumor is not well seen.Ultrasound demonstrated a 37 mm mass wi

indistinct and angular margins and shadowin

After chemotherapy the tumor is not visibon the mammogram.Ultrasound showed shrinkage of the tumor a 18 mm mass, which was categorized as BRADS 6.

BI-RADS 6

DO

1. Use after incomplete excision2. Use after monitoring response to

neoadjuvant chemotherapy

DON'T

1. Don't use after attempted surgicalexcision with positive margins and noimaging findings other than postsurgicascarring. Then use category 2 and addsentence stating the absence ofmammographic correlate for thepathology.

2. Don't use for imaging findings,demonstrating suspicious findings otherthan the known cancer, then useCategory 4 or 5.

Location in Mammography and US

On the left BI-RADS 5 lesion. On the right afterneo-adjuvant chemotherapy BI-RADS 6.
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A complete set of location descriptors consisof:

1. Designation of right or left breast

2. Quadrant and clockface notation(preferably both)

3. On US quarter and clockface notationshould be supplemented on the imageby means of bodymark and transducerposition.

4. Depth: anterior, middle or posterior thir(Mammography only)

5. Distance from nipple

There may be variability within breast imagin

practices, members of a group practice shouagree upon a consistent policy fodocumenting.

When you use more modalities, always maksure, that you are dealing with the samlesion.For instance a lesion found with US does nhave to be the same as the mammographic ophysical finding.Sometimes repeated mammographic imaginwith markers on the lesion found with US cabe helpful.

Cysts can be aspirated or filled with air aftaspiration to make sure that the lesion founon the mammogram is caused by a cyst.

Solid lesions can be injected with contrast ormarker can be placed in difficult cases.

Here images that you've seen before.

They are of a patient with a new lesion founat screening.With ultrasound an intramammary lympnode was found, but we weren't sure whethethis was the same as the mass on thmammogram.Continue with the mammographic imageafter contrast injection.

A mass is seen in the outer lower quadrant of theleft breast at 4 o' clock in the posterior portion ofthe breast at 4cm distance from the nipple.
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Contrast was injected into the node and repeated mammogram was performed.Here we have proof that the mass is causeby an intramammary lymph node, since thmammographic mass contains the contrast.

This patient presented with a tumor in the le

breast.However in the right breast a group amorphous and fine pleomorphic calcificationwas seen.Ultrasound examination was performed

Ultrasound of the region demonstrated airregular mass, which proved to be aadenocarcinoma with fine needle aspiratio(FNA).To find out whether the mass was within tharea of the calcifications, contrast wainjected into the mass.

The mass is evidently in another region of thbreast.Now a vacuum assisted biopsy has to bperformed of the calcifications, becausmaybe we are dealing with DCIS in one are

and an invasive carcinoma in another area.

Size measuremen
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1. Describe the indication for the study.

Screening, diagnostic or follow-up.Mention the patient's history.If Ultrasound is performed, mention ifthe US is targeted to a specific locationor supplementary screening.

2. Describe the breast composition.3. Describe any significant finding using

standardized terminology.Use the morphological descriptors:mass, asymmetry, architecturaldistortion and calcifications.

These findings may have associatedfeatures, like for instance a mass can baccompanied with skin thickening, nippretraction, calcifications etc.Correlate these findings with the clinicainformation, mammography, US or MRIIntegrate mammography and US-findings in a single report.

4. Compare to previous studies.Awaiting previous examinations forcomparison should only take place ifthey are required to make a final

MassLongest axis of a lesion and a secon

measurement at right angles.In a spiculated mass the spiculations shounot be included.

Architectural distortion and AsymmetrieApproximation of its greatest lineadimension.

CalcificationsThe distribution should be measured bapproximation of its greatest linedimension.

LymphnodeMammography: short axis.Ultrasound: cortical thickness.

Reporting
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assessment5. Conclude to a final assessment category

Use BI-RADS categories 0-6 and thephrase associated with them.If Mammography and US are performedoverall assessment should be based onthe most abnormal of the two breasts,based on the highest likelihood ofmalignancy.

6. Give management recommendations.7. Communicate unsuspected findings with

the referring clinician.Verbal discussions between radiologistand referring clinician should bedocumented in the report.

Examples of reporting

Indication for examinationPainful mobile lump, lateral in right breast. Nprevious history of breast pathology.

FindingsNo previous exams available.

MammographyOverall breast composition: b. Scattered areaof fibroglandular density.Lateral in the right breast, concordant witthe palpable lump, there is a mass with aoval shape and margin, partially circumscribe

and partially obscured.The mass is equal dense compared to thfibroglandular tissue.Location: Right breast, 9 o'clock positiomiddle third of the breast.Size: approximation of largest diameter = cm.Additional US of the mass: Concordant witthe lump and the mass on the mammograthere is an oval simple cyst, parallorientation, circumscribed, Anechoic witposterior enhancement. Size : 3,5 x 1,5 cm.In the right breast at least 2 more smallecysts.

AssessmentBI-RADS 2 (benign finding).The palpable mass is a simple cyst. There aat least two more, smaller cysts present in thright breast.

Management
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The palpable cyst was painful, after informeconsent uncomplicated puncture for suction the cyst was performed.

No indication for follow-up, unless symptomreturn, as explained to the patient.

Note:

1. No need to describe the cyst in detail: iis a 'special case'/unique diagnosis.

2. No need to describe the additional cystsin more detail or size. Only the size ofthe most important cyst (1) should bementioned.

3. Do not use terms different from the BI-RADS 2013 descriptors.

4. If Mammography and US are performedAlways describe in two paragraphsintegrated in a single report.

5. Verbal discussions between radiologist,patient and referring clinician should bedocumented in the original report or inan addendum.

Indication for examination

Referral from general practitioner.Mobile lump, lateral in left breast, since months.No previous history of breast pathology.

No previous exams available.

FindingsMammography: Overall breast compositiona.The breasts are almost entirely fatty.Lateral in the left breast, at 3 o'clock positioin the posterior third of the breast, concordawith the palpable lump there is a 3 chyperdense mass with a rounded, but alsirregular shape.

The margins are partially circumscribed anpartially not circumscribed with sommicrolobulations.

Ultrasound: concordant with the lump and thmass on the mammogram there is an slightirregular hypoechoic mass with a non-parallorientation, > 75% circumscribed and localindistinct margin.

AssessmentBI-RADS 4a (low suspicion for malignancy).

1. BI-RADS Tutorial

Tutorial by G. Pfarl, MD & T.H. Helbich, MD,

Department of Radiology, University of Vienna.

2. BI-RADS Lexicon for US and Mammography:

Interobserver Variability and Positive Predictive
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The palpable mass is concordant with a solmass, predominantly well circumscribed.In this 35-year old patient the differentidiagnosis consists of an atypical fibroadenomor a phyllodes.

ManagementAfter informed consent of the patient a 14core needle biopsy was performed, tw

specimens were obtained. No complications.

It was discussed with the patient and threferring general practitioner, that in case BI-RADS 4(a) referral to the breast clinic advised. The patient and the referring generpractitioner preferred to await the results the biopsy .

AddendumThe biopsy showed a fibro-epithelial lesion

probably a benign phyllodes.Referral to the breast clinic was now strongindicated and was put in motion by thgeneral practitioner after telephonconsultation.Diagnosis after excision: 3 cm highly cellulfibroadenoma.

Valueby E. Lazarus, M. B. Mainiero, B. Schepps, S. L.

Koelliker, and L. S. Livingston

Radiology, May 1, 2006; 239(2): 385 - 391.

3. Breast Imaging Reporting and Data System,

Inter- and Intraobserver Variability in Feature

Analysis and Final Assessment

by Wendie A. Berg et al

Department of Radiology, University of

Maryland School of Medicine, 22 S. Greene St.,Baltimore,

AJR 2000; 174:1769-1777

4. Breast Imaging Reporting and Data System?

(BI-RADS?) Atlas

5. ACR-BI-RADS Mammography, 4th edition

2003

Reston, VA, American College of Radiology,

2003

6. Guideline Breast Cancer, NABON 2012

7. ACR BI-RADS Atlas, Breast Imaging

Reporting and Data System, Reston VA,American College of Radiology; 2013

by D'Orsi CJ, Sickles EA, Mendelson EB, Morris

EA et al.

8. Guideline Breast Cancer, NABON 2012(in

dutch)
http://www.oncoline.nl/http://www.oncoline.nl/http://www.acr.org/Quality-Safety/Resources/BIRADShttp://www.ajronline.org/cgi/content/full/174/6/1769#REF15http://radiology.rsnajnls.org/cgi/content/full/239/2/385

Documents

The Radiology Assistant _ Bi-RADS for Mammography and Ultrasound 2013