UW Radiology Review Course Breast Calcifications. BI-RADS 5 th Edition
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1 UW Radiology Review Course Breast Calcifications Grace Kalish, MD Vantage Radiology BI-RADS 5 th Edition Benign Skin Vascular Large rod like Coarse popcorn Suspicious Amorphous Coarse heterogenous Fine pleomorphic Fine linear or fine linear branching Round and punctate Rim Milk of calcium Dystrophic 1
2 Changes Rim (previously rim, eggshell and lucent centered ) Round and punctate clarified: Round >0.5mm but <1mm Punctate <0.5mm Amorphous (no indistinct) Elimination of the Indeterminate category Distribution Diffuse Regional Clustered (formerly Grouped ) Linear Segmental 2
3 Case 1 Question: What is the best BI-RADS description of these calcifications? 1. Coarse, diffuse 2. Round, diffuse 3. Dystrophic, diffuse 4. Coarse heterogenous, diffuse 3
4 Discussion: Coarse Coarse-- classically large (>2-3mm) Round usually between 0.5-1mm Dystrophic irregular in shape Coarse heterogenous between 0.5-1mm Case 2. Diagnostic Mag CC Mag ML 4
5 Question: What is the best BI-RADS description of these calcifications? 1. Fine linear, clustered 2. Milk of Calcium, clustered 3. Coarse heterogenous, clustered 4. Amorphous, clustered Discussion: Milk of Calcium Milk of Calcium, clustered Apparent change is the most important feature CC CC ML ML 5
6 Case 3. Baseline Screen Question: What is the best BI-RADS assessment category? 1. BI-RADS 2 2. BI-RADS 3 3. BI-RADS 0 4. BI-RADS 1 6
7 Question: What is the best BI-RADS assessment category? 1. BI-RADS 2 2. BI-RADS 3 3. BI-RADS 0 4. BI-RADS 1 Discussion: Screening Mammogram Recommendations Options are BI-RADS 0, BI-RADS 2, or BI-RADS 1 These calcifications are indeterminate without diagnostic evaluation No need to describe morphology on screen Sufficient to state that there are calcifications in the right breast at 2 to 3 o clock 7
8 Case 3. Diagnostic Question: What is the best BI-RADS assessment category? 1. Benign BI-RADS 2 2. Short term follow up BI-RADS 3 3. Biopsy BI-RADS 4 4. Biopsy BI-RADS 5 8
9 Question: What is the best BI-RADS assessment category? 1. Benign BI-RADS 2 2. Short term follow up BI-RADS 3 3. Biopsy BI-RADS 4 4. Biopsy BI-RADS 5 Discussion: Coarse Heterogenous Biopsy. BI-RADS 4 Coarse heterogenous, clustered. 13% likelihood of malignancy upon biopsy BI-RADS 5 reserved for fine pleomorphic/linear 70% likelihood of malignancy upon biopsy Source: D Orsi CJ, Sickles EA, Mendelson EB, Morris EA. ACR BI-RADS Atlas. Breast Imaging Reporting System. 5 th Edition pg.61 9
10 Case 4. Screening. Question: What is the best BI-RADS assessment category? 1. BI-RADS 2 2. BI-RADS 1 3. BI-RADS 0 4. BI-RADS 3 10
11 Discussion BI-RADS 2 or B-RADS 1 Skin, diffuse Inframammary fold (IMF), parasternal, axilla, and around the areola Individual groups <5mm If you mention them, BI-RADS 2 Skin Calcs - Atypical CC ML 11
12 Tangential view shows the calcifications to be in the skin Case 5. Diagnostic. 55 year old with new calcifications CC Mag ML Mag Each calcification is <0.5mm 12
13 Question: What is the best BI-RADS description of these calcifications? 1. Round, clustered 2. Punctate, clustered 3. Amorphous, clustered 4. Milk of calcium, clustered Discussion: Punctate Round are >0.5mm but <1mm Margins are visible Do not layer 13
14 Question: What is the best BI-RADS assessment category? 1. BI-RADS 0 2. BI-RADS 2 3. BI-RADS 3 4. BI-RADS 4 Discussion If new clustered, linear, segmental, or adjacent to known cancer = must biopsy These were DCIS upon biopsy 14
15 Case 6. Diagnostic ML Mag Each calcification is <0.5mm Question: What is the best BI-RADS description of these calcifications? 1. Coarse heterogenous, clustered 2. Fine pleomorphic, clustered 3. Round, clustered 4. Fine linear/branching, clustered 15
16 Discussion: Fine pleomorphic Fine pleomorphic, clustered Each calcification usually less than 0.5mm 29% of all biopsied positive Coarse heterogenous Usually >0.5mm but <1mm Fine linear/branching Contains a branch point Source: D Orsi CJ, Sickles EA, Mendelson EB, Morris EA. ACR BI-RADS Atlas. Breast Imaging Reporting System. 5 th Edition pg.61 Case 7. Screening. 16
17 Case 7. Screening. Case 7 17
18 Question: What is the best BI-RADS description of these calcifications? 1. Fine linear/branching, segmental 2. Vascular, segmental 3. Large, rod-like, segmental 4. Coarse heterogenous, segmental Discussion: Large rod-like Large, rod-like calcifications Associated with duct ectasia Most are >0.5mm Ductal distribution, radiating Occasionally branching Usually seen in women who are >60 BI-RADS 2 or BI-RADS 1 18
19 Case 8. Diagnostic. New Calcifications. Question: What is the best BI-RADS description of these calcifications? 1. Fine pleomorphic, regional 2. Fine linear/branching, regional 3. Milk of calcium, regional 4. Large, rod-like, regional 19
20 Discussion: Fine linear/branching <0.5mm versus large/rod-like >0.5mm Branching PPV of 70% Invasive carcinoma upon biopsy Source: D Orsi CJ, Sickles EA, Mendelson EB, Morris EA. ACR BI-RADS Atlas. Breast Imaging Reporting System. 5 th Edition pg.61 Case 9. Screening
21 Question: What is the best BI-RADS description of these calcifications? 1. Coarse heterogenous 2. Dystrophic 3. Coarse, popcorn 4. Rim Discussion: Coarse popcorn Increasing but conforming to expected pattern Large >2-3 mm Associated with benign-appearing stable mass BI-RADS 2 21
22 Case 10. Screening. 73 year old with history of prior breast cancer, status post lumpectomy 10 years ago MLO CC Question: What is the best BI-RADS description of these calcifications? 1. Rim 2. Fine pleomorphic 3. Amorphous 4. Coarse heterogenous 22
23 Discussion: Rim Formerly eggshell, and lucent centered Calcium <1mm when viewed on edge Fat necrosis Calcifications in walls of cysts Case 12. Diagnostic. New Calcifications. ML Mag CC Mag 23
24 Question: What is the best BI-RADS description of these calcifications? 1. Fine pleomorphic, clustered 2. Round, clustered 3. Milk of calcium, clustered 4. Amorphous, clustered Discussion: Amorphous Formerly indistinct Hazy Bilateral diffuse can be benign otherwise biopsy PPV is 20% These were benign 24
25 Case 12. Diagnostic after Baseline Mag ML Mag CC Question: What is the best BI-RADS description of these calcifications? 1. Punctate, diffuse 2. Punctate, regional 3. Amorphous, diffuse 4. Round, regional 25
26 Discussion: Punctate, Regional Regional usually >2cm Punctate <0.5mm Regional PPV 26% OK to BI-RADS 3 since baseline. If not, biopsy. These were biopsied and were benign. 26
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