S. Murgo, MD. Chr St-Joseph, Mons Erasme Hospital, Brussels

Transcription

1 S. Murgo, MD Chr St-Joseph, Mons Erasme Hospital, Brussels?

2 Introduction Mammography reports are sometimes ambiguous and indecisive. ACR has developped the BIRADS. BIRADS consists of a lexicon in order to provide a standardized language, a reporting structure, a decision oriented approach. ACR BI-RADS Mammography. 4 th Edition. Reston VA

3 Introduction Thanks to the BIRADS Reports are more easily understood And because the data are acquired in a similiar fashion, they are more easily pooled or compared with others.

4 Structure of reports After administrative data, the report should include: Clinical informations Number of views by breast Comparison with previous MG The type of breast tissues Significants findings Correlation ultrasounds Conclusion with the definition of the next action.

5 An other form of standardization

6 Clinical informations The indication of examination: screening or clinical anomaly. The principal risk factors as a personal or a familial history of BC, a genetic anomaly as BRCA 1 or 2, a previous result of biopsy as an AEH, SHT... The known benign anomalies as a FA or a cyst

7 Views by breast This allows to assess the quality of an exam. For example, A screening mammogram A single view mammography overlooks as much as 25% of BC (1) The evaluation of a new cluster of calcifications ML projection with magnification. A new architectural distortion ML projection and/or focal compression (1) Wald NJ. BMJ 1995;311:

8 Previous MG The comparison with any pertinent previous MG This is important in order to detect a new anomaly for example an asymmetry of density to confirm the stability of a breast lesion. Kopans DB. Breast Imaging. 2d Edition. Lippincott -Raven

9 Type of breast tissues In the BIRADS, mammographic breast composition is described with 4 categories: 1. fatty breast (<25% glandular tissue) 2. scattered fibroglandular densities ( 25% ) 3. heterogeneously dense ( 50%) 4. extremely dense ( 75%) ACR BI-RADS Mammography. 4 th Edition. Reston VA

10 Type of breast tissues This classification is subjective and there is discordances between readers. Nevertheless, It provides to the referring physician an estimate of the sensitivity of the mammography. ranges from 60% in extremely dense breasts to 90% in fatty breasts (1). in the categories 3 and 4, it is well demonstrated that ultrasounds increase the detection rate of BC ( 16 %) (2). If a implant is present, it should be stated in the report (1) Kopans DB. Breast Imaging. 2d Edition. Lippincott Raven (2) Fritz K. Eur Radiol 2010; 20(5):

11 Significant Findings Description of significant findings with the lexicon of the ACR. Avoid exotic or histological terminology Use radiographically appropriate terms with the exception of some benign pathognomonic lesions such as intramammary lymph nodes, calcified fibro-adenomas, vascular calcifications and the fat containing lesions. Kopans DB. Breast Imaging. 2d Edition. Lippincott -Raven

12 Significant Findings Calcifications Mass Focal asymmetry Architectural distortion Associated findings Kopans DB. Breast Imaging. 2d Edition. Lippincott -Raven

13 Standardization and quality of communication

14 Calcifications FOR CALCIFICATIONS, some characteristics should be described as defined in the lexicon of BIRADS: the morphology, the number, the distribution, the size of the cluster, the associated findings and the location (using the face of a clock or 4 quadrans). ACR BI-RADS Mammography. 4 th Edition. Reston VA

15 Calcifications: morphology 1 Large rond 2 Lucent centered 3 Milk of calcium layers in the lateral projection 4 Small, rond calcifications 5 Rim calcifications Kopans DB. Breast Imaging. 2d Edition. Lippincott -Raven

16 Calcifications: morphology 6 Coarse calcifications 7 Coarse calcifications 8 Vascular calcifications 9 Lucent-centered calcifications 10 Solid rods Kopans DB. Breast Imaging. 2d Edition. Lippincott -Raven

17 Calcifications: morphology 11 Pleomorphic calcifications 12 Linear branching calcifications Kopans DB. Breast Imaging. 2d Edition. Lippincott -Raven

18 Calcifications Milk of calcium layers & Weddelite ~ 0% Rond calcifications < 20 % Punctuated & amorphous calcifications ~ 30%

19 Calcifications Pleomorphic Rond calcifications > % Pleomorphic calcifications Linear branching calcifications ~ 95%

20 Mass A Mass is a space occupying lesion seen in two different projections. If a potential mass is seen in only a single projection, it should be called a density until its three-dimensionality is confirmed. ACR BI-RADS Mammography. 4 th Edition. Reston VA

21 Mass FOR MASSES, some characteristics should be described as defined in the lexicon of BIRADS: the size (largest dimensions excluding spicules), the shape, the margin, the X-ray attenuation, the associated findings and the location in clinical terms (using the face of a clock or 4 quadrans). ACR BI-RADS Mammography. 4 th Edition. Reston VA

22 Masses: shapes Kopans DB. Breast Imaging. 2d Edition. Lippincott -Raven

23 Masses: margins Kopans DB. Breast Imaging. 2d Edition. Lippincott -Raven

24 Mass Rond circumscribed mass associated with «Popcorn like» calcifcations Lobulated circumscribed mass Lobulated mass with ill-defined margins and pleomorphic calcifcations Oval mass with an obscured margin

25 A standardizated round mass with obscured margins

26 Focal asymmetry It is an asymmetry of tissue density visible on two views, but it cannot be described using the other shapes. It could represent a normal breast, but additional imaging may reveal a true mass or an distortion. ACR BI-RADS Mammography. 4 th Edition. Reston VA

27 Focal asymmetry Focal asymmetry with convex margins

28 An other example of asymmetry

29 Architectural distortion The normal architecture is distorted with no definite mass. This includes: spiculations radiating from a point, focal retractions or distortion of the edge of the parenchyma. The distortion can also be an associated finding. ACR BI-RADS Mammography. 4 th Edition. Reston VA

30 Distortion Long radiating spicules against a radiolucent background of fat Spiculations radiating from a point associated with a linear distribution of pleomorphic calcifications

31 A complete distortion of the presentation

32 Ultrasound - briefly For screening in dense normal breasts(categories 3 & 4 of BIRADS) ~ % of patients Increases the detection rate of BC ( 16 %)(1) For clinical or mammographic anomalies Mass cyst or not? Focal asymmetry or distortion mass or not? Cluster of suspect calcifications area of infiltration? For guiding a biopsy or a pre-surgical localization. (1) Fritz K. Eur Radiol 2010; 20(5):

33 Ultrasound Cyst Oval mass with obscured margins

34 Ultrasound Rond mass with obscured margins Oval, echogenic and well circumscribed mass (FA)

35 Ultrasound - briefly Don t forget to confirm or not the correlation between clinical or mammographic anomalies and sonographic anomalies. If the correlation is not sure, inject a small volume of contrast medium under ultrasound in the surrounding of an anomaly and perform a new mammography (in CC and ML projection) to insure the correlation.

36 Final assessment categories A clear and concise conclusion including the decision of the next action. ACR proposes a classification in 7 points: 0: Need additional imaging evaluation. Only when there is no radiologist to immediately review the study and the patient must be recalled for additional investigations (e.g. for magnifications, rolled views and/or an US). 1: Negative. There is nothing that suggests the presence of a breast cancer. ACR BI-RADS Mammography. 4 th Edition. Reston VA

37 Final assessment categories 2: Benign. When the radiologist wishes to confirm that there is no need to perform further evaluations for this anomaly. 3: Probably benign. A short-interval follow-up is suggested. This category should be reserved for small anomalies well described by Sickles (1,2,3) and Varas (4). Low probably of malignancy (< 2 %). Only in these cases, we can confirm that the prognosis of an eventual breast cancer remains good (more than 80 % of T1N0M0) after a short-interval follow-up. (1) Sickles AE. Radiology 1999; 213: (2) Sickles AE. Radiology 1991; 179: (3) Sickles AE. Radiology 1994; 192: (4) Varas X. Radiology 1992; 184:

38 Final assessment categories 4: Suspicious anomality. A biopsy should be considered. 5: Highly suggestive of malignancy. A appropriate action should be taken. A lesion in this category requires an intervention. 6: Malignant lesion confirmed by a histological analysis. For neo-adjuvent chemotherapy ACR BI-RADS Mammography. 4 th Edition. Reston VA

39 Correlation Never wait the cytologic or histologic analysis for writing your report!!! Sometimes, an additional note is usefull in order to confirm or not the correlation between the mammographic and/or sonographic anomaly and the cytologic or histologic analysis.

40 In conclusions A report must be structured and use well defined radiological terms. The conclusion must be short and precises the decision of the next action. The use of BIRADS is strongly recommended Increases the legibility of reports. Makes it possible to share and to compare data.

41 Now if you become more «Standard», I have won my match.

42 Standardization

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