BI-RADS The New BI-RADS Leonard M. Glassman MD FACR Former Chief of Breast Imaging American Institute for Radiologic Pathology Washington Radiology Associates, PC Breast Imaging Reporting and Data System 5 th Edition 4 th edition in 2003 Dated 2013 Released 2014 Sections Mammography Ultrasound MRI Follow-up and outcome monitoring Data dictionary Mammography Mammography Masses Calcifications Architectural distortion Asymmetries Intramammary lymph nodes Skin lesions Solitary dilated duct Breast Density Mass A Fatty B Scattered fibroglandular densities C Heterogeneously dense which may obscure small masses D Extremely dense which lowers the sensitivity of mammography Uses letters not numbers for categories Percentages are dropped 3-dimensional Seen in 2 projections Convex border Denser in the center 1
Mass Shape Mass Margin Oval (+/- 2-3 undulations) Round Irregular Lobulated is dropped and included in oval Circumscribed <25% obscured 0% indistinct, microlobulated, or spiculated Obscured Microlobulated Indistinct Spiculated Mass Density Calcifications High 70% cancer Equal Low Fat containing Typically benign Suspicious Merged intermediate and high probability suspicious into suspicious Typically Benign Suspicious Skin Vascular Coarse or popcorn-like Large rods Round <1 mm round <0.5 mm punctate Rim Includes egg shell and lucent centered Dystrophic Milk of calcium Suture Amorphous 21% malignant Coarse heterogeneous 13% malignant Fine pleomorphic 29% malignant Fine linear or fine linear branching 70% malignant 2
Diffuse Regional (>2 cm) 26% malignant Grouped (<2 cm) 31% malignant Linear 60% malignant Segmental 62% malignant Clustered changed to grouped Distribution Diffuse Regional (>2 cm) 26% malignant Grouped (<2 cm) 31% malignant Linear 60% malignant Segmental 62% malignant Distribution Architectural Distortion Asymmetries Asymmetry Global asymmetry > 1 quadrant Focal asymmetry < 1 quadrant Developing asymmetry 15% malignant Asymmetry Global asymmetry > 1 quadrant Focal asymmetry < 1 quadrant Developing asymmetry 15% malignant Asymmetries Asymmetry >80% summation Global asymmetry > 1 quadrant BI-RADS 2 if not palpable Focal asymmetry < 1 quadrant BI-RADS 3 with negative workup Developing asymmetry 15% malignant BI-RADS 4 Asymmetries 3
Intramammary Lymph Node Skin Lesion Solitary Dilated Duct Category 3 10% malignant (?) <2% malignant Used to establish stability Circumscribed noncalcified solid mass No need to biopsy young woman with probable fibroadenoma Focal asymmetry Solitary group of punctate calcifications? for palpable lesions Only used after diagnostic work-up Not if new or enlarging Category 3 Mammography Summary Six month unilateral (or bilateral) 1 year bilateral 2 year bilateral +/- 3 year bilateral 18 month follow-up dropped Breast density A thru D. No percentages used Lobulated mass is included in oval Calcifications are typically benign or suspicious Clustered is now called grouped Probable fibroadenoma is now BIRADS 3 not 4 18 month follow-up is dropped 4
Ultrasound Ultrasound Tissue Composition Only for screening Homogeneous background fat Homogeneous background fibroglandular Heterogeneous background Ultrasound Ultrasound Masses Calcifications Associated features Architectural distortion Duct changes Skin changes Edema Vascularity Elasticity Special Cases Simple cyst Clustered microcysts Complicated cyst Skin mass Foreign body Intramammary lymph node Axillary lymph node Vascular abnormality Postsurgical fluid collection Fat necrosis Mass Mass Shape Shape Orientation Margin Echo pattern Posterior features No more lesion boundary Oval (+/- 2-3 undulations) Round Irregular Lobulated shapes deleted 5
Mass Orientation Margin Parallel (to the skin) Not parallel Includes round Circumscribed Not circumscribed Indistinct Angular Microlobulated Spiculated Do not use irregular here; it is a mass shape not a margin Echo Pattern Echo Pattern Anechoic Hyperechoic Complex cystic and solid Hypoechoic Isoechoic Heterogeneous Anechoic Hyperechoic Complex cystic and solid Hypoechoic Isoechoic Heterogeneous Posterior features Posterior features No posterior features Enhancement Shadowing Combined pattern No posterior features Enhancement Shadowing Combined pattern 6
Calcifications Associated Features In a mass Outside a mass Intraductal Architectural distortion Duct changes Skin changes Retraction Thickening Edema Vascularity Elasticity Special Cases Category 3 Simple cyst Clustered microcysts Complicated cyst Skin mass Foreign body Intramammary lymph node Axillary lymph node Vascular Postsurgical fluid Fat necrosis Solid oval circumscribed parallel mass Can be palpable in <40 years old Isolated complicated cyst Clustered microcysts Category 2 if very well seen and all cystic Category 3 Ultrasound Summary Six month unilateral (or bilateral) 1 year bilateral 2 year bilateral Lesion boundary is dropped from shape evaluation Lobulated shape is now part of oval Round mass is not parallel orientation Probable fibroadenoma is BIRADS 3 not 4 18 month follow-up dropped 7
MRI Background Parenchymal Enhancement (BPE) Evaluated on first series after contrast Not related to amount of fibroglandular tissue present Does not hinder detection of carcinoma Try to do in follicular phase when elective Do not delay with new diagnosis of cancer BPE Classes Focus Minimal Mild Moderate Marked <5mm Too small to characterize No corresponding noncontrast finding Focus Mass Shape Benign Not unique Possible fatty hilum Persistent kinetics Bright on T2 Stable if prior exam Malignant Unique and distinct No fatty hilum Washout kinetics Increased or new from prior exam Oval (includes lobulated) Round Irregular Mass shape and margin best evaluated on first postcontrast series 8
Mass Margin Internal Mass Enhancement Circumscribed Not circumscribed Irregular Spiculated Homogeneous Heterogeneous Non-enhancing dark internal septations Fibroadenoma if other characteristics benign Non-Mass Enhancement (NME) Non-Mass Enhancement (NME) Neither mass or focus NME Distribution NME Internal Enhancement Focal < 1 quadrant Single duct system Linear Line or single duct Segmental Regional > 1 quadrant Multiple regions Diffuse Homogeneous Heterogeneous Clumped Clustered ring Ductal included now in linear 9
Kinetic Curve Assessment MRI Summary Initial phase is first 2 minutes Slow (<50% enhancement) Medium (50-100%) Fast (>100%) Delayed phase is after 2 minutes Persistant Plateau (+/_ 10%) Washout Ductal NME now included in linear Clustered ring is a new NME internal enhancement descriptor Summary An attempt has been made to use the same descriptors for each modality where possible. There has been an uncoupling of the assessment categories and the treatment or follow-up recommendations. Some descriptors have been merged for simplicity 10