Bi-rads Density for Clinical Reading and Air Pollution Breast Cancer
Bi-RADS for Mammography and Ultrasound 2013
Updated version
Harmien Zonderland and Robin Smithuis
Radiology section of the Academical Medical Centre in Amsterdam and the Rijnland hospital in Leiderdorp, holland
Publicationdate
This article is a summary of the BI-RADS Atlas 2013 for mammography and ultrasound.
It is an updated version of the 2005 commodity.
Since 2000 BI-RADS is required in the Netherlands, as described in the updated Guideline breast cancer 2012 (vi).
The awarding of BI-RADS is role of the national quality assessment program.
We encourage anyone who is involved in breast imaging to order the illustrated atlas to become a full knowledge of BI-RADS edition 2013.
Introduction
The ACR BI-RADS Atlas 2013 (iv) is the updated version of the 2003 Atlas.
BI-RADS® is designed to standardize breast imaging reporting and to reduce confusion in breast imaging interpretations.
Information technology as well facilitates result monitoring and quality cess.
Information technology contains a lexicon for standardized terminology (descriptors) for mammography, breast U.s.a. and MRI, besides equally chapters on Report Organization and Guidance Chapters for use in daily practice.
Standard Reporting
- Describe the indication for the study.
Screening, diagnostic or follow-up.
Mention the patient'south history.
If Ultrasound is performed, mention if the US is targeted to a specific location or supplementary screening. - Describe the breast limerick.
- Describe any significant finding using standardized terminology.
Use the morphological descriptors: mass, disproportion, architectural baloney and calcifications.
These findings may have associated features, like for instance a mass tin can be accompanied with skin thickening, nipple retraction, calcifications etc.
Correlate these findings with the clinical information, mammography, United states or MRI.
Integrate mammography and US-findings in a unmarried written report. - Compare to previous studies.
Awaiting previous examinations for comparing should only accept place if they are required to make a final assessment - Conclude to a concluding assessment category.
Employ BI-RADS categories 0-half dozen and the phrase associated with them.
If Mammography and U.s. are performed: overall assessment should be based on the most abnormal of the two breasts, based on the highest likelihood of malignancy. - Give management recommendations.
- Communicate unexpected findings with the referring clinician.
Exact discussions between radiologist, patient or referring clinician should exist documented in the study.
Mammography and Ultrasound Dictionary
The table shows a summary of the mammography and ultrasound lexicon.
Overstate the tabular array by clicking on the image.
First describe the breast composition.
When at that place is a meaning finding use the descriptors in the tabular array.
The ultrasound lexicon has many similarities to the mammography lexicon, but there are some descriptors that are specific for ultrasound.
We will discuss the lexicon in more particular in a moment.
BI-RADS Assessment Categories
The table shows the final cess categories.
We will first talk over the breast imaging lexicon of mammography and ultrasound and and then talk over in more particular the final assessment categories and the do's and don'ts in these categories.
Mammography - Breast Imaging Dictionary
Chest Composition
In the BI-RADS edition 2003 the assignment of the breast composition was based on the overall density resulting in ACR catergory 1 ( <25% fibroglandular tissue), category 2 ( 25-l%), category 3 (fifty-75%) and category four (>75%).
In BI-RADS 2013 the use of percentages is discouraged, considering in individual cases information technology is more than of import to take into business relationship the take chances that a mass can be obscured past fibroglandular tissue than the percentage of chest density every bit an indicator for breast cancer risk.
In the BI-RADS edition 2013 the assignment of the chest limerick is changed into a, b, c and d-categories followed by a description:
- a - The breast are most entirely fatty.
Mammography is highly sensitive in this setting. - b - There are scattered areas of fibroglandular density.
The term density describes the caste of x-ray attenuation of breast tissue only not detached mammographic findings. - c - The breasts are heterogeneously dense, which may obscure modest masses.
Some areas in the breasts are sufficiently dumbo to obscure small masses. - d - The breasts are extremely dumbo, which lowers the sensitivity of mammography.
Find in the left example the limerick is c - heterogeneously dense, although the book of fibroglandular tissue is less than l%.
The fibroglandular tissue in the upper part is sufficiently dense to obscure pocket-sized masses.
And so information technology is called c, because modest masses tin can be obscured.
Historically this would have been called an ACR two: 25-l% density.
The example on the right has more 50% glandular tissue and is also called composition c.
Mass
A 'Mass' is a space occupying 3D lesion seen in two dissimilar projections.
If a potential mass is seen in but a unmarried project it should be called a 'disproportion' until its three-dimensionality is confirmed.
- Shape: oval (may include 2 or three lobulations), round or irregular
- Margins: circumscribed, obscured, microlobulated, indistinct, spiculated
- Density: high, equal, low or fat-containing.
The images show a fat-containing lesion with a popcorn-like calcification.
All fat-containing lesions are typically benign.
These image-findings are diagnostic for a hamartoma - as well known equally fibroadenolipoma.
The shape of a mass is either round, oval or irregular.
Always make sure that a mass that is found on concrete examination is the same as the mass that is institute with mammography or ultrasound.
Location and size should be practical in any lesion, that must undergo biopsy.
The margin of a lesion can exist:
- Circumscribed (historically well-defined).
This is a benign finding. - Obscured or partially obscured, when the margin is hidden by superimposed fibroglandular tissue. Ultrasound can be helpful to ascertain the margin better.
- Microlobulated. This implies a suspicious finding.
- Indistinct (historically sick-defined).
This is also a suspicious finding. - Spiculated with radiating lines from the mass is a very suspicious finding.
The density of a mass is related to the expected attenuation of an equal volume of fibroglandular tissue.
High density is associated with malignancy.
It is extremely rare for breast cancer to be low density.
Here multiple round confining low density masses in the right chest.
These were the result of lipofilling, which is transplantation of torso fatty to the breast.
Here a hyperdense mass with an irregular shape and a spiculated margin.
Notice the focal skin retraction.
This was reported equally BI-RADS five and proved to exist an invasive ductal carcinoma.
Architectural distortion
The term architectural distortion is used, when the normal compages is distorted with no definite mass visible.
This includes thin directly lines or spiculations radiating from a point, and focal retraction, baloney or straightening at the edges of the parenchyma.
The differential diagnosis is scar tissue or carcinoma.
Architectural baloney tin besides be seen as an associated feature.
For example if there is a mass that causes architectural baloney, the likelihood of malignancy is greater than in the example of a mass without distortion.
Find the baloney of the normal breast architecture on oblique view (yellowish circle) and magnification view.
A resection was performed and only scar tissue was found in the specimen.
Asymmetries
Findings that represent unilateral deposits of fibroglandulair tissue non conforming to the definition of a mass.
- Asymmetry as an expanse of fibroglandulair tissue visible on only one mammographic project, by and large caused by superimposition of normal breast tissue.
- Focal asymmetry visible on 2 projections, hence a real finding rather than superposition.
This has to be differentiated from a mass. - Global asymmetry consisting of an asymmetry over at least one quarter of the chest and is usually a normal variant.
- Developing disproportion new, larger and more conspicuous than on a previous exam.
Here an instance of a focal asymmetry seen on MLO and CC-view.
Local compression views and ultrasound did not evidence any mass.
Here an instance of global asymmetry.
In this patient this is not a normal variant, since there are associated features, that indicate the possibility of malignancy like skin thickening, thickened septa and subtle nipple retraction.
Ultrasound (non shown) detected multiple small masses that proved to be adenocarcinoma.
The PET-CT shows diffuse infiltrating carcinoma.
Disproportion versus Mass
All types of asymmmetry accept dissimilar edge contours than truthful masses and besides lack the conspicuity of masses.
Asymmetries appear like to other discrete areas of fibroglandulair tissue except that they are unitaleral, with no mirror-paradigm correlate in the opposite breast.
An asymmetry demonstrates concave outward borders and usually is interspersed with fat, whereas a mass demonstrates convex outward borders and appears denser in the eye than at the periphery.
The use of the term "density" is confusing, equally the term "density" should simply exist used to draw the ten-ray attenuation of a mass compared to an equal volume of fibroglandular tissue.
Calcifications
In the 2003 atlas calcifications were classified by morphology and distribution either as benign, intermediate business or high probability of malignancy.
In the 2013 version the arroyo has changed.
Since calcifications of intermediate concern and of high probability of malignancy all are being treated the aforementioned manner, which ordinarily means biopsy, it is logic to group them together.
Calcifications are at present either typically benign or of suspicious morphology.
Within this final group the chances of malignancy are different depending on their morphology (BI-RADS 4B or 4C) and also depending on their distribution.
Typically benign
Skin, vascular, coarse, large rodlike, round or punctate (< 1mm), rim, dystrophic, milk of calcium and suture calcifications are typically benign.
At that place is one exception of the rule: an isolated group of punctuate calcifications that is new, increasing, linear, or segmental in distribution, or adjacent to a known cancer can be assigned every bit probably benign or suspicious.
Amorphous, indistinct microcalcifications
Suspicious morphology
- Amorphous (BI-RADS 4B)
So small and/or hazy in advent that a more specific particle shape cannot be determined. - Coarse heterogeneous (BI-RADS 4B)
Irregular, conspicuous calcifications that are generally between 0,5 mm and 1 mm and tend to coalesce but are smaller than dystrophic calcifications. - Fine pleomorphic (BI-RADS 4C)
Usually more conspicuous than amorphous forms and are seen to have discrete shapes, without fine linear and linear branching forms, unremarkably < 0,5 mm. - Fine linear or fine-linear branching (BI-RADS 4C)
Thin, linear irregular calcifications, may exist discontinuous, occasionally branching forms can be seen, usually < 0,5 mm.
Read more on breast calcifications.
Distribution of calcifications
The system of calcifications, the distribution, is at least equally important as morphology.
These descriptors are arranged according to the risk of malignancy:
- Diffuse: distributed randomly throughout the breast.
- Regional: occupying a large portion of breast tissue > 2 cm greatest dimension
- Grouped (historically cluster): few calcifications occupying a small portion of breast tissue: lower limit v calcifications within 1 cm and upper limit a larger number of calcifications within 2 cm.
- Linear: arranged in a line, which suggests deposits in a duct.
- Segmental: suggests deposits in a duct or ducts and their branches.
The 2013 edition refines the upper limit in size for grouped distribution every bit ii cm (historically one cm) while retaining > two cm as the lower limit for regional distribution.
Study the images and describe the calcifications.
Then go along reading.
The findings are:
- Morphology: some are coarse heterogenous and some await more like fine pleomorphic.
- Distribution: Some calcifications are in a group ( <2cm) and some are in a regional distribution ( >2cm), simply not in a segmental or linear arrangement.
This proved to be multifocal DCIS with areas of invasive carcinoma.
Associated features
Associated features are things that are seen in association with suspicious findings like masses, asymmetries and calcifications.
Associated features play a office in the last assessment.
For instance a BI-RADS 4-mass could get a BI-RADS five assessment if seen in association with skin retraction.
Special cases
Special cases are findings with features and so typical that you do non need to describe them in detail, similar for instance an intramammary lymph node or a wart on the pare.
Ultrasound - Breast Imaging Dictionary
Many descriptors for ultrasound are the same as for mammography.
For example when we describe the shape or margin of a mass.
Here we volition focus on findings that are specific for ultrasound:
Breast Limerick:
- Homogeneous echotexture-fat
- Homogeneous echotexture-fibroglandular
- Heterogeneous echotexture
Mass:
- Orientation: unique to US-imaging, and defined equally parallel (benign) or not parallel (suspicious finding) to the peel.
- Echo pattern: anechoic, hypoechoic, complex cystic and solid, isoechoic, hyperechoic, heterogeneous.
Echogenicity tin contribute to the assessment of a lesion, together with other feature categories. Alone it has petty specificity. - Posterior features: enhancement, shadowing.
Posterior features represent the attenuation characteristics of a mass with respect to its acoustic transmission, too of additional value. Alone it has little specificity.
Calcifications:
- On US poorly characterized compared with mammography, but can be recognized as echogenic foci, peculiarly when in a mass.
Associated features:
- Architectural distortion
- Duct changes
- Pare changes
- Edema
- Vascularity
- Elasticity assessment
Special cases - cases with a unique diagnosis or pathognomonic ultrasound appearance:
- Simple cyst
- Complicated cyst
- Amassed microcysts
- Mass in or on skin
- Foreign torso including implants
- Lympnodes- intramammary
- Lymph nodes- axillary
- Vascular abnormalities
- Postsurgical fluid collection
- Fat necrosis
Concluding Assessment Categories
BI-RADS 0
Need Additional Imaging Evaluation and/or Prior Mammograms For Comparison:
Category 0 or BI-RADS 0 is utilized when farther imaging evaluation (e.g. additional views or ultrasound) or retrieval of prior examinations is required.
When additional imaging studies are completed, a final cess is made.
E'er try to avoid this category by immediately doing additional imaging or retrieving one-time films before reporting.
Even better to accept the sometime examinations before starting the examination.
This patient presented with a mass on the mammogram at screening, which was assigned every bit BI-RADS 0 (needs additional imaging evaluation).
Additional ultrasound demonstrated that the mass was caused by an intramammary lymph node.
The concluding cess is BI-RADS 2 (beneficial finding).
Don't forget to mention in the report that the lymph node on US corresponds with the noncalcified mass on mammography.
In the paragraph on location nosotros will hash out how nosotros can exist sure that the lymph node that we found with ultrasound is indeed the same as the mammographic mass.
DO
- Utilise if additional mammographic imaging is needed: additional mammographic views, spot compression
- Use if additional US or (complete) mammography is needed But if equipment or personnel is not available or patient is unable to wait
- Utilise if prior mammography or US are required to make a final assessment and effect an addendum including a revised assessment
DON'T
- Don't use if prior mammography or U.s.a. are non available, still NOT required to make a final cess.
- Don't use if prior mammography or The states are irrelevant, because the finding is already suspicious.
- Don't use for findings that warrant farther evaluation with MRI, but make a written report before the MRI is performed.
BI-RADS 1
Negative:
There is nix to comment on.
The breasts are symmetric and no masses, architectural distortion or suspicious calcifications are present.
BI-RADS 1 (normal). In that location is nothing to comment on.
BI-RADS 1
Practise
- Utilise BI-RADS 1 if there are no abnormal imaging findings in a patient with a palpable abnormality, possible a palpable cancer, Merely add a sentence recommending surgical consultation or tissue diagnosis if clinically indicated.
BI-RADS two
Benign Finding:
Similar BI-RADS ane, this is a normal cess, but here, the interpreter chooses to draw a benign finding in the mammography report, like:
- Follow upwards after breast conservative surgery
- Involuting, calcified fibroadenomas
- Multiple large, rod-like calcifications
- Intramammary lymph nodes
- Vascular calcifications
- Implants
- Architectural distortion clearly related to prior surgery.
- Fat-containing lesions such as oil cysts, lipomas, galactoceles and mixed-density hamartomas. They all have characteristically beneficial appearances, and may be labeled with conviction.
BI-RADS Category 2: Mass seen on mammogram proved to be a cyst.
BI-RADS 2
DO
- Hold in a group do on whether and when to depict benign findings in a study
- Use in screening or in diagnostic imaging when a benign finding is present
- Utilise in the presence of bilateral lymphadenopathy, probably reactive or infectious in origin
- Use in diagnostic imaging and recommend management if appropriate,
- - as in abscess or hematoma
- - as in implant rupture and other foreign bodies
DON'T
- Don't use when a beneficial finding is present but non described in the study, so use Category ane.
- Don't recommend MRI to further evaluate a benign finding.
BI-RADS 3
Probably Benign Finding
Initial Short-Interval Follow-Upwards Suggested:
A finding placed in this category should accept less than a 2% risk of malignancy.
It is non expected to change over the follow-up interval, but the radiologist would prefer to establish its stability.
Lesions appropriately placed in this category include:
- Not-calcified confining mass on a baseline mammogram (unless it can be shown to be a cyst, an intramammary lymph node, or another beneficial finding),
- Focal asymmetry which becomes less dense on spot pinch view
- Solitary group of punctate calcifications
Here a non-palpable sharply defined mass with a group of punctate calcifications.
The mass was categorized as BI-RADS 3.
Go along with follow upwardly images.
Terminal assessment was changed to a Category ii
- The initial short-term follow-upward of a BI-RADS 3 lesion is a unilateral mammogram at 6 months, then a bilateral follow-up examination at 12 months. Assuming stability perform a follow-upwardly after one yr and optionally later some other year.
- If the findings shows no change in the follow upwardly the final assessment is changed to BI-RADS 2 (benign) and no further follow upward is needed.
Follow-up at 6, 12 and 24 months showed no alter and the last cess was changed into a Category ii.
Still the patient and the clinician preferred removal, because the radiologist was non able to present a clear differential diagnosis.
And so add the following sentence in your report:
- BI-RADS 2 (benign finding).
- Instead of stopping the follow-up, tissue diagnosis will be performed, due to patient and referring clinician concern.
PA: benign vascular malformation.
If a BI-RADS 3 lesion shows any change during follow up, information technology will change into a BI-RADS 4 or 5 and biopsy should exist performed.
The upper image shows a few amorphous calcifications initially classified every bit BI-RADS three.
At 12 calendar month follow upwardly more five calcifications were noted in a group.
The findings were now classified equally BI-RADS 4.
This proved to be DCIS with invasive carcinoma.
BI-RADS 3
DO
- Do perform initial short term follow-upwards afterwards 6 months. Bold stability perform a second short term follow-up afterward 6 months (With mammography: image both breasts). Bold stability perform a follow-upward afterwards one yr and optionally another year. And then apply Category ii.
- Do realize, that a benign evaluation may always be rendered before completion of the Category iii assay, if in the stance of the radiologist the finding has no chance of malignancy and thus is Category 2.
- Use in findings on mammography like
- Noncalcified circumscribed solid mass
- Focal asymmetry
- Solitary group of punctuate calcifications - Use in findings on U.s.a. with robust evidence to propose
- Typical fibroadenoma
- Isolated complicated cyst
- Amassed microcysts - Use in a probably benign finding, while the patient or referring clinician notwithstanding prefers biopsy. Then add together sentence: 'Instead of follow-up tissue diagnosis will be performed, due to patient or referring clinician concern'.
DON'T
- Don't utilise if unsure whether to render a benign (Category 2) or suspicious (Category four) assessment. Then use Category 4.
- Don't apply in a screening examination
- Don't use in a diagnostic examination if additional imaging is required to brand a final assessment
- Don't use if a lesion, previously assessed every bit Category 3 has increased in size or extent, like a mass on Us with an increase of 20% or more of longest dimension. And then employ category 4.
- Don't recommend MRI to further evaluate a probably benign finding
BI-RADS 4
Suspicious Aberration - Biopsy Should Be Considered:
This category is reserved for findings that do non take the archetype appearance of malignancy but are sufficiently suspicious to justify a recommendation for biopsy.
BI-RADS 4 has a wide range of probability of malignancy (2 - 95%).
By subdividing Category 4 into 4A, 4B and 4C , it is encouraged that relevant probabilities for malignancy be indicated inside this category then the patient and her physician tin make an informed decision on the ultimate course of activity.
Practice
- Apply for findings sufficiently suspicious to justify biopsy
- Utilize for findings sufficiently suspicious to justify biopsy and the patient or referring clinician refrain from biopsy because of contraindications. Then add together judgement: "Biopsy should be performed in the absenteeism of clinical contraindications".
- Utilise in the presence of suspicious unilateral lymphadenopathy without abnormalities in the chest
- Do use Category 4a in findings as:
- Partially circumscribed mass, suggestive of (atypical) fibroadenoma
- Palpable, lonely, complex cystic and solid cyst
- Likely abscess - Do use Category 4b in findings every bit:
- Group amorphous or fine pleomorphic calcifications
- Nondescript solid mass with indistinct margins - Do use Category 4c in findings every bit:
- New group of fine linear calcifications
- New indistinct, irregular alone mass
The CC mammographic image shows a finding, not reproducible on the MLO view.
This finding is sufficiently suspicious to justify biopsy.
A beneficial lesion, although unlikely, is a possibility.
This could exist for case ectopic glandular tissue inside a heterogeneously dense breast.
This lesion is categorized every bit BI-RADS 4.
Here another BI-RADS iv abnormality.
The pathologist could report to you that it is sclerosing adenosis or ductal carcinoma in situ.
Both diagnoses are concordant with the mammographic findings.
BI-RADS 5
Highly Suggestive of Malignancy.
Appropriate Action Should Be Taken:
BI-RADS 5 must be reserved for findings that are classic breast cancers, with a >95% likelihood of malignancy.
The current rationale for using category 5 is that if the percutaneous tissue diagnosis is nonmalignant, this automatically should be considered as discordant.
- Spiculated, irregular highdensity mass.
- Segmental or linear organisation of fine linear calcifications.
- Irregular spiculated mass with associated pleomorphic calcifications.
Offset study the images and draw the findings.
Then proceed reading.
The findings are:
- Mass with irregular shape.
- Spiculated margin.
- High density.
- Ultrasound also shows irregular shape with indistinct margin.
This mass is categorized as BI-RADS 5.
High density mass with spiculated margin
BI-RADS 5
Practise
- Use if a combination of highly suspicious findings are present:
- Spiculated, irregular mass + loftier-density.
- Fine linear calcifications + segmental or linear system .
- Irregular spiculated mass + associated pleomorphic calcifications.
- Use in findings for which any nonmalignant percutaneous tissue diagnosis is automatically considered discordant
- Employ in findings sufficiently suspicious to justify Category 5 and the patient or referring clinician refrain from biopsy because of contraindications or other concerns.
And so add judgement: "Biopsy should be performed in the absence of clinical contraindications".
DON'T
- Don't use if but 1 highly suspicious finding is present.
Then use Category 4c.
BI-RADS 6
Practice
- Use later on incomplete excision
- Use later on monitoring response to neoadjuvant chemotherapy
DON'T
- Don't use after attempted surgical excision with positive margins and no imaging findings other than postsurgical scarring. Then use category 2 and add sentence stating the absence of mammographic correlate for the pathology.
- Don't apply for imaging findings, demonstrating suspicious findings other than the known cancer, and then use Category 4 or 5.
On the left BI-RADS v lesion. On the correct after neo-adjuvant chemotherapy BI-RADS 6.
Here images of a biopsy proven malignancy.
On the initial mammogram a marker is placed in the palpable tumor.
Due to the dense fibroglandular tissue the tumor is non well seen.
Ultrasound demonstrated a 37 mm mass with indistinct and athwart margins and shadowing.
After chemotherapy the tumor is not visible on the mammogram.
Ultrasound showed shrinkage of the tumor to a 18 mm mass, which was categorized as BI-RADS 6.
Location in Mammography and U.s.a.
A mass is seen in the outer lower quadrant of the left breast at 4 o' clock in the posterior portion of the breast at 4cm distance from the nipple.
A consummate fix of location descriptors consists of:
- Designation of right or left breast
- Quadrant and clockface notation (preferably both)
- On U.s.a. quarter and clockface notation should be supplemented on the prototype by means of bodymark and transducer position.
- Depth: inductive, eye or posterior third (Mammography only)
- Distance from nipple
There may be variability inside breast imaging practices, members of a grouping practice should hold upon a consequent policy for documenting.
When y'all apply more modalities, always make sure, that you are dealing with the same lesion.
For example a lesion found with US does not accept to be the aforementioned equally the mammographic or concrete finding.
Sometimes repeated mammographic imaging with markers on the lesion plant with Us can be helpful.
Cysts can be aspirated or filled with air after aspiration to brand sure that the lesion found on the mammogram is caused by a cyst.
Solid lesions can be injected with dissimilarity or a marker tin can be placed in hard cases.
Hither images that you've seen before.
They are of a patient with a new lesion institute at screening.
With ultrasound an intramammary lymph node was found, just we weren't certain whether this was the same equally the mass on the mammogram.
Keep with the mammographic images after contrast injection.
Contrast was injected into the node and a repeated mammogram was performed.
Hither we have proof that the mass is caused by an intramammary lymph node, since the mammographic mass contains the contrast.
This patient presented with a tumor in the left breast.
However in the right chest a group of amorphous and fine pleomorphic calcifications was seen.
Ultrasound examination was performed
Ultrasound of the region demonstrated an irregular mass, which proved to be an adenocarcinoma with fine needle aspiration (FNA).
To detect out whether the mass was within the area of the calcifications, contrast was injected into the mass.
The mass is plainly in another region of the chest.
Now a vacuum assisted biopsy has to be performed of the calcifications, because perchance we are dealing with DCIS in 1 surface area and an invasive carcinoma in another expanse.
Size measurement
Mass
Longest axis of a lesion and a second measurement at correct angles.
In a spiculated mass the spiculations should not be included.
Architectural distortion and Asymmetries
Approximation of its greatest linear dimension.
Calcifications
The distribution should be measured by approximation of its greatest linear dimension.
Lymphnode
Mammography: curt centrality.
Ultrasound: cortical thickness.
Reporting
- Describe the indication for the study.
Screening, diagnostic or follow-up.
Mention the patient'due south history.
If Ultrasound is performed, mention if the Usa is targeted to a specific location or supplementary screening. - Describe the breast composition.
- Describe any significant finding using standardized terminology.
Use the morphological descriptors: mass, asymmetry, architectural baloney and calcifications.
These findings may have associated features, similar for instance a mass tin can exist accompanied with peel thickening, nipple retraction, calcifications etc.
Correlate these findings with the clinical information, mammography, US or MRI.
Integrate mammography and US-findings in a single study. - Compare to previous studies.
Awaiting previous examinations for comparison should only take place if they are required to brand a terminal assessment - Conclude to a final assessment category.
Apply BI-RADS categories 0-6 and the phrase associated with them.
If Mammography and United states are performed: overall assessment should be based on the most abnormal of the two tests, based on the highest likelihood of malignancy. - Give direction recommendations.
- Communicate unsuspected findings with the referring clinician.
Verbal discussions between radiologist and referring clinician should be documented in the report.
Examples of reporting
Indication for examination
Painful mobile lump, lateral in right breast. No previous history of breast pathology.
Findings
No previous exams available.
Mammography
Overall breast composition: b. Scattered areas of fibroglandular density.
Lateral in the right breast, concordant with the palpable lump, in that location is a mass with an oval shape and margin, partially circumscribed and partially obscured.
The mass is equal dense compared to the fibroglandular tissue.
Location: Right breast, 9 o'clock position, heart tertiary of the breast.
Size: approximation of largest diameter = 3 cm.
Additional Us of the mass: Concordant with the lump and the mass on the mammogram there is an oval simple cyst, parallel orientation, confining, Anechoic with posterior enhancement. Size : three,five x 1,five cm.
In the right breast at least 2 more smaller cysts.
Assessment
BI-RADS ii (beneficial finding).
The palpable mass is a elementary cyst. There are at to the lowest degree two more, smaller cysts present in the correct breast.
Management
The palpable cyst was painful, later on informed consent uncomplicated puncture for suction of the cyst was performed.
No indication for follow-up, unless symptoms return, as explained to the patient.
Note:
- No need to describe the cyst in item: it is a 'special case'/unique diagnosis.
- No need to describe the additional cysts in more detail or size. Simply the size of the most of import cyst (one) should be mentioned.
- Do not apply terms different from the BI-RADS 2013 descriptors.
- If Mammography and US are performed: Ever describe in ii paragraphs integrated in a single report.
- Exact discussions between radiologist, patient and referring clinician should be documented in the original report or in an addendum.
Indication for examination
Referral from general practitioner.
Mobile lump, lateral in left breast, since 2 months.
No previous history of breast pathology.
No previous exams available.
Findings
Mammography: Overall breast composition: a. The breasts are almost entirely fatty.
Lateral in the left chest, at 3 o'clock position in the posterior third of the breast, concordant with the palpable lump in that location is a 3 cm hyperdense mass with a rounded, but also irregular shape.
The margins are partially circumscribed and partially not circumscribed with some microlobulations.
Ultrasound: concordant with the lump and the mass on the mammogram there is an slightly irregular hypoechoic mass with a not-parallel orientation, > 75% circumscribed and locally indistinct margin.
Assessment
BI-RADS 4a (low suspicion for malignancy).
The palpable mass is concordant with a solid mass, predominantly well circumscribed.
In this 35-year old patient the differential diagnosis consists of an atypical fibroadenoma or a phyllodes.
Direction
After informed consent of the patient a 14G cadre needle biopsy was performed, two specimens were obtained. No complications.
It was discussed with the patient and the referring full general practitioner, that in case of BI-RADS 4(a) referral to the breast clinic is advised. The patient and the referring full general practitioner preferred to await the results of the biopsy .
Addendum
The biopsy showed a fibro-epithelial lesion, probably a benign phyllodes.
Referral to the chest clinic was now strongly indicated and was put in move past the general practitioner afterwards telephone consultation.
Diagnosis after excision: 3 cm highly cellular fibroadenoma.
Source: https://radiologyassistant.nl/breast/bi-rads/bi-rads-for-mammography-and-ultrasound-2013
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