2. BI-RADS classification in mammography
Dr. Egle Jonaitiene, Dr. Laima Grinyte
Dr. Ruta Briediene

3. Radiologist report:
…a mass 9mm size in the right breast , a lot of calcifications in the left breast…
Conclusion: what kind of lesion? Malignant? Bening? What next steps to do?

4. BI-RADS Breast imaging reporting and data system MG -1993 US - 2003
Product of ACR
Tool for quality control
To standartise report
To make less interpretation possibility
Monitoring
MG -1993 US

5. Report Indication Breast density Findings
Dynamics, compare with previous
Assessment
Malignancy suspition
Recommendations

6. Assessment 0 – additional information needed (not full exam)
1 – normal (negative)
2 – benign changes
3 – possibly benign
4 – suspicious
5 – very suspicious
6 – proved malignancy

7. BI-RADS classification
Findings
Further management
Incomplete assessment
Need of additional imaging or prior examinations 1
Negative
Routine screening 2
Benign 3
Probably benign - risk of malignancy is lower than 2%,
Ultrasound imaging is necessary or a control mammography imaging and examination within 6 months 4
Suspicious - risk of malignancy is 2-94%,
Further cytology of pathohistology investigation is necessary 5
Highly suspicious - risk of malignancy is higher than 94%
Referral to a surgeon is necessary

8. Density

9. PHT
2000

10. 2002

11. PHT
2004

12. Density

15. Density 3 -4 Dense breast – higher breast cancer risk!
Inform women about low sensitivity of MG in dense breasts
Use digital MG
Ultrasound in screening ?
Ultrasound as further recommendation

16. BI-RADS 1 – negative finding
Symetrical fibroglandular and/or fatty tissue and no masses, architectural distortion or suspicious calcifications are present.
If there is palpable abnormality?

17. Findings Mass Calcifications Architectural distortion Other Size
Form, margins, density
Localisation
Calcifications
Type, form
Distribution
Architectural distortion
Other

18. A mass
Size of a mass
Form, margins, density, calcs

19. BI-RADS 2 – benign finding
Completely or partialy calcified fibroadenomas

22. BI-RADS 2 – benign finding
Fat necrosis calcifications

24. BI-RADS 2 – benign finding
Intramammary lymph nodes

25. BI-RADS 2 – benign finding
Fat containing formations – lipomas and fibroadenolipomas, oil cysts and galactoceles

26. BI-RADS 3 – probably benign finding
Circumscribed, noncalcified masses

27. BI-RADS 3 – probably benign finding
After FU – final assessment
could be changed to BI-RADS 2

28. BI-RADS 3
US and biopsy: TN cancer
US and biopsy: FA

29. Why BIRADS 3? I don’t know It is strange I had similar cancer case
I am not sure about it..
I want to follow-up
Well….

30. Oval, round shape circumscribed margins – BIRADS 2

31. Irregular form spiculated margins – BIRADS 5

32. Shape – oval margins – obscured BIRADS 3? BIRADS 4?

33. Less than 2% risk of malignancy Non-palpable ( < 2 cm ) Stable
BIRADS 3: Probably benign finding ( initial short-interval follow-up suggested )
Less than 2% risk of malignancy
Non-palpable ( < 2 cm )
Stable
Only after complete imaging evaluation
3 type of findings:
Cluster of round (punctate) calcifications
Noncalcified circumscribed solid mass
Focal asymmetric density

34. Classification
“The main potential pitfall is incorrect classification,” - Dr. Luis J. Pina, University Clinic of Navarra, Spain
"Specifically, the BI-RADS 3 category can become a 'holding tank' for problematic lesions which are so categorized without further diagnostic procedures.
This typically occurs when inexperienced radiologists feel uncertain about diagnosis.
By Frances Rylands-Monk, AuntMinnieEurope.com staff writer March 4, 2011

35. BIRADS 3 is a temporary statement until the lesion is definitely classified as category 2 or 4

36. BIRADS 3 – in between benign and unclear lesions
Some malignant tumors can show a benign appearance
Some benign lesions have unusual signs
BIRADS 3 – in between benign and unclear lesions
Not in between benign and malignant lesions!

37. Probably Benign Finding BIRADS 3
Initial Short-Interval Follow-Up Suggested:
A finding placed in this category should have less than a 2% risk of malignancy.
It is not expected to change over the follow-up interval, but the radiologist would prefer to establish its stability.

38. Don't use if unsure whether to render a benign (Category 2) or suspicious (Category 4) assessment. Then use Category 4.
Don't use in a screening examination
Don't use in a diagnostic examination if additional imaging is required to make a final assessment
Don't use if a lesion, previously assessed as Category 3 has increased in size or extent, like a mass on US with an increase of 20% or more of longest dimension. Then use category 4.
Don't recommend MRI to further evaluate a probably benign finding

39. Biopsy of BI-RADS 3 lesions (BI-RADS 4)
Non-palpable lesions with microcalcifications categorized as BI-RADS 3 (probably benign) should undergo a biopsy procedure until a more reliable system for description and classification of microcalcifications is available.
R M PIJNAPPEL , The British Journal of Radiology, 77 (2004)

40. Biopsy in specific situations
Palpable/symptomatic
Planned surgery (augmentation/reduction)
Planned pregnancy
High risk patients
Synchronous cancer
Size of the lesion
Patient´s decision

41. How can we decrease the BI-RADS 3 lesions?
Reclassifying them as:
BIRADS 2
BIRADS 4

42. How to reclassify BI-RADS 3 lesions?
AdditionaI imaging techniques
Compare with previous exams
Radiologist´s experience
Biopsy in specific situations

43. Additional imaging techniques
In a clinical setting we can use all the imaging and biopsy techniques to re-classify a BI-RADS 3 lesion
Complemmentary mammographic views
Tomosynthesis US
Elastography
MRI

44. TN invasive ca
2007
2008

45. Invasive ductal ca

47. Recommendations
Use all imaging modalities for lesion characterisation (not in screening!)
Corellate findings
Use different features for lesion characterisation in one imaging modality
Follow-up if no risk for cancer
Discuss with collegues

48. In an ideal world there would be no BI-RADS 3 category, according to
Dr. Luis J. Pina, University Clinic of Navarra, Spain

49. BI-RADS 4 – suspicious abnormality
Partially circumscribed mass, nondescript solid mass with indistinct margins, new indistinct, irregular solitary mass

50. BI-RADS 4

51. Growing mass/density
2008
2010
2011

53. Continuity in screening rounds
Prior MG (digital)

54. BI-RADS 5 – highly suspicious of malignancy
Spiculated, irregular highdensity mass, irregular spiculated mass with associated pleomorphic calcifications

55. Calcifications Calcifications Distribution Diffuse Type, form Regional
Localisation
Distribution
Diffuse
Regional
Linear
Segmental
Groups
Obenauer et al. Eur Radiol 2005
Lazarus et al. Radiology 2006

56. BI-RADS 2 – benign finding
Large, rod like intraductal and periductal calcifications

58. BI-RADS 2 – benign finding
Simple cyst with mineralized wall

60. BI-RADS 2 – benign finding
Vascular calcifications

63. BI-RADS 3 – probably benign finding
Punctate microcalcifications (scattered or clustered)

64. BI-RADS 3 – probably benign finding
If a BI-RADS 3 lesion
shows any change during FU,
it will change into a BI-RADS 4 or 5
and biopsy should be performed.

65. BI-RADS 4 – suspicious abnormality
Group amorphous or fine pleomorphic calcifications
The pathologist could report sclerosing adenosis or ductal carcinoma in situ. Both diagnoses are concordant with the mammographic findings.

66. BI-RADS 4 – suspicious abnormality
Punctate microcalcifications with background density

67. BI-RADS 5 – highly suspicious of malignancy
Segmental or linear arrangement of fine linear, branching calcifications

68. Pleomorfous calcs BI-RADS 5

69. BI-RADS5 – ductal

70. Architectural distortion assimetry density

71. BI-RADS 2 – benign finding
Architectural distortion clearly related to prior surgery

72. BI-RADS 3 – probably benign finding
Focal asymmetry which becomes less dense on spot compression view

73. BI-RADS 4 – suspicious abnormality
Radial architectural distortion without central density

74. BI-RADS 4 – suspicious abnormality
Asymetrical density with architectural distortion

75. BI-RADS 4
Assimetry/distortion

76. BI-RADS 5 – highly suspicious of malignancy
Radial architectural distortions with central density

77. BI-RADS 0 – incomplete assessment
Additional mammographic imaging is needed: additional mammographic views, spot compression
Additional US or (complete) mammography is needed ONLY if equipment or personnel is not available or patient is unable to wait
Prior mammography or US are required to make a final assessment and issue an addendum including a revised assessment

78. BI-RADS and screening Diagnostic MG Complaints, clinical evaluation
Diagnostic work-up
Follow-up
Screening MG
Yes/no (no BI-RADS)
Suspicious for cancer/ no suspicion
No BI-RADS 3!
BIRADS 1,2 – routine screening
BIRADS 4,5,0 - recall

79. Radiologist report To the woman? To the GP? To the specialist?
Letter for Woman
Cancer was not found
Next screening date
Info for GP

80. Using BI-RADS in screening
Report of benign findings More info for woman/GP Less interval cancers? Economy/finances Must be prepared to examine all women, who got questions about her report
Proper training of radiologists
Training of GP
Info for woman
Proper system of breast services in the country
Centralised data and women recall system