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

S. Murgo, MD

Chr St-Joseph, MonsErasme Hospital, Brussels

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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

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.

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.

An other form of standardizationAn other form of standardization

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…

Views by breast� This allows to assess the quality of an exam.

� For example, � A screening mammogram à A single view

mammography overlooks as much as 25% of BC (1)� The evaluation of a new cluster of calcifications àML

projection with magnification.� A new architectural distortion àML projection and/or

focal compression…

(1) Wald NJ. BMJ 1995;311:1189-1193

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

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%)


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): 1085-1092.

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.


Significant Findings� Calcifications� Mass� Focal asymmetry� Architectural distortion� Associated findings


Standardization and quality of communicationStandardization and quality of communication

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).


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


6 Coarse calcifications

7 Coarse calcifications

8 Vascular calcifications

9 Lucent-centered calcifications

10 Solid rods Kopans DB. Breast Imaging. 2d Edition. Lippincott -Raven


11 Pleomorphic calcifications

12 Linear branching calcifications


Milk of calcium layers &

Weddelite

Rond calcifications

Punctuated & amorphouscalcifications

Calcifications

~ 0%

< 20 %

~ 30%

Rond calcifications

Calcifications

Pleomorphic calcifications

Pleomorphic calcificationsLinear branching calcifications

> 50-60 %

~ 95%

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.


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

Masses: shapes


Masses: margins


Rond circumscribed mass associated with

« Popcorn like » calcifcations

Lobulated mass with ill-defined margins and

pleomorphic calcifcations

Lobulatedcircumscribed mass

Oval mass with anobscured margin

Mass

A standardizated round mass withobscured marginsA standardizated round mass withobscured margins

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.


Focal asymmetry with convex margins

Focal asymmetry

An other exampleof asymmetryAn other exampleof asymmetry

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.


Spiculations radiating from a point associated with a linear distribution of pleomorphic calcifications

Long radiating spicules against a radiolucent background of fat

Distortion

A complete distortion of the presentation

Ultrasound - briefly� For screening in dense normal breasts(categories 3 & 4

of BIRADS) ~ 30-60 % of patients� Increases the detection rate of BC (↑ 16 %)(1)

� For clinical or mammographic anomalies� Mass à cyst or not ?� Focal asymmetry or distortion àmass or not ?� Cluster of suspect calcifications à area of infiltration ?

� For guiding a biopsy or a pre-surgical localization.(1) Fritz K. Eur Radiol 2010; 20(5): 1085-1092.

Oval mass with obscured margins

Cyst

Ultrasound

Oval, echogenic and well circumscribed mass (FA)

Rond mass with obscured margins

Ultrasound

� 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.

Ultrasound - briefly

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.


� 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.

Final assessment categories

(1) Sickles AE. Radiology 1999; 213:11-14.(2) Sickles AE. Radiology 1991; 179:463-468.(3) Sickles AE. Radiology 1994; 192:439-42.(4) Varas X. Radiology 1992; 184:409-414.

� 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

Final assessment categories


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.

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 …à Increases the legibility of reports.àMakes it possible to share and to compare data.

Now if you becomemore « Standard », I have won my match.

Now if you becomemore « Standard », I have won my match.

Standardization …Standardization …

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