BI-RADS

BI-RADS stands for 'breast imaging reporting and data system', and was established by the American College of Radiology. BIRADS is a scheme for p tting the findings of mammograms, !for breast cancer diagnosis", into a small n mber of well-defined categories. Altho gh BIRADS started o t only for mammograms, it was later adapted for se with #RI and ltraso nd as well. BIRADS is something that benefits the radiologists who report mammograms !and #RI and $S". It doesn't do anything directly sef l for patients or for the doctors who referred a patient for breast imaging. %hat benefit do radiologists get& 'he benefit to radiologists, is that it forces them to thin( abo t which category their findings will fit into, and when they assign each case into a category, then it becomes possible to calc late acc racy statistics. 'he acc racy statistics are generally calc lated once a year, and they inform the radiologist abo t whether they are doing a good )ob, or not. 'his will re-ass re the good radiologists to (eep doing whate*er they are doing, b t for radiologists whose acc racy statistics aren't good, it lets them (now that they o ght to get more training. BIRADS classification is not a formal re+ irement for most radiologists to se, b t most do. Another benefit of BIRADS to radiologists, that has indirectly benefitted e*eryone else, is that the categori,ation scheme has helped to standardi,e the words sed in mammographic reporting, and this has red ced the conf sion and impro*ed comm nication betweem radiologists, patients, and physicians. BI-RADS classifcations ha*e also helped in monitoring breast cancer treatment and s pporting breast cancer research, again by ma(ing statistics easier to calc late. A woman is s ally normally not told of the BI-RADS assessment directly. -owe*er, if yo do enco nter these terms, it may be sef l to (now what they mean.

BI-RADS mammographic assessment categories

'he BI-RADS assessment categories are. /- incomplete, 0- negati*e, 1-benign findings, 2-probably benign,

3-s spicio s abnormality, 4-highly s spicio s of malignancy, 5-(nown biopsy with pro*en malignancy.

After the initial breast cancer screening, a follow- p or 'diagnostic' mammogram is often recommended when the BI-RADS category was 2 or higher. By a *ast ma)ority, most breast cancer screening mammograms are classified as either BI-RADS 0 or BI-RADS 1, and those categories don't imply any f rther worries.

The postive predictive value (for confirmed breast cancer) increases at BI-RADS category
$p to 67 of breast cancer screening mammograms will be gi*en a BI-RADS category of 2, 3 or 4, which implies that something needs f rther concern. It t rns o t that BIRADS 2 is rarely sed nowadays, beca se BIRADS 3 and 4 are categories that lead to biopsies, and biopsies gi*e 8definiti*e8 answers, whereas BIRADS 2 often ca ses a 5-month follow- p mammogram, which leads to some 8 ncertainty8 for e*eryone d ring those 5 months. Both radiologists and patients prefer fast answers rather than waiting 5 months. If a mammogram is classified into the BI-RADS category 2, it tends to ha*e a *ery low positi*e predicti*e *al e !less than 17", meaning a low chance of cancer. A BI-RADS category 3 mammogram has a positi*e predicti*e *al e of abo t 2/7, and a category 4 mammogram are almost certainly predicti*e of breast cancer, with a positi*e predicti*e *al e of abo t 647.

BI-RADS assessment categories! "ategory # Assemssment is incomplete

Category / means the Assessment is not completed yet, and additional wor( p is often recommended, s ch as spot compression , magnification, or ltraso nd. Category / means that there was not eno gh information yet to finish the process. In real-life terms, if a screening mammogram shows something li(e a ro nd nod le, and the radiologist thin(s it might be a cyst !not cancer", the radiologist will as( for an $ltraso nd, and assign a BIRADS / category to the mammogram. %hen the ltraso nd res lt is a*ailable, and s ppose it showed a benign cyst, then

the ltraso nd res lt 8completes the BIRADS8 and assigns a category 1 to the case, beca se a cyst is benign.

"ategory $% &egative%
%ith category 0 the breast cancer screening mammogram shows no gro ped or s spicio s microcalcifications, no well-formed mass, a symmetrical gland lar str ct re, and no change from any pre*io s e9am.

"ategory '( benign

Category 1 is a definitely benign finding, and a ro tine screening. 'hat is, something is fo nd, b t it is not breast cancer or malignant in any way. BI-RADS category 1 findings often incl de. 0. Ro nd opacities with macrocalcifications !typical calcified fibroadenoma or cyst" 1. Ro nd opacities corresponding to a typical cyst at ltrasonography 2. :*al opacities with a radiol cent center 3. ;atty densities or partially fatty images !lipoma, galactocele, oil cyst, hamartoma " 4. S rgical scar 5. Scattered macrocalcifications !fibroadenoma, cyst, cytosteatonecrosis, secretory d ctal ectasia"< =. >asc lar calcifications ?. Breast implants,silicone gran loma.

'he specs are benign microcalcifications

-ere the calci m b ild p is in layers, li(e sediment or lea*es in a teac p.

Ro nd, benign microcalcification.

"ategory )% *robably Benign

%ith BI-RADS category 2, a follow- p of 5 months is s ally recommended. :n the breast cancer screening mammogram there may be a finding of some (ind, b t the lesion is nonpalpable. ;indings typical of this category incl de. 0. Cl sters of tiny calcifications if ro nd or o*al 1. @on-calcified solid nod les !no si,e limitation b t non palpable", ro nd, o*oid, welldefined, 2. Selected focal asymmetric areas of fibrogland lar density !not palpable". 'his might incl de conca*e-o tward defined margins, interspersed with fat and witho t central increased fib lar density on two pro)ections. 3. #iscellaneo s focal findings, s ch as a dilated d ct, or post biopsy architect ral distortion witho t central density 4. Aenerali,ed distrib tion in both breasts. ;or e9ample, m ltiple similar lesions with tiny calcifications or nod les distrib ted randomly In some scenerios a perc taneo s biopsy might be considered,e*en with category 2. ;or e9ample, e9treme patient an9iety, or plans for pregnancy, plans for breast a gmentation or red ction s rgery, or if synchrono s carcinoma is present.

'hese tiny specs are diff se p nctate microcalcifications.

'his microcalcification is ro nd b t the edges are not sharply defined. It wo ld be called 'indeterminate BI-RADS 2 and not BIRADS 1, beca se of the poorly defined, f ,,y edge.

'he posti*e predicti*e *al e !the chance of ha*ing a real breast cancer" is *ery low for BI-RADS category 2 lesions, and it has act ally decreased in recent years. %ith ad*ances in research and e9perience, the BB> of a category 2 breast lesions in now considered less than 07.

"ategory

Suspicious or Indeterminate abnormality

A BI-RADS category 3 mammogram is where the concern for breast cancer begins to increase. A biopsy sho ld be recommended with BI-RADS category 3. 'ypically, a lesion has been fo nd, b t does not initially appear to ha*e the morphological characteristics of breast cancer. BI-RADS category 3 is therefore often s bdi*ided into there smaller s b-categories. 8A8 for low s spicion of malignancy, 8B8 for moderate s spicion, and 8C8 for high s spicion. ;indings typical of BI-RADS category 3 incl de. 0. Asymmetric, locali,ed or e*ol*ing hyperdensities with con*e9 conto rs. 1. Indeterminate microcalcifications appearing amorpho s, indistinct partic larly if in a cl ster or heterogeneo s and pleomorphic 2. Ro nd or o*al non cystic opacities with microlob lated or obsc red conto rs

'he positi*e predicti*e *al e !the chance of a real cancer" of BI-RADS 3 mammograms, is tho ght to be in the order of 1/-3/7.

'powderish microcalcifications are s ggesti*e of BI-RADS classification of 3.

'hese 'powderish' microcalcifications appear in large cl sters.

BI-RADS category " has +uite a high positive predictive value for breast cancer
BI-RADS category 3 is now bro(en in to s b-categories A, B, and C. In terms of the positi*e predicti*e *al e for breast cancer, a category 3A mammogram is + ite low at 027, and category 3B also moderately low at abo t 257. B t when we see a mammogram classefied as 3C, the positi*e predicti*e *al e of breast cancer ) mps p to aro nd =67.

The most common finding in BI-RADS category fibrocystic changes

is breast

'he e9act clinical significance of the s bcategori,ations of BI-RADS category 3 remains a bit *ag e. Aenerally spea(ing as we mo*e f rther into categories A,B, and finally C, the chances of the breast lesion being diagnosed as DCIS increases. Abo t =/7 of BI-RADS category 3C breast lesions t rn o t to be d ctal carcinoma in sit , while DCIS is fo nd in category 3B lesions only

abo t 107 of the time, and only 0/7 of the time with category 3A breast lesions. In terms of the fre+ ency of the s bcategories of BI-RADS 3, is may be s ggested that category 3A is seen abo t 4/7 of the time, 3B abo t 2?7 of the time, and category 3C only abo t 027 of the time. 'he most common confirmed diagnostic finding in BI-RADS category 3, generally, is act ally fibrocystic change, at abo t 1?7. DCIS is confirmed abo t 127 of the time, with col mnar cell change and fibroadenoma fo nd in abo t 067 of cases.

"ategory ,% -ighly suggestive of malignancy

A 4 BI-RADS category is assigned when there is a *ery high probability for breast cancer, and a biopsy sho ld be ta(en immediately. ;inding typical of category fi*e incl de . 0. 'ypically malignant microcalcifications< for e9ample, linear with branching pattern< partic larly if n mero s, cl stered and with a segmental distrib tion< 1. Cl sters of microcalcifications with a segmental or galactophoro s distrib tion 2. C*ol*ing microcalcifications or associated with an architect ral distortion or opacity 3. Cl sters of microcalcifications with a segmental or galactophoro s distrib tion 4. Boorly circ mscribed opacities with ill-defined and irreg lar conto rs< 5. Spic lated opacities with radio-opa+ e center. BI-RADS category 4 is s ally reser*ed for lesions ha*ing a 647 probability of malignancy. After biopsy, the a*erage rate of carcinoma in category 4 biopsies is abo t =4-6=7.

Casting microcalcifications appear linear, fragmented, and branching.

In this image the casting microcalcifications are branched, and gran lar.

"ategory .% /no0n "ancer

Category 5 indicates a (nown cancer, pro*en by biopsy. 'his category is sed when patients ndergoing breast cancer treatment ha*e follow- p mammograms. ;or a few years after cancer treatment, category 5 might still be sed. Since e*eryone already (nows there is, or was, a cancer, we can't se categories / thr 4 anymore, so category 5 is assigned. Category 5 isn't sef l for acc racy statistics.

"ertain microcalcifications might even be 1directly1 associated 0ith breast cancer%

BI-RADS mammogram classifications are generali,ations only, and tend to re*ol*e aro nd the presence and type of microcalcifications. %ithin the range of obser*ations abo t the *ario s types and patterns of breast tiss e microcalcifications present, it may be s ggested that co rse heterogeno s microcalcifications are positi*ely associated with breast cancer abo t =7 of the time, and amorpho s microcalcifications abo t 027 of the time. ;ine pleomorphic breast microcalcifications ha*e a positi*e predicti*e *al e for breast cancer of abo t 2/7, while fine linear microcalcifications are associated with confirmed breast cancer in o*er 4/7 of cases.

BI-RADS mammogram classifications are not intended as diagnostic tools, b t only a means of standardi,ing comm nications and helping to indentify sit ations where follow- p is re+ ired, and the most appropriate type of follow- p. 'he fastest and most economical way to arri*e at a positi*e or confirmed diagnosis of breast cancer is by core-biopsy. References 0. :bena er S, -ermann DB, Arabbe C. Applications and Eiterat re Re*iew of the BI-RADS Classification. C r Radiol !1//4" 04. 0/1=-0/25. 1. Siegmann DC, %ersebe A, ;ischmann A, ;ersis @, >ogel $, Cla ssen CD, # ller-Schimpfle # !1//2". Stereotactic *ac m-assisted breast biopsy-s ccess, histologic acc racy, patient acceptance and optimi,ing the BI- RADS-correlated indication. ;ortschr Rontgenstr 0=4. 66-0/3. 2. :rel SA, Day @, Reynolds C, S lli*an DC !0666" BI-RADS categori,ation as a predictor of malignancy. Radiology 100. ?34-?4/. 3. Eiberman E, Abramson A;, S+ ires ;B, Alassman FR, #orris CA, Dershaw DD. 'he breast imaging reporting and data system. positi*e predicti*e *al e of mammographic feat res and final assessment categories. AFR Am F Roentgenol !066?"< 0=0. 24G3/ 4. Eac+ ement #A, #itchell D, -ollingsworth AB !0666". Bositi*e predicti*e *al e of the breast imaging reporting and data system. F Am Coll S rg 0?6. 23-3/. 5. Cberl ##, ;o9 C-, Cdge SB, Carter CA, #ahoney #C. BI-RADS classification for management of abnormal mammograms.F Am Board ;am #ed.! 1//5" #arApr<06!1".050-3. =. Boplac( SB, 'osteson A@, Aro*e #R, %ells %A, Carney BA. #ammography in 42,?/2 women from the @ew -ampshire mammography networ(. Radiology !1///"< 10=. ?21G3/.

?. #onticciolo DE, Caplan ES. 'he American College of RadiologyHs BI-RADS 2 classification in a nationwide screening program. c rrent assessment and comparison with earlier se. Breast F !1//3"< 0/. 0/5G0/. 6. Bent CD, Bassett E%, D':rsi CF, Sayre F%. 'he positi*e predicti*e *al e of BIRADS microcalcification descriptors and final assessment categories. AFR Am F Roentgenol. !1/0/ #ay"<063!4".02=?-?2. 0/. -a th, C., $m ltl , E., D mmel, S., Dimmig, R., ;orsting, #. ;ollow- p of Brobably Benign Eesions !BI-RADS 2 category" in Breast #R Imaging. 'he Breast Fo rnal ! #ayIF ne 1/0/" >ol me 05, Iss e 2, pages 16=G2/3 00. Rosen, CE, Smith-;oley, SA., De#artini, %B., Cby, BR. Beacoc(, S. Eehmen, CD. BI-RADS #RI enhancement characteristics of d ctal carcinoma in sit . 'he Breast Fo rnal ! 1//=" >ol me 02, p. 434-44/. 01. >aras J, Eeborgne F-, Eeborgne ;, #e,,era F, Fa mandre S, Eeborgne ;.Re*isiting the mammographic follow- p of BI-RADS category 2 lesions. AFR Am F Roentgenol. !1//1 Sep" <0=6!2".560-4. 02. Ra,a S, Aold(amp AE, Chi(armane SA, Birdwell RE. $S of breast masses categori,ed as BI-RADS 2, 3, and 4. pictorial re*iew of factors infl encing clinical management.Radiographics.! 1/0/ Sep"<2/!4".0066-102. 03. B rnside CS, :chsner FC, ;owler DF, ;ine FB, Sal(ows(i ER, R bin DE, Sisney AA.$se of microcalcification descriptors in BI-RADS 3th edition to stratify ris( of malignancy. Radiology. !1//= ;eb" <131!1".2??-64. 04. Sanders, #A., Eane, R., S nati, S. Clinical Implications of S bcategori,ing BIRADS 3 Breast Eesions associated with #icrocalcification. A RadiologyBathology Correlation St dy. 'he Breast Fo rnal !Fan aryI;ebr ary 1/0/" >ol me 05, @ mber 0, , pp. 1?-20. -ome

Copyright Ste*en B. -alls, #D East edited 01-September-1/00