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Cecilia L. Mercado, MD
KEYWORDS
Breast Breast imaging BI-RADS BI-RADS atlas Lexicon
KEY POINTS
The new edition of BI-RADS has been updated to provide further clarification of lesion interpretation
and standardization of lesion terminology and reporting.
The BI-RADS revision provides a uniformity of terminology in the lexicon across all 3 imaging mo-
dalities, mammography, ultrasound, and magnetic resonance imaging.
Introduction of new descriptive terms in the updated BI-RADS is reflective of new available technol-
ogies and evidence provided from current publications.
Department of Radiology, New York University School of Medicine, NYU Cancer Institute, 160 East 34th Street,
3rd Floor, New York, NY 10016, USA
E-mail address: cecilia.mercado@nyumc.org
Ultrasound Lexicon
The terminology in the ultrasound lexicon has been
expanded in the new BI-RADS edition. Descriptors
for tissue composition as characterized on ultra-
sound have been revised to correlate to the
mammographic breast densities. These are “ho-
mogeneous-fat”, “homogeneous-fibroglandular”,
and “heterogeneous” tissue composition. As in
the previous edition, there are primary descriptors
to characterize the shape and margin of masses
Fig. 1. Updated mammography lexicon terminology. imaged on ultrasound. Similar to the mammog-
Spot magnification mammography shows rim calcifi- raphy and MRI lexicon, the ultrasound descriptors
cation near lumpectomy site. The descriptors “egg- were updated to maintain consistency among the
shell” and “lucent-centered” used to describe types 3 modalities. There will be certain terms that will
of benign calcifications have been consolidated under be defined such as that for a complicated cyst,
the term “rim”.
which is defined as a circumscribed, oval, mass
parallel orientation containing low-level echoes
“oval” to standardize descriptors across imaging throughout (Fig. 2).
modalities. These changes have been summarized Along with descriptors for the additional section,
in Box 1. Other terms such as “intermediate which include “echo pattern” and “posterior
concern”, used for amorphous and coarse hetero- acoustic features”, there is a new subsection titled
geneous calcifications and the term “higher prob- “Associated Features”, which will include descrip-
ability of malignancy” used for fine pleomorphic, tors for architectural distortion, vascularity, and
fine linear, and fine-linear branching calcifications elastography (tissue stiffness). The descriptive
have also been deleted from the mammography terms for elastography are new and include
lexicon. New published evidence suggests that “soft”, “intermediate”, and “hard”. It is empha-
some of the descriptive terms used to characterize sized that the features of elastography do not
calcifications may not impart the level of suspicion trump the primary features of morphology, shape,
previously believed, and therefore the revised margin, and orientation.3 These changes have
BI-RADS has changed to only using descriptors been summarized in Box 3.
for lesion characterization.4
There are some descriptive terms in the updated Magnetic Resonance Imaging Lexicon
BI-RADS that have been expanded, such as the Several changes were also introduced into the
MRI lexicon. Although previously introduced as a
Box 1
Summary of changes to the BI-RADS Box 2
mammography lexicon Descriptors for types of asymmetry in the
mammography lexicon and appropriate
Lexicon Terminology Updated BI-RADS
assessment category
Grouped–historically Replaces “grouped” or
Types of Asymmetry Assessment Category
clustered “clustered”
Rim Replaces “lucent- Asymmetry BI-RADS 1
centered”, “egg-shell” Global asymmetry BI-RADS 2
Oval Replaces “lobular” Focal asymmetry BI-RADS 3
Developing asymmetry New Developing asymmetry BI-RADS 4
BI-RADS Update 483
Fig. 3. Revised MRI lexicon terminology for mass shape. Axial post-contrast T1-weighted (A) and sagittal post-
contrast subtracted T1-weighted (B) images show an oval enhancing mass in the central right breast. The
descriptor for mass shape “lobular” has been deleted and replaced with the term “oval”.
The new BI-RADS also provides clarification have been paired up appropriately. However,
of terms used to describe lesion location on there are some instances where the management
mammography. Previously, in cases where a recommendations did not go along with the
lesion was located in the central breast or at the BI-RADS assessment. This is the case in the
12:00 location, a specific quadrant could not be BI-RADS Category 3/follow-up at 1-year manage-
assigned. The new BI-RADS has expanded the ment recommendation given at the third follow-up
terminology for lesion location by adding terms recommendation for a probably benign finding.
such as “upper/lower/outer/inner central”. This The new edition provides flexibility for discor-
terminology has been added to the mammography dances between the assessment and the manage-
lexicon and allows for direct correlation of lesion ment. It also includes situations where a benign
location on ultrasound and MRI. Increased clarifi- finding may require an intervention or surgical
cation has also been provided to describe the management: when a patient presents with a
use of subcategories for the BI-RADS assessment palpable mass without imaging findings still
Category 4. The new BI-RADS provides specific requiring surgical management, or cases of thera-
PPV cut-off points for BI-RADS 4A/4B/4C, which peutic cyst aspirations due to patient discomfort.
match certain specific imaging findings. The use The new BI-RADS edition addresses these
of these cut-off points remains optional in the discrepancies.
new edition but is strongly encouraged.4 Other specific situations leading to discrep-
One of the major changes in the new BI-RADS ancies that have been addressed include cases
edition has been the separation of assessment of ruptured silicone implants, abscesses, new he-
categories and management recommendations matoma, and unexplained edema. In these situa-
that had been “linked” in the previous edition. In tions, the imaging findings are benign appearing
most cases, the assessment and management and lead to a benign recommendation but with
Fig. 4. Updated MRI lexicon terminology for nonmass enhancement. Axial post-contrast T1-weighted (A) and
sagittal post-contrast subtracted T1-weighted (B) images demonstrate linear enhancement in the inferior lateral
right breast. The term “ductal” has been eliminated from the lexicon and replaced with the descriptor for non-
mass enhancement “linear”.
BI-RADS Update 485
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11. Carney PA, Sickles EA, Monsees BS, et al. Identi- of non-palpable breast lesions classified as pro-
fying minimally acceptable interpretive performance bably benign at initial mammography and/or ultra-
criteria for screening mammography. Radiology sound (BI-RADS category 3). Eur J Radiol 2013;
2010;255(2):354–61. 82(3):398–403.