ACR BI-RADS Atlas Fifth Edition

QUICK REFERENCE

MAMMOGRAPHY ULTRASOUND MAGNETIC RESONANCE IMAGING

Breast a. The breasts are almost entirely fatty Tissue composition a. Homogeneous background echotexture – fat Amount of a. Almost entirely fat Associated features Nipple retraction
composition (screening only) fibroglandular b. Scattered fibroglandular tissue Nipple invasion
b. There are scattered areas of fibroglandular density b. Homogeneous background echotexture – fibroglandular
tissue (FGT) c. Heterogeneous fibroglandular tissue
c. The breasts are heterogeneously dense, which c. Heterogeneous background echotexture Skin retraction
d. Extreme fibroglandular tissue Skin thickening
may obscure small masses
d. The breasts are extremely dense, which lowers Background Level Minimal Skin invasion Direct invasion
the sensitivity of mammography parenchymal Mild Inflammatory cancer
enhancement Moderate Axillary adenopathy
Masses Shape Oval Masses Shape Oval
(BPE) Marked Pectoralis muscle invasion
Round Round
Symmetric or Symmetric Chest wall invasion
Irregular Irregular
asymmetric Asymmetric Architectural distortion
Margin Circumscribed Orientation Parallel
Focus Fat containing lesions Lymph nodes Normal
Obscured Not parallel
Masses Shape Oval Abnormal
Microlobulated Margin Circumscribed
Round Fat necrosis
Indistinct Not circumscribed Irregular Hamartoma
Spiculated - Indistinct Margin Circumscribed Postoperative seroma/hematoma with fat
Density High density - Angular Not circumscribed Location of lesion Location
Equal density - Microlobulated - Irregular Depth
Low density - Spiculated - Spiculated Kinetic curve Initial phase Slow
Fat-containing Echo pattern Anechoic Internal Homogeneous assessment Medium
enhancement Signal intensity (SI)/
Calcifications Typically benign Skin Hyperechoic Heterogeneous Fast
characteristics time curve description
Vascular Complex cystic and solid Rim enhancement Delayed phase Persistent
Coarse or “popcorn-like” Hypoechoic Dark internal septations Plateau
Large rod-like Isoechoic Washout
Round Heterogeneous Non-mass Distribution Focal Implants Implant material and Saline
Rim Posterior No posterior features enhancement Linear lumen type Silicone
features (NME) Segmental - Intact
Dystrophic Enhancement
Regional - Ruptured
Milk of calcium Shadowing
Multiple regions Other implant material
Suture Combined pattern
Diffuse Lumen type
Suspicious Amorphous Calcifications Calcifications in a mass
morphology - Single
Coarse heterogeneous Calcifications outside of a mass - Double
Fine pleomorphic Intraductal calcifications - Other
Fine linear or fine-linear branching Associated Architectural distortion Internal Homogeneous Implant location Retroglandular
features enhancement Heterogeneous Retropectoral
Distribution Diffuse Duct changes patterns
Regional Skin changes Skin thickening Clumped Abnormal implant Focal bulge
Clustered ring contour
Grouped Skin retraction
Intramammary lymph node Intracapsular silicone Radial folds
Linear Edema findings
Skin lesion Subcapsular line
Segmental Vascularity Absent
Non-enhancing Ductal precontrast high signal on T1W Keyhole sign (teardrop, noose)
Architectural distortion Internal vascularity findings Cyst Linguine sign
Asymmetries Asymmetry Vessels in rim
Postoperative collections (hematoma/seroma) Extracapsular silicone Breast
Global asymmetry Elasticity Soft
assessment Post-therapy skin thickening and trabecular Lymph nodes
Focal asymmetry Intermediate thickening Water droplets
Developing asymmetry Hard Peri-implant fluid
Non-enhancing mass
Intramammary lymph node Special cases Simple cyst
Architectural distortion
Skin lesion Clustered microcysts
Signal void from foreign bodies, clips, etc.
Solitary dilated duct Complicated cyst
Associated Skin retraction Mass in or on skin
features Nipple retraction Foreign body including implants BI-RADS® ASSESSMENT CATEGORIES
Skin thickening Lymph nodes – intramammary Category 0: Mammography: Incomplete – Need Additional Imaging Evaluation and/or Prior Mammograms for Comparison
Trabecular thickening Lymph nodes – axillary Ultrasound & MRI: Incomplete – Need Additional Imaging Evaluation
Axillary adenopathy Vascular AVMs (arteriovenous malformations/ Category 1: Negative
Architectural distortion abnormalities pseudoaneurysms) Category 2: Benign
Calcifications Mondor disease Category 3: Probably Benign
Location of lesion Laterality Postsurgical fluid collection Category 4: Suspicious Category 4A: Low suspicion for malignancy
Mammography
Category 4B: Moderate suspicion for malignancy
Quadrant and clock face Fat necrosis & Ultrasound:
Category 4C: High suspicion for malignancy
Depth Category 5: Highly Suggestive of Malignancy
Distance from the nipple Category 6: Known Biopsy-Proven Malignancy

For the complete Atlas, visit acr.org/birads 07.15