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2 BI-RADS classification in mammographyDr. 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 - 2003Product of ACR Tool for quality control To standartise report To make less interpretation possibility Monitoring MG -1993 US

5 Report Indication Breast density FindingsDynamics, 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 classificationFindings 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

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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 findingSymetrical 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 SizeForm, 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 findingCompletely or partialy calcified fibroadenomas

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22 BI-RADS 2 – benign findingFat necrosis calcifications

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24 BI-RADS 2 – benign findingIntramammary lymph nodes

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

26 BI-RADS 3 – probably benign findingCircumscribed, noncalcified masses

27 BI-RADS 3 – probably benign findingAfter 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 caseI 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 3Initial 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 situationsPalpable/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 techniquesIn 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

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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 toDr. Luis J. Pina, University Clinic of Navarra, Spain

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

50 BI-RADS 4

51 Growing mass/density 2008 2010 2011

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53 Continuity in screening roundsPrior MG (digital)

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

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

56 BI-RADS 2 – benign findingLarge, rod like intraductal and periductal calcifications

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58 BI-RADS 2 – benign findingSimple cyst with mineralized wall

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60 BI-RADS 2 – benign findingVascular calcifications

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63 BI-RADS 3 – probably benign findingPunctate microcalcifications (scattered or clustered)

64 BI-RADS 3 – probably benign findingIf 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 abnormalityGroup 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 abnormalityPunctate microcalcifications with background density

67 BI-RADS 5 – highly suspicious of malignancySegmental 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 findingArchitectural distortion clearly related to prior surgery

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

73 BI-RADS 4 – suspicious abnormalityRadial architectural distortion without central density

74 BI-RADS 4 – suspicious abnormalityAsymetrical density with architectural distortion

75 BI-RADS 4 Assimetry/distortion

76 BI-RADS 5 – highly suspicious of malignancyRadial architectural distortions with central density

77 BI-RADS 0 – incomplete assessmentAdditional 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 evaluationDiagnostic 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 screeningReport 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