Breast radiological cases: training with BIRADS® classification

European Journal of Radiology 54 (2005) 97–106

Breast radiological cases: training with BIRADS® classification

C. Balleyguiera, ∗, D. Vanela, A. Athanasioua, M.C. Mathieub, R. Sigala

a Radiology Department, Institut Gustave-Roussy, 39, rue Camille Desmoulins, 94805 Villejuif Cedex, Franceb Pathology Department, Institut Gustave Roussy, Villejuif, France

Received 22 November 2004; received in revised form 26 November 2004; accepted 29 November 2004

Abstract

The American College of Radiology has established guidelines for outcomes monitoring known as the Breast Imaging Reporting and DataSystem®.

The last edition of the BIRADS® classification includes mammography, but also ultrasonography and MRI. Radiologists must be used tothe BIRADS® lexicon and the BIRADS® assessment, in order to clarify mammography reports and to facilitate communication with the otherphysicians. This work is a training on 20 mammography cases to be familiar with the BIRADS® classification.© 2005 Elsevier Ireland Ltd. All rights reserved.

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Keywords: BIRADS® lexicon; BIRADS® assessment; Breast cancer; Screening

1. Introduction

The American College of Radiology has establishedguidelines for outcomes monitoring known as the BreastImaging Reporting and Data System® (BIRADS®) [1]. Theserecommendations include calculation of positive predictivevalues (PPV) and tracking of both benign and malignanthistology. The new version of the BIRADS® classificationincludes mammographic, sonographic and MRI features ofbreast lesions. Final assessment of BIRADS® should lead tostandardization of the treatment decision.

We present in this paper 20 radiological cases. The pur-pose of this presentation cases is to train with BIRADS®

classification.

2. Case 1

Screening test: cranio-caudal (CC) view of the left breast(Fig. 1).

®

2.1. Answer

CC view of the left breast shows a 15 mm spiculated min the middle of the breast. The BIRADS® final assessmentBIRADS® 5, because of the high density and the spicumargins of this mass. These radiological features are typmalignant; pathology revealed a grade II ductal invasivecinoma. Treatment decision should be a conservativement (lumpectomy with radiation therapy) due to the ssize of the mass[2]. Sentinel node detection might alsoproposed in order to avoid complete axillary dissection[3].

3. Case 2

Screening test: magnification mediolateral (ML) viewthe left breast (Fig. 2).

Question: which is your BIRADS® final assessment?

3.1. Answer
Question: which is your BIRADS final assessment?
∗ Corresponding author. Tel.: +33 1 42 11 60 74; fax: +33 1 42 11 52 79.E-mail address:[email protected] (C. Balleyguier).

Magnification ML view of the left breast shows a clusterof dense and irregular microcalcifications. Due to the smallnumber of microcalcifications, BIRADS® final assessment

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98 C. Balleyguier et al. / European Journal of Radiology 54 (2005) 97–106

Fig. 1.

is BIRADS® 4. Diagnosis decision must lead to stereotacticbreast biopsy, due to the suspicious features of the micro-calcifications. Pathology after vacuum-assisted breast biopsyrevealed a grade II ductal in situ carcinoma (DCIS). Decisiontherapy was lumpectomy followed by radiation therapy.

4. Case 3

Screening test: CC (Fig. 3) view of the right breast.Question: which is your BIRADS® final assessment?

4.1. Answer

CC view of the right breast shows dense, linear macro-calcifications, surrounding arterial vessels of the breast.BIRADS® final assessment is BIRADS® 2. BIRADS® 2assessment corresponds to typically benign lesions. Arte-rial calcifications are commonly detected in mammograms,and might reveal diabetes or coronary disease[4]. No furtherbreast examination is necessary.

Fig. 3.

5. Case 4

Magnification view of CC view of the right breast (Fig. 4).Question: which is your BIRADS® final assessment?

5.1. Answer

This view shows multiple, round, dense and monomor-phous microcalcifications. These radiological features favourthe hypothesis of benign microcalcifications. BIRADS® fi-nal assessment is BIRADS® 3, probably benign microcal-cifications. Because, this woman had a familial history ofbreast cancer, a vacuum-assisted breast biopsy was per-formed. Final diagnosis was fibrocystic microcalcifications.No further surgery was recommended. In case of famil-

Fig. 2.
Fig. 4.

C. Balleyguier et al. / European Journal of Radiology 54 (2005) 97–106 99

Fig. 5.

ial history of breast cancer, a one-year follow-up must berecommended.

6. Case 5

Bilateral CC view in a 63-year-old woman (Fig. 5).Question: which is your BIRADS® final assessment?

6.1. Answer

A 3-cm subareolar spiculated mass is visible in the leftbreast. Biopsy revealed a grade III DIC. BIRADS® final as-sessment is categorized in BIRADS® 5. Typically malignantradiological features include spiculated margins, high den-sity of the mass and asymmetrical features. Mastectomy wasdecided because of the size and the subareolar location of themass.

7. Case 6

CC view of the left breast (Fig. 6a).Question: which is your BIRADS® final assessment?

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Fig. 6.

8. Case 7

Magnification view of the left breast (Fig. 7).Question: which is your BIRADS® final assessment?

8.1. Answer

This view shows multiple, linear and dense microcalci-fications. A special sign is the spiral-shape distribution ofthese calcifications. These calcifications are typical of filarialdisease due to Loa-Loa infection. BIRADS® assessment isBIRADS® 2. Filarial calcifications are induced by calcifica-tion of the dead parasite, within the skin or the subcutaneousfat and are particularly frequent in African women[5]. Tan-gential views might help to diagnose the cutaneous locationof the parasite.

.1. Answer

A well-circumscribed mass is visible in the inner quant of the left breast. Peripheral macrocalcification wihe mass confirms the diagnosis of a calcified fibroadenIRADS® final assessment is BIRADS® 2. Ultrasonograph

eveals benign features (Fig. 6b), including oval shape, weircumscribed margins and posterior acoustic enhanceeither biopsy nor further examination is necessary.


Fig. 7.

9. Case 8

CC view of the left breast (Fig. 8).Question: which is your BIRADS® final assessment?

9.1. Answer

A well-circumscribed round lesion is visible in the middleof the left breast. Association within the same lesion of fatand dense glandular tissue is typical of hamartoma. Patholog-ically, this lesion consisted largely of dense fibroconnectivetissue with variable amounts of glandular elements with littleadipose tissue[6]. BIRADS® final assessment is BIRADS®

2. No further examination, especially no complementary ul-trasonography is necessary. Some hamartomas are presentingwith atypical features and must be explored with ultrasonog-raphy or needle core biopsy[7].

10. Case 9

Stereotactic procedure, left breast (Fig. 9a).Question: which is your BIRADS® final assessment?

10.1. Answer

A poor defined irregular mass is visible in the outer partof the left breast. BIRADS® final assessment is BIRADS®

5, due to the irregular margins of the mass. Ultrasonographyconfirms the suspicious features, including hypoechoic in-

Fig. 8.
Fig. 9.


Fig. 10.

Fig. 11.

Fig. 12.


ternal echostructure and irregular margins (Fig. 9b). The hy-perechoic line circumscribing the lesion is typical of desmo-plastic reaction. Pathology after wire localization confirmeddiagnosis of DIC.

11. Case 10

CC (Fig. 10a) and tangential view (Fig. 10b) of the rightbreast.


11.1. Answer

Linear, wavy microcalcifications are visible in the sub-cutaneous fat of the right breast. BIRADS® assessment isBIRADS® 2, with typical features of another filarial infec-tion. “Bis repetita placent”. . .

12. Case 11

Magnification CC view of the left breast (Fig. 11).Question: which is your BIRADS® final assessment?

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Fig. 14.

2.1. Answer

A round, well-defined macrocalcification is associaith sedimenting calcifications. BIRADS® assessment co

esponds to BIRADS® 2. Calcic sediment is typical of a caified cyst. No further examination is necessary.

3. Case 12

CC, magnification (Fig. 12a) and tangential (Fig. 12b)iews of the right breast.


Fig. 13.


13.1. Answer

Dense macrocalcifications are visible in the subcutaneoustissue. A clear centre is typical of calcified sweat glands.BIRADS® final assessment is BIRADS® 2.

14. Case 13


14.1. Answer

Multiple micro and macrocalcifications are located in theupper and outer quadrant of the left breast. Higher density ofthe lowest calcifications corresponds to “calcic milk” and istypical of cystic calcifications. BIRADS® final assessment isBIRADS® 2.

15. Case 14

Magnification (Fig. 14a and b) and spot compression(Fig. 14c) views of the right breast.

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spiculated lesion without any dense centre. Pathology aftertumorectomy and wire localization confirmed diagnosis of aradial scar. Radial scar is a benign spiculated lesion, whichshould be excised, because of its frequent association withDCIS or tubular carcinoma[8].

16. Case 15

Magnification view of the right breast (Fig. 15).Question: which is your BIRADS® final assessment?

16.1. Answer

This view shows a geometric, rectangular microcalcifica-tion. BIRADS® final assessment is BIRADS® 2. Rectangu-

Fig. 16.


5.1. Answer

Architectural distorsion is visible in the upper and ouuadrant of the right breast. A subtle spiculated lesion, wut any dense centre, is particularly well visible after sompression (Fig. 14c). BIRADS® final assessment is cagorized in BIRADS® 4, due to architectural distorsion

Fig. 15.


Fig. 17.

lar, geometric microcalcifications are typically benign, andcorrespond to the calcium oxalate content of the calcifica-tions, well depicted with polarized light microscopy[9].

17. Case 16

Bilateral CC views (Fig. 16). Screening mammogram.Question: which is your BIRADS® final assessment?

17.1. Answer

Two masses are visible in the outer quadrant of the leftbreast. Margins are different for these two masses. Spicu-lated margins of one mass are a suspicious feature for breastcarcinoma and could be classified in BIRADS® 5 category(arrow). The other one is well circumscribed and can be clas-sified in BIRADS® 2 or 3 category (arrowhead). Ultrasonog-raphy revealed an irregular, vertical, heterogeneous mass,


Fig. 18.

which confirms the BIRADS® 5 assessment for the first one.Pathology confirmed a grade II Ductal Invasive Carcinoma.The other mass was a typical cyst (BIRADS® 2). When twoor more lesions are visible in one breast, BIRADS® finalassessment should correspond to the more suspicious lesion[1].

18. Case 17

Bilateral CC (Fig. 17a), and MLO view (Fig. 17b) of theleft breast.


18.1. Answer

Left CC view shows a poor defined mass in the outerquadrant of the left breast (arrow). BIRADS® assessmentis BIRADS® 5. MLO view shows an additional mass,with polycyclic but clearly delineated margins (arrowhead).BIRADS® assessment for this lesion is BIRADS® 2, becausethis mass is typical of a naevus. Delineated margins are in-duced by air circumscribing the lesion, during compressionof the breast. Nevertheless, for this case, BIRADS® final as-sessment is BIRADS® 5, due to suspicious features of theother lesion. Pathology revealed a grade II DIC.

Fig. 20.
Fig. 19.


19. Case 18

Magnification CC view (Fig. 18).Question: which is your BIRADS® final assessment?

19.1. Answer

A cluster of polymorphous, dense microcalcifications,with a linear distribution in the breast is visible. BIRADS®

final assessment is BIRADS® 5. Linear distribution suggeststhe presence of malignant intraductal calcifications. Pathol-ogy after vacuum-assisted breast biopsy revealed a diffuseDCIS. Mastectomy was performed. Final examination ofspecimen confirmed presence of DCIS in all breast.

20. Case 19


20.1. Answer

This view shows a cluster of irregular and polymorphousmicrocalcifications. The round distribution of these calcifi-cations encounters their suspicious morphological features.BIRADS® assessment is BIRADS® 4. Vacuum-assistedb reat-m ed.W d dis-t uspi-c

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21.1. Answer

Breast density is very high (4 according to BIRADS® clas-sification of breast density[1].

The magnification view shows tiny, high densities struc-tures mimicking a cluster of microcalcifications. This viewseems to delineate a fingerprint. BIRADS® assessmentshould not be done, due to the poor quality of the films, andmammograms must be retaken (BIRADS® 0). Other artifactssuch scratched films, development artefacts, etc.,. . . mightaffect the reading of mammography.

References

[1] American College of Radiology (ACR). Breast Imaging Report-ing and Data System Atlas (BI-RADS (Atlas). Reston, VA;2003.

[2] Graves TA, Bland KI. Surgery for early and minimally invasive breastcancer. Curr Opin Oncol 1996;8:468–77.

[3] Torrenga H, Meijer S, Fabry H, van der Sijp J. Sentinel node biopsyin breast cancer patients: triple technique as a routine procedure. AnnSurg Oncol 2004;11:231S–5S.

[4] Kemmeren JM, Beijerinck D, van Noord PA, et al. Breast ar-terial calcifications: association with diabetes mellitus and car-diovascular mortality. Work in progress. Radiology 1996;201:75–8.

[5] Novak R. Calcifications in the breast in Filaria loa infection. Acta

[ oflogic

;103:

[ achaphic

[ adiale and

[ ls in1;15:

reast biopsy revealed a high grade DCIS. Further tent with lumpectomy and radiation therapy was performhen discordance between morphological features an

ribution occurs, it is necessary to consider the most sious radiological feature to classify the lesion.

1. Case 20

Bilateral MLO (Fig. 20a) and magnification vieFig. 20b). Breast screening program.


Radiol 1989;30:507–8.6] Daya D, Trus T, D’Souza TJ, Minuk T, Yemen B. Hamartoma

the breast, an underrecognized breast lesion. A clinicopathoand radiographic study of 25 cases. Am J Clin Pathol 1995685–9.

7] Berna JD, Nieves FJ, Romero T, Arcas I. A multimodality approto the diagnosis of breast hamartomas with atypical mammograppearance. Breast J 2001;7:2–7.

8] Sloane JP, Mayers MM. Carcinoma and atypical hyperplasia in rscars and complex sclerosing lesions: importance of lesion sizpatient age. Histopathology 1993;23:225–31.

9] Gonzalez JE, Caldwell RG, Valaitis J. Calcium oxalate crystathe breast. Pathology and significance. Am J Surg Pathol 199586–91.

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Breast radiological cases: training with BIRADS® classification