Breast Ultrasound BI-RADS:

The language we speak@DrJiyonLee

Jiyon Lee, MDClinical Associate Professor

Dept of RadiologyNYU School of Medicine

Jiyon.Lee@nyumc.org

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No disclosures

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ACR BI-RADS® Atlas 5th Edition

Cost= $425.00/250.00Weight of hard copy= 5 lbsE-book and app

ACR BI-RADS Atlas, Breast Imaging Reporting and Data System. Reston, VA, American College of Radiology, 2013

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Breast Imaging – Reporting and Data System (BI-RADS)

• First edition in 1992, for mammography only:

– Standardize imaging reporting

– Reduce confusion in breast imaging interpretations

• Common language between individual radiologists, institutions, etc

• Communication to clinicians regarding significance of findings and management recommendations

– Facilitate outcomes monitoring

• 2003 Atlas: mammo 4th ed, US and MRI 1st ed

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Breast Imaging – Reporting and Data System (BI-RADS)

• BI-RADS 5th Ed Atlas (2013)

– Real case examples (not diagrams)

– Harmonize lexicons across modalities to emphasize consistency in terms and definitions

– Uncoupling of assessment and management recs

– Facilitate auditing across modalities, with specific to-do and not to-do recs

– More practical help: FAQs and Guidance chapters

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Breast Imaging – Reporting and Data System (BI-RADS)

The language we speak

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Overview

• ACR BI-RADS history and overarching aims

• Quick refs: tables of changes, helpful checklists to summarize current lexicon

• (Mammography reporting and lexicon—not covered here)

• Ultrasound reporting and lexicon—yes covered here

• (Sections: FAQs and Guidance—not covered here)

• Final reporting: uncoupling of assessment categories and management recs validates flexible language we have been using in reports

• Case examples to illustrate– E.g. descriptors– E.g. composite mammo/US

report with one overall BI-RADS

• (Follow up and outcomes monitoring (FUOM) section—not covered here)

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ACR BI-RADS® Atlas 5 Edition Changes

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ACR BI-RADS® Atlas 5 Edition Changes

JYLee. KSUM 2016JYL2019 11

ACR BI-RADS® Atlas 5 Edition Changes

JYLee. KSUM 2016JYL2019 12

ACR BI-RADS® Atlas 5 Edition Changes

• This talk:

– Ultrasound

JYLee. KSUM 2016JYL2019 13

Quick Ref Cards: Mammo, US, and MRI

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Ultrasound: ReportingReport Structure My Comments

1. Indication for examination

2. Statement of scope and tech of breast US exam e.g. incl HH/ABUS, uni/bil, full/ targeted,

tech/rad/both, spec techniques

3. Succinct description of overall breast composition

(screening exam)

Also for dx exam as appropriate

4. Clear description of any important findings (Rec even neg screen= min 5 images.)

5. Comparison to previous examination(s), include

correlation with physical, mammography, or MRI

findings

(I suggest near top of report, as typical in

practice.) Include if correl w/ palp/mammo/MR,

vs incidental, if enlarging, etc.

6. Composite reports e.g concurrent mg/US, use separate paragraphs,

give one overall BI-RADS

7. Assessment (BI-RADS 0 should be rare) Same as for mg. Rec formal recall from scr US if

generate addtl views/assessment.

8. Management

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Overview: Lexicon Ultrasound

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Ultrasound: Tissue CompositionA. Homogenous background

echotexture—fat

B. Homogenous background

echotexture—fibroglandular

(~extreme density)

C. Heterogeneous

background echotexture

(~scatt/ heterog density) B. Homogeneous- FG

C. Heterogeneous echotexture

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Ultrasound Lesion Types & Lexicon Classification

• Masses– Shape: oval, round,

irregular

– Margin:

• circumscribed

• not circumscribed (angular, microlobulated, indistinct, spiculated

– Orientation (rel to skin)

– Echo pattern

– Posterior features

• Calcifications– Calcs in a mass

– Calcs outside of a mass (i.e. w/o a mass)

– Intraductal calcs

• Associated features

• “Special cases”

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US: Mass Descriptors--Shape

• Similar to mammo• Oval:

– elliptical, egg shaped, up to 2-3 gentle undulations

• Round: – spherical, ball-shaped,

globular

• Irregular: – neither round nor oval

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A. B.

D.

C. E.

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Quiz US: Mass—Shape? Margin? Orientation?Oval vs irregular? Circumscribed vs not?

Lobulated now discouraged …

• Look at all projections

• Need to scan real time

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US: Mass Descriptors—Margin

• Circumscribed

• Not circumscribed:

– Indistinct

– Angular (unique to US)

– Microlobulated

– Spiculated

• Refers to any portion of lesion

• Terms can be combined

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C.

B.

D. E.

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US: Mass Descriptors--Orientation

• Defn: unique to US

• Longest axis relative to skin

• Round cannot be parallel

• Parallel– aka wider-than-tall, horizontal

• Not parallel– aka taller-than-wide, vertical

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A. B.

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US: Mass Descriptors—Echo pattern

• Defn: Fat is reference

• Unique to US

• Anechoic

• Hyperechoic

• Complex cystic and solid

• Hypoechoic

• Isoechoic

• Heterogeneous

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A. B.

C. D.

E. F.

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US: Mass Descriptors--Posterior features

• Defn: unique to US • No posterior features

• Enhancement

• Shadowing

• Combined echo pattern

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A.

B. C. D.

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Ultrasound Lesion Types & Lexicon Classification

• Masses:– Shape: oval, round,

irregular

– Margin:

• circumscribed

• not circumscribed (angular, microlobulated, indistinct, spiculated

– Orientation (rel to skin)

– Echo pattern

– Posterior features

• Calcifications– Calcs in a mass

– Calcs outside of a mass (i.e. w/o a mass)

– Intraductal calcs

• Associated features

• “Special cases”

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Ultrasound: Calcifications

• US not typically used to assess calcs

• Correlate with mammo

• Calcifications

– Calcs in a mass

– Calcs outside of a mass (i.e. w/o a mass)

– Intraductal calcs

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Ultrasound Lesion Types & Lexicon Classification

• Masses:– Shape: oval, round,

irregular

– Margin:

• circumscribed

• not circumscribed (angular, microlobulated, indistinct, spiculated

– Orientation (rel to skin)

– Echo pattern

– Posterior features

• Calcifications– Calcs in a mass

– Calcs outside of a mass (i.e. w/o a mass)

– Intraductal calcs

• Associated features

• “Special cases”

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Ultrasound: Associated Features and Special Cases

• Architectural distortion• Duct changes• Skin changes• Edema• Vascularity• Elasticity assessment

• Simple cyst• Clustered microcysts• Mass in or on skin• Foreign body including

implants• LN-intramammary• LN-axillary• Vascular abnormalities• Postsurgical fluid

collection• Fat necrosis

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Ultrasound: BI-RADS Lexicon

Applying the language we speak

to final assessment andmanagement

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Ultrasound: Assessment and Management

Assessment Management Likelihood of Cancer

Category 0: Incomplete—Need additional imaging evaluation (not mentioned poss need?prior US/etcexams?)

Recall for additional imaging (not mentioned?obtain prior US/etc exams?)

N/A

Category 1: Negative Routine screening (?when/how?) Essentially 0% likelihood of malignancy

Category 2: Benign Routine screening (?when/how?) Essentially 0% likelihood of malignancy

Category 3: Probably benign Short interval (6-month) follow up or continued surveillance

>0% but ≤2% likelihood of malignancy

Category 4: SuspiciousCategory 4A: Low suspicion for malignancyCategory 4B: Moderate suspicion for malignancyCategory 4C: High suspicion for malignancy

Tissue diagnosis >2% but <95% likelihood of malignancy4A: >2% to ≤10% likelihood

4B: >10% to ≤50% likelihood

4C: >50% to <95% likelihood

Category 5: Highly suggestive of malignancy

Tissue diagnosis ≥95% likelihood of malignancy

Category 6: Known biopsy-proven malignancy

Surgical excision when clinically appropriate

N/A

Table 5. US: Concordance Between BI-RADS Assessment Categories and Management Recs (p128)

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Uncoupled BI-RADS Assessment and Management Recommendations

• Addresses cases of seemingly discordant (mismatched) assessment and management recommendations

• After assessment and recommendation, include second sentence to explain

• Already occurring in clinical practice. Now formally sanctioned, encouraged in BI-RADS 5th ed.

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Ultrasound: Summary

• Breast composition

• Lexicon

• Reporting

• If screening generates additional evaluation, called BR-0, recall

• Screening US in flux

• Uncoupling of language of assessment and management recs

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Case 1: Dx M/US one overall BI-RADS; management recs reconciled

• 40 yF for baseline mammography but also complains of new tender, palpable mass in the RUOQ

• Dx mammo= dense BT w/o focal finding, at palp or elsewhere

• Full bilat US=> large simple cyst= palp. No other findings. Give specific size and location. Side, axis, “depth” and distance from nipple.

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Case 1: Dx M/US one overall BI-RADS; management recs reconciled

• Composite report: – Separate paragraphs for mammo and US

• Final assessment: – BI-RADS 2, for benign cyst and no other findings

• Management: – Routine surveillance screening mammography in one year.

– Therapeutic cyst aspiration may be performed as desired.

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Case 2: 66y, screening. BIRADS 0, right breast massReport…rec dx views (which?) “with poss US”

or do you mean “with US”?

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2015

2016

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Case 3: 33y, 3 month palp, 26 wk pregnantDescribe? BI-RADS? Next management?

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Case 3: 33y, 3 month palp, 26 wk pregnantChest MRI r/o thoracic mets

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Case 4: Recall from Scr mammo , enlarging massDescribe? BI-RADs? Next step?

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Case 5: High risk screening (HRS) MRIWould screening US have found this?

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Case 6: Breast US relative to MRI: Role, pros/cons

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Case 7. High risk patient. ?Supplemental screening?

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.

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Case 8. 37yo. Three calcifying masses in same patientMultiplicity of findings is common!

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Case 8. 37yo. 3 x Calcs in mass caseMammo: Right 6:00, classic popcorn calcifications

in involuting FA

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Case 8. 37yo. 3 x Calcs in mass caseMammo: Left 9:00, mass with fewer coarse calcs

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Case 8. 37yo. 3 x Calcs in mass caseMammo: left 2:00, isodense ?oval mass, w regional

faint calcs

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Case 8. 37yo. 3 x Calcs in mass caseMammo: left 2:00, isodense ?oval mass, w regional

faint calcs

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Case 8. 37yo. 3 x Calcs in mass caseMammo: left 2:00, isodense ?oval mass, w regional

faint calcsUS: discrete 4cm oval circumscribed mass with

speckles= faint calcs on mammo

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Case 8. 37yo. 3 x Calcs in mass caseMammo: left 2:00, isodense ?oval mass, w faint calcs

US confirms: 4cm circumscribed oval mass w/calcs= mammographic mass.

US and mammo complements, sometimes completes.“False positives” are still important findings.

No apologies. We’re imagers. Figure out what’s what.

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Summary: US BI-RADSApplying the language we speak

• ACR BI-RADS history and overarching aims

• Quick refs: tables of changes, helpful checklists to summarize current lexicon

• Ultrasound reporting and lexicon—yes covered here

• Final reporting: uncoupling of assessment categories and management recs validates flexible language we have been using in reports

• Case examples to illustrate– E.g. descriptors– E.g. composite mammo/US

report with one overall BI-RADS

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Summary BI-RADS 5th Ed

• Improved harmonization across modalities in terms, assessment, management, and auditing

• Mammography

• Ultrasound

• MRI

• FUOM

• Image case examples, section on Guidanceand FAQs

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Epilogue

• Much of what we do is more than what FDA requires because the BI-RADS committee feels it’s “sound medicine.” Transparency, accountability, constant striving to improve

• BI-RADS engendered other followers in Radiology: e.g. PI-RADS, LUNG-RADS, LI-RADS, and HI-RADS so far

• Continue to do great work, aspire to best practices…

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Thank you

for working

hard and

taking care

of others~

xo Jiyon

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