Elizabeth Morris MD FACR

Chief, Breast Imaging Service

Professor of Radiology

Memorial Sloan Kettering Cancer

Center

The New MRI BI-RADS®

Prior to BI-RADS, Some Mammography

Reports Looked Like This

Unintelligible descriptions; ambiguous recommendations

BI-RADS® is de facto standard for

research -drives advancement of breast

cancer care

• Universally known

• BI-RADS® used for 2 decades

• 5th edition for Mammography

• 2nd editions for US and MRI

• Translated into 8 languages (French,

Spanish, German, Portugese, Croatian,

Russian, Mandarin, Romanian)

• Over 1000 pubmed citations

On-line version available

4

ACR BI-RADS® 2013 Chairs

• Carl D’Orsi, MD – Chair, ACR

Committee on BI-RADS

• Subcommittee chairs

• Ed Sickles, MD – Mammography

• Ellen Mendelson, MD – Ultrasound

• Elizabeth Morris, MD - MRI

BI-RADS® Follow-Up and

Outcome Monitoring section for all

modalities

• Overall Assessment

– If there are different recommendations,

assessment for each breast favored

– If same recommendation for each breast,

single overall assessment adequate

Important Points about Final

Assessment Categories • Assessment is based on imaging findings

– Markers/Hardware are not BI-RADS® 2

– In a patient with known cancer if there are no

imaging findings then it is BI-RADS 1 or 2

– If the patient has a palpable benign cyst &

wants aspiration BI-RADS is still 2

• OK to add additional sentence suggesting

aspiration/biopsy based on clinical findings

Amount of Fibroglandular

Parenchyma

Almost entirely fat

Scattered fibroglandular

tissue

Heterogeneous

Fibroglandular tissue

Extreme

Fibroglandular tissue

Section on Non-enhancing findings

added • Hi contrast on pre C+ in duct

• Simple cyst

• Non-simple cyst

• Hematoma/seroma

• Edema

• Non-enhancing mass

• Dilated ducts

• Skin thickening

• Architectural distortion

• Signal void from clips, foreign bodies

Fat containing lesions added

• Lymph node

– Normal

– abnormal

• Fat necrosis

• Hamartoma

• Postoperative seroma with fat

New – Implants

11

Background Parenchymal Enhancement

(BPE)

• BI-RADS MRI Lexicon

• Minimal, mild, moderate, marked

•

Native breast tissue

• Amount of fibroglandular tissue

• Background parenchymal enhancement

4 – 6 X risk

No two breasts look alike

Background parenchymal enhancement patterns

and intensities vary

MRI BI-RADS® Lexicon – 2nd

edition

Minimal

Mild

Moderate

Marked

minimal mild

moderate

marked

BPE related to the volume

of the FGT that enhances

Patterns are not yet

included ( not enough

robust data )

When do you image BPE?

• First post contrast image following IV

gadolinium injection for routine breast MRI

• Delayed imaging assessment may not

discriminate different categories

• Assess Increase in signal intensity (SI)

– Variable intensity

– Variable patterns

Background Parenchymal

Enhancement patterns in MRI

screening • Qualitative analysis on Subtracted images

– Homogeneous 46/335 (14%)

– Heterogeneous 80/335 (24%)

– Nodular (stippled) 71/335 (21%)

• Young women < 45 y

– Nodular BPE (p<0.0001)

Jansen SA et al Eur Radiol 2011

Pathologically what does stippled

BPE correspond to?

Is BPE a surrogate for the breast

microenvironment?

• Independent of mammographic

density

• Doesn’t act like “density”

• Mammographic breast density does not

correlate with the degree of background

enhancement in MRI

• Scores for background enhancement were

– lower than mammographic scores in 371/468

(79.3%)

– equivalent in 90/468 (19.2%)

– higher in 7/468 (1.5%)

JMRI 2014

BPE likely is a quantifiable functional

assessment of the breast parenchyma

This is BPE – NOT “multiple foci”

“Stippled” is a retired term

BPE & hormonal status relationship has

been recognized for several decades

Kuhl CK, Bieling HB, Gieseke J, et al. Healthy premenopausal breast

parenchyma in dynamic contrast-enhanced MR imaging of the breast: normal

contrast medium enhancement and cyclical-phase dependency. Radiology

1997

Muller-Schimpfle M, Ohmenhauser K, Stoll P, Dietz K, Claussen CD. Menstrual

cycle and age: influence on parenchymal contrast medium enhancement in MR

imaging of the breast. Radiology 1997

Day 25 Day 12

Mastalgia/post Mx

Led to recommendations to only perform

breast MRI in week 2 to eliminate any

spurious enhancement

• Recommendation formulated in a period

where all enhancement was thought to be

suspicious

– Contributed to high false positive rate of

breast MRI

• Background parenchymal enhancement

had not yet been recognized

• Correlation between mammographic breast density and background enhancement (p = 0.011) (n=146) – 9/9 predominately fatty breasts showed minimal (78%) or

mild (12%) BPE

• Inverse correlation between age and BPE (p < 0.0001) – Younger patients with dense breasts were more likely to

demonstrate moderate/marked BPE

• “All premenopausal women should be imaged by breast MRI during the second week, or at least when in the middle of their menstrual cycle, whenever possible”

Eur J Radiol 2012

When should you image patients

based on their cycle?

• Recommendations are based on observation of enhancement

• We now know that BPE is a normal phenomenon

• If we are going to make recommendations we need outcome data

– Are call backs higher

– Are less cancers detected

– Are there too many false positive biopsies?

Hormonal Fluctuation

Focus

• Bright fluid imaging can help in the evaluation of

a focus. Benign lesions are generally very high

in signal intensity (cyst-like).

MIP T1W Imaging

Post Contrast Subtraction T2W Imaging

“Multiple foci” should not be used as this means a pattern of BPE

Mass

• Round

• Oval (includes lobulated)

• Irregular

• Shape descriptors adapted from

mammography BI-RADS for uniformity

Margin

• The edge or border of the lesion

• The margin may be described as

circumscribed or not circumscribed

Margin descriptors adapted from

mammography & US BI-RADS for

uniformity

Circumscribed

• Sharply demarcated with an abrupt

transition between lesion and surrounding

tissue. For MRI, the entire margin must be

well-defined for a mass to qualify as

circumscribed.

Fibroadenoma

Postcontrast

Invasive Ductal

Carcinoma Hematoma

Not circumscribed-irregular

• composed of edges either round or jagged

but not spiculated. Implies suspicious

finding.

Not Circumscribed-spiculated

Invasive Ductal Carcinoma.

Note pectoralis muscle

invasion(arrow)

Invasive Ductal

Carcinoma Invasive Lobular

Carcinoma

Characterized by lines radiating from the mass. Implies a suspicious finding.

Non-Mass Enhancement (NME)

• Non-mass enhancement describes an area that is not a mass

• Includes enhancement patterns extending over small or large regions

• internal enhancing characteristics described as a pattern discrete from normal surrounding background parenchymal enhancement

• Non-mass-like enhancement may have areas or spots of normal glandular tissue or fat between the abnormally enhancing components

NME

internal enhancement

• Homogeneous

• Heterogeneous

• Clumped

• Clustered ring

• Stippled removed as this is a type of BPE

• Clustered ring added as seen more now at high resolution

Clustered Ring

• Thin rings of enhancement clustered together

around the ducts. Enhancement in the

periductal stroma. Best seen on high resolution

images; implies a suspicious finding.

Clustered ring(ROI). Pathology:

Ductal Carcinoma In Situ

Clustered ring. Pathology:

Ductal Carcinoma In Situ

When deciding if you have a focus or

not

First question to ask:

Is it a unique finding or is it part of BPE?

What is a focus?

A focus is UNIQUE and stands out from BPE

but otherwise has no suspicious features

Focus or mass?

A small IDC is able to be detected

despite marked BPE

Follow up of a unique focus without suspicious features

on an initial screening examination is recommended

What is this? A small mass or focus?

CASE: Strong family history of breast

cancer & BRCA 1 positive

2004 High risk screening MRI

• 4/11/04 BILATERAL BREAST MR: CLINICAL STATEMENT: 29-year-old BRCA positive woman with strong family history of breast cancer status post benign left breast biopsy in 2002. Follow-up to last MRI which showed nodular enhancement on the left and stippled parenchymal enhancement on the right. TECHNIQUE: Fat suppressed sagittal T2-weighted, non-fat suppressed sagittal T1-weighted, fat suppressed sagittal T1-weighted pre and post Gadolinium intravenous administration and subtraction images of bilateral breasts were performed using a 1.5 Tesla GE magnet and dedicated breast coil. Additional MIP images were also performed using the first T1-weighted contrast enhanced subtraction imaging series. FINDINGS: Comparison is made with a prior bilateral breast MRI dated 9/2/03. The breasts contain an extreme amount of fibroglandular tissue with marked background parenchymal enhancement. In the upper inner quadrant of the left breast in the region of prior benign biopsy, the previously identified areas of enhancement are less prominent, suggesting that these are postoperative or hormonally related changes (series 12, image 18). There has been no interval development of abnormal enhancement within the left breast. Within the right breast, marked background parenchymal enhancement is again noted and appears unchanged since the prior exam. No suspicious focal areas of enhancement are identified within the right breast. IMPRESSION: LESS PROMINENT AREA OF ENHANCEMENT IN THE UPPER INNER QUADRANT OF THE LEFT BREAST AT THE SITE OF PRIOR BENIGN BIOPSY, SUGGESTING POSTOPERATIVE OR HORMONALLY RELATED CHANGE. BI-RADS 2: BENIGN FINDINGS. RECOMMEND ANNUAL MRI SCREENING.

Continued yearly screening

6 years later…new mass in left breast

Right breast Left breast

What is your assessment?

1. BI-RADS® 0 – Recommend US

2. BI-RADS® 2 – Benign

2. BI-RADS® 3 – 6 month follow up

3. BI-RADS® 4 - biopsy

What is your assessment?

1. BI-RADS® 0 – Recommend US

2. BI-RADS® 2 – Benign

2. BI-RADS® 3 – 6 month follow up

3. BI-RADS® 4 - biopsy

Targeted US performed to

determine method of biopsy

INVASIVE DUCTAL CARCINOMA

The decision to biopsy has already been made prior to the US

47 yo contralateral mastectomy 10

years ago

High risk screen – the NEW focus

What is your assessment?

1. BI-RADS® 0 – Recommend US

2. BI-RADS® 2 – Benign

2. BI-RADS® 3 – 6 month follow up

3. BI-RADS® 4 - biopsy

What is your assessment?

1. BI-RADS® 0 – Recommend US

2. BI-RADS® 2 – Benign

2. BI-RADS® 3 – 6 month follow up

3. BI-RADS® 4 - biopsy

Targeted US negative

MR biopsy

3 mm IDC

Post biopsy cavity

New focus

Biopsy

trocar

Postop MRI for positive margins

What is your assessment?

1. BI-RADS® 0 – Recommend US

2. BI-RADS® 2 – 1 year follow up

2. BI-RADS® 3 – 6 month follow up

3. BI-RADS® 4/5 – biopsy

4. BI-RADS® 6 – Known cancer

What is your assessment?

1. BI-RADS® 0 – Recommend US

2. BI-RADS® 2 – 1 year follow up

2. BI-RADS® 3 – 6 month follow up

3. BI-RADS® 4/5 – biopsy

4. BI-RADS® 6 – Known cancer

Postop MRI for positive margins

What is your assessment?

1. BI-RADS® 0 – Recommend US

2. BI-RADS® 2 – Benign

2. BI-RADS® 3 – 6 month follow up

3. BI-RADS® 4/5 – biopsy

4. BI-RADS® 6 – Known cancer

What is your assessment?

1. BI-RADS® 0 – Recommend US

2. BI-RADS® 2 – Benign

2. BI-RADS® 3 – 6 month follow up

3. BI-RADS® 4/5 – biopsy

4. BI-RADS® 6 – Known cancer

What is BI-RADS after NAC with

complete response on MRI?

Path: Isolated nests of IDC

scattered throughout

What is your assessment?

1. BI-RADS® 1 – Negative

2. BI-RADS® 2 – Benign

2. BI-RADS® 3 – 6 month follow up

3. BI-RADS® 4/5 – biopsy

4. BI-RADS® 6 – Known cancer

What is your assessment?

1. BI-RADS® 1 – Negative

2. BI-RADS® 2 – Benign

2. BI-RADS® 3 – 6 month follow up

3. BI-RADS® 4/5 – biopsy

4. BI-RADS® 6 – Known cancer

Use of BI-RADS 0 for MRI

• Used for retrieval of old exams that are

currently unavailable

• Need additional imaging

– Example: Possible lymph node on MRI – US

or mammography recommended to confirm

benign

– Example: Possible fibroadenoma on MRI –

US recommended for further characterization

Recommending US to prove

something benign

Appropriate use of BI-RADS 0

Use of BI-RADS: 0 OK

Trying to prove something benign

Characteristic “black hole” sign of fat necrosis

Known cancer

MRI performed for staging shows

additional suspicious lesion

MR detected additional lesion

Known cancer

What is your assessment?

1. BI-RADS® 1 – Negative

2. BI-RADS® 2 – Benign

2. BI-RADS® 3 – 6 month follow up

3. BI-RADS® 4/5 – biopsy

4. BI-RADS® 6 – Known cancer

What is your assessment?

1. BI-RADS® 1 – Negative

2. BI-RADS® 2 – Benign

2. BI-RADS® 3 – 6 month follow up

3. BI-RADS® 4/5 – biopsy

4. BI-RADS® 6 – Known cancer

BI-RADS 4 or 5 trumps BIRADS 6

as there is an actionable finding

Conclusions

• BI-RADS® 5th edition is more user friendly

• Increased content

• Uniformity across modalities

• Assessment & Recommendation Uncoupled

• Outcomes section

• Electronic version planned

Question 1

A new unique 6 mm mass with

homogeneous enhancement is a BI-RADS 2

lesion

A. False

B. True

Question 1

A new unique 6 mm mass with

homogeneous enhancement is a BI-RADS 2

lesion

A. False

B. True

Reference: D’Orsi CJ, Sickles EA, Mendelson EB, Morris EA, et al.

ACR BI-RADS Atlas: Breast Imaging Reporting and Data System. 5 ed.

Reston, VA, American College of Radiology, 2013

Question 2

What imaging features would make a focus

suspicious on MRI?

A. Homogeneous enhancement, high signal on

bright fluid imaging, washout kinetics

B. New, homogeneous enhancement and iso on

bright fluid imaging, plateau kinetics

C. Stable, homogeneous enhancement, iso on

bright fluid imaging, persistent kinetics

Question 2

What imaging features would make a focus

suspicious on MRI?

A. Homogeneous enhancement, high signal on

bright fluid imaging, washout kinetics

B. New, homogeneous enhancement and iso on

bright fluid imaging, plateau kinetics

C. Stable, homogeneous enhancement, iso on

bright fluid imaging, persistent kinetics

Reference: D’Orsi CJ, Sickles EA, Mendelson EB, Morris EA, et al.

ACR BI-RADS Atlas: Breast Imaging Reporting and Data System. 5 ed.

Reston, VA, American College of Radiology, 2013

Question 3

Q.1 Which of the following is a BI-RADS 4

finding?

a. Fat necrosis following surgical biopsy

b. Peripherally enhancing cyst that is high in signal

on T2W imaging

c. Multiple foci of enhancement

d. Postoperative seroma cavity

e. New unique 6 mm mass with homogenous

enhancement

Question 3

Q.1 Which of the following is a BI-RADS 4

finding?

a. Fat necrosis following surgical biopsy

b. Peripherally enhancing cyst that is high in signal

on T2W imaging

c. Multiple foci of enhancement

d. Postoperative seroma cavity

e. New unique 6 mm mass with homogenous

enhancement

Reference: D’Orsi CJ, Sickles EA, Mendelson EB, Morris EA, et al.

ACR BI-RADS Atlas: Breast Imaging Reporting and Data System. 5 ed.

Reston, VA, American College of Radiology, 2013

Question 4

Q. 2 Breast MRI biopsy should NOT be performed:

a. to evaluate BI-RADS 4 or 5 lesions not

identified on targeted ultrasound

b. to evaluate BI-RADS 3 lesions if the patient is

anxious and requests biopsy

c. to evaluate BI-RADS 0 lesions

d. clumped segmental enhancement

e. rim enhancing irregular mass with plateau

kinetics

Question 4

Q. 2 Breast MRI biopsy should NOT be performed:

a. to evaluate BI-RADS 4 or 5 lesions not

identified on targeted ultrasound

b. to evaluate BI-RADS 3 lesions if the patient is

anxious and requests biopsy

c. to evaluate BI-RADS 0 lesions

d. clumped segmental enhancement

e. rim enhancing irregular mass with plateau

kinetics

Reference: D’Orsi CJ, Sickles EA, Mendelson EB, Morris EA, et al.

ACR BI-RADS Atlas: Breast Imaging Reporting and Data System. 5 ed.

Reston, VA, American College of Radiology, 2013

THANK YOU!

Evelyn Lauder Outpatient

Breast Center MSKCC Hospital MSKCC

THANK YOU!!