Tracks to face a breast imaging and succeed

Poster No.:

C-1089

Congress:

ECR 2013

Type:

Educational Exhibit

Authors:

V. Mayoral Campos , J. M. Sainz Martinez , C. Bonnet Carron ,

J. A. GUIROLA , J. A. Fernandez Gomez , J. Sancho Prez ;

1

Zaragoza/ES, ZARAGOZA, ZA/ES

Keywords:

Breast, Management, Mammography, Ultrasound, MR, Screening,

Diagnostic procedure, Biopsy, Education and training, Cancer

DOI:

10.1594/ecr2013/C-1089

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Learning objectives
In this e-poster we are willing to remark the following key points:

To review and illustrate the BI-RADS mammogram and ultrasound system.

To describe what to look for in the breast imaging studies in order to help
residents and non-specialized radiologists to lose their fear to the breast
interpretation.

To illustrate with examples all the explanations.

Background
Breast Imaging Reporting and Data System (BI-RADS) was created for the ACR
(American Journal of Radiology) and it is considered the standard for reporting and
assessing the relative malignancy of breast abnormalities. The BI-RADS system was
created in 1992 with the next objetives:

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Fig. 2: BI-RADS Objetives

References: Department of Radiology, Hospital Clinico Lozano Blesa. Zaragoza/Spain
2012
It contains a lexicon for standardized terminology (descriptors) for mammography, breast
US and MRI, as well as standard reporting with final assessment categories and
guidelines for follow-up and outcome monitoring. It is considered the main system of
communication among physicians, as it tells you the next steps to do.

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Fig. 1: BI_RADS system (Breast Imaging Report and Data System)

References: - Zaragoza/ES
When a physician suspect a breast abnormality due to a symptom or a screening test,
women will typically be referred for additional breast imaging such as mammogram,
ultrasound, or MRI. Depending on the results of these imaging tests, they may be referred
for a breast biopsy.

Imaging findings OR Procedure details

Imaging techniques:
Each technique used in breast imaging has a principal role in the diagnoses of breast
cancer. The principal indications are:
Mammography:

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Screening of breast cancer

Palpable mass
Abnormality of skin or nipple
Search of unknown primary cancer
Follow-up study of probably benign lesion or calcifications

Ultrasound:

Inconclusive findings in mammography (specially palpable lesion not visible

at mammography)
Screening of high breast density.
Differenciate cystic from solid lesions.
Pregnant or lactant women
US-guided biopsy

MRI:

Inconclusive findings in conventional imaging

Preoperative staging (screening of contralateral breast cancer)
Unknown primary carcinoma
The evaluation of therapy response in the neoadjuvant chemotherapy setting
Imaging of the breast after conservative therapy (exclusion of local recurrence)
Screening in patients with gene mutations (lifetime risk of 20% or more)
Prosthesis imaging
MR-guided biopsy and lesion localization in lesions that are neither palpable
nor visible on conventional imaging techniques

DESCRIPTORS
Mammography:

First of all, it is important to identifie the mammographic pattern. It is named

as the principal breast tissue:

1.
2.
3.
4.

Predominant fat (less 25% fibroglandular densities)

Heterogeneous ( 25-50% fibroglandular densities)
Heterogeneously dense (51-75%)
Extremely dense (more than 75 %)

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1.

Fig. 3: Breast Composition

References: Department of Radiology, Hospital Clinico Lozano Blesa.
Zaragoza/Spain 2012

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Fig. 4: Breast Composition

References: Department of Radiology, Hospital Clinico Lozano Blesa. Zaragoza/Spain
2012

What to look for in mammography:

1.

Nodule: It is a space occupying lesion seen in two different projections. It is

important to describe:

-Location

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Fig. 5: Lesion location: it describes the different breast planes and how to locate the
lesion using a clock disposition.
References: R. Rostagmo. El informe imagenolgico de mama. 1998
-Size
-Morfology: Round, oval, lobulated, irregular or architectural distortion.

Fig. 6: Nodule Morfology

References: Department of Radiology, HCU Lozano Blesa, Zaragoza, Spain, 2013.

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-Margin:Circumscribed, partially obscured, micro-lobulated, ill-defined, spiculated

Fig. 7: Nodule Margins

References: Department of Radiology, HCU Lozano Blesa, Zaeagoza, Spain 2012
-Density: isodense, hyperdense, hypodense with fat, hypodense without fat
Depends on the nodule characteristics radiologists should give a BI-RADS
categorisation.

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Fig. 8: BI-RADS ASSESSMENTS for Nodules

References: - Zaragoza/ES
It is important to determinate if the lesion is in the breast parenchyma or in the skin.
Cutaneous benign masses can be projected as intramammary. Normally, skin lesions
have air rounding the nodule.

2. Calcification: It is the most common finding in mammography but also the most
difficult to identify. The mammography is the election technique to visualize calcifications.
Radiologists can find the calcification in lobules, ducts, interlobular tissue, vessels, skin,
or soft tissues.
It is important to see distribution, morfology, size and number of calcifications to give a
BI-RADS categorization.

Morfology

Fig. 12: BI-RADS ASSESSMENTS for Calcifications

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References: - Zaragoza/ES

Distribution

Fig. 17: Calcification Distribution

References: Department of Radiology, Hospital Clinico Lozano Blesa.
Zaragoza/Spain 2012
Size:

- <0.5 mm: suspicious

- 0.5-2mm: can be benign or malign
- > 2mm: benign

3. Architectural Distortion: The normal architecture is distorted and there is no definite

mass visible.

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This finding includes fine lines or spiculations radiating from a point, focal retraction or
distortion of the edge of the parenchyma. If there is no traumatic or surgery history, biopsy
is always indicated.
4. Associated findings: they are not specific when they are alone, but in association with
other findings they are suggestive of malignancy.

Skin retraction
Nipple retraction
Axilar adenopathies
Trabecular thickening
Skin thickening

Ultrasound:
BI-RADS assessments for US are based on an analysis of six morphologic features of
solid masses. Whenever possible, the US lexicon uses terms similar to those used in
the mammography lexicon, with the primary overlap related to the shape and margins
of a mass.

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Fig. 20: US Descriptors

References: Raza S et AL. BI-RADS 3, 4, and 5 lesions: value of US in management-follow-up and outcome. Radiology. 2008 Sep;248(3):773-81.

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Fig. 21: US Descriptors

References: Raza S et AL. BI-RADS 3, 4, and 5 lesions: value of US in management-follow-up and outcome. Radiology. 2008 Sep;248(3):773-81.
Final assessment-recommendation is based on the most suspicious finding.

Special cases:

1.
2.
3.
4.
5.
6.

Intramammary lymph nodes : BI-RADS 1 or 2

Complicated cyst: BI-RADS 3
Complex cyst: BI-RADS 4
Group of microcyst: BI-RADS 2
Abscess: BI-RADS 4A
Hematoma: BI-RADS 3

MRI:
MR imaging improves the detection and characterization of primary and recurrent breast
cancers. The assessment categories are based on BI-RADS categories developed

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for mammography. The breast imaging lexicon allows a standardized and consistent
description of the morphologic and kinetic characteristics of breast lesions. The margin
characteristics of a lesion and the intensity of its enhancement at MR imaging 2 minutes or
less after contrast material injection are currently considered the most important features
for breast lesion diagnosis.

FINAL ASSESSMENT CATEGORIES

Fig. 26: FINAL ASSESSMENT CATEGORIES

References: Department of Radiology, Hospital Clinico Lozano Blesa. Zaragoza/Spain
2012
If a lesion is palpable, the BI-RADS final categorie is one point higher.

Example: a palpable fibroadenoma (usually a BI-RADS 2) is a BI-RADS 3

If more than one imaging modality is performed, an integrated report with assessment
based on the highest level of suspicion must be used.

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TESTING YOURSELF:

In the next cases, which BI-RADS final categorie do you report and which
are your management recommendations?

CASE 1

Fig. 37: Case 1

References: Department of Radiology, Hospital Clinico Lozano Blesa. Zaragoza/Spain
2012
CASE 2

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Fig. 38: Case 2

References: Department of Radiology, Hospital Clinico Lozano Blesa. Zaragoza/Spain
2012
CASE 3

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Fig. 39: Case 3

References: Department of Radiology, Hospital Clinico Lozano Blesa. Zaragoza/Spain
2012
CASE 4

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Fig. 40: Case 4

References: Department of Radiology, Hospital Clinico Lozano Blesa. Zaragoza/Spain
2012
SOLUTIONS:
- Case 1: BI-RADS 2, normal follow-up
Mammography shows a round, circunscribed, isodense mass categorizated as BIRADS 3. In US, oval, circumscribed anechoic mass with horizontal orientation and
posterior enhancement, typical appearance of a cyst: BI-RADS 2. In this case the typical
appearance of the cyst give the final assessment categorie.
-Case 2: BI-RADS 5, biopsy
Fine linear branching calcifications with focal distribution.
-Case 3: BI-RADS 2, normal follow-up.

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Multiple coarse calcifications, all of them with morphologies that are high suggestive of
benignity. The calcifications have a diffuse distribution.
-Case 4: BI-RADS 5, biopsy.
Multiple round, hyperdense nodules, some of them spiculated. In US, solid, round
complex nodule with indistinct margins, horizontal orientation and no shape. This is an
atypical case in mammography because this case was a patient with lymphoma and
breast metastases.
Images for this section:

Fig. 9: Nodules Morfology

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Fig. 10: Nodules margins

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Fig. 11: Nodules density

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Fig. 13: Skin nodule: air interface round the nodule indicating that the lesion is located
in the skin.

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Fig. 14: Examples of Benign Calcifications

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Fig. 15: Calcifications with low-medium suspicion. Management recommendations: short

follow-up or Biopsy.

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Fig. 16: Calcifications with high suspicion. Management recommendation: Biopsy

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Fig. 18: Examples of architectural distortion. It is important to know if there is traumatic

or surgery history.

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Fig. 19: Associated findings

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Fig. 22: Examples of US descriptors

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Fig. 23: Examples of US descriptors

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Fig. 24: Examples of special cases

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Fig. 25: Enhancement kinetics curves in MRI. There is 3 different types. Type I is a
pattern of progressive enhancement, with a continuous increase in signal intensity on
each successive contrast-enhanced image. Type II is a plateau pattern, in which an initial
increase in signal intensity is followed by a flattening of the enhancement curve. Type
III is a washout enhancement pattern, in which there is initial increase and subsequent
decrease in signal intensity

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Fig. 27: BI-RADS 0: You need additional imaging evaluation to give a final assessment.

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Fig. 28: BI-RADS 1: predominant fat pattern. There is nothing to comment on.

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Fig. 30: Dense lobulated nodule with coarse calcifications. These are typical of
fibroadenoma. In this case it is not necessary any subsequent conduct. The
recommendation is normal follow-up.

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Fig. 29: BI-RADS 2: benign nodule. In mammogrphy, we can see an isodense nodule,
with oval morfology and with partially indistinct margin. In ultrosund, it is oval, parallel to
the skin, anechoic, circunscribed with posterior enhancement, compatible with a cyst.

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Fig. 31: Mammogrphy shows an isodense nodule, with oval morfology and with partially
indistinct margin. In ultrosund, the nodule is oval, parallel to the skin, hypoechoic and
circunscribed. Bi-RADS 3, probably benign, 6 months follow-up.

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Fig. 32: Mammogrphy shows a dense nodule, with oval morfology and with partially
indistinct margin (arrow in mammography). Ultrasound shows a large cyst with posterior
echogenic components (arrows). BI-RADS 4, Biopsy is recommended.

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Fig. 33: Mammography shows a dense, lobulated nodule, with microlobulated margins.
Ultrasound demostrate an oval hypoechoic nodule, not parallel to the skin,with
microlobulated margins, echogenic halo and posterior shadowing. This lesion is probably
malign, so biopsy is recommended.

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Fig. 34: Mammography shows a hyperdense nodule, with spiculated margins(short

arrows). There is also skin and nipple retraction (long arrow). Highly suggestive of
malignancy. Biopsy and treatment are recommended.

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Fig. 35: Mammography shows a pleomorphic segmentary gruop of calcifications

(arrows), highly suggestive of malignancy. Ultrasound demostrates a hypoechoic,
irregular mass, with spiculated margins and posterior shadowing, categorized as BIRADS 5.

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Fig. 36: In mammography, spiculated hyperdense lesion (arrows in mammography)

and skin thickennig categorizated as BI-RADS 5. The ultrasound demostrates an oval,
spiculated, hypoechoic nodule with vertical orientation and echogenic halo (arrow in US),
categorizated also as BI-RADS 5 because it is highly suggestive of malignancy. Biopsy
and treatment are recommended.

Page 42 of 44

Conclusion
Some things that all radiologists should know to read breast imaging easily:

Make sure that you are looking a breast lesion.

Use standard BI-RADS descriptors for Mammography, Ultrasound and MRI.
Your final assessment has always to be based on the most worrisome
finding.
Make sure that you are looking the same lesion with all the imaging
modalities.

References
1- American College of Radiology. BI-RADS-Mamography. 4th ed. In: Breast Imaging
Reporting and Data System (BI-RADS) atlas. 4th ed. Reston, Va: American College of
Radiology, 2003.
2- American College of Radiology. BI-RADS-Ultrasound. 1st ed. In: Breast Imaging
Reporting and Data System (BI-RADS) atlas. 4th ed. Reston, Va: American College of
Radiology, 2003.
3- American College of Radiology. BI-RADS-MRI. 41st ed. In: Breast Imaging Reporting
and Data System (BI-RADS) atlas. 4th ed. Reston, Va: American College of Radiology,
2003.
4- Harvey JA, Nicholson BT, Cohen MA. Finding early invasive breast cancers: a practical
approach. Radiology. 2008 Jul;248(1):61-76.
5- Raza S, Goldkamp AL, Chikarmane SA, Birdwell RL. US of breast masses categorized
as BI-RADS 3, 4, and 5: pictorial review of factors influencing clinical management.
Radiographics. 2010 Sep;30(5):1199-213
6- Raza S, Chikarmane SA, Neilsen SS, Zorn LM, Birdwell RL. BI-RADS 3, 4, and
5 lesions: value of US in management--follow-up and outcome. Radiology. 2008
Sep;248(3):773-81.

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7- Mann RM, Kuhl CK, Kinkel K, Boetes C. Breast MRI: guidelines from the European
Society of Breast Imaging. Eur Radiol. 2008 Jul;18(7):1307-18.
8- Macura KJ, Ouwerkerk R, Jacobs MA, Bluemke DA. Patterns of enhancement
on breast MR images: interpretation and imaging pitfalls. Radiographics. 2006 NovDec;26(6):1719-34;

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