Clues You Can Use: Core Breast Breast Imaging Division March 2018 BI-RADS® Assessment Categories o Assessments are divided into incomplete Category 0 and final assessment categories Categories 1-6 o Overall assessment based on the most worrisome finding or the need for immediate additional evaluation o Screening mammograms may be assigned Category 0,1,2 BI-RADS® Assessment Categories o BI-RADS® Category 0: INCOMPLETE - NEED ADDITIONAL IMAGING EVALUATION AND/OR PRIOR MAMMOGRAMS FOR COMPARISON o BI-RADS® Category 1: NEGATIVE o BI-RADS® Category 2: BENIGN o BI-RADS® Category 3: PROBABLY BENIGN o BI-RADS® Category 4: SUSPICIOUS o BI-RADS® Category 5: HIGHLY SUGGESTIVE OF MALIGNANCY o BI-RADS® Category 6: KNOWN BIOPSY-PROVEN MALIGNANCY Management Recommendations o Management recommendations on a per Assessment basis o Wording emphasizes recall, routine mammography screening, tissue diagnosis, surgical excision o Management recommended wording for tissue diagnosis is: “Biopsy should be performed in the absence of clinical contraindications.” o Management recommended wording for BI-RADS® 6 is : “Surgical excision when clinically appropriate.” o Category 0: INCOMPLETE - NEED ADDITIONAL IMAGING EVALUATION AND/OR PRIOR MAMMOGRAMS FOR COMPARISON Recall for additional imaging and/or comparison with prior examinations o Category 1: NEGATIVE Routine mammography screening o Category 2: BENIGN Routine mammography screening o Category 3: PROBABLY BENIGN Short interval 6 month follow-up OR continued surveillance o Category 4: SUSPICIOUS ABNORMALITY Biopsy should be performed in the absence of clinical contraindications o Category 5: HIGHLY SUGGESTIVE OF MALIGNANCY Biopsy should be performed in the absence of clinical contraindications o Category 6: KNOWN BIOPSY-PROVEN MALIGNANCY Surgical excision when clinically appropriate BI-RADS® Assessment Categories o BI-RADS® Category 0: INCOMPLETE - NEED ADDITIONAL IMAGING EVALUATION AND/OR PRIOR MAMMOGRAMS FOR COMPARISON o BI-RADS® Category 1: NEGATIVE o BI-RADS® Category 2: BENIGN o BI-RADS® Category 3: PROBABLY BENIGN <2% chance CA o BI-RADS® Category 4: SUSPICIOUS 2-95% chance CA o BI-RADS® Category 5: HIGHLY SUGGESTIVE OF MALIGNANCY >95% chance CA o BI-RADS® Category 6: KNOWN BIOPSY-PROVEN MALIGNANCY BI-RADS® Category 3 Assignment NO ! MAYBEEE ➢ Screening mammogram ➢ MUST complete diagnostic ➢ Solitary dilated duct (B-R 4) workup prior to assigning BI- RADS® 3 ➢ BI-RADS® Atlas older edition so- called indeterminate ➢ Solitary solid mass with benign calcifications (B-R 4) mammogram and ultrasound features ➢ Developing asymmetry ➢ Focal asymmetry with negative ➢ Any mass with mammogram or ultrasound features of CBE and ultrasound malignancy (B-R 4) ➢ Fat necrosis calcifications ➢ Masses in BRCA gene mutation ➢ Young women with palpable pts (B-R 4) mass, imaging = FA ➢ Multiple bilateral circumscribed masses (B-R 2) Screening Mammography o Standard projections MLO and CC o If Baseline risk pt: Begin age 40 and annual thereafter o High risk screening pt: test or tests determined by her specific risk parameters ie mammo+US/MR o SEARCH! Screening mammogram hallmarks of malignancy: suspicious mass, calcifications, site of architectural distortion, asymmetry Asymmetries Unilateral deposits of fibroglandular tissue not conforming to the definition of a radiodense mass. Four types: 1. ASYMMETRY - visible in only one mammographic projection. Typically summation artifact 2. GLOBAL ASYMMETRY - large amount of fibroglandular-density tissue over a substantial portion of breast at least a quadrant compared to contralateral breast. Usually normal variant 3. FOCAL ASYMMETRY - relatively small amount of fibroglandular-density tissue over a confined portion of breast < a quadrant. Concave borders and interspersed fat distinguish from mass. DDx Superimposition of two normal structures, Mass 4. DEVELOPING ASYMMETRY - focal asymmetry that is new, larger, or more conspicuous than previously. 15% are CA Architectural Distortion defined o Normal breast architecture is distorted with no definite mass o Thin straight lines of spiculations radiating from a point; focal retraction, distortion, straightening at the anterior or posterior edge of the parenchyma o May also be seen in association with asymmetry or calcifications o Determine if concordant history of trauma or surgery o DDx = Cancer, Radial scar, Posttraumatic/Surgical scar The Abnormal Screening Mammogram Abnormal screening mammogram is assigned BI-RADS® CATEGORY 0 and is called back for a Diagnostic breast imaging workup o For mass/asymmetry: compression magnification views in MLO and CC possibly followed by targeted ultrasound o For architectural distortion: compression magnification views in MLO and CC possibly followed by targeted ultrasound o For calcifications: compression magnification views in TL 90 and CC o PPV1 based on abnormal screening exam 3-8% o PPV2 when biopsy - surgical, FNA, or core - recommended 20-40% The Abnormal Screening Mammogram ACR BI-RADS® 5th ed Desirable Medical Audit #s for interpreting radiologists o Cancer detection rate per 1000 exams >2% o Abnormal interpretation ie recall rate 5-12% o Sensitivity >75% o Specificity 88%-95% o PPV1 based on abnormal screening exam 3-8% o PPV2 when biopsy -surgical, FNA, or core - recommended 20-40% Classic Benign Breast Disease Fibroadenoma Simple Cyst o Most common breast mass in o Occur in 10% of all women patients <35 yo o May be palpable, painful, o Contain stromal tissue and breast grow/regress quickly ductules o Anechoic mass, imperceptible wall, o Sensitive to hormone changes - eg pregnancy posterior enhancement o Oval parallel circumscribed o Painful cysts can be aspirated under hypoechoic ultrasound - benign type fluid is o May contain calcifications yellow, green o Biopsy is recommended for newly palpable or increasing in size or demonstrating suspicious features on exam Classic Benign Breast Disease Complicated Cyst Clustered Microcysts o Homogeneous low level internal o Etiologies include fibrocystic echoes change and apocrine metaplasia o May have a layered appearance o Lesion consists of cluster of tiny anechoic foci, individually smaller o Fluid-debris levels may shift than 3 mm with pt position o Present as asx mammogram mass, o May also contain brightly occasionally palpable echogenic foci that scintillate as o Thin intervening septations and no they shift discrete solid component for B-R 3 o NOT complex cystic and solid vs B-R 2 mass echo mass o Complex cystic and solid mass B-R 4 mass Classic Benign Breast Disease Fat Necrosis Papilloma o Benign condition o Solitary intraductal papillomas usu o Trauma-induced may be surgical, located centrally or in the although patient may have no retroareolar region knowledge of precipitating event o Present with bloody or clear nipple o Typically presents as palpable mass discharge - oil cyst o Most commonly observed in o Occasionally present as irregular symptomatic perimenopausal mass or calcifications that merit patients in the past CNB o Now presenting as mass on mammogram in younger asx o Round or oval circumscribed masses, may be complex, intraductal, calcifications Classic Benign Breast Disease Lactating Adenoma Galactocele o Unique to pregnant and lactating pt o Unique to pregnant and lactating pt o Fibroadenoma mimicker o Typically present as fluctuating o Oval parallel circumscribed mass in pt who recently ceased hypoechoic breastfeeding o <3cm and contain stromal tissue o Round or oval parallel and breast ductules circumscribed mass. May be an- hypo- or hyperechoic, depending o May contain calcifications on fat content. Mammo TL proj for o May infarct and present with fat fluid level enlarging mass o Tend to regress spontaneously and o Tend to regress after cessation of most do NOT require aspiration breastfeeding o May be aspirated FA appearance in pregnant? Fat fluid levels Think LA! true lat Classic Breast Disease Phyllodes DCIS o Fibroepithelial - histologically o Accounts for 20-25% CA similar to fibroadenoma o Confined to the ducts o Typically present as rapidly o Increased risk in pts with family enlarging mass history, elevated BMI o Appearance is similar to large postmenopausal, dense breasts fibroadenoma o Mortality is extremely low and o May be complex and contain cystic related to IDC 8-10 years post spaces diagnosis of DCIS o 10% malignant - no distinguishing o Mammographically detected features o May also present with mass, nipple o Excision of benign discharge, Paget disease AND malignant o On MRI - NME o Recurrence is local. with delayed peak Rare lung, bone, enhancement liver mets kinetic Mammo Calcifications BI-RADS® AtAWord BENIGN SUSPICIOUS o All ‘typically benign’: Round, Rim, o Fine linear and fine linear Dystrophic, Coarse ie Popcorn, branching 70% risk Milk of Calcium, Large Rod-Like ie o Fine pleomorphic 29% Secretory, Skin, Vascular, Suture o Amorphous 21% 0% risk o Coarse heterogeneous 13% o Diffuse o Segmental 62% o Linear 60% CA % RISKS reported are in BOLD o Grouped 31% o Regional 26% Mammo Mass BI-RADS® AtAWord BENIGN SUSPICIOUS Mass Mass Shape: Oval Round Shape: Irregular Margin: Circumscribed Margin: Spiculated Indistinct Density: Fat Low Microlobulated Density: High Equal Associated Features: Skin retraction Nipple retraction Skin thickening Trabecular thickening Axillary adenopathy US Mass BI-RADS® AtAWord BENIGN SUSPICIOUS Mass Mass Shape: Irregular Shape: Oval Orientation: Not parallel Orientation: Parallel Margin: Not circumscribed Margin: Circumscribed Echogenicity: Echogenicity: Anechoic