Introduction to the Breast Imaging Reporting and Data System

Harmien Zonderland
Radiology department of the Leiden University Medical Centre, Leiden, the Netherlands

 Introduction
 Report Organization
 Breast Imaging Lexicon
o Mammographic Breast Composition
o Mass
o Architectural distortion
o Focal asymmetry
o Calcifications
 Final Assessment Categories

Publicationdate February 1, 2006

This article is based on the publication of the ACR BI-RADS Atlas 2003 and supplemented
with some recommendations from the Netherlands Guideline Breast Cancer and the Dutch
College of Breast Imaging.

Introduction

The illustrated BI-RADS atlas

In 2000 the Dutch Institute for Health Care Improvement (CBO) has chosen to use the Breast
Imaging Reporting and Data System (BI-RADS) for breast imaging.
All other systems that were previously used were abandoned, because unlike the BI-RADS
system, they lacked quantification and used very subjective and undefined terms and were not
evidence-based.
Breast Imaging Reporting and Data System - BI-RADS Atlas


BI-RADS is a quality assurance tool designed to standardize mammography reporting, reduce

confusion in breast imaging interpretations, and facilitate outcome monitoring.
It contains a lexicon for standardized terminology (descriptors) for mammography, breast US
and MRI, aswell as Standard Reporting with Final Assessment Categories and guidelines for
Follow-up and Outcome Monitoring.
It even enables you to evaluate the quality of your reporting.

Report
Organization

The reporting system is designed to provide an organized approach to image interpretation

and reporting.

1. Describe the indication for the study.

2. Describe the breast composition.
3. Describe any significant finding. 
4. Compare to previous studies.
5. Conclude to a final assessment category.
6. Give management recommendations.
When you describe a lesion use standard BI-RADS descriptors for Mammography,
Ultrasound and MRI (see below).
If an additional imaging modality is added, mention type and rationale for each modality.
If more than one imaging modality is performed, for instance US with Mammography or with
MRI, an integrated report with assessment based on the highest level of suspicion must be
used.
When you use more modalities, always make sure, that you are dealing with the same lesion.
For instance a lesion found with US does not have to be the same as the mammographic or
physical findings. Sometimes repeated mammographic imaging with markers on the lesion
found with US can be helpful.

Breast Imaging
Lexicon
Mammographic Breast Composition

Mammographic breast composition is described as follows:

1. the breast is almost entirely fat ( 2. scattered fibroglandular densities (25-50%)
3. heterogeneously dense breast tissue (51-75%)
4. extremely dense (> 75% glandular)

Mass

A 'Mass' is a space occupying lesion seen in two different projections. If a potential mass is
seen in only a single projection it should be called a 'Density' until its three-dimensionality is
confirmed.

Circumscribed (well-defined or sharply-defined) margins: The margins are sharply

demarcated with an abrupt transition between the lesion and the surrounding tissue. Without
additional modifiers there is nothing to suggest infiltration.
Indistinct (ill defined) margins: The poor definition of the margins raises concern that there
may be infiltration by the lesion and this is not likely due to superimposed normal breast
tissue.
Spiculated Margins: The lesion is characterized by lines radiating from the margins of a
mass.

Architectural distortion

The normal architecture is distorted with no definite mass visible. This includes spiculations
radiating from a point, and focal retraction or distortion of the edge of the parenchyma.
Architectural distortion can also be an associated finding.

Focal asymmetry

This is a density that cannot be accurately described using the other shapes.
It is visible as asymmetry of tissue density with similar shape on two views, but completely
lacking borders and the conspicuity of a true mass. 
It could represent an island of normal breast, but its lack of specific benign characteristics
may warrant further evaluation. 
Additional imaging may reveal a true mass or significant architectural distortion. 
 Due to confusion of the term mass with the term 'density' which describes attenuation
characteristics of masses, the term 'density' has been replaced with 'asymmetry'.

Amorphous, indistinct microcalcifications

Calcifications

Amorphous or Indistinct Calcifications:

These are often round or 'flake' shaped calcifications that are sufficiently small or hazy in
appearance that a more specific morphologic classification cannot be determined.

Heterogeneous microcalcifications

Coarse, Heterogeneous Calcifications:

Irregular calcifications with varying sizes and shapes that are usually larger than 0.5 mm in
diameter.


Fine, pleomorphic and branching microcalcifications

Fine, Pleomorphic or Branching Calcifications:

Fine pleomorphic calcifications are more conspicuous than the amorphic forms.
They vary in sizes and shapes and are usually smaller than 0,5 mm. 
Fine branching calcifications are thin, linear or curvilinear, may be discontinuous and smaller
than o,5 mm. 
Their appearance suggests filling in of the lumen of a duct involved irregularly by breast
cancer.

Benign calcifications

Benign Calcifications:
Benign calcifications are usually larger than calcifications associated with malignancy. 
They are usually coarser, often round with smooth margins and are much more easily seen.

When you describe an abnormality (mass, architectural distortion, focal asymmetry or

calcifications) always use the standard BI-RADS descriptors and mention the lesion size and
location.

Final
Assessment
Categories


A negative diagnostic examination is one that is negative, with a benign or probably benign
finding (BI-RADS 1, 2 or 3).
In BI-RADS 3 the radiologist prefers to establish the stability of a lesion by short term
follow-up.
In the evaluation of your BI-RADS 3 lesions the malignancy rate should be A positive
diagnostic examination is one that requires a tissue diagnosis (BI-RADS 4 and 5).
In BI-RADS 4 the radiologist has sufficient concern to urge a biopsy (2-95% chance of
malignancy).
In BI-RADS 5 the chance of malignancy should be > 95%.

BI-RADS 0 at screening.Additional ultrasound after referral was performed allowing final assessment.

BI-RADS 0
Need Additional Imaging Evaluation and/or Prior Mammograms For Comparison:
BI-RADS 0 is utilized when further imaging evaluation (e.g. additional views or ultrasound)
or retrieval of prior films is required. 
When additional imaging studies are completed, a final assessment is made. 
Always try to avoid this category by immediately doing additional imaging or retrieving old
films before reporting. 
Even better to have the old films before starting the examination.


BI-RADS Category 1

BI-RADS 1
Negative:
There is nothing to comment on. 
The breasts are symmetric and no masses, architectural distortion or suspicious calcifications
are present.

BI-RADS Category 2. A mass seen on mammogram proved to be a cyst.

BI-RADS 2
Benign Finding:
Like BI-RADS 1, this is a normal assessment, but here, the interpreter chooses to describe a
benign finding in the mammography report. Involuting, calcified fibroadenomas, multiple
secretory calcifications, fat-containing lesions such as oil cysts, lipomas, galactoceles and
 mixed-density hamartomas all have characteristically benign appearances, and may be
labeled with confidence. 
The interpreter may also choose to describe intramammary lymph nodes, vascular
calcifications, implants or architectural distortion clearly related to prior surgery, while still
concluding that there is no mammographic evidence of malignancy.

BI-RADS 3. Non-palpable sharply defined lesion with a cluster of punctate calcifications.

BI-RADS 3
Probably Benign Finding - Initial Short-Interval Follow-Up Suggested:
A finding placed in this category should have less than a 2% risk of malignancy.
It is not expected to change over the follow-up interval, but the radiologist would prefer to
establish its stability.
Lesions appropriately placed in this category include:

 Nonpalpable,
circumscribed
mass on a
baseline
mammogram
(unless it can
be shown to
be a cyst, an
intramammar
y lymph node,
or another
benign
finding), 
 Focal
asymmetry
which
becomes less
dense on spot
compression
view
  Cluster of
punctate
calcifications

Follow up at 6, 12 and 24 months showed no change. Final assessment was changed to a Category 2.

The initial short-term follow-up is a unilateral mammogram at 6 months, then a bilateral

follow-up examination at 12 months and 24 months after the initial examination.
If the findings shows no change in the follow up the final assessment is changed to BI-RADS
2 (benign) and no futher follow up is needed.

Upper: Category 3 lesion. There are two indeterminate or amorphous calcifications.Lower: 12 month follow up.Final
diagnosis: Invasive carcinoma within an area of DCIS.

If a BI-RADS 3 lesion shows any change during follow up, it will change into a BI-RADS 4
or 5 and appropriate action should be taken.

The case on the left shows a few amorphous calcifications initially classified as BI-RADS 3. 
At 12 month follow up more calcifications were noted in a cluster.
 The findings were now classified as BI-RADS 4.
This proved to be DCIS with invasive carcinoma.

LEFT: Solid, circumscribed, oval mass with horizontal orientation, most likely fibroadenoma, BI-RADS 3RIGHT: Solid,
circumscribed mass with horizontal orientation and irregular shape. It can be an older sclerotic fibroadenoma, but because of
its atypical appearance it should be assigned a BI-RADS 4(a)

A solid mass with circumscribed margins, oval shape and horizontal orientation is most likely
a fibroadenoma and can be assigned a BI-RADS 3, irrespective if the lesion is palpable or
not.
As a consequence, solid lesions that do not possess all the typical characteristics of a
fibroadenoma should be assigned a BI-RADS 4 and always be biopsied.

First and second control after conservative treatment for breast cancer (BI-RADS 3 and BI-RADS 2)

First control after conservative treatment for breast cancer: new scars and postirradiation
thickening of skin and interstitium is assigned BI-RADS 3.
2nd control after Conservative treatment for breast cancer: decrease of sequalae of treatment,
BI-RADS category can be changed into BI-RADS 2 (figure)


Category 4: There is an abnormality suspicious for malignancy, but a benign lesion, although unlikely, is a possibility ( for
instance ectopic glandular tissue within a heterogeneous breast).

BI-RADS 4
Suspicious Abnormality - Biopsy Should Be Considered:
BI-RADS 4 is reserved for findings that do not have the classic appearance of malignancy but
have a wide range of probability of malignancy (2 - 95%). 
By subdividing Category 4 into 4A, 4B and 4C , it is encouraged that relevant probabilities
for malignancy be indicated within this category so the patient and her physician can make an
informed decision on the ultimate course of action.

The case on the left shows another BI-RADS 4 abnormality.

The pathologist could report to you that it is sclerosing adenosis or ductal carcinoma in situ. 
In both cases you as a radiologist would agree.


BI-RADS 5
Highly Suggestive of Malignancy. Appropriate Action Should Be Taken: 
BI-RADS 5 must be reserved for findings that are classic breast cancers, with a >95%
likelihood of malignancy. 
A spiculated, irregular high-density mass, a segmental or linear arrangement of fine linear
calcifications or an irregular spiculated mass with associated pleomorphic calcifications are
examples of lesions that should be placed in BI-RADS 5.

BI-RADS 5 contains lesions for which one-stage surgical treatment could be considered
without preliminary biopsy. 
However, current oncologic management may require percutaneous tissue sampling as, for
example, when sentinel node imaging is included in surgical treatment or when neoadjuvant
chemotherapy is administered.


LEFT: initial mammogram with marker on palpable mass. Biopsy proven carcinoma.RIGHT: Follow up after chemotherapy.
Tumor is hardly visible.

BI-RADS 6
Known Biopsy Proven Malignancy. Appropriate Action Should Be Taken 
BI-RADS 6 is reserved for lesions identified on the imaging study with biopsy proof of
malignancy prior to definitive therapy.
This category was added to the classification because sometimes patients are treated with
neo-adjuvant chemotherapy. 
During the course of the treatment the tumor may be less visible, while still you know you are
dealing with cancer (figure).

Category 6: Initial tumor measures 3.6 cm. After treatment 1.8 cm.

Same case as above. Initial ultrasound shows large tumor. After chemotherapy shrinkage of
the tumor.