BIRADS IN

MAMMOGRAPHY

Pranav Dwivedi
Anatomy of the Breast
• The breast is composed of –

1. Adipose tissue- Subcutaneous, Retromammary and Interlobar.

2. Glandular Parenchyma
3. Vessels
4. Connective Tissue
Anatomy
Anatomy- Glandular Component
• Modified apocrine gland. • WATER DENSITY
• The breast is composed of multiple
lobes(15-20 in number), each drained
by a lactiferous duct.
• Each lobe in turn is composed of
multiple lobules which have terminal
branches, ending into a ductile and
an acini.
• These terminal branches are termed
Terminal Duct Lobular unit
Connective Tissue of the Breast
There are two types of the connective tissues in the breast-

• Stromal/ Interlobular Connective tissue

1. Deep Fascia
2. Superficial fascia
3. Interconnecting Cooper’s Ligaments

• Intralobular lax specialised connective tissue

Both types as well as muscles

show WATER density
ACR BI-RADS
• Initially developed in 1993, the American College of Radiology Breast Imaging
Reporting and Data System (BI-RADS) lexicon serves to standardize breast
imaging reports, improve communication with referring physicians, and
provide a quality assurance tool.

• ACR has published different lexicons for Ultrasound, Mammography and MRI.

• Lesions are categorized into different BI-RADS categories by their appearance

on the respective modalities
Report Organisation
• Always to be started by describing the breast parenchyma.

• Four categories of parenchyma in BIRADS-

a) The breasts are almost entirely fatty
b) There are scattered areas of fibro-glandular density
c) The breasts are heterogeneously dense, which may obscure small masses
d) The breasts are extremely dense, which lowers the sensitivity of
mammography
• Breast density is classified using the denser breast. In this case, because the
fibro-glandular tissue in the upper outer right breast is sufficiently dense to
obscure small masses, the examination should be classified as
HETEROGENEOUSLY DENSE, even though far less than 50% of the volume of
this (denser) breast contains fibro-glandular-density tissue.
DESCRIPTION OF FINDINGS- MASS
• Size
• Shape
Oval
Round
Irregular
• Location
• Margins
• Density
• Associated features
• Calcifications
Size
• Mass: Longest axis of a lesion and a second measurement at
right angles.
• In a spiculated mass the spiculations should not be included.
• Architectural distortion and Asymmetries: Approximation of its
greatest linear dimension.
• Calcifications: The distribution should be measured by
approximation of its greatest linear dimension.
• Lymph Nodes: Mammography: short axis. Ultrasound:
cortical thickness.
SIZE
 Margins

• Circumscribed
• Obscured
• Micro-lobulated
• Indistinct
• Spiculated
Location and Density
Architectural distortion
• When the normal architecture is distorted with no definite mass visible.

• Descriptors include - thin straight lines or spiculations radiating from a

point, and focal retraction, distortion or straightening at the edges of
the parenchyma.

• Architectural distortion can also be seen as an associated feature with a

mass.
Asymmetries
Findings that represent unilateral deposits of 1. Global asymmetry - Asymmetry seen in
tissue not conforming to definition of a mass. least one quadrant of the breast - usually a
1. Asymmetry - visible on normal variant.
only one mammographic projection 2. Developing asymmetry- new/larger and
2. Focal Asymmetry- visible on two more conspicuous than on a previous
projections- differentiate from a mass. examination.
• Focal Asymmetry

• USG

• Focal compression view.

Calcifications
 Calcifications
Typically benign calcifications-
• Skin
• Vascular
• Coarse/ Popcorn-like
• Round/Punctate
• Milk of calcium
• Suture
• Large rod-like
 Calcifications
Suspicious morphology
a) Amorphous - so small and/or hazy in appearance that a more specific particle shape
cannot be determined. - BI-RADS 4b
b) Fine Pleomorphic- usually more conspicuous than amorphous calcifications with
different discrete shapes, <0.5mm. - BI-RADS 4b
c) Coarse Heterogenous- irregular conspicuous calcifications that are in range of
0.5 – 1mm. - BI-RADS 4b
d) Linear/ Linear Branching- thin, linear irregular calcifications, may be discontinuous,
occasionally branching forms can be seen, usually < 0,5 mm.
- BI-RADS 4c
Suspicious Calcifications
Distribution of Calcifications
Distribution of calcifications is as important as their distribution.
1. Diffuse - distributed randomly throughout the breast.
2. Regional - occupying a large portion of breast tissue; > 2 cm in greatest
dimension
3. Grouped - occupying a small portion of breast tissue < 2 cm in greatest
dimension
4. Linear arranged in a line, which suggests deposits in a duct.
5. Segmental - suggests deposits in a duct or ducts and their branches.
Associated Features
BI-RADS Assessment Categories
BI-RADS 0

• Translates to “Incomplete assessment.”

• Utilised when further imaging evaluation and/or comparison with
prior imaging is required.
• E.g. : USG needed in view of dense breasts or additional spot
compression views are needed.
 BI-RADS 1
• Translates to “Negative/ Normal • The breasts are symmetric with no
Breasts” masses/ Calcifications or any
• There is nothing to remark upon.
architectural distortion.
• Management is to continue with
routine screening.
BI-RADS 2
Translates to “Benign Finding”
Includes:
• Calcified fibroadenomas
• Multiple large-rod like calcifications
• Intra-mammary lymph nodes.
• Vascular complications
• Implants
• Fat-containing lesions like – Oil cysts, Lipomas, galactoceles, etc.
BI-RADS 3
• Probably benign finding. Short term follow-up suggested.
• Lesion placed in this category should have a chance of malignancy below 2%.
• Lesions placed in this category include:

1. Circumscribed mass on a mammogram( unless it can be shown to be a cyst,

an intra-mammary node or another benign finding.)
2. Focal symmetry which turns less dense on spot compressions.
3. Solitary group of punctate calcifications.
BI-RADS 3
A well defined isodense
lesion with internal
punctuate calcifications.

BI-RADS 3
BI-RADS 3
The initial short term follow up of BIRADS 3 lesions is a unilateral mammogram
at 6 months.
• Followed by a bilateral mammogram at 12 and 24 months.

If the lesion remains stable throughout this period, it may be labelled as BIRADS
2.

However, if any change in the lesion is seen during the follow up, it will be
changed into a BIRAD 4 or 5 lesion.
BI-RADS 4
Suspicious abnormality – biopsy must be done.
Findings placed in this category do not give classical appearance of a
malignancy but are suspicious enough to be biopsied.
Divided into sub-categories –
A. BIRADS 4a -
B. BIRDS 4b
C. BIRADS 4c
BI-RADS 4a
Used in the following findings:

1. Partially circumscribed mass/ Obscured margins, Atypical

fibroadenoma.
2. Palpable, solitary mass with partially or completely
microlobulated margins.
3. Probable abscess
BI-RADS 4b
Used in the following findings:

1. Grouped Fine Pleomorphic calcifications

2. Grouped amorphous calcifications

3. Mass with in distinct margins

BIRADS 4C
Used in the following findings:

1) New fine linear/ linear branching calcifications.

2) Irregular, indistinct mass.

BIRADS 5
Highly suggestive of malignancy

Used when a combination of highly suspicious findings are present-

1. Spiculated + irregular + high density mass.
2. Fine linear or linear branching calcifications + segmental or linear
distribution.
3. Irregular spiculated mass with associated pleomorphic calcifications
BIRADS 5
BIRADS 6
• Known, biopsy proven malignancy.

• This category is used when assessing or monitoring treatment response

in a malignancy.
For e.g. – Incomplete excision of a mass, or after Chemo/Radio-therapy
• Not to be used in a surgical excision with positive margins but only post-
operative scar/distortion is visible on the mammogram.
• Not to be used if a new lesion is seen, other than the known cancer.
SPOTTERS