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BI-RADS 5: More than Cancer
Kimberly A. Dao, MD
Anna F. Rives, MD, PhD
Liza M. Quintana, MD
Michael A. Kritselis, DO
Michael D. C. Fishman, MD
Rutuparna Sarangi, MD
Priscilla J. Slanetz, MD, MPH
Abbreviation: BI-RADS = Breast Imaging Re-
porting and Data System
RadioGraphics 2020; 40:1203–1204
https://doi.org/10.1148/rg.2020200054
Content Code:
From the Departments of Radiology (K.A.D.,
A.F.R., M.D.C.F., R.S., P.J.S.) and Pathology
(M.A.K.), Boston University Medical Center,
Boston University School of Medicine, 830
Harrison Ave, Moakley Building Ste 1300, Bos-
ton, MA 02118; and Department of Pathology,
Beth Israel Medical Center, Harvard Medical
School, Boston, Mass (L.M.Q.). Presented as
an education exhibit at the 2019 RSNA Annual
Meeting. Received March 28, 2020; revision re-
quested May 22 and received June 13; accepted
June 17. M.D.C.F. and P.J.S. have provided
disclosures (see end of article); all other au-
thors have disclosed no relevant relationships.
Address correspondence to K.A.D. (e-mail:
Kimberlyanhdao@gmail.com).
©
RSNA, 2020
1203
BREAST IMAGING |
RADIOGRAPHICS FUNDAMENTALS
The full digital presentation is available online.
Imaging evaluation of the breast relies on the American College of Ra-
diology Breast Imaging Reporting and Data System (BI-RADS), which
offers a standard lexicon for describing, assessing, and managing breast
imaging findings. The BI-RADS 5 assessment category is used when
the likelihood of malignancy is estimated to be greater than or equal to
95% on the basis of imaging findings. However, according to Yao et al,
the actual positive predictive value for a BI-RADS 5 assessment ranges
from 78% to 97.5%. Hence, not all BI-RADS 5 lesions are malignant.
There are several benign entities affecting the breast that may manifest
with highly suspicious imaging features and BI-RADS 5 categoriza-
tion. In this online presentation, we review the imaging features used
in a BI-RADS 5 assessment, a range of benign entities that can mimic
malignancy, the importance of radiologic-pathologic correlation, and
the management of a discordant biopsy result.
There are specific imaging features of BI-RADS 5 malignancies
depicted at mammography, US, and MRI. Typical mammographic
features that warrant BI-RADS 5 assessment include an irregular mass
with spiculated margins with or without associated distortion, fine
linear branching or pleomorphic calcifications, segmental pleomorphic
calcifications, or some combination of these findings (Figure). At US,
typical imaging features of a BI-RADS 5 mass include irregular shape,
nonparallel orientation, hypoechoic echo pattern, spiculated margin,
ductal extension, echogenic halo, or posterior shadowing. Imaging
features that warrant a BI-RADS 5 assessment at MRI include an
irregular enhancing mass with noncircumscribed margins and type II
(plateau) or III (washout) kinetics.
The Table lists the various benign processes that can mimic malig-
nancy at mammography, US, or MRI and consequently could result in
a BI-RADS 5 assessment. For each entity, we review its clinical mani-
festations, imaging features, histologic findings, and management. The
more common benign processes include chronic and inflammatory
mastitis, granulomatous mastitis, fat necrosis, complex sclerosing lesion
or radial scar, granular cell tumor, and infection. The less common
benign processes include lymphocytic (diabetic) mastopathy, atypical
infection, fibromatosis or desmoid tumor, and myofibroblastoma.
TEACHING POINTS
„ A BI-RADS category 5 assessment is used when the likelihood of malignancy is believed to
be greater than or equal to 95% on the basis of the imaging findings. Not all BI-RADS 5
lesions are found to be malignant.
„ A benign percutaneous biopsy result for a BI-RADS 5 assessment warrants repeat percu-
taneous biopsy or excision.
„ A variety of benign entities may be categorized as BI-RADS 5 because of suspicious imag-
ing features. The most common BI-RADS 5 mimics are chronic and inflammatory mastitis,
granulomatous mastitis, fat necrosis, complex sclerosing lesions, granular cell tumors, and
infection.
1204  September-October 2020 radiographics.rsna.org
Figure.  Focal asymmetry seen at mammo-
graphic screening in a 47-year-old woman.
Mediolateral oblique (a) and craniocaudal (b)
spot compression mammograms show an ir-
regular high-density mass with a spiculated
margin. This imaging finding was classified
as BI-RADS 5. The results of a core biopsy re-
vealed invasive ductal carcinoma.
When a lesion is assessed as BI-RADS 5, the
first step in management is percutaneous biopsy.
When a benign pathologic test result is obtained,
this most often is considered discordant, and in
these cases, repeat biopsy or surgical excision
would then be recommended. Delving into the
clinical history of the patient can sometimes aid
in the diagnosis of a suspicious lesion and, in
rare circumstances, possibly even help avoid the
need for repeat biopsy. For example, a history
of surgery or accidental trauma to the breast
may support the diagnosis of fat necrosis. If the
patient has a history of diabetes, the diagnosis of
lymphocytic mastopathy may be reasonable. A
clinical history of systemic lupus erythematosus
can explain a diagnosis of inflammatory mastitis.
After reviewing this presentation, the reader
will become familiar with the imaging features
and management of benign entities that can
demonstrate BI-RADS 5 imaging characteristics.
Recognizing these imaging features, correlating
them with the clinical history, and being aware of
benign entities that may mimic malignancy will
help radiologists provide optimal patient care.
Disclosures of Conflicts of Interest.—M.D.C.F. Ac-
tivities related to the present article: disclosed no relevant
relationships. Activities not related to the present article:
advisory board member for Hologic; consultant to Ze-
bra Medical Vision; provided expert witness case review
for Abramson, Brown and Dugan; institution received
a Strategic Alignment Grant from the Association of
University Radiologists. Other activities: disclosed no
relevant relationships. P.J.S. Activities related to the pres-
ent article: disclosed no relevant relationships. Activities
Benign Entities Possibly Classified as BI-RADS 5
Atypical infection
Complex sclerosing lesion and radial scar
Fat necrosis
Fibromatosis or desmoid tumor
Granular cell tumor
Granulomatous mastitis
Inflammatory mastitis (autoimmune)
Lymphocytic (diabetic) mastopathy
Mastitis
Myofibroblastoma
Other benign entities (amyloidosis)
not related to the present article: received royalties from
UpToDate. Other activities: treasurer and fund-raising
liaison for the Association of University Radiologists.
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