CHAPTER 21: BREAST IMAGING REPORTING AND DATA SYSTEM

I. Introduction
II. Mammography Lexicon
A. Breast Composition
B. Masses
C. Calcifications
D. Architectural Distortion
E. Asymmetries
F. Associated Features
III. Ultrasound Lexicon
IV. MRI Lexicon
V. Reporting
VI. Follow-up and Outcome Monitoring
A. Statistical Terms
B. Medical Adult

INTRODUCTION
Breast Imaging Reporting and Data-System (BIRADS)

MAMMOGRAPHY LEXICON

A. Breast Composition
 Also known as breast density
 Refers to amount of fibroglandular tissue in the breast tissue relative to the amount of fat
o Fibroglandular tissue attenuates x-rays more than fat
 Dense breast tissue: white; Fat: DARK gray
 Classified according to composition
o (A) The breasts are almost entirely fatty
o (B) There are scattered areas of fibroglandular density
o (C) The breasts are heterogeneously dense, which may obscure small masses;
o (D) The breasts are extremely dense, which lowers the sensitivity of
mammography
 Based on densest area
o Location of dense tissue can be also included in report

B. Masses
  3D structures that occupies space in the breast
 Seen on two different mammographic projections and has outward convex margins
 Characterize according to shape, margin and density

Shape

Irregular mass- more likely to be assessed as BIRADS 4 (suspicious) or 5 (highly

suspicious)

Margins
 Many benign processes have a
circumscribed margin. However, some
cancers (ie. phyllodes tumors and
invasive ductal carcinomas (IDCs)
such as high-grade IDC, medullary,
mucinous, and papillary subtypes of
IDC can appear circumscribed

Obscured margins- less frequent with

increased use of digital breast
tomosynthesis

Microlobulated- can be seen with

benign clustered microcysts but can
also be worrisome for malignancy
when associated with solid mass

Spiculated- due to desmoplastic

reaction surrounding the tumor
- Assessed as BIRADS 5 in
almost all cases
- Important to distinguished
from architectural distortion
(AD) which lacks 3D structure
and outward convex margins

 Choose the most worrisome feature in description

Density
 X-ray attenuation relative to the fibroglandular tissue
 Invasive breast cancers- appear high density or more white on a mammogram
 Fat containing mass- present with an area that is dark gray as a fat lobule
o Almost always benign
o Circumscribed fat-containing masses- lipomas, oil cysts, galactoceles, lymph
nodes and hamartomas
o Can be malignant- suspicious shape or margin
 Low density- Less white than surrounding tissue
o Examples: cysts
o Often a more benign feature
 Equal density- similar x-ray attenuation with the surrounding tissue
 High density- whiter than surrounding tissue and most worrisome

C. Calcifications
 Described according to morphology and distribution
 Pathologic microcalcifications- often associated with necrotic tumor debris
o Commonly seen in ductal carcinoma in situ (DCIS)
 Does not have direct access to vascular system; thus, the cancerous cells
at the center of a duct cannot get enough nutrients -> become necrotic
or die -> then begin to calcify resulting in a thin layer of casting
calcifications seen within center of the lumen of a milk duct containing
DCIS
 Ductal distribution -> higher likely of malignancy
o Calcification morphology descriptor associated with malignancy

Small and fuzzy in appearance

Differential diagnosis includes DCIS
(often low grade), high-risk lesions
(atypical ductal hyperplasia, atypical
lobular hyperplasia, and lobular
carcinoma in situ), fibrocystic changes,
and sclerosing adenosis.

Larger (0.5 to 1 mm)

Differential diagnosis includes DCIS
(often high grade), degenerating
fibroadenoma or papilloma, fibrocystic
changes or fat necrosis.
 <0.5 mm in size
Similar to coarse heterogeneous
calcifications but with higher
likelihood for malignancy of about
30%

Thin and linear with appearance

similar to ductal system or branches of
a tree
“Y” or “V” like calcification within
the branches of a milk duct
Highest likelihood of malignancy

 Classification according to distribution

Random distribution
Lowest correlation with malignancy
Occupy a large area that is more than
one ductal system

Occupy small area usually within 2 cm

Arranged in a line suggestive of

location within a milk duct
Often seen with DIC

Wedged shaped with broad base close

to the chest wall and tapering toward
the nipple
Spam more than half the distance from
chest wall to nipple
Resemble a triangle and correspond to
an entire ductal system and all of its
branches
Most worrisome for malignancy
 Benign calcifications

Usually lucent centered and multiple

in number
Usually superficial on one of the
mammographic view
Special view (tangential view)-
confirmation of their location in skin
Common in inframammary fold,
cleavage and areola
Can be seen in scars

“Tram-track” appearance of double lines

following the path of arterial supply
Wider at the posterior aspect of breast and
becomes narrower toward the nipple
DBT or magnification- help identify if tube is
assoc. with calcification
Seen in wall of the tube (artery), NOT in the
center of tube (milk duct) as seen in DCIS

Large around 2-3 mm in size

Oval, circumscribed mass which is an
involuting or degenerating fibroadenoma
Benign calcifications of the duct showing
branching pattern
Smooth and cigar shaped
Most often diffuse, bilateral and seen almost
exclusively in postmenopausal women
Also called secretory calcifications

Can be benign or malignant

Look like smooth round circles, often
numerous and identical in appearance
Distribution is key (diffuse or regional ->
benign; grouped -> low likelihood of
malignancy (BIRADS 3) while linear,
segmental, new, increasing or near a known
cancer -> suspicious)

Calcium that has precipitated out of fluid within a

cyst
Changed shape on different mammographic views
Appears like fuzzy puddles on CC view
Tiny curvilinear meniscus or teacup on ML or LM
(medial lateral or lateral medial) view

Associated with prior trauma or surgery

Usually round or oval calcifications with lucent
center
Resembles an eggshell
Often calcification of the wall of an oil cyst or fat
necrosis
 May also have lucent center but are more irregular in
shape
Also result of prior trauma, surgery or radiation

Suture calcifications- deposited around suture material following its shape and appearance and
always have a surgical history

D. Architectural Distortion

Normal breast tissue

 Consists of undulating intermixed fat lobules and fibroglandular tissue
 Lines that mark tissue-fat interface are soft, respectful and similar to waves in an ocean
 Visible thin Cooper ligaments with similar appearance

Fibrosing process
 Lines become straight and architecture becomes distorted
 Mammogram: straight lines often radiating from a central point
o Retracted or pulled in parenchyma

No mass present in architectural distortion

 If present- spiculated mass
Causes (benign or malignant)

DBT- easier to look for architectural distortion

E. Asymmetries
 Seen only in one breast
 Represent summation of normal structures but can be seen in malignancy
 Subdivided into

Often represents superimposition of normal

structures
Seen only on one mammographic view

Large, involving more than one quadrant

Often benign variant or normal anatomy in absence
of other suspicious findings (eg. Calcifications, AD,
nipple retraction or palpable mass)
 Seen on two mammographic views and smaller than
a quadrant

Most suspicious type with highest association with

malignancy

F. Associated Features

Skin retraction, nipple retraction, skin thickening, trabecular thickening, and axillary
adenopathy: Important signs of malignancy
ULTRASOUND LEXICON

Shape (similar to mammogram)

Margin (generally same as mammogram)

 Classified as
o Circumscribed- well-defined, smooth interface between the mass and the
surrounding tissue
o Not-circumscribed- include indistinct, angular, microlobulated, and spiculated
 Angular margin- unique in ultrasound where edges of mass are forming
acute angles or tail-like extensions, may signify extension of mass from
milk duct
Echopattern
 Echogenicity of internal contents
 Anechoic or completely black inside- more common in fluid containing structures (ie
cysts)
 Hyperechoic- more echogenic or white than fat
 Hypoechoic- less echogenic or darker than fat
 Isoechoic- same as fat and may be difficult to identify
 Complex cystic and solid mass
 Heterogeneous- mixed features

Orientation
  Normal fibroglandular tissue and many benign findings- parallel to chest wall
 Antiparallel (or taller than wide)- suspicious for invasive breast ca

Posterior features
 No posterior features
 Enhancement- structures with high water content (cysts or necrotic tumors)
 Shadowing- invasive breast can, dense fibrosis and large calcifications
 Combined pattern

Cystic breast mass

 Simple cyst- completely anechoic with tin imperceptibly wall
 Microcysts- numerous adjacent tiny cysts (1-3 mm in size)
 Complicated cyst- diffuse low-level echoes and may be indistinguishable from
hypoechoic solid mass
 Complex cystic and solid mass- contain both solid- and fluid- containing spaces
o highest associated with malignancy
o may represent abscess, hematoma formation, fat necrosis or post-surgical
collection
Associated features
 AD, duct changes, skin thickening or retraction, edema and vascularity
 Elastography- stiffness of tissue
o Firm or hard assessment- cancers
o Intermediate
o Soft

Axillary lymph nodes- also checked on ultrasound

REPORTING AND FOLLOW-UP AND OUTCOME MONITORING

Category 2- includes cyst, fat necrosis, normal lymph nodes

Category 3- short interval follow-up for a total of 2 years
Category 4- divided into 4A (2-10% chance of malignancy), 4B (10-50%) and 4C (50-95%)
Category 5- 95%wiht classic appearance of cancer (irregular, spiculated, high-density masses or
segmental fine linear branching calcifications