METHODOLOGICAL PUBLICATION

Tünde TASNÁDI,
Reporting protocol for breast MRI
Gábor FORRAI
examination according to the BI-
RADS lexicon II
Medical report templates
Reporting protocol for breast MRI examination according to the BI-RADS lexicon II - Report templates

Use of standardized BI-RADS codes and templates will result an easier, more precise reporting, which is
the most time-consuming part of the radiologists' work. The elaborated templates are suggestions for
report text of standard negative examinations as well as special MRI morphology descriptions of
pathological changes. Optional texts could be chosen and complemented with personalized content.
The goal of these templates is the standardization of MRI reports in Hungary.
Key words: BI-RADS, breast cancer, breast MRI, structured reporting
In the first part of this publication we introduce the The templates are already useful as they are; it is
key terms and morphological characteristics which advisable to save them on the computer/RIS system
are recommended to be included in the breast MRI used for reporting and to edit them further.
reports. The use of standardized reporting codes and Individual medical reports can be prepared with the
uniform templates can make the written reporting help of these templates by selecting the appropriate
easier and more precise, which is the substantial options from the list, deleting the others, applying
part of radiological work. The final goal is to promote slight modifications, and of course by adding your
structured reporting, towards which this it is an own content, if necessary.
important step to establish a uniform reporting "History and clinical context" and "Diagnostic
terminology and to use consistently the concepts of question, proposed diagnosis" sections are
the BI-RADS atlas in the cases of breast MRI important elements of all breast MRI reports.
examinations. However, each institution has its own Recording them is absolutely necessary because the
right and responsibility to determine the specific observed changes can only be interpreted and
form of its reports. commented in the knowledge of these facts.

Using the templates

The elaborated templates are suggestions for report

text of standard negative examinations as well as
special MRI morphology descriptions of pathological
changes.
Reports of diagnostic imaging procedures should etc.). Lack of documentation regarding the contrast
include the basic "Technical informations" regarding substance may entail legal consequences.
the performed examination, i.e. in this case the field
We described certain MRI morphological features
strength of the MRI equipment, the scanning
using the suggested terms in the BI-RADS MRI
method (e.g. coil, region, sequences), and the name
lexicon (or the Hungarian equivalent thereof). The
and dose of the applied contrast substance. We
precise application of these terms is fundamental in
would like to put extra emphasis on the latter, as if
order to prepare reports that harmonize with the
complications or problems related to the contrast
current ACR BI-RADS (Breast Imaging Reporting and
substance occur later on (e.g. NSF, Gd-deposition, 1
Data System) atlas. Systematic description of these

Magyar Radiológia Online 2017; 8(3): 3/1-6. 1

features also provides a great assistance when
setting up a diagnosis. Some special terms were not
part of the terminology in Hungary before. We made
our best efforts to provide comprehensible, well
applicable and practical Hungarian names for these.
Reports end with a summarized medical opinion.
Additional care should be taken to use accurate
wording. According to the EUSOBI and EUSOMA
recommendations, the summarized opinion should
also include the BI-RADS categorisation of the
2, 3, 4
lesion.
The "Recommendations" section (additional options
for the report) is one of the most important parts of
the report.

History and clinical context:

□ palpable lesion
□ discharge
□ signs of inflammation
□ mammography / ultrasound scan findings
□ results of prior breast MRI scans
□ histopathology, surgery, radiotherapy, neoadjuvant therapy, etc.
□ year of implantation, first or replaced implant

Question, proposed diagnosis:

□ characterisation of lesions revealed by other imaging modalities
□ assessment of extension of confirmed tumour(s)
□ assessment of multifocality and contralaterality
□ follow-up of neoadjuvant therapy
□ screening of high-risk patients
□ detection of occult tumour
□ suspected implant rupture
□ follow-up examination
□ other

Technical informations:
The following sequences were performed, native / and after the IV administration of …........ type
contrast material with a 1.5 Tesla scanner, using double breast coil:

Breast MRI reporting template

2 Tasnádi et al.: Reporting protocol for breast MRI examination according to the BI-RADS lexicon II.
Suggestions on further steps might give great
support for the referring clinician or the radiologist
performing the basic breast examinations, and also
when providing information for the patient. We have
also elaborated them in accordance with the
contents of the current ACR BIRADS atlas. Depending
on the MRI BI-RADS category, a targeted second-look
ultrasound scan, ultrasound-guided core biopsy,
MRI-guided biopsy or MRI-guided wire localization
followed by surgical excision might be necessary.
This should be specified in all cases, as the expert
physician performing the MRI scan of a given patient
has the best insight on which of the special
interventions listed above could be performed or
which would be the most appropriate.

Minimal / mild / moderate / marked background parenchymal enhancement is shown in the breast tissue on both
sides.
No circumscribed lesions can be identified in the glandular tissue.
No pathological contrast enhancement or pathological diffusion detected.
No pathological lymph nodes detected in the visible parts of the axillae and the internal mammary chain.
The observable regions of the thoracic wall have normal structure.

Impression:
No pathological lesion found by MRI (BI-RADS 1). Based on this, invasive malignant processes and DCIS of
higher grades can most likely be excluded.

Breast MRI examination template 1 - negative, BI-RADS 1

Minimal / mild / moderate / marked background parenchymal enhancement is shown in the breast tissue on both
sides.
No pathological contrast enhancement or pathological diffusion detected.

Options (common additional findings):

• Several contract-enhancing foci, smaller than 5 mm are shown, which can be associated with proliferative
mastopathy or adenosis.
• Several small structures with fluid signal, corresponding to cysts, can be observed.

No other circumscribed lesions can be identified in the glandular tissue.

No pathological lymph nodes detected in the visible parts of the axillae and the internal mammary chain.
The observable regions of the thoracic wall have normal structure.

Impression:
The lesion(s) described on the right / left / both sides represent(s) benign (BI-RADS2) cyst(s) / focus/foci.
No pathological lesion was found in the contralateral breast by MRI (BI-RADS 1).
Invasive malignant processes and DCIS of higher grades can most likely be excluded.

Breast MRI examination template 2 – with attachment, BI-RADS 2

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Minimal / mild / moderate / marked background parenchymal enhancement is shown in the breast tissue on both sides.

Options (common alterations):

• Nodular (solid) lesions:
A nodular mass is shown in the right / left breast, located in the …. quadrant, in superficial / parenchymal /
retroparenchymal
position, ... __ __ mm in diameter, round / oval / irregular shape with regular / irregular /
spiculated margins.
After administration of contrast material, homogeneous / heterogeneous / rim-like enhancement / dark internal
septations can be observed.
• Non-mass lesions:
A non-mass contrast enhancement is shown in the right / left breast, located in the … quadrant, with a diameter of
... _____________________ mm, its distribution is focal / linear / segmental / regional / multiple regional / diffuse
with a homogeneous / heterogeneous / clumped / clustered ring pattern. The process is rapid / slow during the initial
phase, the delayed phase shows continuous increase / plateau / washout, the detected contrast enhancement curve is
type 1 / 2 / 3. This type of dynamics is primarily typical of benign / malignant / indeterminate processes.
The lesion shows / does not show decreased diffusion in the DWI sequence.
The ADC value is ....mm2/s, which is primarily characteristic of benign / malignant / indeterminate processes.
Further __ masses with similar characteristics can be observed within a total area with a diameter of … mm,
affecting the areas of the … __________________________________________ quadrant(s). The diameter of
individual foci is between … _________________________________________ and … __ mm.

No other circumscribed pathological structures or pathological contrast enhancement can be detected in the breast
tissue.
No pathological lymph nodes detected in the visible parts of the axillae and the internal mammary chain.
The observable regions of the thoracic wall have normal structure.

Impression:
A likely benign (BI-RADS 3) / suspicious for malignant (BI-RADS 4) / highly suspicious for malignant (BI-RADS
5) process with a single focus / multiple foci is visible in the right / left / both breast(s). The overall clinical picture
likely suggests an invasive / DCIS type process.

Recommendations (additional options for the medical opinion):

• Targeted second-look ultrasound is required: in case of successful identification of the lesion, ultrasound-guided
core biopsy can be performed. If failed to identify the lesion at the second-look ultrasound, MRI-guided biopsy /
MRI-guided wire localization followed by surgical excision / 6-month MRI follow-up is recommended.
• Due to multifocality, biopsy sampling should be performed from two distant locations: in order to provide
histopathological justification for mastectomy in case of positive results.
• The lesion(s) described in the right / left / both breast(s) is likely benign (BI-RADS 3). Follow-up of the lesion is
recommended (follow-up breast MRI 6 months from now).

Breast MRI examination template 3 - with pathological alteration, BI-RADS 3, 4, 5

4 Tasnádi et al.: Reporting protocol for breast MRI examination according to the BI-RADS lexicon II.
The "Additional information" section at the end of
the report (comment options) draws attention for
several important facts. The main purpose of these is
to inform the patient and the physician who
requested the examination about the proper context
and limitations of the given breast MRI report among
the potential diagnostic options. For example, it is
important to emphasize (for legal as well as other
reasons) that breast MRI does not substitute
mammography, and also that the native scanning of
implants is not carried out in order to evaluate the
breast tissue.
By using the elaborated templates, breast MRI
reports issued in Hungary can hopefully become
standardized, thus promoting a closer relationship
between clinicians and radiologists and the
development of a common language.

The purpose of this examination is to assess the integrity of breast implants. The breast tissue was not assessed, thus the
examination is NOT suitable to exclude malignancy.
Single-lumen / double-lumen breast implants filled with silicone / physiological saline in normal position are shown on both
side.
No pathological structural changes of the implants detected.
The integrity of the implant shells is intact.
No free silicone can be detected in the examined region.
No pathological lymph nodes detected in the visible parts of the axillae and the internal mammary chain.

Options (common alterations):

• Invaginations of the shell are visible on the right / left / both sides, representing normal radial folds.
• Several small (max. 2 mm) droplet signs shown within the right / left / both implants, representing a structural
abnormality or early phases of degradation. These findings alone may not be considered pathological.
• Keyhole / subcapsular line / reverse teardrop / linguine(i) sign shown, compatible with an intracapsular rupture.
• Free silicone / silicone granuloma visible outside the capsule, suggesting extracapsular rupture.
• Alteration(s) with silicon-like signal characteristics can be detected in the right / left / both axillary / internal mammary
lymph nodes, representing an indirect sign of implant rupture / possibly originating from a previous, ruptured and
replaced implant, as the current implants show no direct signs of rupture.
• A thin fluid layer is detected in the surroundings of the implant(s), which cannot be considered as pathological.
• A homogeneous fluid layer exceeding 10 mm in thickness is detected in the surroundings of the implant(s), possibly
suggesting a reactive process.
• A heterogeneous fluid layer exceeding 10 mm in thickness is detected in the surroundings of the implant(s), rising a
suspicion of inflammatory processes.

Options for medical opinion:

• Implant rupture cannot be confirmed.
• Minimal structural alterations detected in the right / left / both implant(s), without pathological nature. Further follow-
up is recommended.
• Early stage / moderate / advanced intracapsular / extracapsular implant rupture confirmed in the right / left / both
side(s). Consultation with plastic surgeon recommended.

MRI template 4 - implant

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• Breast MRI does not substitute regular screening mammography, because some tumours, pre-cancerous
conditions (particularly low or intermediate grade DCISs) may remain unrecognized.
• Breast MRI itself cannot exclude malignity with full certainty. For the safe evaluation of MRI images,
mammography images should be reviewed, which images we did not receive.
• As per the currently accepted protocols, no final medical opinion should be issued regarding the condition of
breasts above 35 years of age without mammography; therefore a potential malignant process still cannot be
excluded with full certainty.

Additional information (comment options for Template 1, 2, 3):

• The performed native breast MRI examination does not substitute mammography (screening) which can be
performed in the majority of patients with implanted breasts.
• A consultation with a plastic surgeon is required to decide on further steps to be taken regarding the alterations
detected in the implants.

Additional information (comment options for Template 4):

References:

1. American College of Radiology Breast Imaging
Reporting and Data System (BI-RADS Atlas) MRI-Lexicon.
5th ed. American College of Radiology, Reston, VA, 2013.
2. Sardanelli F, Boetes C, Borisch B, Decker T,
Federico M, et al.: Magnetic resonance imaging of the
breast: recommendations from the EUSOMA working
group. Eur J Cancer 2010; 46(8):1296-316.
doi:10.1016/j.ejca.2010.02.015
3. Mann RM, Balleyguier C, Baltzer PA, Bick U, Colin
C, et al.: Breast MRI: EUSOBI recommendations for
women's information for the European Society of Breast
Imaging (EUSOBI), with language review by Europa Donna-
The European Breast Cancer Coalition. Eur Radiol 2015; 25:
3669-78. doi:10.1007/s00330-015-3807-z
4. Mann RM, Kuhl CK, Kinkel K, Boetes C: Breast
MRI: guidelines from the European Society of Breast
Imaging. Eur Radiol 2008; 18(7): 1307-18.
doi:10.1007/s00330-008-0863-7

Corresponding address: Dr. Tünde Tasnádi

Békés County Central Hospital, Réthy Pál Hospital, Department of Radiology;
18 Gyulai Street, Békéscsaba 5600, Hungary
E-mail: tasotunde@gmail.com

Authors' workplace:
Gábor Forrai: Duna Medical Center, Department of Radiology, Budapest
Tünde Tasnádi: Békés County Central Hospital, Réthy Pál Hospital, Department of Radiology,
Békéscsaba

6 Tasnádi et al.: Reporting protocol for breast MRI examination according to the BI-RADS lexicon II.