Classification On Mammography-Ultrasound 21 Sept Baru

BIRADS CLASSIFICATION ON
MAMMOGRAPHY-ULTRASOUND
Hari Soekersi
Departemen Radiologi – FKUP / RSHS
CONTENT
1. History and Physical examinations
2. Anatomy and Histology
3. Classifications BIRADS 5th Mammography
and Ultrasound
4. Imaging Radiology
2
C. Balleyguier et al. / European Journal of Radiology 61 (2007) 192–194
History and physical
examinations
Relevant Patient History
Breast Cancer Risk Factors
Purpose of patient visit
• Screening (asymptom)
• Diagnostic (symptom)
• Follow up (post biopsy, post surgery,
post radiation, and post chemotherapy)
Physical examination
• A complete clinical
breast examination
(CBE) includes an
assessment of both
breasts and the chest,
axillae, and regional
lymphatics.
• In premenopausal
women, the CBE is
best done the week
following menses
• The “triple touch”
technique; axilla;
supraclavicular area;
neck; and chest wall,
assessing the size,
texture, and location
of any masses
7
Anatomy and Histology
Normal Breast Gross Anatomy
• Anatomy (deep to superficial)
– Pectoralis Major
muscle
– Pectoral Fascia
– Retroglandular fat
– Mammary gland
– Skin
• Cooper’s
suspensory
ligaments
– Bands of connective tissue attaching glandular tissue to the
overlying skin
Anatomy and Histology
11
Normal Lobule Normal TDLU
TDLU’s
Stromal component : Epithelial
fat and fibrous tissues Myoepithelial
component
Classifications
BIRADS 5th edition
Mammography and Ultrasound 2013
ADVANTAGE AND
LIMITATION BIRADS
• Advantage : Allows a homogenization of the
radiological language, between the
radiologists themselves, but also between
radiologists and clinicians.
• Limitation: This classification has a great
inter and intra observer variability for the
images which are more difficult to classify,
especially in the BIRADS 3 and 4 categories.
16
C. Balleyguier et al. / European Journal of Radiology 61 (2007) 192–194
1.Describe the indication for the study.
Screening, diagnostic or follow-up.
Mention the patient's history.
If Ultrasound is performed, mention if the US is targeted to a
specific location or supplementary screening.
2.Describe the breast composition.
3.Describe any significant finding using standardized
terminology.
Use the morphological descriptors: mass, asymmetry,
architectural distortion and calcifications.
These findings may have associated features, like for instance a
mass can be accompanied with skin thickening, nipple
retraction, calcifications etc.
Correlate these findings with the clinical information,
mammography, US or MRI.
Integrate mammography and US-findings in a single report.
4.Compare to previous studies.
Awaiting previous examinations for comparison should only
take place if they are required to make a final assessment
5.Conclude to a final assessment category.
Use BI-RADS categories 0-6 and the phrase associated with
them.
If Mammography and US are performed: overall assessment
should be based on the most abnormal of the two breasts,
based on the highest likelihood of malignancy.
6.Give management recommendations.
7.Communicate unexpected findings with the referring
clinician.
Verbal discussions between radiologist, patient or referring
clinician should be documented in the report.
http://www.radiologyassistant.nl/en
BREAST COMPOSITION
A B C
A- The breast are almost entirely fatty.
Mammography is highly sensitive in this setting.
Atlas of Breast imaging 2nd edition Dr Col CS Pant VSM

BREAST COMPOSITION
A B C D
B- There are scattered areas of fibroglandular density.

The term density describes the degree of x-ray attenuation of breast tissue but not
discrete mammographic findings.
BREAST COMPOSITION
A B C D
C- The breasts are heterogeneously dense, which may obscure small masses.
Some areas in the breasts are sufficiently dense to obscure small masses.
BREAST COMPOSITION
A B C D
D - The breasts are extremely dense, which lowers the sensitivity of

mammography.
MASS
A 'Mass' is a space occupying 3D lesion seen in two
different projections.
If a potential mass is seen in only a single projection it
should be called a 'asymmetry' until its three-
dimensionality is confirmed
MASS
ROUND
Fibroadenoma showing as round shape lesion

OVAL
Fibroadenoma showing as oval shape lesion

MICROLOBULATION
Lesion showing microlobulation: HP-Fibroadenoma

IRREGULAR
XRM shows malignant lesion having irregular shape

MASS MARGIN
Ultrasound a suspicious finding.
a suspicious finding.
a very suspicious finding.
CIRCUMSCRIBED
Two examples of benign lesions showing circumscribed margins
Largely seen in benign masses. However medullary / mucinous malignancy

can also appear circumscribed. If any lesion is solid on US, irrespective of
the margins, FNAC / biopsy is mandatory

LOBULATED
Typical fibroadenoma showing lobulated margins
Seen both in benign and malignant conditions

ILL DEFINED / POORLY DEFINED
Poorly defined margins in left retroareolar lesion HP infiltrating ductal carcinoma
Seen both in malignant and benign condition

OBSCURED
Case of infiltrating ductal carcinoma showing Obscured margins (left half),

benign lesion showing Obscured margins (right half).
Obscured margin is generally due to overlying fibroglandular tissue,

special mammographic view or US correlation is recommended

SPICULATED
Spiculated margins typically seen in malignant lesion

Spiculated is largerly seen in malignant conditions. It has been widely
reported in the literature that mass lesion with speculated margins
have high probability (>95%) of being malignant lesion with exception
of radial scar / changes due to prior surgery.
MASS DENSITY
malignancy.
The density of a mass is related to the expected attenuation of an equal volume of

fibroglandular tissue. High density is associated with malignancy.
It is extremely rare for breast cancer to be low density.
LOW
FAT CONTAINING
Here multiple round circumscribed low density masses in the right breast.
These were the result of lipofilling, which is transplantation of body fat to the
breast.
EQUAL
HIGH
Wood RW, Sisney GS, The Mammographic Density of a Mass Is a Significant Predictor of Breast Cancer; 2011
ASYMMETRY AND
ARCHITECTURAL DISTORTION
ASYMMETRY AND
] DISTORTION
ARCHITECTURAL
ASYMMETRY AND
GLOBAL ASYMMETRY
• If clinically palpable (at least a quadrant) high possibility of

malignancy;
• not palpable usually due to hormone influence/ normal
variant.

GLOBAL ASYMMETRY

FOCAL ASYMMETRY
• 2 views
• Indistinctly marginated mass
GLOBAL ASYMMETRY
• Here an example of global asymmetry.

In this patient this is not a normal variant, since there are associated features, that
indicate the possibility of malignancy like skin thickening, thickened septa and subtle
nipple retraction.
• Ultrasound (not shown) detected multiple small masses that proved to be
adenocarcinoma.
The PET-CT shows diffuse infiltrating carcinoma. http://www.radiologyassistant.nl/en
DEVELOPING ASYMMETRY
A developing asymmetry is a focal
asymmetry that is new or increased in
conspicuity compared with the previous
mammogram.
It is challenging to evaluate, as it often
looks similar to fibroglandular tissue at
mammography.
A developing asymmetry should be
viewed with suspicion because it is an
uncommon manifestation of breast
cancer.
Diagnostic mammography forms the
foundation of diagnostic evaluation of a
developing asymmetry and begins with
additional spot compression, lateral,
and/or rolled views to evaluate and
localize it in three-dimensional space.
https://pubs.rsna.org/doi/full/10.1148/rg.2016150123
• Normal architecture is distorted with no

definite visible mass.
• Look for abnormal straight lines or
spiculations radiating from a point.
• Differential diagnosis :
- Carcinoma vs scar tissue
Radial Scar
The characteristics of radial scar are:

Benign lesion mimicking malignancy
Idiopathic
Produces scar like lesion
Nidus – elastic tissue component mixed with fibrosis
Excision biopsy is a must
Fat Necrosis (no history of trauma or breast
surgery)
Post Biopsy
ARCHITECTURAL DISTORTION (MALIGNANT LESION)
CALCIFICATIONS
• Microcalcification is unnerving for many patients
and referring clinician. However, all calcification are
not malignant. The calcification can broadly be
divided according to its morphology an distribution
description as follows:
• Benign / coarse heterogenous
• Indeterminate
• Malignant
– Pleomorphic
– Granular / clustered
– Fine branching
CALCIFICATIONS
Distribution
Diffuse
Regional
Grouped
Linear
Segmental
CALCIFICATIONS
SUSPICOUS - INDETERMINATE
CALCIFICATIONS
A B C
D E F
• A-B. AMORPHOUS
So small and/or hazy in appearance that a more specific particle shape cannot be determined.
• C. FINE PLEOMORPHIC
Usually more conspicuous than amorphous forms and are seen to have discrete shapes, without fine
linear and linear branching forms, usually < 0,5 mm.
• D. COARSE HETEROGENEOUS
Heterogenous dense, coarse, Irregular, conspicuous calcifications that are generally between 0,5 mm
and 1 mm and tend to coalesce but are smaller than dystrophic calcifications. Associated with benign
process
• E-F. FINE LINEAR OR FINE-LINEAR BRANCHING
Thin, linear irregular calcifications, may be discontinuous, occasionally branching forms can be seen,
usually < 0,5 mm. http://www.radiologyassistant.nl/en
DISTRIBUTION CALCIFICATIONS
DISTRIBUTION OF CALCIFICATIONS
Diffuse
• distributed randomly throughout the breast.
Regional
• Regional >2cm3 volume of breast tissue not
conforming to a duct scattered in large
volume (occupying a quadrant or more)
Grouped (historically cluster)

• few calcifications occupying a small portion
of breast tissue: lower limit 5 calcifications
within 1 cm3 and upper limit a larger number
of calcifications within 2 cm3.
Linear
• arranged in a line, which suggests deposits
in a duct.
Segmental
• suggests deposits in a duct or ducts
and their branches
ASSOCIATED FEATURES
ASSOCIATED FEATURES
Skin thickening from radiotherapy
ASSOCIATED FEATURES
Right breast ultrasound showing skin thickening and underlying

marked inflammatory changes with increased echogenicity.
ASSOCIATED FEATURES
Axillary lymphadenopathy
Birads
ultrasound
Axillary artery 
Humerus
BREAST COMPOSITION
• Many descriptors for ultrasound are the same

as for mammography.
For instance when we describe the shape or
margin of a mass.
• Breast Composition:
• Homogeneous echotexture-fat
• Homogeneous echotexture-fibroglandular
• Heterogeneous echotexture
BREAST COMPOSITION
Ultrasound characteristics seen in dense breast subcutaneous

fat (SCF), retromammary fat (RMF) Cooper’s ligament (CC) and
terminal duct lobular units (TDLUS)
BREAST COMPOSITION
Mammogram showing entirely fatty breast. Normal breast

ultrasound anatomy ( fatty breast)
Predominantly fatty breast, fibrofatty nodule appearing as
echogenic SOL (arrow).
BREAST COMPOSITION
BREAST COMPOSITION
BREAST COMPOSITION
MASS
• Definition : a mass occupies space and should be seen in two

projections
• Masses can be distinguished from normal anatomic

structures, such as ribs or fat lobules, using two or more
projections and real-time scanning
MASS
• Orientation: unique to US-imaging, and defined as parallel

(benign) or not parallel (suspicious finding) to the skin.
• Echo pattern: anechoic, hypoechoic, complex cystic and
solid, isoechoic, hyperechoic, heterogeneous.
Echogenicity can contribute to the assessment of a lesion,
together with other feature categories. Alone it has little
specificity.
• Posterior features: enhancement, shadowing.
Posterior features represent the attenuation characteristics
of a mass with respect to its acoustic transmission, also of
additional value. Alone it has little specificity.
MASS
Masses : the big three

1. Shape →
- Oval (including macrolobulated)
- Round
- Irreguler (neither round nor oval)
2. Orientation →
- Parallel to skin → Parallel or “wider than tall”
- Not parallel → AP or vertical dimension is greater than the transverse or horizontal
dimension. Synonyms : vertical or taller than wide
Non-parallel masses can also be obliquely oriented.
3. Margins →
- Circumscribed – well defined, smooth, distinct rim
- Not circumscribed ( includes echogenic rim ) →
Indistinct ( poorly defined )
Microlobulated ( > 3 small, short-cycle undulations )
Angular ( part or all margins have sharp corners or form acute angles)
Spiculated ( margins formed or characterized by sharp lines projecting from the mass )
SHAPE
Oval (including macrolobulated) Round - spherical, circular or globular
Irreguler (neither round nor oval)

ORIENTATION
Parallel to skin → long axis of lesion

parallels the skin line ( “wider than
tall” or horizontal )
ORIENTATION
Parallel to skin → Parallel or “wider than tall”

ORIENTATION
Not parallel → long axis not oriented along the skin line (taller than wide or vertical,
includes round).
ORIENTATION
Not parallel → AP or vertical dimension is greater than the transverse or horizontal dimension.
Synonyms : vertical or taller than wide
Non-parallel masses can also be obliquely oriented.
MARGINS
Circumscribed
A margin that is well defined or sharp, with an

abrupt transition between the lesions and
• Not circumscribed – the mass has one or more of the
following features :
a. Indistinct – no clear demarcation between a mass and
its surrounding tissue.
b. Angular – some or all of the margin has sharp corners,
often forming acute angles.
c. Microlobulated – short cycle undulations impart a
scalloped appearance to the margin of the mass.
d. Spiculated – margin is formed or characterized by sharp
lines projecting from the mass.
MARGINS
Indistinct Margin
• No clear demarcation between the margin or
a portion of the margin and the adjacent
breast tissues
• Also includes echogenic rim
MARGINS
64 year old with screen detected abnormality

US: indistinct margin
Core bx = IDC grade 1
MARGINS
INDISTINCT / POORLY DEFINED

MARGINS
INDISTINCT / POORLY DEFINED
MARGINS
Angular Margin
• Margins with sharp angles
• Often seen at point where Cooper’s ligament
reach surface of malignant nodule
56 year old with a left
breast lump
US : Angular and
microlobulated margins;
note angular margin at
the site of Cooper’s
ligament (pink arrow)
Core bx =
IDC ER-/PR-/HER2+
MARGINS
ANGULAR
MARGINS
ANGULAR
MARGINS
MIcrolobulations
• Multiple small lobulations (1-2mm usually)
close to each other
MARGINS
63 year old with a left breast lump

US : microlobulations (pink arrow)
MARGINS
MICROLOBULATED
MARGINS
MICROLOBULATED
MARGINS
MICROLOBULATED
MARGINS
Spiculated Margin
• Borrowed from mammography and applied to US
• Indicates invasion into adjacent tissue
• Alternating hypoechoic* and slightly hyperechoic~ straight
lines radiating out from surface of nodule
(*to fingers of invasive tumour or duct extension)
(~due to interface between tumour and surrounding breast
tissue, or invasive tumour too small to be resolved by US)
MARGINS
52 year old
Right mastectomy for DCIS 5 years ago
Now has new asymmetric density in left UOQ on mammogram
US : irregular mass with spiculated margins
MARGINS
SPICULATED
MARGINS
SPICULATED
Benign breast disease
Why is it important?
• Common cause of symptoms
• Accounts for a majority of doctors visits
• Can mimic malignant lesions on imaging
• Some are risk factors for developing future
breast cancer
US features of benignity :
solid nodules
• Circumscribed margin (NPV 90%)

• Oval shape (NPV 84%)
• Parallel orientation (NPV 78%)
• Complete thin echogenic capsule (NPV 95%)
• Purely echogenic (NPV 100%)
BI-RADS for sonography: positive and negative preditive values of sonographic features; AS Hong et al, AJR 2005
ULTRASONOGRAPHY
MASS CHARACTERISTICS
BENIGN MALIGNANT
• Well circumscribed, hyperechoic • Sonographic spiculation: 87-90% 1,4
tissue: ~100%
• Deeper (taller) than wide: 74-80% 1,4
• Wider than deep: 99% • Microlobulations: 75%
• Gently curving smooth • Thick hyperechoic halo: 74 %
lobulations (<3 in a wider than
deep nodule, i.e. D/W ratio <1): • Angular margins: 70%
99% • Markedly hypoechoic nodule: 70%
• Thin echogenic pseudocapsule • Sonographic posterior accoustic
in a wider than deep nodule: shadowing: 50%
99%
• Branching pattern: 30%
• It is best seen on
• Punctate calcifications: 25%
anterior/posterior margins,
perpendicular to the beam • Duct extension: 25%
• Probably represents normal • Heterogeneous echotexture 3
compressed tissue consistent • Compressibility : malignant lesions
with a non infiltrative process. displace the breast tissue without
changing in height (elastography).
MASS CHARACTERISTICS
ECHO PATTERN
1. Anechoic → without internal echoes
2. Hyperechoic → homogeneously hyperechoic, defined relative to fat,

equal to fibroglandular tissue
3. Hypoechoic → defined relative to fat, low-level echoes throughout (e.g

complicated cyst or FA)
4. Isoechoic → same echogenicity as fat

ECHO PATTERN
Anechoic
ECHO PATTERN
Anechoic echo pattern
39 year old presenting with left breast lump x 1 month duration

Reported as a cyst; BIRADS 2
ECHO PATTERN
Hyperechoic → homogeneously hyperechoic, defined
relative to fat, equal to fibroglandular tissue
ECHO PATTERN
Isoechoic → same echogenicity as fat

ECHO PATTERN
ECHO PATTERN
Hypoechoic → defined relative to fat, low-level echoes
throughout (e.g complicated cyst or FA)
ECHO PATTERN
Heterogenous echo pattern
No calcification seen on mammo

Core bx : grade 3 IDC triple +ve
ECHO PATTERN
POSTERIOR ACOUSTIC FEATURES
• Reflects degree of desmoplasia

• Posterior acoustic shadowing:
- Due to presence of desmoplastic reaction
- Usually in low and intermediate grade tumors
• Enhancement:
- Due to highly cellular high grade malignant lesions
- Lack of desmoplasia due to tumour which has grown too quickly
• Combined Pattern:
- Due to heterogeneity of lesion
• Not useful to differentiate from a benign lesion
 None : no posterior acoustic change
 Enhancement : increased posterior echoes
 Shadowing : decreased posterior echoes, excluding edge shadows

ONLY ABOUT 60% OF CANCERS WILL SHADOW
 Combined pattern : both shadowing and enhancement

None : no posterior acoustic change
SHADOWING
ENHANCEMENT
SHADOWING
ENHANCEMENT
SHADOWING
65 year old with breast lump
US: posterior features shows combined pattern
(pink arrow:shadowing, blue arrow:enhancement)
Mastectomy:35 mm grade 2 IDC, ER+/PR+/HER2+
CALCIFICATIONS
• No seen
• Present
- Calcifications in a mass
- Calcifications outside of a mass
- Intraductal calcifications
CALCIFICATIONS
Calcifications in a mass
CALCIFICATIONS
Calcifications outside of a mass
CALCIFICATIONS
Intraductal calcifications
ASSOCIATED FEATURES
• No effect of mass
• Architectural distorsion
• Vascularity → Absent; Internal vascularity, Vessels in rim
• Elasticity assessment (malignancies-hard; benign – soft ),
quantification by ratio newly allowed by FDA (kPa)
• Duct changes
• Skin changes → Skin thickening ; Skin retraction
• Edema
ASSOCIATED FEATURES
Architectural distortion
• Mammographic term applied to US
= flattening or pulling in of Cooper’s ligaments
towards mass
ASSOCIATED FEATURES
Architectural distortion
• Mammographic descriptor applied to US

• Flattening or pulling in of Cooper’s ligaments toward mass
• Mammographic descriptor applied to US

• Mastectomy: 27 mm grade 1 IDC, ER+/PR+/HER2-
ASSOCIATED FEATURES
Skin Changes: thickening
31 year old with right breast lump

Core boc grade 2 IDC, ER+/PR+/HER2+
SPECIAL CASES
SPECIAL CASES
SPECIAL CASES
Echotexture of breast lesion

Simple Cyst
Anechoic,
wellcircumscribed mass
with imperceptible wall and
posterior acoustic
enhancement
Simple cyst do not require
intervention because they
have no malignant potential
SPECIAL CASES
Complicated Cyst :
Cyst containing internal echoes on US
No “COMPLEX” features (e.g. no thick wall, thick
septations,intracystic mass or solid component)
The risk of malignancy among
complicated cyst is <2%
Generally can be managed with
short –interval follow up
imaging or aspiration
SPECIAL CASES
Ultrasound Featured of Complicated Cyst

Color Doppler Ultrasound
CDUS &PDUS can impart energy to internal debris and facilitate recoqnition of its
mobility
DD/ of Complicated Cyst
Simple cyst with Artifactual Internal echoes
∙Usually anterior reverberation artifact
∙Worst with cyst <8 mm
∙THI reduces artifact
∙Appropriate gain & focal zone at mass
Proteinaceous Cyst
• Homogenous low level
echoes on US
• Fluid typically cloudly
yellow in aspiration
Hemorrhagic Cyst
*Debris may appear tumefactive
*Bloodly fluid should sent for cytology
●can be due to papillary lesion
●Surveillance suggested in 3-6 months to exclude
underlying mass that bleed : consider excision
• Abscess :
• Associated edema, tender, may have erythema,
usually near the nipple
US findings : mixed echogenicity, surrounding increased
echogenicity due to edema
Abscess
• Galactocele :
Pregnant or lactating woman
US findings : Fluid –debris level with nondependent
Fatty debris
Can have hyperechoic fat plug
SPECIAL CASES
SPECIAL CASES
SPECIAL CASES
SPECIAL CASES
SPECIAL CASES
SPECIAL CASES
SPECIAL CASES
TEACHING POINTS
• The Breast Imaging Report and Data System
(BIRADS) of the American College of Radiology
(ACR) is today largely used in most of the
countries where breast cancer screening is
implemented.
• It is a tool defined to reduce variability
between radiologists when creating the
reports in mammography, ultrasonography or
MRI
154
European Journal of Radiology 61 (2007) 192–194
TEACHING POINTS
• BI-RADS mammogram classifications are
generalizations and tend to revolve around the
presence and type of microcalcifications.
• Certain microcalcifications might even be ‘directly’
associated with breast cancer
• BI-RADS mammogram classifications are not
intended as a diagnostic tool, but only as a means
of standardizing communications and helping to
identify situations where follow-up is required, and
the most appropriate type of follow-up
155
https://breast-cancer.ca/bi-rads/
TEACHING POINTS
• For a lesion with benign characteristics, emerging
data suggest that short-interval follow-up is a
reasonable option
• If follow-up US shows a progressive decrease in the
mass size and stable benign US features, the final
assessment category can be changed to BI-RADS 2.
• For an older patient, the threshold for biopsy should
be lowered, and biopsy may be warranted even in
the setting of probably benign imaging features
156
RadioGraphics 2010; 30:1199–1213
TEACHING POINTS
• Mammogram challenges
– Focal asymmetry, developing asymmetry
– One view finding
• Ultrasound challenges:
– Mimickers of “cystic” lesion
– Limitations of US and elastography
• Atypical imaging finding:
– High grade cancer and certain subtypes
• Mimickers of expected lesion/finding
• Post-surgical breast
TEACHING POINTS
• A Typical malignant breast lesion on US is
usually due to a low to intermediate grade
cancer
• High grade cancer and certain cancer breast
cancers can mimic benign nodules or cysts
• Be wary of new lesions or increase in size of
lesions, especially in peri-menopause or
menopausal patients
TERIMA KASIH...
159
Normal breast anatomy
• Glandular (TDLU)
Component:
• Minor variations during
different phases of the
menstrual cycle
• Increase in size and
number during pregnancy
and lactation
• Decrease in size and
number after menopause,
sclerosis or fat replacement
Normal breast anatomy
Stromal component:
• large vacation in the
amount of fibrous
stroma between
individuals.
• Varies with hormonal
status and age
• Results in differences in
tissues composition on
US
CASE EXAMPLE
CALCIFICATIONS
BI-RADS 2 – benign finding

– Large, rod like intraductal and periductal
calcifications
CALCIFICATIONS

– Simple cyst with mineralized wall
CALCIFICATIONS
– Simple cyst with mineralized wall

CALCIFICATIONS

– Vascular calcifications
CALCIFICATIONS
CALCIFICATIONS
CALCIFICATIONS
BI-RADS 3 – probably benign finding

– Punctate microcalcifications (scattered or clustered)
CALCIFICATIONS
If a BI-RADS 3 lesion
shows any change
during FU,
it will change into a
BI-RADS 4 or 5
and biopsy should
be performed.
CALCIFICATIONS
BI-RADS 4 – suspicious abnormality

– Group amorphous or fine pleomorphic calcifications
The pathologist could report sclerosing adenosis or ductal carcinoma in situ.

Both diagnoses are concordant with the mammographic findings.
CALCIFICATIONS

– Punctate microcalcifications with background density
CALCIFICATIONS
BI-RADS 5 – highly suspicious of malignancy

– Segmental or linear arrangement of fine linear, branching
calcifications
CALCIFICATIONS
Pleomorfous calcs BI-RADS 5

CALCIFICATIONS
BI-RADS5 – ductal
ASYMMETRY
– Focal asymmetry which becomes less dense on spot compression
view
ASYMMETRY
– Radial architectural distortion without central density
ASYMMETRY
– Asymetrical density with architectural distortion
ASYMMETRY
BI-RADS 4
Assimetry/distortion
ASYMMETRY
– Radial architectural distortions with central density
Causes of benign solid nodules
• Fibroadenoma, fibroadenoma variants
• Benign phyllodes tumour
• Harmatoma
• Epithelial proliferative disorders:
– Sclerosing adenosis
– Papilloma
– Radial scar
• Stromal proliferative disorders:
– Focal fibrosis
– Fibrous mastopathy
– Pseudoangiomatous stromal hyperplasia (PASH)
Fibroadenomas (FA’s)
• US features
⁻ Ellliptical or gently lobulated shape
⁻ Well Circumscribed
⁻ Wider – than – tall
⁻ Parallel to skin
⁻ Isoechoic to hypoechoic echotexture
⁻ Thin echogenic pseudocapsule
29 year old with left breast lump
Ex bx =FA
Example of FA with irregular shape and angular margin
Typical fibroadenoma
35 year old with palpable lump in right upper breast

17 year with right breast lump
Ex bx = fibroadenoma
34 year old with US detected lesion
core bx = FA
Example of FA with irreguler shape and angular margins
24 year old with left breast lump
Core bx = tubular adenoma
Fibroadenoma variants
• Juvenile/giant FA
• Cellular FA
• Tubular adenoma/lactating adenoma
• Complex FA
Contain epithelial poliferative changes
(cyst formation, apocrine metaplasia, epithelial
hyperplasia with calcifications, sclerosing adenosis)
1,5-2X increased relative risk (generalised and not
within the complex FA)
45 year old with US detected mass
core bx = complex SA
Benign phylloides tumour
• Presents with rapidly growing palpable lump
• Path : mixture of epithelial and stromal
components, but with dominant stromal
proliferation
• US features:
– Solid oval or lobulated well circumscribed nodule
– May have small cysts or echogenic striations within
– Resembles complex FA and cellular FA
Hamartomas
• Presents as a palpable lump, sometimes tender; or
incidentally detected on imaging
• Path :focal overgrowthof varying amounts of epithelial,
fibrous, and fatty elements
• Other terms : fibroadenolipoma
• US features:
– Usually heterogeneous
– Variable appearance depending on the amount of fatty
(isoechoic), glandular (isoechoic), and fibrous (hyperechoic)
elements
– May or may not have a thin echogenic pseudocapsule
52 year old
US : incidental harmatoma detected
Elasticity assesment: intermadiate and soft
Focal fibrosis
• Present as a palpable lump in 4 th
to 5th decade
• Path: focal area of dense stromal fibrous tissue
• US features:
⁻ Well circumscribed purely echogenic nodule
Diabetic Fibrous mastophaty (DFM)
• Present as a hard palpable lump or abnormal
imaging finding
• Usually occurs 20 years after onset of diabetes
• Path : collagenous stroma with limphocytic infiltrates
• US features
⁻ Irreguler shaped with ill-defined, angular margins,
posterior acoustic shadowing
• May be multifocal, multicentric or bilateral; more
lesions may develop over time in different areas
Pseudoangiomatous stromal hyperplasia (PASH)
• Presents as a palpable lump

• Path: focal overgrowth pf stromal tissue
• Main differential: low grade angiosarcome
• US features:
- Variable
- May mimic fibroadenoma or may mimic malignancy:
irregular shape, ill-defined or angular margins
Sclerosing adenosis
• Presents as an imaging abnormality

 Mammo : amorphous or punctate microcals
 US : variable, enlarge TDLU or duct, solid nodule with angular or
spiculated margins
• Path : proliferation and enlargement of ductules (adenosis) leading

to increase in size and number of lobules; associated with stromal
fibrosis (sclerosis)
• Marker of slightly increased risk in future

Papilloma
• Central (large duct papilloma,LDP) or peripheral (terminal duct, PP)
• Presents with nipple discharge (LDP) or abnormal imaging (PP)
• Path: ductal epithelial proliferation, grows in frond-like pattern,
central fibrovascular stalk
• US features:
- variable
- depend on presents/absence of ductal dilatation, length of
duct involved, extension into a duct, become encysted
• Can undergo necrosis, haemorrhage, infarction
RADIAL SCAR/COMPLEX SCLEROSING LESION
• Presents as an imaging abnormality (Mammo : “Black Star”) or as an

incidental finding
• Path :
 Central fibro – Elastic core surrounded by stellate proliferation of ducts and
lobules
 ADH and DCIS can arise from radial scars
• US features :
 Mimics malignancy
 Solid nodule with angular or spiculated margins
Causes of benign solid nodules
• Fibroadenoma, fibroadenoma variants, Complex Fa

• Benign phyllodes tumour
• Harmatoma
• Epithelial proliferative disorders :
Slightly Increased Risk of Breast
 Sclerosing adenosis Cancer in Future (1.5-2x)
 Pappiloma
 Radial scar
• Stromal proliferative disorders :
 Focal fibrosis
 Fibrous mastopathy
 Pseudoangiomatous stromal hyperplasia
Simple cyst
• Most common type of breast mass

• Peak incidence 30-50 Years
• Over-distention of TDLU’s due to progressive filling
of liquid, coalescence Of dilated ductules
• Hormonally sensitive
• Fluctuate in size and number with cycle
• More common in menopausal women on HRT
• Natural history: develop and regress
Fibroademonas (FA’s)
• Peak incidence in 3rd decade, second peak in 5th decade
• Path: benign tumors arising from TDLU, grow by
incorporating surrounding tissues
• Contain both stromal and epithelial components (fibro-
adenoma)
• Most common cause precipitating biopsy in
adolescents and young adult <30
• Hormonally sensitive (oestrogen stimulates)
• Multiple in 20-25%
43 year old with mammographically detected opacity
Core bx = cellular FA
Galactocoele
• Painless lumo that appears few weeks/months after
cessation of lactation
• Also seen on 3rd trisemester
• Due to dilated termial ducts/ductules which filled with
milk
• US features:
- Depends on stage of development
- Anechoic at first
- Becomes echogenic as they age
- May have fat-fluid level
Complex Solid Cystic Mass
• Can be further categorized into 4 types :

Type 1 Thick outer wall (>/=0.5mm), thick internal
Type 2 Presence of intra-cystic mass
Type 3 Mixed cystic (at least 50%) and solid components
Type 4 Mixed solid (at least 50%) and cystic components

Complex Solid Cystic Mass (Type 3)
50 year old with left breast mass

Core bx : infarcted papilloma
Complex solid cystic mass (type 4)
73 year old with right breast mass

Core bc intracystic papillary Ca
Non-mass US lesion: ductal pattern
43 year old; p/w left nipple discharge

Non-mass US lesion: non-ductal
pattern
40 year old with right breast pain and swelling x 2/52

US: non-ductal pattern of non-mass abnormal areas in region of
concern
Core bx = grade 2 ILC ER+PR+HER2equiv
BIRADS
0 Need additional imaging evaluation and/or prior
mammograms for comparison.
1 Symmetric breast, masses – architectural distortion –
suspicious calcification (-).
2 • F.U after breast conservative surgery.
• Involuting, calcified fibroadenoma.
• Multiple large, rod-like calcifications.
• Intramammary lymph nodes.
• Vascular calcifications.
• Implants.
• Architectural distortion clearly related to prior surgery.
• Fat containing lesions.
BIRADS
3 • Nonpalpable, circumscribe mass on a baseline
mammogram.
• Focal asymmetry which Becomes less dense on spot
compression view.
• Solitary group of punctate calcifications.
4 a. • Partially circumscribed mass, sugestive of (atypical)

fibroadenoma.
• Palpable, solitary, complex cystic and solid cyst.
• Probable abscess.
b. • Group amorphous or fine pleomorphic

calcifications.
• Nondescript solid mass with indistinct margins.
c • New group of fine linear calcifications.
• New indistinct, irregular solitary mass
BIRADS
5 • Spiculated, irregular high density mass.

• Segmental or linear arrangement og fine linear
calcifications.
• Irregular spiculated mass with associated
pleomorphic calcifications.
6 • Known biopsy-proven malignancy
BIRADS 0
• Assessment is not complete and breast cancer specialists may
recommend additional work-up. So, further work-up may
include spot compression, magnification, or breast ultrasound.
• In real-life terms, if a screening mammogram shows something
like a round nodule and the radiologist thinks it might be a cyst
(not cancer), the radiologist will ask for an ultrasound and
assign a BIRADS 0 category to the mammogram.
• When the ultrasound result is available, and, for example, shows
a benign cyst, then the ultrasound result “completes the
BIRADS” and assigns a category 2 to the case because a cyst is
benign.
223
BI-RADS 0 – incomplete assessment
• Additional mammographic imaging is
needed: additional mammographic
views, spot compression
• Additional US or (complete)
mammography is needed ONLY if
equipment or personnel is not
available or patient is unable to wait
• Prior mammography or US are
required to make a final assessment
and issue an addendum including a
revised assessment
BIRADS 1
BIRADS 1 Negative
• With category 1 the breast cancer screening
shows no grouped or suspicious
microcalcifications, no well-formed mass,
asymmetrical glandular structure and/or no
change from any previous exam.
226
Bi-RADS for Mammography and Ultrasound 2013 Updated version Harmien Zonderland and Robin
Smithuis
BI-RADS 1
DO
Use BI-RADS 1 if there are no
abnormal imaging findings in a
patient with a palpable
abnormality, possible a
palpable cancer, BUT add a
sentence recommending
surgical consultation or tissue
diagnosis if clinically indicated.
BIRADS 2
BIRADS 2 Benign
• Category 2 is a definitive benign finding and a routine screening. That is, there is
something abnormal on mammogram but it is not breast cancer or malignant in
any way.
• BI-RADS category 2 findings often include:
1. Round opacities with macrocalcifications (typical calcified fibroadenoma or
cyst)
2. Round opacities corresponding to a typical cyst at ultrasonography
3. Oval opacities with a radiolucent center
4. Fatty densities or partially fatty images (lipoma, galactocele, oil cyst,
hamartoma )
5. Surgical scar
6. Scattered macrocalcifications (fibroadenoma, cyst, cytosteatonecrosis,
secretory ductal ectasia);
7. Vascular calcifications
8. Breast implants, silicone granuloma.
229
– Completely or partialy calcified fibroadenomas
BIRADS 2 Benign
The specs are benign Here the calcium

microcalcifications buildup is in layers,
like sediment or leaves
in a teacup
Round, benign 231

microcalcification. https://breast-cancer.ca/bi-rads/
BI-RADS Category 2: Mass seen on mammogram proved to be a cyst
– Fat necrosis calcifications
– Intramammary lymph nodes
– Fat containing formations – lipomas and fibroadenolipomas, oil
cysts and galactoceles
Smithuis
BI-RADS 2
DO
Agree in a group practice on whether and when to describe benign findings in a
report
Use in screening or in diagnostic imaging when a benign finding is present
Use in the presence of bilateral lymphadenopathy, probably reactive or infectious in
origin
Use in diagnostic imaging and recommend management if appropriate,
- as in abscess or hematoma
- as in implant rupture and other foreign bodies
DON'T
Don't use when a benign finding is present but not described in the report, then use
Category 1.
Don't recommend MRI to further evaluate a benign finding.
BIRADS 3
BIRADS 3 Probably Benign
• With BI-RADS category 3 recommend a follow-up at 6
months. Sometimes on a breast cancer screening
mammogram there may be a finding of some kind, but no
palpable lesion is present.
• In some scenarios a percutaneous biopsy (usually
core-needle biopsy) might be considered even for BIRADS
category 3. For example, extreme patient anxiety or plans
for pregnancy, plans for breast augmentation or reduction
surgery, or if synchronous carcinoma is present.
241
Findings typical of this category include:
1. Clusters of tiny calcifications – round or oval
2. Non-calcified solid nodules (no size limitation but non palpable on
physical examination), round, ovoid and well-defined.
3. Selected focal asymmetrical areas of fibroglandular densities (not
palpable): This might include concave-outward defined margins,
interspersed with fat and without central increased fibular density
on two projections.
4. Miscellaneous focal findings, such as a dilated duct or post biopsy
architectural distortion without central density
5. Generalized distribution in both breasts. For example, multiple
similar lesions with tiny calcifications or nodules distributed
randomly
242
• Positive predictive value (PPV) or the chance of
having a real breast cancer is very low for BI-RADS
category 3 lesions. In addition there has been a
decrease in PPV for BIRADS category 3 in recent
years. So, with advances in both research and
experience, specialists consider the PPV of a
category, breast lesions 3 as less than 1%
243
These tiny specs are This microcalcification is round

diffuse punctate but the edges are not sharply
microcalcifications. defined. It would be called
‘indeterminate BI-RADS 3 and
not BI-RADS 2, because of the
poorly defined, fuzzy edge.
244
Smithuis
The initial short-term follow-up of a BI-RADS 3 lesion is a unilateral

mammogram at 6 months, then a bilateral follow-up examination at 12 months.
Assuming stability perform a follow-up after one year and optionally after
another year.
If the findings shows no change in the follow up the final assessment is changed
to BI-RADS 2 (benign) and no further follow up is needed.
Follow-up at 6, 12 and 24 months showed no change and the final assessment
was changed into a Category 2.
Nevertheless the patient and the clinician preferred removal, because the
radiologist was not able to present a clear differential diagnosis.
So add the following sentence in your report:
BI-RADS 2 (benign finding).
Instead of stopping the follow-up, tissue diagnosis will be performed, due to
patient and referring clinician concern.
PA: benign vascular malformation
Smithuis
If a BI-RADS 3 lesion shows any change during follow up, it

will change into a BI-RADS 4 or 5 and biopsy should be
performed.
The upper image shows a few amorphous calcifications
initially classified as BI-RADS 3.
At 12 month follow up more than five calcifications were
noted in a group.
The findings were now classified as BI-RADS 4.
This proved to be DCIS with invasive carcinoma.
BI-RADS 3
US and
biopsy: TN
cancer
US and
biopsy: FA
Smithuis
Here a non-palpable sharply defined mass with a group of punctate

calcifications.
The mass was categorized as BI-RADS 3
Final assessment was changed to a Category 2
Smithuis
If a BI-RADS 3 lesion shows any

change during follow up, it will
change into a BI-RADS 4 or 5 and
biopsy should be performed.
The upper image shows a few amorphous

calcifications initially classified as BI-RADS 3.
At 12 month follow up more than five
calcifications were noted in a group. The
findings were now classified as BI-RADS
4.This proved to be DCIS with invasive
carcinoma.
Smithuis
BI-RADS 3
DO
Do perform initial short term follow-up after 6 months. Assuming stability perform a
second short term follow-up after 6 months (With mammography: image both
breasts). Assuming stability perform a follow-up after one year and optionally
another year. Then use Category 2.
Do realize, that a benign evaluation may always be rendered before completion of
the Category 3 analysis, if in the opinion of the radiologist the finding has no chance
of malignancy and thus is Category 2.
Use in findings on mammography like
- Noncalcified circumscribed solid mass
- Focal asymmetry
- Solitary group of punctuate calcifications
Use in findings on US with robust evidence to suggest
- Typical fibroadenoma
- Isolated complicated cyst
- Clustered microcysts
Use in a probably benign finding, while the patient or referring clinician still prefers
biopsy. Then add sentence: 'Instead of follow-up tissue diagnosis will be performed,
due to patient or referring clinician concern'.
Smithuis
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 intramammary lymph
node, or another benign finding),
Focal asymmetry which becomes less dense on spot compression
view
Solitary group of punctate calcifications
BIRADS 3: Probably benign finding
( initial short-interval follow-up suggested )
• Less than 2% risk 3 type of findings:

of malignancy
• Non-palpable ( < 2 – Cluster of round
cm ) (punctate) calcifications
• Stable – Noncalcified
circumscribed solid
• Only after mass
complete imaging – Focal asymmetric
evaluation density
Classification
• “The main potential pitfall is incorrect
classification,” - Dr. Luis J. Pina, University Clinic
of Navarra, Spain
• "Specifically, the BI-RADS 3 category can
become a 'holding tank' for problematic lesions
which are so categorized without further
diagnostic procedures.
• This typically occurs when inexperienced
radiologists feel uncertain about diagnosis.
By Frances Rylands-Monk, AuntMinnieEurope.com staff writer March 4, 2011

• BIRADS 3 is a temporary
statement until the lesion is
definitely classified as category
2 or 4
• Some malignant tumors can show a
benign appearance
• Some benign lesions have unusual
signs
• BIRADS 3 – in between benign and unclear

lesions
• Not in between benign and malignant lesions!
Probably Benign Finding BIRADS 3
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.
• Don't use if unsure whether to render a benign (Category 2)
or suspicious (Category 4) assessment. Then use Category 4.
• Don't use in a screening examination
• Don't use in a diagnostic examination if additional imaging is
required to make a final assessment
• Don't use if a lesion, previously assessed as Category 3 has
increased in size or extent, like a mass on US with an increase
of 20% or more of longest dimension. Then use category 4.
• Don't recommend MRI to further evaluate a probably benign
finding
Biopsy of BI-RADS 3 lesions (BI-RADS 4)
• Non-palpable lesions with microcalcifications

categorized as BI-RADS 3 (probably benign)
should undergo a biopsy procedure until a
more reliable system for description and
classification of microcalcifications is available.
R M PIJNAPPEL , The British Journal of Radiology, 77 (2004)

Biopsy in specific situations
• Palpable/symptomatic
• Planned surgery (augmentation/reduction)
• Planned pregnancy
• High risk patients
• Synchronous cancer
• Size of the lesion
• Patient´s decision
How can we decrease the BI-RADS 3 lesions?
Reclassifying them as:

• BIRADS 2
• BIRADS 4
How to reclassify BI-RADS 3 lesions?
• AdditionaI imaging techniques

• Compare with previous exams
• Radiologist´s experience
• Biopsy in specific situations
Additional imaging techniques
In a clinical setting we can use all

the imaging and biopsy techniques
to re-classify a BI-RADS 3 lesion
• Complemmentary mammographic
views
• Tomosynthesis
• US
• Elastography
• MRI
TN invasive
ca
2007 2008
Invasive ductal ca
2011 03 2011 12
2011 03 2011 12
Recommendations
• Use all imaging modalities for lesion
characterisation (not in screening!)
• Corellate findings
• Use different features for lesion
characterisation in one imaging modality
• Follow-up if no risk for cancer
• Discuss with collegues
• In an ideal world there would be no BI-RADS 3
category, according to
Dr. Luis J. Pina, University Clinic of Navarra, Spain
BIRADS 4
BIRADS 4 Suspicious or Indeterminate
abnormality
• A BI-RADS category 4 is where typically, a
lump is present, but does not initially appear to
have the morphological characteristics of breast
cancer.
• Therefore, there are 3 sub-categories of BI-RADS
category 4 and these are as follows:-
1. BIRADS 4AThere is a low suspicion of malignancy.
2. BI- RADS 4B There is a moderate suspicion of
malignancy.
3. BIRADS 4C There is a high suspicion of malignancy.
269
abnormality
Findings typical of BIRADS category 4 include:
• Asymmetric, localized or evolving hyperdensities with
convex contours.
• Indeterminate microcalcifications appearing
amorphous and indistinct particularly if in a cluster or
heterogeneous and pleomorphic
• Round or oval non cystic opacities with
microlobulated or obscured contours
• Positive predictive value (the chance of a real cancer)
of BI-RADS 4 mammograms to be around 20-40%
270
abnormality
Powderish These ‘powderish’

microcalcifications are microcalcifications appear
suggestive of BI-RADS in large clusters.
classification of 4
271
abnormality
• Specialists divide BI-RADS category 4 into
three sub-categories A, B, and C.
• Positive predictive value for breast cancer:
• Bi-rads 4A mammogram is at 13%
• Bi-rads 4B mammogram is at 36%
• Bi-rads 4C mammogram is at 79%
272
abnormality
• Generally speaking, as we move further into
categories A,B, and finally C, the chances of the
breast lesion being diagnosed as
Ductal Carcinoma in Situ (DCIS) increases.
• Around 70% of BI-RADS category 4C breast
lesions turn out to be ductal carcinoma in situ.
With category 4B lesions Radiologists find DCIS
about 21% of the time, but this drops to 10%
of the time with category 4A breast lesions
273
abnormality
• In terms of the frequency of the subcategories of BI-
RADS 4, specialists suggest that category 4A is
present around 50% of the time, whilst category 4B
about 38% of the time and finally category 4C only
about 13% of the time.
• The most common confirmed diagnostic finding in BI-
RADS category 4 generally, is actually
fibrocystic changes (fibrocystic disease) in around
28% of cases. DCIS is confirmed about 23% of the
time with columnar cell change and fibroadenoma
found in about 19% of cases
274
Smithuis
BI-RADS 4
Suspicious Abnormality - Biopsy Should Be Considered:
This category is reserved for findings that do not have the
classic appearance of malignancy but are sufficiently
suspicious to justify a recommendation for biopsy.
BI-RADS 4 has 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.
Smithuis
DO
Use for findings sufficiently suspicious to justify biopsy
Use for findings sufficiently suspicious to justify biopsy and the patient or referring
clinician refrain from biopsy because of contraindications. Then add sentence:
"Biopsy should be performed in the absence of clinical contraindications".
Use in the presence of suspicious unilateral lymphadenopathy without abnormalities
in the breast
Do use Category 4a in findings as:
- Partially circumscribed mass, suggestive of (atypical) fibroadenoma
- Palpable, solitary, complex cystic and solid cyst
- Probable abscess
Do use Category 4b in findings as:
- Group amorphous or fine pleomorphic calcifications
- Nondescript solid mass with indistinct margins
Do use Category 4c in findings as:
- New group of fine linear calcifications
- New indistinct, irregular solitary mass
Smithuis
– Partially circumscribed mass, nondescript solid mass with indistinct
margins, new indistinct, irregular solitary mass
BI-RADS 4
Growing
mass/density
2008 2010 2011

• Continuity in
screening rounds
• Prior MG (digital)
BIRADS 5
BIRADS 5 Highly suggestive of malignancy
• BI-RADS category 5 is usually reserved for
lesions having a 95% probability of
malignancy. After biopsy the average rate
of carcinoma in category 5 biopsies is
about 75-97%.
284
Findings typical of category five include:
1. Typically malignant microcalcifications; for example,
linear with branching pattern; particularly if numerous,
clustered and with a segmental distribution;
2. Clusters of microcalcifications with a segmental or
galactophorous distribution
3. Evolving microcalcifications or associated with an
architectural distortion or opacity
4. Clusters of microcalcifications with a segmental or
galactophorous distribution
5. Poorly circumscribed opacities with ill-defined and
irregular contours;
6. Spiculated opacities with radio-opaque center. 285
In this image the casting Casting microcalcifications appear

microcalcifications are branched, linear, fragmented, and branching.
and granular
286
Smithuis
The findings are:

• Mass with irregular shape.
• Spiculated margin.
• High density.
• Ultrasound also shows irregular shape with indistinct margin.
This mass is categorized as BI-RADS 5.
Smithuis
High density mass with spiculated margin
Smithuis
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.
The current rationale for using category 5 is that if the
percutaneous tissue diagnosis is nonmalignant, this
automatically should be considered as discordant.
Spiculated, irregular highdensity mass.
Segmental or linear arrangement of fine linear calcifications.
Irregular spiculated mass with associated pleomorphic
calcifications.
Smithuis
BI-RADS 5
DO
Use if a combination of highly suspicious findings are present:
Spiculated, irregular mass + high-density.
Fine linear calcifications + segmental or linear arrangement .
Irregular spiculated mass + associated pleomorphic calcifications.
Use in findings for which any nonmalignant percutaneous tissue diagnosis is
automatically considered discordant
Use in findings sufficiently suspicious to justify Category 5 and the patient or
referring clinician refrain from biopsy because of contraindications or other
concerns.
Then add sentence: "Biopsy should be performed in the absence of clinical
contraindications".
DON'T
Don't use if only one highly suspicious finding is present.
Then use Category 4c
BIRADS 6 Known Cancer
• Category 6 indicates a known cancer, proven by biopsy.
• This category is used when patients undergoing breast
cancer treatment have follow-up mammograms.
• For a few years after breast cancer treatment, category 6
was still in use.
• Since everyone already knows there is, or was, a cancer,
we can’t use categories 0 thru 5 anymore, so category 6
is assigned.
• Category 6 isn’t useful for accuracy statistics.
291
Smithuis
BI-RADS 6
DO
Use after incomplete excision
Use after monitoring response to neoadjuvant
chemotherapy
DON'T
Don't use after attempted surgical excision with positive
margins and no imaging findings other than postsurgical
scarring. Then use category 2 and add sentence stating
the absence of mammographic correlate for the
pathology.
Don't use for imaging findings, demonstrating suspicious
findings other than the known cancer, then use Category
4 or 5.
Smithuis
On the left BI-RADS 5 lesion. On the right after

neo-adjuvant chemotherapy BI-RADS 6.
– Spiculated, irregular highdensity mass, irregular spiculated mass
with associated pleomorphic calcifications
CALCIFICATIONS
• The findings are:

• Morphology: some are coarse heterogenous and some look more like fine
pleomorphic.
• Distribution: Some calcifications are in a group ( <2cm) and some are in a
regional distribution ( >2cm), but not in a segmental or linear arrangement.
• This proved to be multifocal DCIS with areas of invasive carcinoma.
BENIGN CALCIFICATIONS













INDETERMINATE CALCIFICATIONS
• They are not typically benign. They appear as round

or flake-shape deposits and usually small (<0.5
mm) and hazy.
• It is not always possible to differentiate between
malignant and indeterminate microcalcification.
• Pleomorphic microcalcification represents
malignancy if they are irregular and varying in
shape and size (<0.5mm) and density, in clustered
distribution (five or more in a cubic cm)
• Hence, all indeterminate calcification must be
follow up and biopsied.



MALIGNANT CALCIFICATIONS
• In the absence of typical speculated mass lesion it is
important to pick up suspicious microcalcification which
mostly represents ductal carcinoma in situ (DCIS), the
malignancy at this stage is confined to ducts and offers full
cure to the patient.
• Fine linear or branching pattern is highly suggestive of
malignancy which can be further divided into casting
pattern usually seen in comedo variety or punctuate
pattern seen in cribriform variety
• The pleomorphic calcification in segmental distribution
associated with mass lesion is highly suggestive of
malignant pathology and should be considered under
BIRADS category V
• Fine linear or branching pattern is highly suggestive of
malignancy which can be further divided into casting
pattern usually seen in comedo variety or punctuate
pattern seen in cribriform variety
• The pleomorphic calcification in segmental distribution
associated with mass lesion is highly suggestive of
malignant pathology and should be considered under
BIRADS category V


At times it becomes difficult to differentiate between

amorphous (representing benign) and pleomorphic
microcalcification (suspicious for malignancy).

Classification On Mammography-Ultrasound 21 Sept Baru

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BIRADS CLASSIFICATION ON

Atlas of Breast imaging 2nd edition Dr Col CS Pant VSM

B- There are scattered areas of fibroglandular density.

D - The breasts are extremely dense, which lowers the sensitivity of

Fibroadenoma showing as round shape lesion

Atlas of Breast imaging 2nd edition Dr Col CS Pant VSM

Fibroadenoma showing as oval shape lesion

Atlas of Breast imaging 2nd edition Dr Col CS Pant VSM

Lesion showing microlobulation: HP-Fibroadenoma

XRM shows malignant lesion having irregular shape

Ultrasound a suspicious finding.

Two examples of benign lesions showing circumscribed margins

Largely seen in benign masses. However medullary / mucinous malignancy

Atlas of Breast imaging 2nd edition Dr Col CS Pant VSM

Typical fibroadenoma showing lobulated margins

Seen both in benign and malignant conditions

Atlas of Breast imaging 2nd edition Dr Col CS Pant VSM

Poorly defined margins in left retroareolar lesion HP infiltrating ductal carcinoma

Seen both in malignant and benign condition

Atlas of Breast imaging 2nd edition Dr Col CS Pant VSM

Case of infiltrating ductal carcinoma showing Obscured margins (left half),

Obscured margin is generally due to overlying fibroglandular tissue,

Atlas of Breast imaging 2nd edition Dr Col CS Pant VSM

Spiculated margins typically seen in malignant lesion

The density of a mass is related to the expected attenuation of an equal volume of

• If clinically palpable (at least a quadrant) high possibility of

Atlas of Breast imaging 2nd edition Dr Col CS Pant VSM

Atlas of Breast imaging 2nd edition Dr Col CS Pant VSM

• Here an example of global asymmetry.

• Normal architecture is distorted with no

The characteristics of radial scar are:

Grouped (historically cluster)

Skin thickening from radiotherapy

Right breast ultrasound showing skin thickening and underlying

• Many descriptors for ultrasound are the same

Ultrasound characteristics seen in dense breast subcutaneous

Mammogram showing entirely fatty breast. Normal breast

• Definition : a mass occupies space and should be seen in two

• Masses can be distinguished from normal anatomic

• Orientation: unique to US-imaging, and defined as parallel

Masses : the big three

Oval (including macrolobulated) Round - spherical, circular or globular

Irreguler (neither round nor oval)

Parallel to skin → long axis of lesion

Parallel to skin → Parallel or “wider than tall”

A margin that is well defined or sharp, with an

64 year old with screen detected abnormality

INDISTINCT / POORLY DEFINED

63 year old with a left breast lump

• Circumscribed margin (NPV 90%)

1. Anechoic → without internal echoes

2. Hyperechoic → homogeneously hyperechoic, defined relative to fat,

3. Hypoechoic → defined relative to fat, low-level echoes throughout (e.g

4. Isoechoic → same echogenicity as fat

39 year old presenting with left breast lump x 1 month duration

Isoechoic → same echogenicity as fat

No calcification seen on mammo

• Reflects degree of desmoplasia

 None : no posterior acoustic change

 Enhancement : increased posterior echoes

 Shadowing : decreased posterior echoes, excluding edge shadows

 Combined pattern : both shadowing and enhancement