Current concepts in screening mammography

Current concepts in screening mammography and BIRADS lexicon

1. CURRENT CONCEPTS IN SCREENING MAMMOGRAPHY AND BI-RADS

2. BI-RADS Breast Imaging Reporting And Data System By ACR (American College of Radiology) Introduced in 1992 Quality assurance tool designed to: STANDARDISE reporting, reduce confusion in breast IMAGING INTERPRETATION AND MANAGEMENT RECOMMENDATIONS and facilitates OUTCOME MONITORING .

3. Latest edition – 5 th (in 2013) LEXICON: to issue unambiguous breast imaging reports and standardise language in reports throughout the world Several changes and expanded definitions in latest edition

4. HIGHLIGHTS OF 5 TH EDITION Changes in few descriptors for better clarity of reporting. Flexibility in describing mass features. Flexibility to separate assessment categories from management has been added. BI-RADS category 3 label issued only after adequate work-up. Multiple descriptors when used to describe a mass lesion or group of calcifications, management recommendation based on most worrisome feature. Ultrasound portion now includes tissue composition, anatomy, image quality, labelling . MRI includes a section on breast implants and defines troublesome issues like background enhancement and foci.

5. SCREENING MAMMOGRAPHY: ACR GUIDELINES ASYMPTOMATIC WOMEN FROM 40 YRS OF AGE ASYMPTOMATIC WOMEN BELOW 40 YRS WHO ARE AT INCREASED RISK OF BREAST CANCER Known mutation/ genetic syndrome (carrier of BRCA 1): start by 25 - 30 yrs Untested female with first degree relative with known BRCA mutation: start by 25 - 30 yrs Women with first degree relatives with premenopausal breast cancer or 20% or more lifetime risk based on breast cancer risk model : start by 25 - 30 yrs or 10 yrs earlier than age of affected first degree relative, whichever is later H/o mantle radiation between 10 and 30 yrs: start 8 yrs after radiation therapy (not before 25 yrs)

6. SCREENIG MAMMOGRAPHY (cont..) 3. WOMEN WITH BIOPSY PROVEN: lobular neoplasm Atypical ductal hyperplasia DCIS Invasive breast cancer Yearly from time of diagnosis, regardless of age. 4. SELF REFERRED FEMALE 5. SELF REQUESTING FEMALE 6. ASYMPTOMATIC WOMEN WITH BREAST IMPLANTS

7. BI-RADS MAMMOGRAPHY LEXICON

8. MAMMOGRAPHY REPORT Indication for examination Overall breast composition Clear description of important findings Comparison to previous examinations Assessment of BI-RADS category Management

9. BREAST COMPOSITION A: breasts are almost entirely fatty B: There are scattered areas of fibroglandular density

10. C: breasts are heterogenously dense, which may obscure small masses D: breasts are extrmely dense, which lowers sensitivity of mammography

11. BI-RADS 2003 CATEGORIES OF BREAST DENSITY (removed) 1: dense glandular tissue occupying < 25% breast parenchyma 2: dense glandular tissue occupying 25 – 50% breast parenchyma 3: dense glandular tissue occupying 50- 75% breast parenchyma 4: dense glandular tissue occupying >75% breast parenchyma

12. I) MASSES Mass is 3 dimensional occupies space is seen in 2 different mammographic projections with convex outer borders and appears denser in center than periphery when radiodense .

13. A) SHAPE Oval – includes lobular round irregular

14. B) MARGINS (COMIS)

15. MARGINS circumscribed obscured indistinct spiculated microlobulated

16. C) DENSITY high equal low Fat cont

17. II) CALCIFICATIONS TYPICALLY BENIGN SUSPICIOUS MORPHOLOGY DISTRIBUTION

18. TYPICALLY BENIGN skin vascular rim coarse

19. TYPICALLY BENIGN Large rod-like Dystrophic (irradiated breast)

20. Milk of calcium

21. TYPICALLY BENIGN round punctate suture

22. SUSPICIOUS MORPHOLOGY amorphous Coarse heterogenous

23. SUSPICIOUS MORPHOLOGY Fine pleomorphic Fine linear branching

24. CALCIFICATIONS (cont..) NUMBER (2003 BI-RADS) <5 : benign 5 – 10: indeterminate >10 : malignant

25. DISTRIBUTION diffuse grouped linear segmental regional

26. III) ARCHITECTURAL DISTORTION Parenchyma distorted with no Definite mass visible Thin straight lines / spiculations Focal retraction / distortion Straightening of anterior or posterior edge of parenchyma

27. IV) ASYMMETRIES ASYMMETRY GLOBAL ASYMMETRY FOCAL ASYMMETRY DEVELOPING ASYMMETRY

28. ASYMMETRY

29. FOCAL ASYMMETRY

30. GLOBAL ASYMMETRY

31. DEVELOPING ASYMMETRY

32. V) INTRAMAMMARY LYMPH NODE VI) SKIN LESION VII) SOLITARY DILATED DUCT

33. VIII) ASSOCIATED FEATURES Skin retraction Nipple retraction Skin thickening Trabecular thickening Axillary adenopathy Architectural distortion calcifications Skin thickening + axillary adenopathy Nipple retraction

34. IX) LOCATION OF LESION Laterality Quadrant & clock face Depth- anterior, middle and posterior third Distance from nipple 12’ o clock lesions- upper central 6’ o clock lesions- lower central 3/9’ o clock lesions- outer/ inner central CENTRAL , RETROAREOLAR, AXILLARY TAIL

35. BI-RADS MAMMOGRAPHY LEXICON 2013 BREAST COMPOSITION I) MASSES : SHAPE : oval, round, irregular : MARGIN : circumscribed, obscured, microlobulated , indistinct, spiculated : DENSITY : high, equal, low, fat containing II) CALCIFICATION : TYPICALLY BENIGN : skin, vascular, coarse /popcorn- like, large rod-like, round, rim, dystrophic, milk of calcium, suture SUSPICIOUS MORPHOLOGY: amorphous, coarse heterogenous , fine pleomorphic , fine linear/ fine linear branching DISTRIBUTION : Diffuse, regional, grouped, linear, segmental

36. MAMMOGRAPHY LEXICON (cont…) III) ARCHITECTURAL DISTORTION IV) ASYMMETRIES : asymmetry, global asymmetry, focal asymmetry, developing asymmetry V) INTRAMAMMARY LYMPH NODE VI) SKIN LESION VII) SOLITARY DILATED DUCT VIII) ASSOCIATED FEATURES : skin retraction, nipple retraction, skin thickening, trabecular thickening, axillary adenopathy , architectural distortion, calcifications IX) LOCATION OF LESION : laterality, quadrant and clock face, depth, distance from nipple

37. BI-RADS ASSESSMENT CATEGORIES BI-RADS 0 Need Additional Imaging Evaluation and/or Prior Mammograms For Comparison: Category 0 or BI-RADS 0 is utilized when further imaging evaluation (e.g. additional views or ultrasound) or retrieval of prior examinations is required. When additional imaging studies are completed, a final assessment is made. ADDITIONAL IMAGING : Spot compression (with/without magnification) Special mammographic views Ultrasound MRI

38. BI-RADS 1 There is nothing to comment on. The breasts are symmetric and no masses, architectural distortion or suspicious calcifications are present. Mx : routine screening

39. BI-RADS 2 Involuting , calcified fibroadenomas Multiple large, rod-like calcifications Skin calcification Vascular calcifications Intramammary lymph nodes Implants Architectural distortion clearly related to prior surgery. Fat-containing lesions such as oil cysts, lipomas , galactoceles and mixed-density hamartomas . Mx : routine screening

40. BI-RADS 3 Non- calcified circumscribed solid mass on a baseline mammogram Focal asymmetry Solitary group of punctate calcifications Mx : short term follow-up: (biopsy at discretion) @6 month follow-up: upgrade to category 4/5 or category 3 if stable 6 month follow up: upgrade to category 4/5 or category 3 if stable 1 year follow-up: upgrade to category 4/5 or category 3 if stable 2 year follow-up: upgrade to category 4/5 or category 2 if stable

41. BI-RADS 4 4A : Partially circumscribed mass, suggestive of (atypical) fibroadenoma Palpable, solitary, complicated cyst Probable abscess

42. 4B : Group of amorphous or fine pleomorphic calcifications Nondescript solid mass with indistinct margins

43. 4C : New group of fine linear calcifications New indistinct, irregular solitary mass

44. BI-RADS 5 Use if a combination of highly suspicious findings are present: Irregular, spiculated , high density mass with associated microcalcifications / associated findings . Fine linear calcifications IN segmental or linear arrangement . Use in findings for which any nonmalignant percutaneous tissue diagnosis is automatically considered discordant if only one highly suspicious finding is present, use Category 4c. Mx : TISSUE DIAGNOSIS

45. BI-RADS 6 Following complete surgical excision/ biopsy proving malignancy For monitoring of response to neoadjuvant chemotherapy Attempted complete surgical resection with positive resection margins (given only if there is atleast 1 mammographic finding s/o residual tumor). If only post surgical scar noted on mammography, BI-RADS 2 assessment given. Mx : SURGICAL EXCISION WHEN CLINICALLY APPROPRIATE

46. MANAGEMENT OF BI- RADS ASSESSMENT CATEGORIES

47. SUMMARY BREAST COMPOSITION is no longer indicated in ranges of percentage of breast density SHAPE OF MASSES: no longer includes lobular CALCIFICATION: no longer includes indeterminate & high probability types, instead suspicious morphology added. No role for number of calcifications in assessing suspicion of malignancy. Punctate calcification as subset of round. Amorphous, coarse heterogenous , fine pleomorphic calcifications included under BI-RADS 4B & fine linear/ fine linear branching included under BI-RADS 4C FLEXIBILITY IN DESCRIPTION OF MASSES: the more suspicious descriptor alone mentioned FLEXIBILITY IN BI-RADS ASSESSMENT CATEGORIES AND MANAGEMENT

48. DIGITAL BREAST TOMOSYNTHESIS (DBTS) Emerging digital technique that provides sectional images which help to distinguish the glandular breast tissue from true lesions, especially in dense breasts. Multiple projections are acquired at different depths by a digital detector from a mammographic X-ray source that moves gradually in a small arc over the compressed breast. Reconstructed in sections similar to CT (0.5mm)

49. DBTS for noncalcified mammographic findings such as masses, asymmetries, and distortion.

50. USG BI-RADS LEXICON

51. BREAST TISSUE COMPOSITION A) homogenous background echotexture – fat

52. B) homogenous background echotexture – fibroglandular

53. C) heterogenous background echotexture

54. A) MASSES : I) SHAPE round oval irregular

55. II) ORIENTATION parallel Not parallel

56. III) MARGINS circumscribed indistinct microlobulated angulated spiculated

57. IV) ECHOPATTERN ANECHOIC HYPERECHOIC COMPLEX CYSTIC AND SOLID HYPOECHOIC ISOECHOIC HETEROGENOUS (new) anechoic

58. V) POSTERIOR FEATURES Term ACOUSTIC has been removed enhancement shadowing no posterior features Enhancement Shadowing Combined pattern

59. B) CALCIFICATIONS INTRODUCED IN BI-RADS 2013 Calcifications in a mass Calcifications outside of a mass Intraductal calcifications

60. C) ASSOCIATED FEATURES ARCHITECTURAL DISTORTION DUCT CHANGES SKIN CHANGES : skin thickening, skin retraction EDEMA VASCULARITY : absent internal vascularity vessels in rim ELASTICITY ASSESSMENT : soft, intermediate, hard

61. D) SPECIAL CASES SIMPLE CYST CLUSTERED MICROCYSTS COMPLICATED CYST MASS IN OR ON SKIN FOREIGN BODY INCLUDING IMPLANTS INTRAMAMMARY LYMPH NODES AXILLARY LYMPH NODES VASCULAR ABNORMALITIES : AVM, MONDOR’S DS POST SURGICAL FLUID COLLECTION FAT NECROSIS Clustered microcyst implant

62. BI-RADS 2: Simple cysts Intramammary lymph nodes Post surgical fluid collections Breast implants Complicated cysts probable fibroadenomas that are unchanged foratleast 3 years BI-RADS 3: solid mass with oval shape, circumscribed margin, parallel orientation (mostly fibroadenoma ) Isolated complicated cyst BI-RADS 4: no classic appearance of malignancy but suspicious enough for biopsy (A, B, C).

63. MRI BI-RADS LEXICON

64. BREAST COMPOSITION A) ALMOST ENTIRELY FAT

65. B) SCATTERED FIBROGLANDULARTISSUE

66. C) HETEROGENOUS FIBROGLANDULAR TISSUE

67. D) EXTREME FIBROGLANDULAR TISSUE

68. BACKGROUND PARENCHYMAL ENHANCEMENT (BPE) : NEW 1) LEVEL Minimal Mild Moderate Marked 2) SYMMETRY Symmetric asymmetric

69. I) FOCUS A focus is a dot of enhancement so small (<5mm) that it cannot be otherwise characterized; its shape and margin cannot be seen clearly enough to be described. Multiple foci (i.e., not unique) can be separated widely in the breast by normal fibroglandular tissue or fat and usually represent a pattern of background parenchymal enhancement.

70. II) MASSES : A)SHAPE round oval irregular

71. B) MARGIN CIRCUMSCRIBED NOT CIRCUMSCRIBED Irregular spiculated circumscribed irregular spiculated

72. C) INTERNAL ENHANCEMENT homogenous heterogenous Rim enhancement Dark internal septation

73. PREVIOUSLY DESCRIBED INTERNAL ENHANCEMENT PATTERNS (NOW REMOVED) Enhancing septa Central enhancement

74. III) NON-MASS LIKE ENHANCEMENT (NME) DISTRIBUTION Focal (NEW) Linear (DUCTAL REMOVED) Segmental Regional Multiple regions diffuse

75. focal linear segmental regional Multiple region diffuse

76. NME B) INTERNAL ENHANCEMENT PATTERNS Homogenous Heterogenous Clumped Clustered ring CHANGES FROM PREVIOUS BI-RADS: Stippled/ punctate (REMOVED) Reticular/ dendritic (REMOVED) clumped Clustered ring homogenous heterogenous

77. IV) INTRAMAMMARY LYMPH NODE V) SKIN LESION VI) NON- ENHANCING FINDINGS: cysts, post-op collections, post therapy skin and trabecular thickening, non-enhancing mass, architectural distortion, signal void from foreign body & clips VII) ASSOCIATED FEATURES: Nipple retraction, invasion Skin retraction, thickening, invasion Axillary adenopathy Pectoralis muscle invasion Chest wall invasion Architectural distortion

78. VIII) FAT CONTAINING LESIONS: lymph nodes, fat necrosis, hamartoma , post- op seroma , hematoma with fat IX) LOCATION OF LESION : position, depth X) IMPLANTS (NEW) : Implant material and lumen type Implant location Abnormal implant contour Intracapsular silicone findings Extracapsular silicone Periimplant fluid Water droplets Linguine sign

79. XI) KINETIC CURVE ASSESSMENT: SI / TIME CURVE TYPE 1 CURVE TYPE 2 CURVE TYPE 3 CURVE

80. BI-RADS 2: intramammary lymph node, implants, metallic foreign body, enhancing and non- enhancing fibroadenomas , cysts, old non- enhancig scars/ recent scars, post-op collection, fat containing lesions (oil cysts, lipomas , galactocele , hamartoma ) BI-RADS 3: menstruating female/ women on HRT oval/ round shaped lesion with circumscribed margins & homogenous internal enhancement. Non mass-like enhancement: linear, clumped, segmental BI-RADS 4: cannot be included in category 3 and 5 (not divided into A, B, C) BI-RADS 5: combination of suspicious findings

81. REFERENCES ACR BI-RADS® Atlas, Breast Imaging Reporting and Data System, Reston VA, American College of Radiology; 2013 ACR-BI-RADS® Mammography, 4th edition 2003 Reston, VA, American College of Radiology, 2003 ACR ® APPROPRIATENESS CRITERIA AND SCREENING GUIDELINES, MAY 2016

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