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Tracks to face a breast imaging and succeed
Poster No.: C-1089Congress: ECR 2013Type: Educational
ExhibitAuthors: V. Mayoral Campos1, J. M. Sainz Martinez1, C.
Bonnet Carron1,
J. A. GUIROLA2, J. A. Fernandez Gomez1, J. Sancho
Prez1;1Zaragoza/ES, 2ZARAGOZA, ZA/ES
Keywords: Breast, Management, Mammography, Ultrasound, MR,
Screening,Diagnostic procedure, Biopsy, Education and training,
Cancer
DOI: 10.1594/ecr2013/C-1089
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Learning objectives
In this e-poster we are willing to remark the following key
points:
To review and illustrate the BI-RADS mammogram and ultrasound
system.
To describe what to look for in the breast imaging studies in
order to helpresidents and non-specialized radiologists to lose
their fear to the breastinterpretation.
To illustrate with examples all the explanations.
Background
Breast Imaging Reporting and Data System (BI-RADS) was created
for the ACR(American Journal of Radiology) and it is considered the
standard for reporting andassessing the relative malignancy of
breast abnormalities. The BI-RADS system wascreated in 1992 with
the next objetives:
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Fig. 2: BI-RADS ObjetivesReferences: Department of Radiology,
Hospital Clinico Lozano Blesa. Zaragoza/Spain2012
It contains a lexicon for standardized terminology (descriptors)
for mammography, breastUS and MRI, as well as standard reporting
with final assessment categories andguidelines for follow-up and
outcome monitoring. It is considered the main system
ofcommunication among physicians, as it tells you the next steps to
do.
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Fig. 1: BI_RADS system (Breast Imaging Report and Data
System)References: - Zaragoza/ES
When a physician suspect a breast abnormality due to a symptom
or a screening test,women will typically be referred for additional
breast imaging such as mammogram,ultrasound, or MRI. Depending on
the results of these imaging tests, they may be referredfor a
breast biopsy.
Imaging findings OR Procedure details
Imaging techniques:
Each technique used in breast imaging has a principal role in
the diagnoses of breastcancer. The principal indications are:
Mammography:
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Screening of breast cancer Palpable mass Abnormality of skin or
nipple Search of unknown primary cancer Follow-up study of probably
benign lesion or calcifications
Ultrasound:
Inconclusive findings in mammography (specially palpable lesion
not visibleat mammography)
Screening of high breast density. Differenciate cystic from
solid lesions. Pregnant or lactant women US-guided biopsy
MRI:
Inconclusive findings in conventional imaging Preoperative
staging (screening of contralateral breast cancer) Unknown primary
carcinoma The evaluation of therapy response in the neoadjuvant
chemotherapy setting Imaging of the breast after conservative
therapy (exclusion of local recurrence) Screening in patients with
gene mutations (lifetime risk of 20% or more) Prosthesis imaging
MR-guided biopsy and lesion localization in lesions that are
neither palpable
nor visible on conventional imaging techniques
DESCRIPTORS
Mammography:
First of all, it is important to identifie the mammographic
pattern. It is namedas the principal breast tissue:
1. Predominant fat (less 25% fibroglandular densities)2.
Heterogeneous ( 25-50% fibroglandular densities)3. Heterogeneously
dense (51-75%)4. Extremely dense (more than 75 %)
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1.
Fig. 3: Breast CompositionReferences: Department of Radiology,
Hospital Clinico Lozano Blesa.Zaragoza/Spain 2012
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Fig. 4: Breast CompositionReferences: Department of Radiology,
Hospital Clinico Lozano Blesa. Zaragoza/Spain2012
What to look for in mammography:
1. Nodule: It is a space occupying lesion seen in two different
projections. It isimportant to describe:
-Location
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Fig. 5: Lesion location: it describes the different breast
planes and how to locate thelesion using a clock
disposition.References: R. Rostagmo. El informe imagenolgico de
mama. 1998
-Size
-Morfology: Round, oval, lobulated, irregular or architectural
distortion.
Fig. 6: Nodule MorfologyReferences: Department of Radiology, HCU
Lozano Blesa, Zaragoza, Spain, 2013.
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-Margin:Circumscribed, partially obscured, micro-lobulated,
ill-defined, spiculated
Fig. 7: Nodule MarginsReferences: Department of Radiology, HCU
Lozano Blesa, Zaeagoza, Spain 2012-Density: isodense, hyperdense,
hypodense with fat, hypodense without fat
Depends on the nodule characteristics radiologists should give a
BI-RADScategorisation.
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Fig. 8: BI-RADS ASSESSMENTS for NodulesReferences: -
Zaragoza/ES
It is important to determinate if the lesion is in the breast
parenchyma or in the skin.Cutaneous benign masses can be projected
as intramammary. Normally, skin lesionshave air rounding the
nodule.
2. Calcification: It is the most common finding in mammography
but also the mostdifficult to identify. The mammography is the
election technique to visualize calcifications.Radiologists can
find the calcification in lobules, ducts, interlobular tissue,
vessels, skin,or soft tissues.
It is important to see distribution, morfology, size and number
of calcifications to give aBI-RADS categorization.
Morfology
Fig. 12: BI-RADS ASSESSMENTS for Calcifications
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References: - Zaragoza/ES
Distribution
Fig. 17: Calcification DistributionReferences: Department of
Radiology, Hospital Clinico Lozano Blesa.Zaragoza/Spain 2012
Size:
- 2mm: benign
3. Architectural Distortion: The normal architecture is
distorted and there is no definitemass visible.
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This finding includes fine lines or spiculations radiating from
a point, focal retraction ordistortion of the edge of the
parenchyma. If there is no traumatic or surgery history, biopsyis
always indicated.
4. Associated findings: they are not specific when they are
alone, but in association withother findings they are suggestive of
malignancy.
Skin retraction Nipple retraction Axilar adenopathies Trabecular
thickening Skin thickening
Ultrasound:
BI-RADS assessments for US are based on an analysis of six
morphologic features ofsolid masses. Whenever possible, the US
lexicon uses terms similar to those used inthe mammography lexicon,
with the primary overlap related to the shape and marginsof a
mass.
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Fig. 20: US DescriptorsReferences: Raza S et AL. BI-RADS 3, 4,
and 5 lesions: value of US in management--follow-up and outcome.
Radiology. 2008 Sep;248(3):773-81.
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Fig. 21: US DescriptorsReferences: Raza S et AL. BI-RADS 3, 4,
and 5 lesions: value of US in management--follow-up and outcome.
Radiology. 2008 Sep;248(3):773-81.Final assessment-recommendation
is based on the most suspicious finding.
Special cases:
1. Intramammary lymph nodes : BI-RADS 1 or 22. Complicated cyst:
BI-RADS 33. Complex cyst: BI-RADS 44. Group of microcyst: BI-RADS
25. Abscess: BI-RADS 4A6. Hematoma: BI-RADS 3
MRI:
MR imaging improves the detection and characterization of
primary and recurrent breastcancers. The assessment categories are
based on BI-RADS categories developed
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for mammography. The breast imaging lexicon allows a
standardized and consistentdescription of the morphologic and
kinetic characteristics of breast lesions. The
margincharacteristics of a lesion and the intensity of its
enhancement at MR imaging 2 minutes orless after contrast material
injection are currently considered the most important featuresfor
breast lesion diagnosis.
FINAL ASSESSMENT CATEGORIES
Fig. 26: FINAL ASSESSMENT CATEGORIESReferences: Department of
Radiology, Hospital Clinico Lozano Blesa. Zaragoza/Spain2012
If a lesion is palpable, the BI-RADS final categorie is one
point higher.
Example: a palpable fibroadenoma (usually a BI-RADS 2) is a
BI-RADS 3If more than one imaging modality is performed, an
integrated report with assessmentbased on the highest level of
suspicion must be used.
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TESTING YOURSELF:
In the next cases, which BI-RADS final categorie do you report
and whichare your management recommendations?
CASE 1
Fig. 37: Case 1References: Department of Radiology, Hospital
Clinico Lozano Blesa. Zaragoza/Spain2012
CASE 2
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Fig. 38: Case 2References: Department of Radiology, Hospital
Clinico Lozano Blesa. Zaragoza/Spain2012
CASE 3
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Fig. 39: Case 3References: Department of Radiology, Hospital
Clinico Lozano Blesa. Zaragoza/Spain2012
CASE 4
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Fig. 40: Case 4References: Department of Radiology, Hospital
Clinico Lozano Blesa. Zaragoza/Spain2012
SOLUTIONS:
- Case 1: BI-RADS 2, normal follow-up
Mammography shows a round, circunscribed, isodense mass
categorizated as BI-RADS 3. In US, oval, circumscribed anechoic
mass with horizontal orientation andposterior enhancement, typical
appearance of a cyst: BI-RADS 2. In this case the typicalappearance
of the cyst give the final assessment categorie.
-Case 2: BI-RADS 5, biopsy
Fine linear branching calcifications with focal
distribution.
-Case 3: BI-RADS 2, normal follow-up.
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Multiple coarse calcifications, all of them with morphologies
that are high suggestive ofbenignity. The calcifications have a
diffuse distribution.
-Case 4: BI-RADS 5, biopsy.
Multiple round, hyperdense nodules, some of them spiculated. In
US, solid, roundcomplex nodule with indistinct margins, horizontal
orientation and no shape. This is anatypical case in mammography
because this case was a patient with lymphoma andbreast
metastases.
Images for this section:
Fig. 9: Nodules Morfology
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Fig. 10: Nodules margins
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Fig. 11: Nodules density
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Fig. 13: Skin nodule: air interface round the nodule indicating
that the lesion is locatedin the skin.
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Fig. 14: Examples of Benign Calcifications
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Fig. 15: Calcifications with low-medium suspicion. Management
recommendations: shortfollow-up or Biopsy.
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Fig. 16: Calcifications with high suspicion. Management
recommendation: Biopsy
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Fig. 18: Examples of architectural distortion. It is important
to know if there is traumaticor surgery history.
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Fig. 19: Associated findings
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Fig. 22: Examples of US descriptors
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Fig. 23: Examples of US descriptors
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Fig. 24: Examples of special cases
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Fig. 25: Enhancement kinetics curves in MRI. There is 3
different types. Type I is apattern of progressive enhancement,
with a continuous increase in signal intensity oneach successive
contrast-enhanced image. Type II is a plateau pattern, in which an
initialincrease in signal intensity is followed by a flattening of
the enhancement curve. TypeIII is a washout enhancement pattern, in
which there is initial increase and subsequentdecrease in signal
intensity
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Fig. 27: BI-RADS 0: You need additional imaging evaluation to
give a final assessment.
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Fig. 28: BI-RADS 1: predominant fat pattern. There is nothing to
comment on.
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Fig. 30: Dense lobulated nodule with coarse calcifications.
These are typical offibroadenoma. In this case it is not necessary
any subsequent conduct. Therecommendation is normal follow-up.
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Fig. 29: BI-RADS 2: benign nodule. In mammogrphy, we can see an
isodense nodule,with oval morfology and with partially indistinct
margin. In ultrosund, it is oval, parallel tothe skin, anechoic,
circunscribed with posterior enhancement, compatible with a
cyst.
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Fig. 31: Mammogrphy shows an isodense nodule, with oval
morfology and with partiallyindistinct margin. In ultrosund, the
nodule is oval, parallel to the skin, hypoechoic andcircunscribed.
Bi-RADS 3, probably benign, 6 months follow-up.
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Fig. 32: Mammogrphy shows a dense nodule, with oval morfology
and with partiallyindistinct margin (arrow in mammography).
Ultrasound shows a large cyst with posteriorechogenic components
(arrows). BI-RADS 4, Biopsy is recommended.
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Fig. 33: Mammography shows a dense, lobulated nodule, with
microlobulated margins.Ultrasound demostrate an oval hypoechoic
nodule, not parallel to the skin,withmicrolobulated margins,
echogenic halo and posterior shadowing. This lesion is
probablymalign, so biopsy is recommended.
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Fig. 34: Mammography shows a hyperdense nodule, with spiculated
margins(shortarrows). There is also skin and nipple retraction
(long arrow). Highly suggestive ofmalignancy. Biopsy and treatment
are recommended.
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Fig. 35: Mammography shows a pleomorphic segmentary gruop of
calcifications(arrows), highly suggestive of malignancy. Ultrasound
demostrates a hypoechoic,irregular mass, with spiculated margins
and posterior shadowing, categorized as BI-RADS 5.
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Fig. 36: In mammography, spiculated hyperdense lesion (arrows in
mammography)and skin thickennig categorizated as BI-RADS 5. The
ultrasound demostrates an oval,spiculated, hypoechoic nodule with
vertical orientation and echogenic halo (arrow in US),categorizated
also as BI-RADS 5 because it is highly suggestive of malignancy.
Biopsyand treatment are recommended.
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Conclusion
Some things that all radiologists should know to read breast
imaging easily:
Make sure that you are looking a breast lesion. Use standard
BI-RADS descriptors for Mammography, Ultrasound and MRI. Your final
assessment has always to be based on the most worrisome
finding. Make sure that you are looking the same lesion with all
the imaging
modalities.
References
1- American College of Radiology. BI-RADS-Mamography. 4th ed.
In: Breast ImagingReporting and Data System (BI-RADS) atlas. 4th
ed. Reston, Va: American College ofRadiology, 2003.
2- American College of Radiology. BI-RADS-Ultrasound. 1st ed.
In: Breast ImagingReporting and Data System (BI-RADS) atlas. 4th
ed. Reston, Va: American College ofRadiology, 2003.
3- American College of Radiology. BI-RADS-MRI. 41st ed. In:
Breast Imaging Reportingand Data System (BI-RADS) atlas. 4th ed.
Reston, Va: American College of Radiology,2003.
4- Harvey JA, Nicholson BT, Cohen MA. Finding early invasive
breast cancers: a practicalapproach. Radiology. 2008
Jul;248(1):61-76.
5- Raza S, Goldkamp AL, Chikarmane SA, Birdwell RL. US of breast
masses categorizedas BI-RADS 3, 4, and 5: pictorial review of
factors influencing clinical management.Radiographics. 2010
Sep;30(5):1199-213
6- Raza S, Chikarmane SA, Neilsen SS, Zorn LM, Birdwell RL.
BI-RADS 3, 4, and5 lesions: value of US in management--follow-up
and outcome. Radiology. 2008Sep;248(3):773-81.
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7- Mann RM, Kuhl CK, Kinkel K, Boetes C. Breast MRI: guidelines
from the EuropeanSociety of Breast Imaging. Eur Radiol. 2008
Jul;18(7):1307-18.
8- Macura KJ, Ouwerkerk R, Jacobs MA, Bluemke DA. Patterns of
enhancementon breast MR images: interpretation and imaging
pitfalls. Radiographics. 2006 Nov-Dec;26(6):1719-34;
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