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BIRADS 3 LESIONS BREAST MR Kavita Dhamanaskar Radiologist @ Juravinski hospital, Hamilton Disclosures None relevant
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Birads 3 lesions breast mr - cpd.utoronto.ca · BI-RADS 3 lesions NME- Non Mass-like Enhancement Overall MR interpretation trend is to wards lower number of cases designated as Birads

Apr 17, 2020

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Page 1: Birads 3 lesions breast mr - cpd.utoronto.ca · BI-RADS 3 lesions NME- Non Mass-like Enhancement Overall MR interpretation trend is to wards lower number of cases designated as Birads

BIRADS 3 LESIONS BREAST MR

Kavita Dhamanaskar Radiologist @ Juravinski hospital, Hamilton

Disclosures

�N

one relevant

Page 2: Birads 3 lesions breast mr - cpd.utoronto.ca · BI-RADS 3 lesions NME- Non Mass-like Enhancement Overall MR interpretation trend is to wards lower number of cases designated as Birads

Learning objectives

�D

efinition and Characterization of BI-R

ADS 3

lesions on MR

�Correlation w

ith conventional imaging

�Follow

up protocols

BI-R

ADS 3

category on MR

�“A finding assessed using this category should have �����

������ �� ���

�������������������������������������������

������ �� ���

��������� ����characteristically benign finding.

ACR B

I-���

��!"#$%&'

��(!�����)*

Page 3: Birads 3 lesions breast mr - cpd.utoronto.ca · BI-RADS 3 lesions NME- Non Mass-like Enhancement Overall MR interpretation trend is to wards lower number of cases designated as Birads

BI-R

ADS 3

lesions on MR

: Challenges �

No strong data for definitive characterization of B

i-rads 3 lesions

�D

ifferences in study design and criteria from published studies

�R

isks and benefits of short term follow

- up –

Patient anxiety and non compliance

–H

igh risk lesion mim

icks

BI-R

ADS 3

Lesions

FOCI

NM

E- Non M

asslike enhancement

MASS

Page 4: Birads 3 lesions breast mr - cpd.utoronto.ca · BI-RADS 3 lesions NME- Non Mass-like Enhancement Overall MR interpretation trend is to wards lower number of cases designated as Birads

Birads 3

lesions on MR

FO

CI

�Foci are defined as sm

all dots (</=

5m

m) of enhancem

ent that are unique and stand out from

the BPE.

�They are too sm

all to be accurately assessed with respect

to margin or internal enhancem

ent.

•ACR

BI-R

ADS®

ATLAS — BB

REAST M

RI

BI-R

ADS 3

Page 5: Birads 3 lesions breast mr - cpd.utoronto.ca · BI-RADS 3 lesions NME- Non Mass-like Enhancement Overall MR interpretation trend is to wards lower number of cases designated as Birads

Birads 3

lesions on MR

FO

CI

�1 ��2

4�

����6������������*

����� ���

��������7

������������������� 8

���)��

��9�����������������

������� 8��

������� ����������������;������

>�77

�5

mm

UUnique focus w

ith washout characteristics –

Birads 3

lesion requiring short interval follow

up MR

(6m

onthsG�77

•Liberm

anL., M

ason G., M

orris E.A

., et al: Does size m

atter? Positive predictive value of M

RI-detected breast

lesions as a function of lesion size. AJR

Am

J Roentgenol2006; 186: pp. 426-430

**E

byP.R

., DeM

artiniW.B

., Gutierrez R

.L., et al: Characteristics of probably benign breast M

RI lesions. A

JR A

m J

Roentgenol2009; 193: pp. 861-867

�Clauser Q�������V�

�)WG- show

ed that all foci that enlarged on follow up, w

ere �

��������7

–166 H

IGH

–RISK wom

en –

68 foci were detected and follow

ed. Majority stable, few

disappeared. –

3% enlarged – w

ere malignant

�O

verall malignancy rate in biopsied foci can be upto �

*�

>�Hence patient’s risk

���� ���� ����� ������������� ��

����� ���77

Birads 3

lesions on MR

FO

CI

P Clauser et al. Radiol X

���)�)

�VYG��W))

-W)Z> ��)W

�X���)

�7

R

aza S et al., Acad ��� � ����

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77

W

einstein SP et al.,Radiology �

�)�[�

44

]Z*)

-ZZ7

7

Page 6: Birads 3 lesions breast mr - cpd.utoronto.ca · BI-RADS 3 lesions NME- Non Mass-like Enhancement Overall MR interpretation trend is to wards lower number of cases designated as Birads

�5

mm

UUnique (bright) focus w

ith/without w

ashout characteristics –

–Birads 3 lesion requiring short interval follow

up MR (6m

onths). –

If enlarging on follow up- w

arrants BIOPSY B

irads 3 lesions on M

R

FOCI

P Clauser et al. Radiol X

���)�)

�VYG��W))

-W)Z> ��)W

�X���)

Raza S et al., Acad �

�� � �����)

�[)\

]^)�

-)\

Weinstein SP et al.,R

adiology ��)�

[�4

4]Z

*)-ZZ

H

a R, Sung J, Lee C, et al. Clin R

adiol>���)^

[W\

]Z)4–

Z�

�>�

BI-R

ADS 3

Lesions

FOCI

NM

E- Non M

asslike enhancement

MASS

Page 7: Birads 3 lesions breast mr - cpd.utoronto.ca · BI-RADS 3 lesions NME- Non Mass-like Enhancement Overall MR interpretation trend is to wards lower number of cases designated as Birads

BI-R

ADS 3

lesions N

ME- N

on Mass-like Enhancem

ent �

Overall M

R interpretation trend is tow

ards lower num

ber of cases designated as B

irads 3

�Som

e reasons- –

Bilateral NM

E now labelled BPE and belongs to BI-RAD

S 1 (ACR BI-RADS

lexicon)

�N

ME that is unique and separate from

the overall background enhancement

should undergo assessment based on m

orphology and kinetics. –

Not included are segm

ental, linear or clumped nodular enhancem

ent (BI-RADS 4)

•ACR

BI-R

ADS®

ATLAS 5th ��� ���

�)*

�— BB

REAST M

RI

��

��9 ���� ������

(�����������������

BI-R

ADS 3

lesions- NM

E- Non M

ass-like Enhancement

MR

Bx-

Benign breast

tissue w

proliferative change

Page 8: Birads 3 lesions breast mr - cpd.utoronto.ca · BI-RADS 3 lesions NME- Non Mass-like Enhancement Overall MR interpretation trend is to wards lower number of cases designated as Birads

Bilateral N

ME

Findings resolved at 6 m

onth FU M

R

Page 9: Birads 3 lesions breast mr - cpd.utoronto.ca · BI-RADS 3 lesions NME- Non Mass-like Enhancement Overall MR interpretation trend is to wards lower number of cases designated as Birads

BI-R

ADS 3

Lesions

FOCI

NM

E- Non M

asslike enhancement

MASS

�`

���(�������������

������

���

��{�� ���������������V'

Q|�\4

-)��

�G

�Q� �����6�������������V(�9��)

���������6�G>�'Q|�

\*

-)��

������� 8

������� ��� ��� ������������G

�D

ark / Non enhancing internal septations '

Q|�\Y

Macura K

J, et al., Radiographics �

��

W[�

W])Z)\-*^

BI-R

ADS 3

lesions M

ass

Page 10: Birads 3 lesions breast mr - cpd.utoronto.ca · BI-RADS 3 lesions NME- Non Mass-like Enhancement Overall MR interpretation trend is to wards lower number of cases designated as Birads

BI-R

ADS 3

- classic findings

BI-R

ADS 0

- Incomplete assessm

ent Suggest U

S

Page 11: Birads 3 lesions breast mr - cpd.utoronto.ca · BI-RADS 3 lesions NME- Non Mass-like Enhancement Overall MR interpretation trend is to wards lower number of cases designated as Birads

Bi-�

����*

���� ��>�1 �� 8��9�~W

� �����{�

���8��������� ���

Stable bilateral fibroadenomas

���W��

����1��~��

Page 12: Birads 3 lesions breast mr - cpd.utoronto.ca · BI-RADS 3 lesions NME- Non Mass-like Enhancement Overall MR interpretation trend is to wards lower number of cases designated as Birads

�Targeted U

ltrasound- –

Allows further characterization/confirm

ation –

FU X 2 yrs to establish benignity

������ ����1���

�����6��� 8�(�

�������8���9������

������������8

���(�9��)����6��- progressive

enhancement characteristics

�X

��� �����������������6������(�

������

BI-R

ADS 3

lesions M

ass

LEFT breast- MU

CINO

US CA

And bilateral smaller FA

Page 13: Birads 3 lesions breast mr - cpd.utoronto.ca · BI-RADS 3 lesions NME- Non Mass-like Enhancement Overall MR interpretation trend is to wards lower number of cases designated as Birads

Avoid BI-R

ADS 3

Chronic inflamed cysts- w

ell defined thin rim enhancem

ent (birads �G

�Fat N

ecrosis- same density as fat w

ith thin rim enhancem

ent. Hx of

surgery (bi-Rads �

G>�$��� ����9������������- Birads ^

���������� ��exclude recurrence.

�Intra-m

amm

ary LN- (�

������� 8

����������������� ���

BI-R

ADS 3

Cancer yield ??

�TH

E EVIDEN

CE

Page 14: Birads 3 lesions breast mr - cpd.utoronto.ca · BI-RADS 3 lesions NME- Non Mass-like Enhancement Overall MR interpretation trend is to wards lower number of cases designated as Birads

Summ

ary of Literature on MR

Imaging–

detected Probably B

enign (BI-R

ADS Category 3

) Lesions

*Num

bers in parentheses are percentages. †Num

bers in parentheses are raw data.

Radiology. 2016 S

ep;280(3):707-15.doi: 10.1148/radiol.2016151548. Epub

2016 Apr 18.

Characteristics, M

alignancy Rate, and Follow

-up of BI-R

ADS C

ategory 3 Lesions Identified at Breast M

R

Imaging: Im

plications for MR

Image Interpretation and M

anagement.

Chikarm

aneS

A1,B

irdwell R

L1,P

oole PS

1,Sippo

DA

1,Giess

CS

1.

“Probably benign” interpretations in H

igh risk wom

en at MR

�7First study to determ

ine the results of probably benign lesions on FU.

��

��� �9���6����� ��� ��*W

Z�8

��������

9� �����

�Y

\� ��*

WZ

�V�^�

G�����;$-R

AD 3

interpretation given

�Characteristics of B

i-rads 3 - '

&'

�����������������

����W4

�������

����–

*4

�FU

usually 6 m

onths first time. Subsequent 6

months- )

����

�X

��������������Z- )�

����������9 9���� �

*Liberman

L, Morris E

A, B

enton CL, et al. P

robably benign lesions at breast magnetic resonance im

aging:prelim

inary experience in high-risk wom

en. Cancer 2003;98(2):377–88.

Page 15: Birads 3 lesions breast mr - cpd.utoronto.ca · BI-RADS 3 lesions NME- Non Mass-like Enhancement Overall MR interpretation trend is to wards lower number of cases designated as Birads

Freq. of malignancy in probably benign

lesions at CE-X�

$�V�%�$'

�WW

WZ

G �

)�W

� ��\W

\�8

����8

�������������� ��� ��������������������;$-R

ADS 3

lesions in � �������������������V��

)^4

���� ��G

–M

asses- 37 –

Non-m

ass enhancement- 59

–Foci of enhancem

ent- 47

�����

�yrs followup

–83 (78.3%

) of 106- stable –

23 (21.7%) – had tissue diagnosis –

–18 had benign pathology, 2 had AH

& 1 had D

CIS

�B

I-RAD

S 3 lesions- )

� ��)�W

�9�������–�����

���������V�>\

�G

W

iensteinet al R

adiology:Volume 255: N

umber 3—

June 2010

BI-R

ADS 3

lesions �

Study by Lourenco et al describes -Frequency, Lesion Type, and Rate

of Malignancy

�*

^Y

���� �����^*Z

��� ������6��%"-M

R exam

s studied

�Y)

���������9������

�Characteristics –

125- foci (2- 4mm

size) Cancer Yield- 0.8%

–52 non m

ass like (6- 35mm

) Cancer Yield- 3.8%

–171 m

asses with sm

ooth margins (5-20m

m) Cancer Yield- 1.2%

Q� ������;�����;

������X�

$�!�� ��]�1����������!�� ��(�9������������ ��X

��������>�����Q>�! ����� ��X�

�7�X

�������(�����X��

Chung, MD

, and Martha B

. Mainiero, M

D. J. M

agn. Reson>�$�

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\–

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Page 16: Birads 3 lesions breast mr - cpd.utoronto.ca · BI-RADS 3 lesions NME- Non Mass-like Enhancement Overall MR interpretation trend is to wards lower number of cases designated as Birads

BI- R

ADS 3

Breast M

R category

Notes:

�B

reast MR

comm

only used in higher risk wom

en

�Low

specificity of MR

in small lesions w

ith overlap between

high risk lesions and benign lesions

�Learning curve of radiologists

�B

aseline Study Vs follow up im

aging

�A desirable goal for the frequency of m

aking category 3

���������������X

�$�������������)�

�>

�As experience grow

s and with internal audits this num

ber �� ��������

-*�

As per published studies/literature

BI- R

ADS 3

Breast M

R category

Notes:

Page 17: Birads 3 lesions breast mr - cpd.utoronto.ca · BI-RADS 3 lesions NME- Non Mass-like Enhancement Overall MR interpretation trend is to wards lower number of cases designated as Birads

�M

amm

ogram and U

ltrasound- useful to ultimately assign a B

I-RAD

S 3

for a first time detected finding on B

aseline or screening MR

�M

asses have highest correlation on ultrasound

�Foci and N

ME not usually identified and can go straight to M

R follow

up or M

R biopsy (high risk)

BI- R

ADS 3

Breast M

R category

Notes:

Summ

ary �

BI-R

ads 3 category is not easy to assign and requires a m

ethodological approach

�Com

monly 3

types

–Foci

–N

ME

–M

ass

�Correlation to prior im

aging including MR

, mam

mogram

s and ultrasound would help

in accurate characterization and BI-R

ADS designation

�Clinical characteristics and risk factors need to be taken into account

�1 �� 8

��9���������~�W��

����������������� �����W��

���������������������� ��)�� ��

�years to establish benignity

�For N

ME attributable to phase of m

enstrual cycle may consider repeat M

R in 6

-Y�

8����8

����~�����

������8����Z

-)������� �������

��������������

Page 18: Birads 3 lesions breast mr - cpd.utoronto.ca · BI-RADS 3 lesions NME- Non Mass-like Enhancement Overall MR interpretation trend is to wards lower number of cases designated as Birads

THAN

K YO

U