ACR BI-RADS® Atlas Fifth Edition [PDF]

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ACR BI-RADS Atlas Fifth Edition ®



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Breast composition



MAMMOGRAPHY



ULTRASOUND



a. The breasts are almost entirely fatty



Tissue a. Homogeneous background echotexture – fat composition (screening only) b. Homogeneous background echotexture – fibroglandular c. Heterogeneous background echotexture



b. There are scattered areas of fibroglandular density c. The breasts are heterogeneously dense, which may obscure small masses d. The breasts are extremely dense, which lowers the sensitivity of mammography



Masses



Shape



Oval Round



Masses



Shape



Irregular Margin



Density



Calcifications



Typically benign



Suspicious morphology



Irregular Orientation



Circumscribed Obscured Microlobulated



Margin



Parallel Not parallel Circumscribed



Indistinct Spiculated High density Equal density Low density Fat-containing Skin Vascular Coarse or “popcorn-like” Large rod-like Round



Echo pattern



Not circumscribed - Indistinct - Angular - Microlobulated - Spiculated Anechoic Hyperechoic Complex cystic and solid Hypoechoic Isoechoic Heterogeneous



Rim



Posterior features



No posterior features



Dystrophic Milk of calcium Suture Amorphous



Calcifications



Coarse heterogeneous Fine linear or fine-linear branching Diffuse



Enhancement Shadowing Combined pattern Calcifications in a mass Calcifications outside of a mass



Fine pleomorphic Distribution



Oval Round



Intraductal calcifications Associated features



Architectural distortion



Regional



Duct changes Skin changes Skin thickening



Grouped



Skin retraction



Linear



Edema Vascularity



Segmental Architectural distortion Asymmetries Asymmetry



Internal vascularity Vessels in rim Elasticity assessment



Global asymmetry Focal asymmetry Developing asymmetry Intramammary lymph node



Absent



Soft Intermediate Hard



Special cases



Simple cyst



Skin lesion



Clustered microcysts



Solitary dilated duct Associated Skin retraction features Nipple retraction



Complicated cyst Foreign body including implants



Skin thickening



Lymph nodes – intramammary



Trabecular thickening Architectural distortion



Lymph nodes – axillary Vascular AVMs (arteriovenous malformations/ abnormalities pseudoaneurysms)



Calcifications Laterality Quadrant and clock face



Mondor disease Postsurgical fluid collection Fat necrosis



Axillary adenopathy



Location of lesion



Mass in or on skin



Depth Distance from the nipple



MAGNETIC RESONANCE IMAGING Amount of fibroglandular tissue (FGT)



a. b. c. d.



Background parenchymal enhancement (BPE)



Level



Almost entirely fat Scattered fibroglandular tissue Heterogeneous fibroglandular tissue Extreme fibroglandular tissue



Symmetric or asymmetric



Minimal Mild Moderate Marked Symmetric Asymmetric



Focus Masses



Shape



Oval Round Irregular Circumscribed Not circumscribed - Irregular - Spiculated



Margin



Internal enhancement characteristics



Associated features



Homogeneous Heterogeneous Rim enhancement



Fat containing lesions



Location of lesion Kinetic curve assessment Signal intensity (SI)/time curve description



Nipple retraction Nipple invasion Skin retraction Skin thickening Skin invasion



Direct invasion Inflammatory cancer



Axillary adenopathy Pectoralis muscle invasion Chest wall invasion Architectural distortion Lymph nodes Normal Abnormal Fat necrosis Hamartoma Postoperative seroma/hematoma with fat Location Depth Initial phase Slow Medium Delayed phase



Fast Persistent Plateau



Dark internal septations



Washout Non-mass enhancement (NME)



Distribution



Internal enhancement patterns



Focal Linear Segmental Regional Multiple regions Diffuse Homogeneous Heterogeneous Clumped Clustered ring



Intramammary lymph node



Implant material and lumen type



Saline



Implant location



Other implant material Lumen type Retroglandular Retropectoral Focal bulge



Abnormal implant contour Intracapsular silicone findings



Skin lesion Non-enhancing findings



Implants



Silicone - Intact - Ruptured



Radial folds Subcapsular line



Ductal precontrast high signal on T1W



Keyhole sign (teardrop, noose)



Cyst



Linguine sign



Postoperative collections (hematoma/seroma)



Extracapsular silicone



Post-therapy skin thickening and trabecular thickening



Water droplets



Non-enhancing mass



Peri-implant fluid



Breast Lymph nodes



Architectural distortion Signal void from foreign bodies, clips, etc.



BI-RADS® ASSESSMENT CATEGORIES Category 0: Mammography: Incomplete – Need Additional Imaging Evaluation and/or Prior Mammograms for Comparison Ultrasound & MRI: Incomplete – Need Additional Imaging Evaluation Category 1: Negative Category 2: Benign Category 3: Probably Benign Category 4: Suspicious



Category 4A: Low suspicion for malignancy Mammography & Ultrasound: Category 4B: Moderate suspicion for malignancy Category 4C: High suspicion for malignancy



Category 5: Highly Suggestive of Malignancy Category 6: Known Biopsy-Proven Malignancy



For the complete Atlas, visit acr.org/birads