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BIRADS

DR. ENRIQUE
CUEVAS
MEDICO RADIOLOGO

QUIZA ENTRE LO MAS


IMPORTANTE, EL SISTEMA BIRADS
DEFINE LA EVALUACION DE LAS
CATEGORIAS PARA DESCRIBIR EL
NIVEL RADIOLOGICO DE
SOSPECHA DE UN HALLAZGO
MAMOGRAFICO.

A)
B)
C)
D)

The Breast Imaging Reporting and Data


System (BI-RADS) lexicon was developed by
the American College of Radiology (ACR) to
standardize mammographic reporting.
Includes terms for :
Describing breast parenchymal patterns,
Features of masses and calcifications,
Associated findings, and
Final assessment categories.

Potential benefits of the lexicon


include increased clarity in
reporting, improved communication,
and facilitation of research,
particularly across different
institutions.

A) BREAST
PARENCHYMAL

The BI-RADS lexicon describes four


classes of breast parenchymal
density:
class 1, almost entirely fat;
class 2, scattered fibroglandular
densities;
class 3, heterogeneously dense;
class 4, dense

Fig. 1.Breast parenchymal density as seen on


mediolateral oblique view mammograms. (A)
Fatty (ACR class 1); (B) Mildly dense (ACR
class 2);

(C) Moderately dense (ACR class 3); (D)


Dense (ACR class 4).

Analysis of the impact of breast


density on breast cancer incidence
are complicated by the inverse
relationship between age and breast
parenchymal density and by the
lower sensitivity of mammography in
women with dense breasts.

B) MASS

A mass is defined as a spaceoccupying lesion seen in two


different projections; if a potential
mass is seen in only a single
projection, it should be called a
density until its three-dimensionality
is confirmed.

Mass margins are described as


circumscribed,
microlobulated (undulate in short cycles),
obscured (hidden by superimposed adjacent
tissue),
indistinct (poor definition not caused by
superimposed tissue, raising the possibility
of infiltration of the lesion into adjacent
tissue), and
spiculated (lines radiate from the margins)
(Fig. 2) .

Fig. 2.Mass margin characteristics as defined by the


BI-RADS lexicon. (A) Circumscribed mass, shown to be
a simple cyst at sonography.
(B) Partially obscured mass; sonography showed as
simple cyst.

(C) Microlobulated mass corresponding to palpable


lump denoted by radiopaque skin marker; biopsy
showed infiltrating ductal carcinoma and ductal
carcinoma in situ (DCIS).
(D) Spiculated mass; biopsy showed infiltrating ductal
carcinoma and DCIS.

Mass shape can be described as


round,
oval,
lobular, or irregular.

Mass density can be described as


high,
equal,
low, or
fat containing.

Architectural distortion is shape with


radiating spicules but no definite mass visible
(Fig. 3) .

Fig. 3.Spiculated
architectural distortion
at mammography
(straight arrow),
corresponding to a
vaguely palpable
thickening denoted by
radiopaque skin marker.
Biopsy yielded
infiltrating lobular
carcinoma.
There was an adjacent
lobulated mass with
coarse calcification
(curved arrow), stable
from prior years and
consistent with a benign
fibroadenoma.

The lexicon also defines special


cases, including:
intramammary lymph node (typically
reniform or with radiolucent notch
because of fat in the hilum, most
often seen in the upper outer
quadrant) (Fig. 4) ;

Fig. 4.A
benign
intramammary
lymph node
(BI-RADS
category 2).
Note the notch
corresponding
to the fatty
hilum.

Solitary dilated duct (usually of minor


significance unless it represents an interval
change from prior mammograms);

Asymmetric breast tissue (judged relative to


the corresponding area in the contralateral
breast, usually a normal variant, but may be
important when it corresponds to a palpable
asymmetry);

Focal asymmetric density (a density that


cannot be accurately described using the
other shapes, could represent an island of
fibroglandular tissue, but may warrant
additional evaluation)

CALCIFICATIONS

The lexicon defines specific terms to


describe the shapes (morphology) of
calcifications and the patterns in
which they are arrayed in the breast
parenchyma (distribution).

Morphologic descriptors are


typically benign,
intermediate concern,
and higher probability of malignancy .
Typically benign calcifications include
skin, vascular, coarse or popcorn-like,
large rod-like, round (or punctate if
smaller than 0.5 mm), lucent-centered,
eggshell or rim, milk of calcium,
suture, and dystrophic (Fig. 5) .

TIPICAMENTE
BENIGNAS

DE LA PIEL.
VASCULARES.
ASPERAS O EN PALOMITA DE MAIZ ( GROSERAS).
LARGAS EN VARA
REDONDEADAS O PUNTIFORMES ( MENORES A
0.5 MM)
CON CENTRO RADIOLUCIDO
EN CASCARON DE HUEVO
EN LECHE CALCICA
DE LAS SUTURAS
DISTROFICAS

Fig. 5.Typically benign calicifications. (A) Variety of


benign calcifications: peripherally calcified oil cysts of
fat necrosis, large rod-like calcifications of secretory
disease, and vascular calcifications. (B) Milk of calcium.
Note the layering or teacup appearance of this 90
lateral magnification view (arrows).

(C) Popcorn calcification typical of


fibroadenoma. (D) Eggshell calcifications
associated with architectural distortion in
area of postoperative fat necrosis.

LINEALES

REDONDEADEAS

LIPOS

EN ANILLO O CASCARA DE HUEVO


SE ADAPTAN A LAS PAREDES DE UNA ESFERA
(QUISTE, FIBROADENOMA)

LECHE CALCICA

Intermediate
calcifications

Are amorphous or indistinct; these


calcifications are often round or
flake shaped and are sufficiently
small or hazy that a more specific
morphologic classification cannot be
determined.

HIGHER
PROBABILITY OF
MALIGNANCY

Calcifications with a higher


probability of malignancy include
pleomorphic or heterogeneous
calcifications (formerly called
granular) and fine linear or fine,
linear, branching (casting)
calcifications (Fig. 6) .

Fig. 6.Calcifications with higher probability of malignancy.


(A) Calcifications with linear morphology and linear
distribution (arrows). Biopsy yielded ductal carcinoma in situ
(DCIS) with calcification. (B) Pleomorphic calcifications in
segmental distribution. Biopsy yielded infiltrating ductal
carcinoma and DCIS, with calcifications present in DCIS.

(C) Two clusters of pleomorphic calcifications (arrows).


Both yielded DCIS with calcifications at biopsy, and the
patient was treated with mastectomy.

The distribution of calcifications has been


described as
grouped or clustered (multiple
calcifications in less than 2 mL tissue),
linear,
segmental (suggesting deposits in a duct),
regional (large volume not necessarily
conforming to a duct distribution),
diffuse/scattered (random distribution),
or multiple.

The lexicon defines associated findings,


used with
masses or calcifications or alone when
no other abnormality is present,
including
skin or nipple retraction, skin or
trabecular thickening,
skin lesion,
axillary adenopathy, or architectural
distortion.

The lexicon suggests that the location


of the lesion be expressed by
indicating
the side (left, right, or both),
the location (according to the face of
the clock and subareolar, central, or
axillary tail, if appropriate)
and the depth of the lesion (anterior,
middle, or posterior).

BIRADS

CATEGORIAS DE
EVALUACION DEL LEXICO
BIRADS

0.

EVALUACION INCOMPLETA. SE NECESITA


EVALUACION IMAGENOLOGICA ADICIONAL

1.

ESTUDIO NEGATIVO A CANCER. SE NECESITA


EVALUACION IMAGENOLOGICA ADICIONAL.

2.

HALLAZGOS BENIGNOS. SE RECOMIENDA


MAMOGRAFIA DE RUTINA.

3.

HALLAZGO PROBABLEMENTE BENIGNO . SE


SUGIERE REGRESAR EN UN PERIODO CORTO
DE TIEMPO ( 6 MESES)

4.

SOSPECHOSA. DEBERA
CONSIDERARSE BIOPSIA.

4.A. BAJA POSIBILIDAD DE MALIGNIDAD


4.B. MEDIANA POSIBILIDAD DE
MALIGNIDAD
4.C. ALTA POSIBILIDAD DE MALIGNIDAD
5.

MALIGNA

6.

CONFIRMADA POR BIOPSIA

LAS CATEGOIRIAS DE
EVALUACION DEL LEXICO BIRADS
SON UTILES PREDICTORES DE
MALIGNIDAD

BIRADS/USG

The ACR has developed an initial draft of a


breast ultrasound lexicon , supported by
the Office on Women's Health, Department
of Health and Human Services.
The initial draft includes descriptors for
mass shape (oval, round, or irregular),
echopattern (anechoic, hyperechoic,
complex, or hypoechoic), and posterior
acoustic features (none, enhancement,
shadowing, or combined).

Mass orientation is described as


parallel (oriented along skin line,
wider than tall) or not parallel (axis
not oriented along skin line, or taller
than wide).

Mass margins are circumscribed (with


no rim, thin rim, or thick rim) or
irregular (indistinct, angular,
microlobulated, or spiculated).

Effect on surrounding tissue is also noted,


including effect on ducts or Cooper ligaments,
edema, architectural distortion, skin thickening or
retraction, and unclear plane with pectoral muscle.

Also included are descriptors for associated


calcifications (none, macrocalcifications,
microcalcifications in mass, microcalcifications
outside of mass), special cases (mass in or on skin,
foreign body, intramammary lymph nodes, or
axillary lymph nodes), vascularity (cannot assess,
none, same as normal tissue, decreased, or
increased), and final assessment categories.

Mendelson et al suggest that


descriptors should be based on
multiple views of masses obtained in
orthogonal imaging planes and that
the location of the abnormality be
described using a quadrant, clockface location, or labeled diagram of
the breast, ideally including distance
from the nipple.

Development of a sonographic lexicon is


made more complex by additional
variables in sonography, including the high
level of operator dependence, technical
differences dependent on equipment, and
availability of real-time assessment.

Further work is needed to validate the


lexicon terminology and to assess the
positive and negative predictive values of
the different descriptors.

SONOGRAPHIC CHARACTERISTICS USED TO


CATEGORIZE BREAST LESIONS
Benign

Malignant

Margins

Smooth, welldefined

Irregular, indistinct

Echogenicity
Internal

Anechoic or
hypoechoic

Variable

Echo pattern

None or
homogeneous

Heterogeneous

Retrotumoral
acoustic
phenomenon

None, posterior
Irregular
enhancement, or
shadowing
bilateral shadowing

Compressibility

Variable

Lateral/anteroposte Greater than one


rior dimension

VariableNone
Less than one

BIRADS/RMN

Supported by the Office of Women's Health and the


ACR, The International Working Group on Breast MRI
Imaging is developing a lexicon of terms for breast MRI
reporting, the first version of which was published in
1999 .

Schnall and Ikeda suggested that MRI reports include


descriptions of clinical abnormalities, previous biopsies,
hormonal status, and comparison with prior studies.

Technical factors should be stated, including the


location of markers and significance, magnet field
strength, use of a dedicated breast coil, contrast media,
pulse sequence, anatomy (including slice thickness and
scan orientation and plane), and post-processing
techniques.

Findings described should include


mention of artifacts that affect
interpretation, breast composition,
implants, and presence or absence
of abnormal enhancement, with
specific descriptors defined for focal
enhancement, kinetics, summary
impression, and recommendations

Descriptive terms for breast MRI were


elegantly illustrated by Morris
Focus/foci
Mass margin
Smooth, Irregular,Spiculated
Mass shape
OvalRoundLobulatedIrregular
Mass enhancement
Homogeneous,Heterogeneous,Rim,
Dark internal septations,Enhancing
internal septations, Central enhancement

Non-mass enhancement
Linear (smooth, irregular, or
clumped),Segmental,Regional,Multi
ple regions,Diffuse.
Non-mass enhancement
descriptors for all other types
Homogeneous,Heterogeneous,Stipple
d/punctate,Clumped,Septal/dendritic

Symmetric versus asymmetric for


bilateral studies

Based on MRI findings, guidelines were suggested by


Kuhl et al in an investigation of breast MRI for highrisk screening.

In that study, BI-RADS category 1 was assigned to


lesions without any contrast material enhancement.

BI-RADS category 2 was assigned to lesions in which


enhancement was detected but was classified as
benign (focal masses with well-circumscribed
morphology, internal septations but otherwise
homogeneous enhancement, with centrifugal
progression of enhancement; or non-mass-related
gradual enhancement).

BI-RADS category 3 was assigned to lesions


compatible with unidentified bright objects or
UBOs (spontaneous, hormone-induced enhancement)
and in lesions with presumably benign masses that
lacked some of the BI-RADS category 2 features.

MRI of
fibroadenoma.
Sagittal, T1weighted, contrastenhanced image
shows a lobulated
enhancing mass
with non-enhancing
internal septations.

BI-RADS category 4 was assigned to


lesions with suspicious morphology,
irrespective of kinetics.

Morphology was suspect if there was


spiculated or irregular lesion
configuration, heterogeneous internal
architecture (particularly rim
enhancement), and asymmetric segmental
or linear enhancement (see Fig. 11 ).

Fig. 11.MRI patterns of breast cancers in sagittal, T1weighted, contrast-enhanced images. (A) Spiculated, irregular
enhanced mass in superior breast; biopsy yielded infiltrating
ductal carcinoma and ductal carcinoma in situ (DCIS). Note
suboptimal fat suppression inferiorly. (B) Lobulated mass with
heterogeneous and rim enhancement; histologic analysis
yielded infiltrating ductal carcinoma and DCIS.

(C) Extensive linear and segmental


clumped enhancement; biopsy
yielded DCIS.

BI-RADS category 5 was attributed


to lesions in which morphologic and
architectural features were
suggestive of malignancy.
Owever further work is needed to
validate this approach.

Direccin General de Epidemiologa


Direccin de Vig. Epi. de Enfermedades No Transmisibles /
CC-RHNM-Y2K

Datos sobre la mamografa:


- Sensibilidad 85 a 90% 90% es en mujeres

mayores de 50 aos
- Especificidad 30 a 40% en anomala no
palpable
- 85 a 90% para tumor maligno clnicamente
evidente
- Puede detectar tumor 2 aos antes de ser
palpable
- Anomala ms comn: microcalcificaciones,
deteccin de ndulos, distorsin.

CASOS

Grupos de edad y Sexo:

En el 2000 se registraron 91,913 tumores malignos que


corresponden a 92.3 casos por 100,000 habitantes.

El grupo de 0 a 4 aos tiene mayor nmero de casos que el de 5 a


14 aos.

Posteriormente se presenta un aumento progresivo hasta alcanzar


el mximo en el grupo de 70 y ms aos.

Por sexo, en el masculino se report el 34.3% y en el femenino el


65.7%, en ambos es mayor el nmero de casos registrados en el
grupo de 0 a 4 aos que el de 5 a 14 aos y posteriormente existe
un aumento progresivo,

Es importante destacar en las mujeres el aumento ms intenso que


se d a los 20 aos (23) y en los hombres hasta los 40 aos (46). Por
otra parte, en ms del 5% de casos en ambos sexos se desconoce la
edad.

PRINCIPALES TUMORES
Los tumores malignos que se
registraron con mayor frecuencia
fueron:
el de cuello del tero (24%),
piel (14%),
mama (11%),
prstata (6%) y estmago (3%).

En los hombres la frecuencia se represent


por:

cncer de piel (20%),


prstata (17%) y
estmago (6%).

En cambio en las mujeres se encontr el

cncer crvico uterino (36%)


mama (17%) y
piel (11%).

GRUPOS ESPECIALES DE
EDAD

Los grupos especiales con mayor


nmero de registros por 100,000
habitantes fueron la edad
posproductiva (581) seguida por la
productiva alta (245); la edad
escolar fue la de menor tasa (7).

En la edad productiva (15-44 aos) la frecuencia en


hombres se represent por el cncer de testculo (3),
el cncer de piel (2) y el linfoma no hodgkin difuso
(1). En mujeres el crvico uterino in situ (28) e
invasor (14), el cncer de mama (11) y el ovario (3).

Comparando con la edad productiva alta (45-64


aos), la frecuencia en hombres se marca por el
cncer de piel (27), prstata (20) y el cncer de
estmago (10). En mujeres el crvico uterino
(invasor: 61, in situ: 51), el cncer de mama (68) y el
cncer de piel (28).

En la edad pos-productiva (65 y ms aos), los


tumores malignos de mayor importancia en hombres
son el cncer de prstata (164), piel (132) y el cncer
de estmago (35). En mujeres el de piel (126), el
crvico uterino (invasor: 65, in situ: 33) y el de mama
(72).

Morbilidad por tumores


malignos, EN MUJERES
CAUSA

CIE 10

CASOS

PIEL
MAMA

C 49
C 50

5236
9605

REG/HA
%
B
12.4
10.3
40.3
15.9

CUELLO
DEL
UTERO

C 53

9501

41.1

16.2

IN SITU
DEL
CUELLO

DO 06

17 749

49.3

19.5

Morbilidad por tumores


malignos, EN HOMBRES
CAUSA

CIE
10

CASO
S

REG/HAB

PIEL

C44

5564

11.3

17.6

TESTICUL
O

C62

917

1.9

2.9

ESTOMAG
O

C16

1721

3.5

5.5

Principales neoplasias malignas en mujeres


en edad productiva alta (45 - 64 aos)

Principales neoplasias malignas en


mujeres en edad posproductiva (65 y
ms aos)

PRINCIPALES NEOPLASIAS MALIGNAS EN


HOMBRES / EDAD PRODUCTIVA (15-44
aos) AO 2001

PRINCIPALES NEOPLASIAS
MALIGNAS EN HOMBRES / EDAD
PRODUCTIVA ALTA (45-64 aos) AO
2001

PRINCIPALES NEOPLASIAS MALIGNAS EN


HOMBRES / EDAD POSPRODUCTIVA (65 y
ms aos)

PRINCIPALES NEOPLASIAS MALIGNAS EN


MUJERES / EDAD PRODUCTIVA (15-44 aos)

PRINCIPALES NEOPLASIAS MALIGNAS EN


MUJERES / EDAD PRODUCTIVA ALTA (4564 aos)

PRINCIPALES NEOPLASIAS MALIGNAS EN


MUJERES / EDAD POSPRODUCTIVA (65 y ms
aos)

DISTRIBUCIN PORCENTUAL DE LAS


DEFUNCIONES POR TUMORES MALIGNOS,
MXICO 2001

BIBLIOGRAFIA

BREAST IMAGING REPORTING AND DATA


SYSTEM (BI-RADS) Radiologic Clinics of North
America
Volume 40 Number 3 May 2002

BREAST ULTRASOUND Edgar D. Staren MD,


PhD Thaddeus P. O'Neill Department of General
Surgery, Rush Medical College, Chicago, Illinois

CANCER SCREENING Richard C. Wender, MD


Robert Smith, PhD b Diane Harper, MD, MPH,
MS Primary Care; Clinics in Office Practice
Volume 29 Number 3 September 2002