Dr. G.W. Eklund Portland, OR, USA

Breast ultrasound lexicon and BI-RADS® classification Breast ultrasound (BUS) is used to improve the specificity of mammographic and clinical findings. BUS has become the imaging-guidance method of choice for percutaneous procedures such as cyst aspiration, needle biopsy and pre-operative localization. The development of a universally accepted lexicon to accurately describe imaging features has significantly improved the ability to communicate with commonly understood terminology that minimizes the risk for interpretive, communication or management errors.

The assignment of assessment categories (BI-RADS® CLASSIFICATION) is based on the assessment of multiple features, not any single feature of a sonographic finding. It is essentially the summation of pertinent findings and a final conclusion as to the normal, benign or potentially malignant nature of a given sonographic finding. The goal is to insure, to the greatest degree possible, appropriate management of sonographic findings.

The Breast Imaging and Reporting Data System (BI-RADS®) for breast ultrasound is based on the Breast Imaging and Reporting Data System for mammography.

The following are reprinted with permission of the American College of Radiology:

BI-RADS® – US A. Masses: A mass occupies space and should be seen in two different projections. Shape (select one) Description ❏ Oval Elliptical or egg-shaped (may include 2 or 3 undulations, i.e. “gently

lobulated” or “macrolobulated”) ❏ Round Spherical, ball-shaped, circular, or globular

❏ Irregular Neither round nor oval in shape Orientation (select one) Description ❏ Parallel Long axis of lesion parallels the skin line (“wider than tall” or horizontal) ❏ Not parallel Long axis, not oriented along the skin line (“taller than wide” or

vertical, includes round) Margin (select one) Description ❏ Circumscribed A margin that is well defined or sharp, with an abrupt transition

between the lesion and surrounding tissue ❏ Not circumscribed* The mass has one or more of the following features:

indistinct, angular, microlobulated or spiculated ❏ Indistinct No clear demarcation between a mass and its surrounding tissue ❏ Angular Some or all of the margin has sharp corners, often forming acute angles ❏ Microlobulated Short cycle undulations impart a scalloped appearance to the

margin of the mass ❏ Spiculated Margin is formed or characterized by sharp lines projecting from the

mass Lesion Boundary (select one) Description ❏ Abrupt interface The sharp demarcation between the lesion and surrounding

tissue can be imperceptible or a distinct well-defined echogenic rim of any thickness

❏ Echogenic halo No sharp demarcation between the mass and surrounding tissue, which is bridged by an echogenic transition zone

Echo Pattern (select one) Description ❏ Anechoic Without internal echoes ❏ Hyperechoic Having increased echogenicity relative to fat or equal to

fibroglandular tissue ❏ Complex Mass contains both anechoic and echogenic components ❏ Hypoechoic Defined relative to fat; masses are characterized by low-level

echoes throughout (e.g. appearance of a complicated cyst or fibroadenoma) ❏ Isoechoic Having the same echogenicity as fat (a complicated cyst or

fibroadenoma may be isoechoic or hypoechoic) Posterior Acoustic Features (select one) Description ❏ No posterior acoustic features No posterior shadowing or enhancement ❏ Enhancement Increased posterior echoes ❏ Shadowing Decreased posterior echoes; edge shadows are excluded ❏ Combined pattern More than one pattern of posterior attenuation, both

shadowing and enhancement

Surrounding Tissue Description Identifiable effect (select all that apply) ❏ Duct changes Abnormal caliber and/or arborization ❏ Cooper’s ligament changes Straightening or thickening of Cooper’s ligaments ❏ Edema Increased echogenicity of surrounding tissue; reticulated pattern of

angular, hypoechoic lines ❏ Architectural distortion Disruption of normal anatomic planes ❏ Skin thickening Focal or diffuse skin thickening (Normal skin is 2 mm or less in

thickness except in the periareolar area and lower breasts) ❏ Skin retraction/irregularity Skin surface is concave or ill-defined, and appears

pulled in ACR BI-RADS®–US Lexicon Classification Form For each of the following categories, select the term that best describes the dominant lesion feature. Wherever possible, definitions and descriptors used in BI-RADS® for mammography will be applied to ultrasound. * Note: Irregular is used as descriptor of shape rather than margin Copyright 2003 American College of Radiology B. Calcifications: Calcifications are poorly characterized with ultrasound but can be recognized particularly in a mass. Calcifications Description If present (select all that apply) ❏ Macrocalcifications Greater than or equal to 0.5 mm in size ❏ Microcalcifications out of mass Echogenic foci that do not occupy the entire

acoustic beam and do not shadow. Less than 0.5 mm in diameter ❏ Microcalcifications in mass Embedded in a mass, microcalcifications are well

depicted. The punctate, hyperechoic foci will be conspicuous in a hypoechoic mass

C. Special Cases: Special cases are those with a unique diagnosis or finding. Special Cases (select all that apply) Description ❏ Clustered microcysts A cluster of tiny anechoic foci each smaller than 2-3 mm in

diameter with thin (less than 0.5 mm) intervening septations and no discrete solid components

❏ Complicated cysts Most commonly characterized by homogeneous low-level internal echoes Complicated cysts may also have fluid-fluid, or fluid-debris levels that may shift with changes in patient’s position

❏ Mass in or on skin These masses are clinically apparent and may include sebaceous or epidermal inclusion cysts, keloids, moles and neurofibromas

❏ Foreign body May include marker clips, coil, wire, catheter sleeves, silicone, and metal or glass related to trauma

❏ Lymph nodes - intramammary Lymph nodes resemble small kidneys with an echogenic hilus and hypoechoic surrounding cortex. Found in the breast, including axilla

❏ Lymph nodes - axillary Lymph nodes resemble small kidneys with an echogenic hilus and hypoechoic surrounding cortex. Found in the breast, including axilla

D. Vascularity Vascularity (select one) ❏ Not Present or not assessed ❏ Present in lesion ❏ Present immediately adjacent to lesion ❏ Diffusely increased vascularity in surrounding tissue E. Assessment Category (select one) Assessment Category (select one) Description ❏ Category 0 – Incomplete Additional imaging evaluation needed before final

assessment Final Assessment ❏ Category 1 – Negative No lesion found (routine follow-up) ❏ Category 2 –Benign finding No malignant features; e.g. cyst (routine follow-up

for age, clinical management) ❏ Category 3 – Probably benign finding Malignancy is highly unlikely, e.g.

fibroadenoma (initial short interval followup) ❏ Category 4 – Suspicious abnormality Low to moderate probability of cancer,

biopsy should be considered ❏ Category 5 – Highly suggestive of Almost certainly cancer, appropriate action

should be taken malignancy ❏ Category 6 – Known cancer Biopsy proven malignancy, prior to institution of therapy Copyright 2003 American College of Radiology

This US lexicon classification form is for data collection and does not constitute a written US report.

American College of Radiology BI-RADS® – US ASSESSMENT CATEGORIES a. Assessment is Incomplete Category 0 Need Additional Imaging Evaluation: In many instances, the US examination completes the evaluation of the patient. If US is the initial study, other examinations may be indicated. An example would be the need for mammography if US were the initial study for a patient in her late 20’s evaluated with US for a palpable mass that had suspicious sonographic features. Another example might be where mammography and US are nonspecific, such as differentiating between scarring and recurrence in a patient with breast cancer treated with lumpectomy and radiation therapy. Here, MRI might be the recommendation. A need for previous studies to determine appropriate management might also defer a final assessment. b. Assessment is Complete — Final Categories Category 1 Negative: This category is for sonograms with no abnormality, such as a mass, architectural distortion, thickening of the skin or microcalcifications. For greater confidence in rendering a negative interpretation, an attempt should be made to correlate the ultrasound and mammographic patterns of breast tissue in the area of concern. Category 2 Benign Finding(s): Essentially a report that is negative for malignancy. Simple cysts would be placed in this category, along with intramammary lymph nodes (also possible to include in Category 1), breast implants, stable postsurgical changes and probable fibroadenomas noted to be unchanged on successive US studies. Category 3 Probably Benign Finding—Short-interval Follow-Up Suggested: With accumulating clinical experience and by extension from mammography, a solid mass with circumscribed margins, oval shape and horizontal orientation, most likely a fibroadenoma, should have a less than 2 percent risk of malignancy. Although additional multicenter data may confirm safety of follow-up rather than biopsy based

on US findings, short-interval follow-up is currently increasing as a management strategy. Nonpalpable complicated cysts and clustered microcysts might also be placed in this category for short-interval follow-up. Category 4 Suspicious Abnormality—Biopsy Should be Considered: Lesions in this category would have an intermediate probability of cancer, ranging from 3 percent to 94 percent. An option would be to stratify these lesions, giving them a low, intermediate, or moderate likelihood of malignancy. In general, Category 4 lesions require tissue sampling. Needle biopsy can provide a cytologic or histologic diagnosis. Included in this group are sonographic findings of a solid mass without all of the criteria for a fibroadenoma and other probably benign lesions. Category 5 Highly Suggestive of Malignancy—Appropriate Action Should be Taken: (Almost certainly malignant) The abnormality identified sonographically and placed in this category should have a 95 percent or higher risk of malignancy so that definitive treatment might be considered at the outset. With the increasing use of sentinel node imaging as a way of assessing nodal metastases and also with the increasing use of neoadjuvant chemotherapy for large malignant masses or those that are poorly differentiated, percutaneous sampling, most often with imaging-guided core needle biopsy, can provide the histopathologic diagnosis. Category 6 Known Biopsy-Proven Malignancy—Appropriate Action Should Be Taken: This category is reserved for lesions with biopsy proof of malignancy prior to institution of therapy, including neoadjuvant chemotherapy, surgical excision or mastectomy.

Reprinted with permission of the American College of Radiology. No other representation of this material is authorized without expressed, written permission from the American College of Radiology. This permission applies to this request only and any additional reprinting requires another request. All materials cited must reference the specific edition of the Atlas. The ACR suggests the following format for citation as to source and appropriate section: American College of Radiology (ACR). ACR BI-RADS®--4th Edition. ACR Breast Imaging Reporting and Data System, Breast Imaging Atlas; BI-RADS. Reston, VA. American College of Radiology; 2003.

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