BIRADS
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.
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 :
A) Describing breast parenchymal patterns,
B) Features of masses and calcifications,
C) Associated findings, and
D) 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 space-occupying 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 CATEGORIAS 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, clock-face 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, well-defined Irregular, indistinct
Echogenicity Internal Anechoic or hypoechoic Variable
Echo pattern None or homogeneous Heterogeneous
Retrotumoral acoustic None, posterior Irregular shadowing
phenomenon enhancement, or bilateral
shadowing
Compressibility Variable VariableNone
Lateral/anteroposterior Greater than one Less than one
dimension
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
Oval Round Lobulated Irregular
Mass enhancement
Homogeneous, Heterogeneous, Rim,
Dark internal septations, Enhancing internal
septations, Central enhancement
Non-mass enhancement
Linear (smooth, irregular, or
clumped), Segmental, Regional, Multiple
regions, Diffuse.
Non-mass enhancement descriptors for all
other types
Homogeneous, Heterogeneous, Stippled/puncta
te, 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 high-risk 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, T1-weighted,
contrast-enhanced 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, T1-weighted, 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.
Dirección General de Epidemiología
Dirección de Vig. Epi. de Enfermedades No Transmisibles / CC-RHNM-Y2K
Datos sobre la mamografía:
- Sensibilidad 85 a 90% 90% es en mujeres mayores
de 50 años
- Especificidad 30 a 40% en anomalía no palpable
- 85 a 90% para tumor maligno clínicamente evidente
- Puede detectar tumor 2 años antes de ser palpable
- Anomalía más común: microcalcificaciones,
detección de nódulos, distorsión.
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 años tiene mayor número de casos que el de 5 a 14 años.
Posteriormente se presenta un aumento progresivo hasta alcanzar el máximo
en el grupo de 70 y más años.
Por sexo, en el masculino se reportó el 34.3% y en el femenino el 65.7%, en
ambos es mayor el número de casos registrados en el grupo de 0 a 4 años que
el de 5 a 14 años y posteriormente existe un aumento progresivo,
Es importante destacar en las mujeres el aumento más intenso que se dá a los
20 años (23) y en los hombres hasta los 40 años (46). Por otra parte, en más 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 útero (24%),
piel (14%),
mama (11%),
próstata (6%) y estómago (3%).
En los hombres la frecuencia se representó por:
cáncer de piel (20%),
próstata (17%) y
estómago (6%).
En cambio en las mujeres se encontró el
cáncer cérvico uterino (36%)
mama (17%) y
piel (11%).
GRUPOS ESPECIALES DE EDAD
Los grupos especiales con mayor número 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 años) la frecuencia en
hombres se representó por el cáncer de testículo (3), el
cáncer de piel (2) y el linfoma no hodgkin difuso (1). En
mujeres el cérvico uterino in situ (28) e invasor (14), el
cáncer de mama (11) y el ovario (3).
Comparando con la edad productiva alta (45-64 años), la
frecuencia en hombres se marca por el cáncer de piel (27),
próstata (20) y el cáncer de estómago (10). En mujeres el
cérvico uterino (invasor: 61, in situ: 51), el cáncer de
mama (68) y el cáncer de piel (28).
En la edad pos-productiva (65 y más años), los tumores
malignos de mayor importancia en hombres son el cáncer
de próstata (164), piel (132) y el cáncer de estómago (35).
En mujeres el de piel (126), el cérvico uterino (invasor: 65,
in situ: 33) y el de mama (72).
Morbilidad por tumores malignos,
EN MUJERES
CAUSA CIE 10 CASOS REG/HA %
B
PIEL C 49 5236 12.4 10.3
MAMA C 50 9605 40.3 15.9
CUELLO C 53 9501 41.1 16.2
DEL
UTERO
IN SITU DO 06 17 749 49.3 19.5
DEL
CUELLO
Morbilidad por tumores malignos,
EN HOMBRES
CAUSA CIE CASOS REG/HAB %
10
PIEL C44 5564 11.3 17.6
TESTICULO C62 917 1.9 2.9
ESTOMAGO C16 1721 3.5 5.5
Principales neoplasias malignas en mujeres en edad
productiva alta (45 - 64 años)
Principales neoplasias malignas en mujeres en
edad posproductiva (65 y más años)
PRINCIPALES NEOPLASIAS MALIGNAS EN
HOMBRES / EDAD PRODUCTIVA (15-44 años)
AÑO 2001
PRINCIPALES NEOPLASIAS MALIGNAS
EN HOMBRES / EDAD PRODUCTIVA ALTA
(45-64 años) AÑO 2001
PRINCIPALES NEOPLASIAS MALIGNAS EN
HOMBRES / EDAD POSPRODUCTIVA (65 y más
años)
PRINCIPALES NEOPLASIAS MALIGNAS EN MUJERES /
EDAD PRODUCTIVA (15-44 años)
PRINCIPALES NEOPLASIAS MALIGNAS EN
MUJERES / EDAD PRODUCTIVA ALTA (45-64
años)
PRINCIPALES NEOPLASIAS MALIGNAS EN MUJERES /
EDAD POSPRODUCTIVA (65 y más años)
DISTRIBUCIÓN PORCENTUAL DE LAS DEFUNCIONES
POR TUMORES MALIGNOS, MÉXICO 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
