ACR BI-RADS CLASSIFICATION IN

BREAST ULTRASOUND

BSNT Trần Thị Linh

 CONTENT

1. GENERAL ANATOMY
2. TECHNIQUE ULTRASOUND
3. BREAST IMAGING LEXICON
4. BIRADS CLASSIFICATION
5. CONCLUSION
 GENERAL : BREAST ANATOMY

 BREAST LOCATION: chest wall

between 2nd -6th ribs within layers
of the superficial pectoral fascia.
• Segment starts peripheral
branches and ends in larger
colleting ducts that go to nipple
 TDLU consists of the:
1. extra-lobular terminal duct
2. Intra-lobular terminal duct
3. lobule
Most cancers and benign lesions arise
in the terminal duct either inside or
just proximal to the lobule
(Radiopaedia.org)
 Ductal carcinoma: 75%. Lobular
carcinoma 15% ( UICC manual of
clinical oncology)
 GENERAL : BREAST ANATOMY

 Skin
 Pre-mammary fat layer
 Mammary layer
 Retro-mammary layer
 Rib
 Pectoralis muscle
 Cooper’s ligament
 Pleural
Lymph Node
 TECHNIQUE
PATIENT POSITION
 SCAN TECHNIQUES

 Scan technique: Grid scanning or radial

scanning patterns. However you do it
make sure you cover the entire region.
 Apply gently uniform pressure with
the ultrasound transducer
 TECHNIQUE
The 5th ACR BI-RADS® - 2013: IMAGE QUALITY (from 5th edition).

1.Transducer

2.FOV

3.Focal zone

4.Gray scale gain

5.Color Doppler
 1. Transducer
 Transducer Frequency: broadband
linear array transducer with center
frequency of AT LEAST 10 MHz. High
frequency (12-18 MHz).
 12 MHz use for penetration of deeper
tissue up to 5 cm.
 2. Field of view (FOV)
 Should be deep enough (breast
tissue, pectoralis muscle; no the
pleura, lung).
 TECHNIQUE
3 . Focal zone:
• When evaluating a lesion, the focal zone is optimally placed in the
center of the lesion.
4. Gray scale gain:
• If gain is be set too high: cyst appears solid.

• If gain is be set too low: marked hypoechoic solid lesion appears simple cyst.

• Reference setting: subcutaneous fat lobules

 Should appear medium gray, never black.
5. Color Doppler:
- No compression: Tiny vessels occluded.
- Low PRF (pulse repetition frequency): 500 –
1000Hz (0.5 – 1kHz) (color velocity scale: 2 – 5 cm/s).
• Mode:
– Power Doppler is more sensitive to slow flows but is
also more sensitive to artifacts.
 BREAST IMAGING LEXICON —
ULTRASOUND (2013)

A. Masses
B . Calcifications
C. Associated features
D. Special cases

Carl J. D’Orsi, MD et al. ACR BI-RADS® Atlas Breast Imaging Reporting and Data System. The 5 th Edition. 2013.
 BREAST IMAGING LEXICON
—
ULTRASOUND (2013)
A. Masses:
1. Shape.
2. Orientation.
3. Margin.
4. Echo pattern.
5. Posterior features.

Carl J. D’Orsi, MD et al. ACR BI-RADS® Atlas Breast Imaging Reporting and Data System. The 5 th Edition. 2013.
 BREAST IMAGING LEXICON
—
A. Masses: ULTRASOUND (2013)
1. Shape:
a. Oval (may include 2 or 3 lobulations)
b. Round
c. Irregular.
 BREAST IMAGING LEXICON
—
A. Masses: ULTRASOUND (2013)
2. Orientation: a. Parallel; b. Not parallel.
Parallel Not parallel
TDLU

fibroadenoma
Fibroadenoma arise within the lobule Carcinoma is thought to arise within the
TDLU at the level of the junction of the
and is forced to grow in plane that is
extralobular terminal duct and the lobule.
perpendicular to the long axis of the Growth of the tumor is down the
terminal ductolobular unit – TDLU. extralobular
terminal duct into the main ductal sytem.
A. Thomas Stavros. Breast Ultrasound. 1st Edition. 2004 Lippincott Williams & Wilkins.
 BREAST IMAGING LEXICON
3. Margin.
—
a.Circumscribed
ULTRASOUND (2013)
b.Not circumscribed (Indistinct; Angular; Micro-lobulated; Spiculated).
 BREAST IMAGING LEXICON
—
A. Masses: ULTRASOUND (2013)
4. Echo pattern: a. Anechoic; b. Hyperechoic; c. Complex
cyst and solid; d. Hypoechoic; e. Isoechoic; f. Heterogeneous.

Partial cystic mass with solid component, assessed as suspicious – moderate

suspicion category 4B intra-cystic papillary carcinoma.
Carl J. D’Orsi, MD et al. ACR BI-RADS® Atlas Breast Imaging Reporting and Data System. The 5 th Edition. 2013.
 BREAST IMAGING LEXICON
—
A. Masses:
ULTRASOUND (2013)
5. Posterior features: a. No posterior features; b.
Enhancement; c. Shadowing; d. Combined pattern.

Thick echogenic halo is usually combined with Posterior

shadowing.

Carl J. D’Orsi, MD et al. ACR BI-RADS® Atlas Breast Imaging Reporting and Data System.
The 5th Edition. 2013.
 BREAST IMAGING LEXICON
—
B. Calcifications: ULTRASOUND (2013)
1. Calcifications in a mass.
• Eun-Kyung Kim et al, 2008. Major findings of malignancy include: 1.
Irregular shape; 2. Spiculated margin; 3. Microcalcifications.
2. Calcifications outside of a mass.
3. Intra-ductal calcifications (probe with high resolution).

Carl J. D’Orsi, MD et al. ACR BI-RADS® Atlas Breast Imaging Reporting and Data System. The 5 th Edition. 2013.
 BREAST IMAGING LEXICON
—
ULTRASOUND (2013)

C. Associated features:
1. Architectural distortion (DDx with scar).
2. Duct changes
3. Skin changes: a. Skin thickening (> 2 mm); b.
Skin retraction (the skin surface is concave).
4. Edema.

Carl J. D’Orsi, MD et al. ACR BI-RADS® Atlas Breast Imaging Reporting and Data System. The 5 th Edition.
2013.
 BREAST IMAGING LEXICON
—
ULTRASOUND (2013)
5. Vascularity: a. Absent;
b. Internal vascularity; c. Vessels
in rim (not to use vascularity as the only diagnostic
feature in interpretation. Malignant lesions may not be hyper-
vascular. Benign lesions may be highly vascular (papillomas,
inflammatory processes).

Benign features Malignant feature

 BREAST IMAGING LEXICON
—
ULTRASOUND (2013)

5. Vascularity: ACR is not yet refer to Pulse Doppler.

* Reference.
RI – resistance index > 0.83 suggestive malignant (sensitivity
75%, specificity 97%).

Mehri Sirous et al. Evaluation of different aspects of power Doppler sonography in differentiating and prognostication
of breast masses. Journal of Research in Medical Sciences. February 2015
 BREAST IMAGING LEXICON
—
ULTRASOUND (2013)

6. Elasticity
assessement: a. Soft; b. Intermediated; c. Hard
* Not yet cut-off values refer from ACR.

It must be emphasized that the 2D ultrasonic

criterion of shape,margin, and echogenicity
are far more predictive for malignancy than
hardness or softness
 BREAST IMAGING LEXICON
—
D. Special cases: ULTRASOUND (2013)
1. Simple cyst.
2. Clustered micro-cysts.
3. Complicated cyst.
4. Mass in or on skin.
5. Foreign body including implants.
6. Lymph nodes – intra-mammary.
7. Lymph nodes – axillary.
8. Vascular abnormalities: a. AVMs (arteriovenous
malformations/pseudo-aneurysms); Mondor disease (thrombosis of
the superficial lateral thoracic vein).
9. Postsurgical fluid collection.
10. Fat necrosis.

Carl J. D’Orsi, MD et al. ACR BI-RADS® Atlas Breast Imaging Reporting and Data System. The 5 th
Edition. 2013.
BI-RADS CLASSIFICATION
 • Category 0: Incomplete.
• Category 1: Negative (0% malignant).
• Category 2: Benign (0% malignant).
– Circumscribed, oval, parallel orientation, hyperechoic
(in comparison with fat).
– Simple cyst.
• Category 3: Probably Benign (≤ 2% malignant).
– Circumscribed, oval, parallel orientation, hypoechoic
(in comparison with fat).
– Clustered microcysts, complicated cyst (with uniform
low-level echoes, thin septa).
Carl J. D’Orsi, MD et al. ACR BI-RADS® Atlas Breast Imaging Reporting and Data System. The 5 th Edition.
 BI-RADS 3 (probably benign)
Follow-up at 6 month, 12 months and 24 months.
- Unchangeability in diameter and other US characters in 6
months, 12 months and 24 months can assessment as benign
category 2.
- An increase in diameter of more than 20% in 6 months or
other suspicious change should prompt assessment as
suspicious  category 4 Tissue diagnosis.

Carl J. D’Orsi, MD et al. ACR BI-RADS® Atlas Breast Imaging Reporting and Data System. The 5 th Edition. 2013.
 • Category 4 (4A, 4B, 4C): Suspicious Tissue diagnosis.
– Not yet ACR - official criteria.

• Category 5: Highly Suggestive of Malignancy Tissue

diagnosis.
– Not yet ACR - official criteria (until 2013).

Until now, not yet full criterion for classification

ACR BI-RADS® Ultrasound from 0 to 6!.

Carl J. D’Orsi, MD et al. ACR BI-RADS® Atlas Breast Imaging Reporting and Data System. The 5 th
Edition. 2013.
 HOW TO CLASSIFICATION?

BENIGN SOLID FINDINGS

1. Hyperechoic (to fat).
2. Wider than tall (parallel orientation).
3. Macro-lobulations (≤ 3 lobulations).
4. Complete thin capsule.

A. Thomas Stavros. Breast Ultrasound. 1st Edition. 2004 Lippincott Williams & Wilkins.
 HOW TO CLASSIFICATION?
Kim et al (2008). Sonographic BI-
RADS (2003) descriptors showing
major findings of malignancy
include irregular shape, spiculated
margin, and microcalcifications.
(4,668 cases, 421 cases failed)

Hong et al (2005). Sonographic BI-

RADS (2003) descriptors showing
high predictive value for malignancy
include spiculated margin (86%),
irregular shape (62%), and
nonparallel orientation (69%).

(403 cases)
Eun-Kyung Kim et al. Clinical Application of the BI-RADS Final Assessment to
Breast Sonography in Conjunction
with Mammography. AJR 2008; 190:1209–1215.
 Major findings of malignancy

Irregular shape

Spiculated margin
Non-parallel
orientation
Microcalcification
Minor findings of Malignancy

1. Round shape
2. Microlobulated, indistinct, angular margin
3. Duct extension
4. Complex echogenicity
5. Posterior shadowing
The US lexicon (2013) also includes two addition findings:
6. Internal vascularity
7. Hard elasticity.
 HOW TO CLASSIFICATION?

. Eun-Kyung Kim et al. Clinical Application of the BI-RADS Final Assessment

to Breast Sonography in Conjunction
with Mammography.
BS Nguyễn Quang Trọng
CONCLUSION

Until now, not yet full criterion for classification ACR BI-RADS ®
Ultrasound from 0 to 6!.

Kim’s BI-RADS ultrasound classification is a useful reference for us

approaching ACR BI-RADS ® ultrasound.

- 2D ultrasound is still play an essential role.

It should complement by the signs in Doppler US and
Elastography US
Case study

A 56-year-old female has clinical diagnosis with

fibroadenoma.
Pathology :
 RECOMMENDATION

ELASTOGRAPHY FOR EVALUATION OF BREAST

MASSES
Thank you for your
attention!