BIRADS – What to do with the report

Updated: 19may6

BIRADS

BIRADS stands for Breast Imaging-Reporting and Data System.

BIRADS is a standard system of describing breast imaging findings and results.  The system sorts the results into categories numbered 0 through 6.

0 – incomplete

1 – negative

2 – benign findings

3 – probably benign

4 – suspicious abnormality

5 – highly suspicious of malignancy

6 – known biopsy with proven malignancy

BIRADS is a widely used risk assessment and quality assurance tool in mammography, ultrasound or MRI.  It started with mammograms and later, it was adopted for use in ultrasound and MRI for breasts.

At the moment, reporting BIRADS is not a formal requirement for radiologists in the Philippines and abroad but most include such reporting nowadays.

The objectives for coming out with BIRADS is to make the reporting of breast imaging (which started with mammograms) more standardized and comprehensible to all, radiologists, non-radiologists and even patients, reading the report.

What do the BIRADS scores mean?

Category Definition What it means
0 Additional imaging evaluation and/or comparison to prior mammograms is needed. This means the radiologist may have seen a possible abnormality, but it was not clear and you will need more tests, such as the use of spot compression (applying compression to a smaller area when doing the mammogram), magnified views, special mammogram views, or ultrasound. This may also suggest that your doctor should compare your new mammogram with older ones to see if there have been changes in the area over time.
1 Negative There’s no significant abnormality to report. Your breasts look the same (they are symmetrical) with no masses (lumps), distorted structures, or suspicious calcifications. In this case, negative means nothing bad was found.
2 Benign (non-cancerous) finding This is also a negative mammogram result (there’s no sign of cancer), but the reporting doctor chooses to describe a finding known to be benign, such as benign calcifications, lymph nodes in the breast, or calcified fibroadenomas. This ensures that others who look at the mammogram will not misinterpret the benign finding as suspicious. This finding is recorded in your mammogram report to help when comparing to future mammograms.
3 Probably benign finding – Follow-up in a short time frame is suggested The findings in this category have a very high chance (greater than 98%) of being benign (not cancer). The findings are not expected to change over time. But since it’s not proven benign, it’s helpful to see if the area in question does change over time.

You will likely need follow-up with repeat imaging in 6 months and regularly after that until the finding is known to be stable (usually at least 2 years). This approach helps avoid unnecessary biopsies, but if the area does change over time, it still allows for early diagnosis.

4 Suspicious abnormality – Biopsy should be considered Findings do not definitely look like cancer but could be cancer. The radiologist is concerned enough to recommend a biopsy. The findings in this category can have a wide range of suspicion levels. For this reason, some, but not all, doctors divide this category further:

4A: Finding with a low suspicion of being cancer

4B: Finding with an intermediate suspicion of being cancer

4C: Finding of moderate concern of being cancer, but not as high as Category 5

5 Highly suggestive of malignancy – Appropriate action should be taken The findings look like cancer and have a high chance (at least 95%) of being cancer. Biopsy is very strongly recommended.
6 Known biopsy-proven malignancy – Appropriate action should be taken This category is only used for findings on a mammogram that have already been shown to be cancer by a previous biopsy. Mammograms may be used in this way to see how well the cancer is responding to treatment.

Source:

http://www.cancer.org/treatment/understandingyourdiagnosis/examsandtestdescriptions/mammogramsandotherbreastimagingprocedures/mammograms-and-other-breast-imaging-procedures-mammo-report

Implications of the BIRADS report in terms of risk for breast cancer (assumption: accurate readings):

  • BIRADS I: ~ 1%
  • BIRADS II: ~1%
  • BIRADS III: ~2%
  • BIRADS IV: ~30%
    • BIRADS IVA: ~13%
    • BIRADS IVB: ~36%
    • BIRADS IVC: ~79%
  • BIRADS V: ~95%
  • BIRADS VI:~99%

 

BIRADS as a standardizing tool in communication

The BIRADS categorization or reporting is not primarily intended as a diagnostic tool although a diagnosis can be deduced.  It is primarily intended to standardize communications. For diagnosis, reliance should be placed more on the reported imaging findings, both positive and negative findings, rather than on BIRADS categorization.  The reported imaging findings should be correlated with the clinical findings to come out to a pretreatment diagnosis.

Radiologists usually include a footnote in their imaging report that runs like this: “the abovementioned report is a subjective medical opinion based on the objective radiographic findings and should be correlated clinically.”

How I as a breast specialist do it with regards to imaging reports and BIRADS categorization

I always correlate the imaging (mammogram, ultrasound and MRI) findings and BIRADS categorization with my clinical findings.

I always look at the imaging plates (if done and available) in patients with BIRADS 4 to 6 categorization to understand the report of the radiologists.

My experience has shown the following practices on BIRADS reporting in the Philippines (Note: as I discuss this, I will include what I usually do to arrive to a pretreatment diagnosis in the challenging cases; my usual practice with imaging reports; and recommendations for the radiologists):

  • BIRADS-0 is more commonly reported in mammogram than in ultrasound (practically nil).
  • Those with reported BIRADS-0 on mammography and with no dominant breast mass palpated and other abnormal physical examination findings on the breasts, I look for imaging signals for cancer particularly clustered microcalcifications on the report. If there are no imaging signals for breast cancer, I treat the BIRADS-0 as BIRADS-1 or BIRADS-2 (depending on the physical findings).
  • Those with reported BIRADS-4 on mammogram or ultrasound, if there are no dominant breast mass palpated and other abnormal physical examination findings on the breasts, I usually give two options. The first option is watchful monitoring consisting of monthly breast self-examination, regular breast specialist clinical examination and evaluation at closely planned interval, and repeat the imaging procedure after 3 months.  The second option is to repeat the imaging procedure with a report of BIRADS-4 in another institution for a second opinion and then act accordingly.  My experience has shown that majority of those with BIRADS-4 reading will have a shift to BIRADS-3 reading upon repeat in another institution.  My experience has also shown that majority of those with BIRADS shift from 4 to 3 have no clinical breast cancer after years (longest – more than 10 years) of follow-up.  [A case in point – latest event – May 3, 2016 – YC, 54-year-old female with BIRADS-4B on ultrasound of the breast 2 years ago, with no dominant breast mass and other abnormal physical examination findings on the breasts.  Repeat ultrasound a week after consulting me done in another facility showed BIRADS 3.   Another repeat ultrasound in 2016 still showed BIRADS-3.  She had been on regular check-up with me for the past 2 years.  As of May 3, 2016, 2 years after having an initial BIRADS 4B report, there is no development of clinical breast cancer.]
  • The radiologists commonly include recommendations on what further diagnostic procedure to do for those with reports of BIRADS 4 to 5. My advice to them is not to include anymore.  Let the clinical breast specialists discuss and decide on this issue with the patient.
  • The radiologists commonly include recommendations on repeat imaging procedures after so many months for those with reports of BIRADS 1-3. My advice to them is not to include anymore.  Let the clinical breast specialists discuss and decide on this issue with the patient.

ROJ-TPOR@16may4


Since 2016, I have been collecting patients with BIRADS 4 on ultrasound and/or mammography which turned out to be negative or became BIRADS 3 on subsequent imaging tests and with at least one year of follow-up.  The patients had no clinical dominant mass.  They were just monitored.

As of August 26, 2018, I have collected 19 patients.  I think I have incomplete recording.  The number can be more.  I will try to update it.  I will also try to collect more until I reach 30 patients.


ROJ@18aug26


As of May 6, 2019, I have collected 21 patients.  I think I have incomplete recording.  The number can be more.  I will try to update it.  I will also try to collect more until I reach 30 patients.

ROJ@19may6


 

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