Bi-Rads for Ultrasound - HD

Introduction

Marcella Bon Veles, president Weinstein Imaging in Pittsburgh, Pennsylvania, which is a private practice specialized in women's imaging.

I will be speaking on birads for ultrasound today. Today I'm gonna be talking about Birads for ultrasound. These are my disclosures.

BI-RADS Atlas Overview

Birads Atlas fifth Edition came out in January, 2014. The Atlas, the chairman of the committee was Dr. Dorsey, and it was, the committee was divided into three subcommittees, one mammography, which was the fifth edition. Dr. Sickle led that committee. And then, Dr. Elizabeth Morris led the MRI edition, second edition. The ultrasound second edition was chaired by Dr. Ellen Mendelssohn. Dr. Mendelssohn, Dr. Berg and I were the writing committee.

BIRAD stands for Breast Imaging Reporting and Data System. It's a practice management system developer imaging containing several important components. One, a Lexington Lexicon of descriptors for feature analysis of breast lesions. Also, a reporting structure, which includes final assessment categories and management recommendations. In addition, it's a framework for data collection and aline the birad structure contains different, chapters. One in anatomy, another image quality tissue composition feature analysis, the lexicon, which includes masses, calcifications associated features and special cases. It also includes a part in reporting systems guidance, frequently asked questions, and there's an appendix.

Changes in the Fifth Edition

The addition changes from the previous addition include den the, discussion on density, limitations of mammography, the need of correlation with ultrasound, depiction of tissue composition. There's an increase, there's been an increase in the sec anatomy section. There's also now a new section about associated features, which includes the effect of lesions on surrounding tissue. Architectural distortion also includes vascularity and elasticity assessment of the lesion. There's a expanded, the, the importance of image quality and accurate interpretation has been expanded. There's guidance in frequently asked questions. This section has also been expanded to include screening considerations and the need for audit.

Breast Density and Tissue Composition

As we know, there's been a lot of talk recently about breast density. The radiologists need to discuss the need for the radiologist to, to discuss the breast density. It's in, in its implication to increase risk of breast cancer. And here in a mammogram, we know very well that breast density has been divided into, fatty b typical scattered breast density. Heterogeneous would be C and d, a very dense breast Mammography is very limited in those patients with a very dense breast compared to those patients with a very fatty breast.

Ultrasound can also determine the, tissue, composition of the breast, as in this case, you can see a medial light oflike projection of a mammogram showing a very dense press, correlating very well with this ultrasound. Adjacent ultrasound, perpendicular projections. You can see that the, skin layer is seen through echogenic lines, separated by a hypo coic area. Beneath that is a subcutaneous fat. And then you see very echogenic tissue with tubular hypo coic structures, which represent ducts. This is typical, a typical case of a homogeneous fibro glandular tissue, breast.

Also, the breast could be homogeneously fat, and this is a good example showing, which is composed uniformly of hypo coic fat lobules and echogenic tissue arcs, which are the Cooper's ligaments, or we could describe the tissue as heterogeneous, and that's either focally or diffusely variable in echo texture with many small areas increased in decreased echogenicity. And here you go on the mammogram, medial lateral like projections. You can see heterogeneous, breast density in which there's areas of f lineal tissue and areas of fat. Corresponding well very well with the adjacent ultrasound study, showing the subcutaneous fat, and then an area of echogenic tissue within the echogenic tissue. There's hypo coic areas, which is fat within the five glandular tissue.

We've increased the section. We've made it, much more, descriptive. The area, the area on anatomy and, the breast, is described as a modified swept gland between two layers of superfic superficial petrol fascia on the anterior thorax between the second and sixth ribs. The posterior fascia layer lies just anterior to the pectoral muscle, and the anterior fascia layer lies, just beneath the skin. The breast is made up of 15 to 26 months of major ducks and branches. The loles radiate from the nipple and subdivide into lo loles subcutaneous kinetic tissue from septa. The Cooper's ligament between the lo lobes and loles, which go from the dermis to the superficial fascia, can many times be identified well with ultrasound.

Nipple-Areolar Complex

The nipple aerial complex can be difficult sometimes to see with ultrasound, unless we do certain maneuvers, for example. This is a normal nipple aerial complex can be seen well because abundant gel was placed, between the nipple and the, transducer. Here we see nicely that the nipple, is seen as a hypo coic well, circumscribed mass. And the, the skin layers are well seen here to echogenic layers, separated by, hypo coic, area. But important here is that we can see very well by using this technique, we can use very well. You can see the area behind the nipple, when, you are not, when you don't choose gel or you don't use an offset pad, many times the nipple can cause posterior acoustic shadow obliterating visualization posterior to the nipple.

The new automated breast ultrasound units also are very helpful in visualizing the aerial, the nipple aerial complex in the tissue posterior to it. As you can see here, this is the coronal view. You see nicely the skin and the nipple. And here are the, perpendicular projections. And the nipple can be well evaluated, in contrast to this patient, which a lot of gel was also used to be able to, visualize well the nipple. But in this case, a patient had a very large nipple, and this was mucin carcinoma. The nipple, a very rare, process.

The ducks can be seen by ultrasound as koic bands up to eight millimeters wide near the nipple. They decrease in size distally to about a one millimeter. And you can see theorization here in, in these two ultrasound images.

Associated Features

We've added a new section associated features, and it's the effect of the lesions to the surrounding tissue includes architectural distortion, skin thickening, pulling of the nipple, and I'm gonna show you a few cases of that. Also, the, effect of vascularity in the lesion and elasticity assessment, the associated features include no effect of the mass, no effect of, the surrounding tissue to the mass or some sort of effect. Architectural distortion can be seen as disruption of anatomic planes, cooper's ligament straightening or thickening the top duct changes in the caliber arborization skin thickening or retraction or edema. In addition, vascularity, is it present or is it absent? Is it in the mass or is it outside of the mass? And the effect, a less in evaluation of elasticity.

Here is a supine automated breast ultrasound unit, image showing, very nicely the, cancer architecture. You can see a hypo coic ill-defined mass pulling off the skin. There is, straightening of the Cooper's ligaments and the adjacent, it's very well seen that there is a associated, surrounding, effect, to the tissue. Here on the lower left is a coronal view, which is a lateral coronal view seen here on this diagram, showing nice the speculations, of the mass, the effect it has on the surrounding tissue. The cross hairs here all correspond to each other, and you can see well that on this diagram that this mass was, is, was this image was obtained in the left lateral projection. And at the time it is two o' clock and this distance, it is from the skin in the distance, it is from the nipple.

Another, patient you can see, or on the Corona view, the s**c little hypo coic or s**c actually spiculated mass on the coronal projection. When you put the cross hairs there, you see that the masses an irregularly marginated mass with posterior acoustic shadowing, pulling of the Cooper's ligaments, thickening of these ligaments and pulling. And, so there is a definitely effect on the surrounding tissue. In addition, you can see that the masses protruding into the ducks invading the adjacents and ducks affect, what effect the lesion has on vascularity. And here you have a very irregular mass, edema surrounding the mass. This is a suspicious mash, some enhancement, very suspicious. When we put flow, we see that there is increased black flow, not only to the mass, but in the surrounding emus tissue, a different patient with only increased flow in the rim of the mass. The mass is well circumscribed, it's heterogeneous, and there's no flow within it. The flow is in the surrounding tissue, and this is an abscess.

Elasticity Assessment

Elasticity is tissue stiffness, and it's really become the 21st century palpation. The expectation is that malignancy is hard and something benign will be soft. However, there is, super imposition of both. There's two types. There's the strain in the sheer wave elastography, and we still need to develop descriptors for these two types of, elastography. Now, we can also quantify by the, amount of tissue stiffness, which will help us in better determine if the lesion is hard or soft. And here in sheer wave you can see, an example of a blue is soft, and that's supposed to be benign and hard is red, as you can see in this little image. There's lots of red and yellow surrounding this mass. And then there's a big range of cases that are inter indeterminate.

And here are two different patients. Again, ill defined on the, on the B mode. You can see, ill defined ma hypo cogic mass with shi shadowing irregular shaped. And this is looks like a cancer. And when you put the elastography, you see that there is very stiff tissue surrounding the mass. In contrast to this, on your right, a circumscribed oval mass parallel to the skin layers sonographic, it has all the characteristics of a benign lesion. When we did a elastography, yet it corresponded well with it blew. It was soft, the mass was soft, the adjacents tissue was soft. This would correspond to a bin and give you confidence that the, this does not need any further evaluation with a biopsy strain elastography, it's been described that trilaminar sign in patients which have debris containing cysts. And here's a, a hypo coic debris containing cyst, which, enhancement posterity. And many times you can't tell in these cases if it's, a debris containing cyst or actually a, a a a mass. Well, they've described the trilaminar sign in which the three colors are seen, red, yellow, and blue. And this should help you differentiate debris containing cyst from, a cancer.

However, I wanna show you this case I had, recently in which you see a you regularly marginated mass hypo coic mass. This looks, it is suspicious for malignancy. When we did the elastography got the trilaminar sign, which would lead us to believe that it was benign. However, because of the morphology of the mass, we biopsied it. And this was am mucinous carcinoma. So you need to be careful. Morphology is most important.

Image Quality and Accurate Interpretation

We also have really expanded the section on the importance of image quality and accurate interpretation. We talk about the trans transducer frequency, important to have a high end transducer that's 12, between 12 and 18 megahertz with a five centimeter penetration. The importance of gain and focal zone to differentiate a cyst from a solid mass. We also talk about the importance of knowing when to use compound imaging and when to use harmonic harmonics. The feel of view, the depth setting of the tissue that will display on the monitor should not include a flora or the lung for large lesions, consider using an extended feel of view, panoramic, or sometimes said to be called para monic. Panoramic or the OID acquisition can be used in these, large lesions. Important the patient positioning. Also avoid compression when evaluating with color to to, to avoid occluding the blood vessels.

Here we have two different, we have the same patient with using a 12 megahertz and a 17 megahertz transducer on the top. The 12 megahertz transducer does identify the calcifications within the ducts. However, the 17 linear 17 better visualizes the, calcifications within the ducts. Here's two pa two, images with the same, cyst. And you can see that the tissue posterior to the simple cyst, it enhances brightly, but the refraction shattering at the lateral margins of the cyst obscures the adjacent tissue. In this with a native mode, when you add the, spatial compounding, you can see much better the, margins of the cyst. Also, you can see the area posterior to the cyst, even though the enhancement is decreased with com spatial compounding. So it's important for you to know that you should be able to go back and forth, use spatial compounding when you may evaluating the cyst. And sometimes you may need to go back and use a native mode wide field of view.

It can be very, helpful in cases in which you have multiple cyst to try to, to see the, relationship between one mass and the other mass. And this is the panoramic view that can be obtained with most, machines. And here is the automated breast ultrasound unit showing very nicely, a fuel of view that extends 14 centimeters. And so you can see multiple dilated ducts with hypo coic material with it. It's also seen in the Corona projection here, in this patient who had multiple abscesses.

Feature Analysis of Masses

A mass. A mass is defined as something that occupies space and should be seen in two projections. Masses can be distinguished from normal structures such as ribs or fat lobules using two or more projections and real time scanning. It's combined. Multiple features are the best predictors of a mass. If it's benign or malignant, multiple features will always be used, but the most important are shape margins and orientation for ultrasound, don't just select one parallel or wider than taller is not always benign. Many cancers can also be parallel to the skin. So the Lexington feature analysis of the masses, the big three include shape, orientation and margins. Shape includes oval, including macro, lobulated, round, or irregular orientation is parallel to the skin or not parallel to the skin. And margins include circumscribed or not circumscribed. We are now including in this section the echogenic rim. Under non circumscribed, it's indistinct, micro lobulated, angular and speculated.

Shape

So masses can either be oval, round or irregular or oval or when they're elliptical or egg shape. They may include two or three undulations, gently lobulated or macro lobulated. Wrong is when it's it's spherical ball shaped circular or gular. Irregular is when it's neither round nor oval. Here's a good example of an oval mass. It's, two projections. Here's different cases, three different cases of a round mass. In both projections, the masses are round. Now in this case it's a papilloma. Here is a clot within a cyst. And here is a new, metastatic lymph adenopathy. Irregular is when it's neither round or oval. And you can see here three different examples of irregular masses orientation.

Orientation

That's a property of masses unique to ultrasound. It's defined with a reference to the skin line. It's parallel wider than taller. Orientation is a feature of some benign masses such as omas, but can also be seen in carcinomas. Shape orientation and marginal character characteristics should always dictate the assessment category. Here is a diagram of the, an oval shape and a mass that's oval, but also oriented parallel to the skin. These are usually fibroadenoma cysts or sebaceous cyst, but they can also be seen in cancers. And here's an example of two ultrasound cases. Long axis of the lesions is aligned with the skin layer. It's horizontal or wider, better wider than taller. However, on your left side you see the circumcised mass, which is, has a characteristics of a benign fibroadenoma on your right. Also a mass that's parallel to the skin. And also you can see that this patient had implants. It's the mass is just abutting the implant, but this mass is not well or it's not circumscribed, it's lobulated, it's irregular. And this was a cancer, another irregular, mass, which was parallel to the skin layers in both projections. And this was a cancer.

What about masses that are not parallel to the skin? The anterior, posterior, or vertical dimensions is greater than the transverse or hor or horizontal dimension. Sometimes calls referred to as vertical or taller than wider round masses are not parallel. Non-parallel masses can also be obliquely oriented. And here are two irregular masses which are not parallel to the skin layers. And these were two different types of infiltrate ductal carcinoma. And here is a diagram showing a round mass, which is, not peril to the skin. And these usually refer to as cancers, but can be seen in cys, in abscesses margins.

Margins

Circumscribed or not circumscribed. The margin is the edge or the border of the legion. Circumscribed means well-defined, smooth, distinct rim. And here you see it in a cyst. Non circumscribed include indistinct can be either indistinct, angular, micro lobular, or speculated. Angular is part of all margins have sharp corners or form acute angles, as in this case in the perpendicular projection, you can see that there's angulation of the margins indistinct or poorly defined. And you can see here this hypo coic mass, which you can't really delineate well. And this was an infiltrate ductal carcinoma too. Micro lobulated, when there's greater than three small short cir cir cycle in, as in this case, these are perpendicular projections of the same mass, which was also a cancer speculated. These are margins form or characterized by sharp lines projecting in from the mass into the adjacent tissue. And this mass, you can see here, perpendicular protection was a malignancy.

We have now moved the echogenic halo rim to, to be part of the non circumscribed margins. And the echogenic rim is not a sharp demarcation when there's not a sharp demarcation between the mass and surrounding tissue. This can be seen in cancers and also in abscesses echo par pattern.

Echo Pattern

Well, it can be either ncoic when there's no internal echos hyper coic when it's defined, it's defined relative to the fat and equal to the fibroid linear tissue. Hypo coic is defined also relative to the fat. And it's low level echoes throughout it's seen. It can be seen in complicated cysts or fibroid omas, usually anti coic. Here's a example of a mass with no internal echos, and this was a cyst hypo coic re relative to the fat low level echoes throughout and similar to the adjacent, or when compared, it's hypo coic compared to the adjacent uh, fat loles. This can be seen in, complicated ssis seen in this case of fibroadenomas. Hyper coic is when it's homogeneously hyper coic defined relative to the fat. And here we see a hyper hyper coic mass relative to the fat.

Now when you correlate this with your, the mammogram, which a patient came in with a palpable mass, you can see that this, there was no solid mass here, but just a fat lole. So this represented a lipoma in this patient who had a palpable mass, which was hyper colic on ultrasound. And that note on, on mammography, it showed that it was fat density, another patient which has a very fatty breast. When we did the ultrasound of the palpable abnormality, which there was an ill-defined density there, or ill ill-defined mass, we saw that the mass were hyper eCOA compared to the adjacent fat loles in this case because of the borders of the mass. And on both the mammogram and ultrasound ultrasound guided core biopsy and was done. And this was an infiltrate duct carcinoma. Another patient, this was a hyper coic mass. She presented with a palpable abnormality and the hyper coic mass was also very echogenic or hyper. The borders were not well defined with, some shadowing and this was a, a lymphoma echo pattern can also include iso coic when it's the same echogenicity as fat, or it can be a complex cystic and solid mass combined as in this example where it is a cystic area and also an echogenic area. And here is an example which can be correlated. Well, with a mammogram in a patient with fat necrosis, mixed hyper and hypoechoic, echo pattern can be seen. That's when portion of the masses are hyper coic to fat and portions are hypoechoic to the fat with no cystic component.

Posterior Acoustic Features

What about posterior acoustic features? Well, there could be no posterior acoustic, change or there can be enhancement. Increased posterior echos shadowing, decrease, posterior echos extending, excluding, excluding edge shadows. And this can be seen in 60% of the ca cancers or you could have combined pattern in which there is both shadowing and enhancement. Here are three different patients. On this one. On your left, there is really no significant, posterior acoustic, features. On your right, you see that this com mass that has a cystic and a solid components has, prominent posterior acoustic enhancement shadowing is seen in this patient with regular mass, with hypo coic and shadowing, posterior to it. And in this mass here, it seems like there may be both some posterior and some enhancement to it.

Calcifications

Calcifications important to identify if they are not seen or if they are present. If they are present, are they microcalcifications larger than 0.5 millimeters or are they microcalcifications, which are out of the mass, outside of the mass or in the ducts or within a mass? Here is an ultrasound showing little calcifications within echogenic tissue in a patient with, calcifications. So we're outside of a mass. And here you see nicely on the mammogram. Magnified view shows a patient with ductal carcinoma situ and the calcifications were able to be identified with ultrasound. The importance of this is that if you can identify the calcifications on ultrasound, you can do the biopsy under ultrasound guidance, which is much easier, quicker for the patient than a stereotactic core biopsy.

A different patient came in with a palpable mass, and here you see medial lateral block projection and C view. Right in the area there is some cal, there are some calcifications and better seen here in ultrasound. You see the mass and the, when the calcifications are within the mass, they're usually much easier to see. This is a mass that was, had cystic and solid components and the calcifications were seen another patient in which calcifications were seen on the mammogram. Going back and looking under ultrasound to see that the cal of these calcifications were seen within this duck is, as I said, you are not going to change your decision if you're going to biopsy this because of what you see on ultrasound. You're gonna make your decision on the morphology on them, on the mammogram. But by visualizing them on ultrasound, you can certainly do the biopsy, and sample them.

Special Cases

We have a section on special cases. These include cyst, complicated cyst, clustered, microcyst, introductory mass mass in or on the skin, foreign body lymph node, interem or axillary male breasts, post breast conversation, fat necrosis and including vascular abnormalities such as AV malformation, pseudo aneurysms and RS disease. And I'm gonna show you ex a few examples of these.

Clustered Microcysts

Here's an example, micro, a clustered microcyst. And these are perpendicular projections. And you can see this is a mass with multiple tiny little cysts. Septations are thin. There are no solid components. It's very important to evaluate these carefully. Make sure there's not a soil component because it's been shown that there, if you do see a soil component, you probably should biopsy these. If you do not see any soil component, there's septations like these things septations, these are benign and don't even need to be followed.

Occult Masses

Octal masses. Here's a case that the panoramic imaging wide field of view helped to show the extent of this UCT mass, which was at papilloma.

Masses in or on the Skin

What are bat masses in the skin? Well, this is a magnified view as you can see of the two skin layers and the hypo coic, area between the two, skin layers. You can see here within it there is a mass, which is debris containing with a little peak, very typical of a complicated sage seba cyst. These sebaceous cyst, usually nothing needs to be done unless the patient is symptomatic and sometimes you'll aspirate them for a relief of the pain. But another patient here also had a little mass adjacent to the skin and we did a, cone compression view and we could see it was arising from the skin. And you can see on ultrasound that it's really between, it's seen between the two skin layers. However, this mass had a very irregular borders or margins as you can see here. And because of that it was cord and this was an infiltrate ductal carcinoma. So make sure margins are clear are circumscribed.

Foreign Bodies

Also this in this section it's including foreign bodies such as free silicone. Here you see echogenic material outside, the, implant or postoperative scar in which can be, seen sometimes as a hypo coic mass with shadowing and can assimilate a cancer. However, you see this mask goes right into the skin and there is disruption of the skin layer where the surgery was done.

Lymph Nodes

Lymph nodes, lymph nodes are in this section here is abnormal lymph nodes. An asymmetry asymmetrical thickening of this cortex, is very, suspicious for metastatic, lymph node, metastatic cancer to the axillary lymph node. Lymph nodes can be very large. The size is not as important as the region. of how much cortex is involved with, is hypo coic in this case. This is a large echogenic lymph node in the a axilla and is completely normal adjacent to it. There was another one and the reason is the, hili is completely, filled with, fatty tissue. These are two other normal appearing sonographic, appearing lymph nodes in the, breast tissue. And these look like, almost like kidneys. They have a hypo cortex and a echogenic hilum and flow can be seen going right into the hyla.

Male Breasts

In this section, we've included the male breast and here is a patient with a patient, a male with a palpable left subular mass. You can see that there is an asymmetry between one side and the other side. We con compress the view and posterior to it. We did see some irregularity and increased flow in this patient who had a gynecomastia In these cases, sometimes you are forced to biopsy them if you're not sure, you can make the diagnosis with the ultrasound and mammogram. Another patient came in here with a popup, a male with a palpable right subular mass. Now you can see on the mammogram the mass has irregular borders. There is retraction of the nipple pulling by the mass. And on ultrasound there was a, a irregular ma, mass hypo coic. And this was, an infiltrate ductal carcinoma.

Fat Necrosis

In this section we also included fat necrosis. And here you can see on ultrasound the mass. If you did just an ultrasound on this patient who came in with a palpable abnormality, you would see an irregular high round hypo coic mass, which is suspicious for cancer. However, when you correlate it with a mammogram, you see that this is the region of the fat, of the lumpectomy side, and she has, developed fat necrosis mondor disease.

Vascular Abnormalities

This, is including this section in which you can see here, a vessel. The patient came in with a palpable abnormality and this was partially, occluded this, vein, another patient also a very dilated, beaded like appearance of a vein, which, did not have any flow and even did not compress. And this was amond disease in two different patients.

Assessment Categories

So at the end, we need to also, after evaluating mass, we need to be able to assess it. Is it negative and give it a birads one. Is it benign? Give it birads two, such as a cyst or a thyroid anoma. Is it, is it a probable benign? In this case you may include omas and you wanna short interval follow-up. These are usually lesions that you think have less than 2% likelihood of malignancy. Or is it suspicious for malignancy greater than we have di sub-divided. Now, birads four has been divided into birads four A, which is two to four, two to 10%, malignancy risk or four B, 11 to 50% risk of malignancy or four C 51 to 95%, risk of malignancy or is it birads five in which there's highly suspicious for malignancy greater than 95% likelihood. Or is it a patient that had already a known carcinoma and now is here for evaluation of another lesion?

Summary

So in summary, check technical quality before attempting to interpret any imaging examination, appreciate the importance of real time observation and in analyzing a lesion, use the feature analysis categories first, that shape the margins in the orientation descriptors within each category should also be included. Integrate ultrasound with other modalities in clinical data. Reach a conclusion, final assessment with a recommendation. Thank you.