What does BIRADS on your mammography/ ultrasound report mean?

Lot of times in my Breast Clinic at CK Birla Hospital, Gurgaon, I get patients who come and tell me that they are suffering from stage III breast cancer. When I ask them how do they know about that, the answer which I usually hear is that “my mammogram/ ultrasound report shows BIRADS III.” Not only patients but I have also seen some doctors getting confused with the BIRADS reporting.

BIRADS (Breast Imaging Reporting and Data Systems) is a standardized way of reporting breast radiology reports.  This helps radiologists categorize patients from a score of 0-6 and it helps breast cancer surgeons in taking decisions based on this score. Having a uniform reporting system is useful because patients might get their radiology and breast disease treatment done at different places.

The score doesn’t imply the stage of cancer and patients should be aware of this to avoid unnecessary anxiety after seeing the radiology report.

  • BIRADS 0 means an incomplete investigation – This usually occurs when a mammogram is done in a patient with a dense breast and it does not yield any meaningful information. In such a case, usually an ultrasound or MRI Breast is done

 

  • BIRADS 1 is a negative scan, which basically implies that there is no lesion in the breast and everything is normal. In these patients we advise them to follow up after 1 year

 

  • BIRADS 2 is suggestive of a benign lesion, which has essentially a 0% risk of cancer and these lumps don’t require a biopsy. They can be followed up in a year’s time. Simple cysts, most typical fibroadenomas fall under this category.

 

  • BIRADS 3 lesions are probably benign and these breast lesions/ lumps should be followed up every 6 months (short term follow-up). These lumps do not require a biopsy/ FNAC but if you have a family history of breast cancer, then the clinician might be inclined to do more tests/ biopsy at this stage rather than wait for 6 months.  Fibroadenomas, duct ectasias can fall under this category of lesions.

 

  • BIRADS 4 breast lumps/ lesions are suspicious lesions and they need to be biopsied to confirm the diagnosis. They are further sub-divided into 4a, 4b, 4c which implies low, medium and high risk for cancer. These patients should be counselled accordingly and a tru-cut/ core needle biopsy should be scheduled as soon as possible. Atypical fibroadenomas, suspicious microcalcifications, duct papillomas usually fall under this category of lesions

 

  • BIRADS 5 lesions are highly suggestive of malignancy and the risk of cancer in these breast lumps is more than 95%. All patients with these breast lumps should be subjected to the tru-cut biopsy, which is preferred over a FNAC (fine needle aspiration cytology)

 

  • BIARDS 6 lesions are when a radiological test is done after confirming the diagnosis of breast cancer.

 

The table below summarizes the BIRADS score and the action which needs to be taken in each category.

The Radiology Assistant : Bi-RADS for Mammography and Ultrasound 2013

 

So the next time you receive your mammography / breast ultrasound report, don’t be surprised to see the BIRADS score. Discuss the report with your radiologist and breast cancer surgeon and take action accordingly. Remember, that all breast lumps are not cancerous and all of them don’t even require a biopsy/ FNAC test.

 

This information has been provided by

Dr. Rohan Khandelwal

Principal Consultant,

The Breast Centre

CK Birla Hospital, Gurugram

Interesting Mammogram #4 

47 year old lady with complaints of bilateral breast pain since 3 months. Pain was non cyclical and relieved by oral paracetamol. She had a hysterectomy 6 years back and she was a known asthmatic.

On examination, she has multiple tender nodules in both the breasts, localised in the peri-areolar region. 

Mammogram revealed multiple, well defined, rounded densities in both the breasts with a rim of calcification around them (refer to figures). 

Multiple round densities in the breast


Ultrasound done revealed dense fibroglandular tissue with multiple sub-centimetric cysts in the breasts. 

Differential – 1. Multiple oil cysts with calcification 

2. Cysts secondary to fibroadenosis

Case managed by:

Dr Rohan Khandelwal

Consultant, Department of Breast Diseases and Cancer Care

W Pratiksha Hospital, Gurgaon  

8 simple tips to reduce your risk of developing breast cancer and aid in early detection

Recent data has indicated that breast cancer is the now the most common cancer among Indian women. One in 22 Indian women will be affected from this cancer during their lifetime. A healthy lifestyle can help in reducing one’s risk of getting this disease.
I am sharing 8 simple tips, which can help in reducing your risk of developing this disease and also help in early detection.
1. Regular exercise – at least 30 mins of exercise 4 times a week
2. Avoid smoking
3. Avoid alcohol consumption
4. Over-weight and obese individuals have a higher incidence of breast cancer. Maintain your weight in the normal range
5. Be breast aware – do regular self examinations
6. Clinical breast examination by an experienced breast surgeon after the age of 35 years (annually)
7. Regular mammograms after 40 years of age. Although they just take 10 mins, ladies often decide to skip them. The simplest way to remember this is to ‘gift yourself a mammogram’ on your birthday.
8. If there is a family history of breast cancer, do consult your oncologist to discuss your risk of breast cancer.
#BreastCancer #WorldCancerDay #Cancer
breastcancer
Consultant, Breast Onco-Surgeon
Gurgaon, India

Interesting Mammograms #3

Case 1: 44 year old lady with a rapidly enlarging lump in the right breast of 6 months duration. On examination, she had a 3×3 cm hard lump in the lower half of her right breast. Surprisingly, she had a 5×5 cm hard, fixed axillary lymph node.

Reason of sharing this mammogram: bulky axillary lymphadenopathy with the lymph nodes being larger than the primary.

20130705_162845

 

Case 2: Patient had a lesion in the left breast, which was biopsied. Wanted to point out the steri-strip (artifact) after biopsy.

Pre- biopsy
IMG_20140910_144444

Post- biopsy
IMG_20140910_144305

 

Information provided by:

Dr. Rohan Khandelwal

Consultant, Breast Oncosurgeon

W Pratiksha Hospital

Interesting Mammogram #2

Case: 45 year old lady that presented with a painless, progressive breast lump on the left side of 7 months duration.

On examination: A10x10 cms firm, mobile lump involving the entire left breast was palpable. There were dilated veins overlying the lump with no palpable axillary lymphadenopathy.

Mammogram is shown below:

image

image

Mammogram was suggestive of an encapsulated lesion with smooth margins, probably a phyllodes tumor.

Tru-cut : Phyllodes tumor
HPE: Benign phyllodes

Learning objective: Benign encapsulated tumor on mammogram suggestive of phyllodes. Capsule is visualized as a radiolucent halo around the lump.

 

Information provided by:

Dr. Rohan Khandelwal

Consultant, Breast Oncosurgeon

W Pratiksha Hospital

Interesting Mammograms #1

Mammography is a vital tool used for screening & diagnosing breast lumps (benign & malignant). In this new thread, I will be sharing some interesting mammograms every week, which I see in my practice.

Case #1

Calcified Fibroadenoma in a 32 year old lady.

H/o lump in the left breast for the last 12 years. Not increasing in size & Painless.

X-ray mammography revealed an area of dense calficification (macrocalcification) at 9-10 o’ clock position.

Calcified Fibroadenoma

 

 

Case # 2: 

X-ray mammogram highlighting the difference between benign & malignant lymph nodes in the axilla.

History: 45 year old lady with an enlarging right breast lump x 4 months

On examination: 4×4 cm hard breast lump in the upper outer quadrant of the right breast with palpable axillary LN.

Mammogram showing the primary lesion (cancerous growth) in the right breast and malignant axillary LN on the right side (rounded LN with loss of fatty hilum).

Benign LN can be seen in the left axilla (with preserved fatty hilum).

Primary & nodes

 

The second mammography picture highlights the difference between malignant (right) & benign (left) lymph nodes in the axilla

Nodes

 

Information provided by:

Dr. Rohan Khandelwal

Consultant, Breast Oncosurgeon

W Pratiksha Hospital

Paget’s disease of the Breast

Paget’s disease of the breast or nipple is an eczematous condition involving the nipple and areolar skin, which is histologically characterized by the presence of malignant cells interspersed within the keratinocytes of the epidermis (cells of the skin). In approximately 90% of cases, the condition is associated with an in situ or invasive breast carcinoma.

Symptoms:

  • Chronic eczematous lesion involving the nipple (most common presentation) [highlighted in the image]
  • Nipple erythema or ulceration
  • Nipple inversion
  • Nipple discharge
  • Pruritus
  • As many as 40% of women have a palpable mass on presentation, and some may present with enlarged axillary lymph nodes.
Ulceration of the nipple

Ulceration of the nipple

Imaging:

90% patients who present with an underlying breast lump along with Paget’s have abnormal findings on mammography but only 50% patients who present with Paegt’s without a breast lump show mammographic abnormalities. Magnetic resonance imaging (MRI) is increasingly being used, particularly in cases without a palpable mass. MRI is particularly useful to establish extent of disease in patients in which breast-conserving surgery is being contemplated.

Pathology: The hallmark of Paget’s is the presence of neoplastic cells within the epidermis that show abundant clear cytoplasm and tend to spread individually in between the native keratinocytes (Image). They tend to display prominent nucleoli and frequent mitoses. In addition, they commonly show intracytoplasmic mucin-filled vacuoles, which are stained with a periodic-acid-Schiff or mucicarmine stain.

Paget cells seen in the epidermis

Paget cells seen in the epidermis

Paget cells are usually positive for markers of breast epithelium differentiation like:

  • Cytokeratin 7
  • CAM 5.2
  • Low-molecular-weight cytokeratins (negative for high-molecular-weight cytokeratins)
  • Vast majority of cases show strong overexpression of the HER2/neu proteinion of the gene
  • Positive for mucin
  • 18-20% of Paget’s cells express S100 protein but contrary to melanoma cells, HMB45 is consistently negative.

Toker cells are immunophenotypically similar to Paget cells, sharing expression of cytokeratin 7 and CAM 5.2, absence of high-molecular-weight cytokeratin expression, and negative S100- and HMB45-expression. They differ in the negative expression of mucin, HER2/neu, and epithelial membrane antigen. The similarities between Toker and Paget cells have suggested that the former may represent the cell that undergoes malignant transformation in the initial phases of PD. Toker cells can be present in normal patients as well.

The most accepted explanation for the development of PD is that Paget cells result from the migration of cells from the underlying adenocarcinoma through the epidermis, the so-called epidermotropic theory. This theory is supported by the existence of an underlying carcinoma in about 90% of cases of PD, which usually shares phenotypic similarities with Paget cells.

 

Differential Diagnosis:

  • Eczema – tends to be bilateral and responds to topical steroids
  • Nipple adenoma

Diagnosis: 

  • Wedge biopsy
  • Punch biopsy

Management: Management of PD depends on the underlying breast lump. Traditionally, the surgical procedure of choice has been a mastectomy but there are numerous studies which show that breast conservation surgery can be carried out in patients with PD. Prognosis in PD is largely determined by the underlying breast tumor.

 

Source: 1. Bland & Copeland – The Breast. 4th Edition 2. Michael Sabel – Essentials of Breast Surgery