breast and chest imaging Flashcards
- imaging techniques of chest diseases
- X-ray
- Ultrasound
- CT
- MRI
o Introduction:
- Approximately 40% of all radiographic examinations are performed to investigate pathologies of the chest
- Plain film, fluoroscopy, CT, MRI, Ultrasound, Angiography
- Keys to read x-ray well: good understanding of normal anatomy and good search pattern
o Chest x-ray: (heart and lungs)
- Still the initial examination procedure for diseases of heart and lungs
- The radiation burden of a conventional chest radiograph is low
- Chest x-ray in standing position (performed in deep inspiration with posteroanterior and lateral images along the left side)
- Chest x-ray in supine patient (in patients unable to walk, lateral image not obtained)
o Fluoroscopy:
- Used as additional investigation in selected cases
- Radiation burden depends on the duration of the investigation
- Indications: Assessment of the motion of the diaphragm and control of pacemaker probes
o CT:
- Most sensitive examination for diagnostic investigation of pulmonary and mediastinal processes
- Indication (wide):
1. Solitary pulmonary nodules
2. Diffuse lung disease
3. Staging of lung tumors
4. Investigation of mediastinal and pleural pathologies
5. CT-guided biopsy of pathological findings
6. Pulmonary embolism
7. Complication in pneumonia
8. Aortic dissection
9. Chest trauma
10. Bronchiectasis
- Investigation usually conducted in inspiration
- Contrast with iodine is requires to assess mediastinum
- Radiation load of CT of chest may be more than a hundred-fold higher than of chest x-ray
o Ultrasonography:
- Used to demonstrate and quantify pleural effusions
- Used for optimal setting of the puncture or drainage site for pleural effusions - In cases of pleural empyema (septations can be viewed prior to drainage) - Intrapleural septations are imaged more clearly on USG than CT
- Exact location and spread of a chambered effusion is better on CT than USG - Also used to detect pneumothorax
o MRI:
- Currently of secondary importance for investigation of pulmonary pathologies - However, important indications for MRI are the following:
1. Problematic issues in staging lung carcinoma
2. Classification of mediastinal tumors
3. Investigation of patients with an iodine allergy
- chest x-ray evaluation
o Introduction:
- Keys to read x-ray well is:
1. Good understanding of normal anatomy
2. A good search pattern
3. Important to understand how x-rays are produced:
o Imaging: (general info from lecture)
- X-ray beams contains photons of different energies
- As they pass through patients:
1. Some are absorbed completely
2. Some penetrated directly to the plain film
3. Some are absorbed partially
4. Some are deflected (scatter)
- Tissue density is a product of the type of tissue and the thickness of it (results in differential absorption)
Differential absorption:
1. Penetration of the x-ray beam is dependent on tissue density
2. Denser object = less penetration
3. Less beam striking on the film = more absorption = whiter
4. More beam striking the film = blacker
5. Black = Air (lungs/trachea/outside body)
6. White = Bone, metals/atherosclerosis plaque
7. Air 🡪 Fat 🡪 Water 🡪 Bone 🡪 Metal (from black to white)
o Chest radiographs:
- PA (posteroanterior) and Lateral (left) – minimizes magnification of heart
- Portable (nearly always AP) – supine or erect
o Evaluation:
1. Heart size (normal is < 50 % on PA upright radiograph
2. Lungs (Lung fields – Upper – Middle – Lower)
3. Chest radiographs are read concentrically (from periphery towards the centre)
4. First circle = outside the bony thorax (skin, soft tissues, mammary gland and subdiaphragmatic area)
5. Second circle = The bony thorax and diaphragm
6. Third circle = pulmonary parenchyma (volume, radiodensity, vascularization, no need for contrast material, you have here a natural angiogram, so take advantage of it!)
7. Read lung parenchyma from top to bottom and from left to right
8. Fourth circle = the mediastinum (identification of the main mediastinal junction lined and stripes and analysis of the 4 most important regional nodal stations
9. Silhouette sign: The lower right border of the heart is not visible. Air space consolidation with air bronchogram: bronchopneumonia of the middle lobe
o Target evaluation:
1. First target: The retroclavicular zone (foci of pulmonary tuberculosis, neoplasms, pancoast´s tumor)
2. Second target is: the hilum (density, size, abnormal opacity, lymph nodes)
3. Third target is: retrocardiac region (bronchopneumonia, atelectasis, neoplasm
o Important!:
- Always ask if previous film exist
- Warning: beware of the S.O.S syndrome (satisfaction of search)
66.inflammatory lung diseases
o Pneumonia:
- Infectious diseases of lungs may be caused by bacteria, virus, fungi or parasites - The auscultation report (sonorous rales) correlated with the radiopgraphic report only in 40 % of cases
- Pneumonia classified into:
1. Lobar pneumonia: - Very rare because of the effective antibiotic therapy
- Inflammation arises in peripheral airways (alveoli) and spreads rapidly though the pores of Kohn (connective tissue between the alveoli)
- Typically the whole lobe is affected
- Bordered by fissures and a positive air bronchogram
- Air bronchogram means that the aerated bronchi can be identified within the pneumonic consolidation
- Posteroanterior chest x-ray shows alveolar shadow and air bronchogram
- Other symptoms: Dyspnea, leukocytosis, rales on auscultation, fever
- Bronchopneumonia (lobular)
- Not originating in the alveoli but terminal bronchioles (in contrast to lobar) - Secondary spread of the inflammatory process to alveoli causes patchy infiltration marked by absence of an air bronchogram (dark bronchi made visible by opacification of alveoli - meaning that there is radiopaque content in the alveoli instead of air)
- The demarcation line between lobular and lobar pneumonia disappears under treatment - Dens and patchy shadow without air bronchogram
- Other symptoms: Fever, dyspnea
- Sometimes silhouette sign - Interstitial pneumonia:
- Frequently caused by viruses (CMV, Herpes)
- Especially in children by the RSV virus, mycoplasma or pneumocystitis jirovecii
- Symptoms: auscultation may be normal and leukocytosis may not be very pronounced - Invasion of the bronchial wall and interolobular septa leads to striated reticular shadow
- Nearly always diffuse and bilateral shadow
- Confluencing patchy shadows as well 🡪 A sign of exudation into alveoli
o Remission:
- Takes about 10-14 days, sometime even 8-10 weeks
- Follow up in complication patients (abscess)
o Sarcoidosis:
- granulomatous disease
- unknown etiology
- systemic epitheloid type of inflammation
- most commonly leads to (90%) involvement of intrathoracic lymph nodes (hilar, mediastinal) and lung parenchyma
- Acute and chronic type
Radiology stages:
0. Normal chest x-ray
1. Hilar or mediastinal adenopathy with no pulmonary manifestation
2. Adenopathy with pulmonary manifestation
3. Pulmonary manifestation without adenopathy
4. Irreversible fibrosis of lung parenchyma
- Many discovered on routine x-ray of chest
- Mediastinal adenopathy most common manifestation
- On CT: nodular and partly confluencing granulomas with characteristic peribronchovascular and perilymphatic distribution
o Tuberculosis:
- Caused by mycobacterium tuberculosis
- Tropical countries
- One third infected with mycobacterium tuberculosis and nearly 2 million deaths - X-ray still is the best procedure for TB
- Pathognomonic signs of TB do not exist, but typical changes of TB are known to exist - Chest x-ray is essential to establish primary diagnosis, as well as control the course of disease, assess disease activity and monitor therapy
Radio investigations of primary lung TB:
1. Consolidation
2. Lymphadenopathy
3. Pleural effusion
4. Obstructive atelectasis
5. Basal lower lobes, middles lobes and anterior upper lobes mostly affected Radio investigations of post-primary tuberculosis:
- Exudative changes (patchy shadows)
- Endobronchial spread
- Healing with scarring, destruction and shrinkage of upper lobe
- Tight hilum and apical thickening of pleura
- diffuse interstitial lung diseases
- imaging
- idiopathic lung fibrosis
- exogenous allergic alveolitis
- collagenosis
- pneumoconiosis
- sarcoidosis (check previous task )
o Introduction:
- A number of pathological processes are manifested in the interstitial connective tissue of the lung
- These include: interstitial edema, carcinomatous lymphangitis, atypical infection, immunological interstitial lung disease
o Imaging technique:
- HRCT is the method of choice for diagnosis and description of interstitial lung disease - Interstitium of a healthy lung is usually not seen on conventional x-ray
Types of interstitial shadows seen on HRCT and x-ray in advanced disease:
1. Linear – reticular consolidation (Interlobular septa run in subpleural aspect perpendicular to pleura
2. Nodular consolidations (small nodules with sharp margins
- May also see lymphadenopathy, pleural effusion, emphysema
- Sometimes transbronchial biopsy or open lung biopsy are required
o Interstitial lung diseases includes:
- Idiopathic lung fibrosis:
- Immune triggered reaction to noxious agents
- Reticular consolidations with small cysts (honeycomb lung)
- These are found especially in basal and subpleural aspects - Exogenous allergic alveolitis:
- Caused by inhaled noxious agents or immunological reactions
- X-ray may be normal
- The changes can be evaluated more sensitively on HRCT
- Overinflated areas (air trapping) and normal condensed areas lying adjacent to each other - Fibrotic changes - Collagenosis:
- Various diseases of connective tissue (Lupus, scleroderma, CREST) are manifested in a lung affected by interstitial fibrosis
- Chest x-ray = increase in reticular structures (especially in basal and subpleural aspect) - Clinically symptoms in other organs (arthritis, nephritis, cardititis, myositis) - Biopsy required sometimes - Pneumoconiosis:
- Nearly all inorganic dust diseases culminate in lung fibrosis
- Depending on type of dust, one may find additional calcified nodules in lung parenchyma, calcifications of lymph nodes (silicosis) or pleural calcifications (asbestosis, talcosis) - Chest x-ray can be used
- tumours of lungs and bronchi
- bronchial carcinoma
- small cell carcinoma
- lung metastasis
- pulmonary hamartoma
o Introduction:
- Malignant tumors (bronchial carcinoma, metastases, lymphoma)
- Benign tumors (leiomyoma, hamartoma)
- Tumor-stimulating (AVMs, round atelectasis, granuloma (TV), pseudotumor
o Bronchial carcinoma
- Squamous cell and adenocarcinoma (30-35%)
- Small-cell carcinoma (20-25%)
- Undifferentiated large cell carcinoma (15-20%)
- Rare: carcinoid, adenocystic carcinoma, carcinosarcoma
- Smoking, asbestosis, post-tuberculosis/silicosis scar
- Cough, hemoptysis, chest pain, dyspnea, fever, lack of appetite, weight loss, fatique
Imaging procedure:
- Chest x-ray
- CT (best imaging method)
- SCC (centrally located) and AC (peripheral solitary pulmonary nodules, hyperdense)
- (AC) Lymhogenic metastasis develop early in pleura
- (AC) Hematogenic metastasis in lung
- (SSC) metastases arise early in regional hilar lymph nodes
- Pancoast tumor (subtype of SSC and AC) = Invasion imaged on CT and MRI in right upper lobe
Staging:
- use CT/MRI
- TNM classification
o Small-cell carcinoma:
- Arise from neuroendocrine cells
- Regarded as a systemic disease
- Several metastases (hematogenic and lymphogenic) at diagnosis
- Central location
- Grows very fast and MTS early (thus, systemic disease)
- Also used TNM system for staging
o Metastasis of bronchial carcinoma:
- BC have a generally bad prognosis
- Hematogenic metastasis: nearly always found in Small cell carcinoma at time of diagnosis (less frequently in other types) 🡪 Typical spread to adrenal glands, CNS, liver and skeleton - Lymphogenic metastasis: occur in all lung cancer at very early stage (lymph nodes, carcinomatous lymphangitis,
carcinomatous pleuritis
- Local invasion: endobronchial or transbronchial metastases
- Look at page 279 for info about solitary pulmonary nodules ☺
o Pulmonary hamartoma:
- Benign neoplasm usually in isolation
- Rarely turn malignant
- Solid pulmonary nodules (round focal consolidation surrounded by air)
- CT by evidence of a fatty portion or typical popcorn-like calcifications
o Metastasis of extrathoracic tumors:
- Metastases are the most common type of malignant lung disease
- Found in 30-50% of malignant tumors
- Frequently derived from lungs, breast, colon, head, neck, stomach, pancreas, melanoma - Chest x-ray
- Ct most sensitive method (should always be performed in these cases)
- pulmonary circulation disorders
- pulmonary venous hypertension
- pulmonary edema
- pulmonary embolism
o Pulmonary arterial hypertension: Radiopedia and book page 297-298 and 290-293 - Defined as a resting mean pulmonary arterial pressure of 25 mmHg or greater at right heart catheterisation
- Increased blood pressure in pulmonary arteries
May be caused by:
1. Autoimmune diseases
2.Heart failure, stenosis etc.
3. Drugs
4. Lung diseases (pulmonary embolism, asthma, bronchitis, emphysema)
- Idiopatic when no apparent cause, secondary if cause
- Slowly progressive shortness of breath
- Chest pain, syncope with exertion can occur
o Pulmonary venous hypertension:
- Increased blood pressure in the pulmonary veins
- Caused by congestive heart failure
- Mitral stenosis or mitral regurgitation may contribute to pulmonary venous hypertension
o Pulmonary edema: - Defined as pathological accumulation of extravascular fluid in lung parenchyma - Fluid collects primarily in the pulmonary interstitium, followed by alveoli - Two types: hydrostatic edema (increased capillary pressure), permeability edema (increased capillary permeability) - Hydrostatic caused by: increase venous pressure due to renal failure or fluid overload - Alveolar shadow develops immediatlely in cases of acute PE Imaging assessment (chest x-ray) - Size of heart - Vascular pedicle (width of upper mediastinum) - Intrapulmonary vessels (greater in diameter in case of PE) - Congestions grades (1, 2, 3) according visualization of diameter of vessels (upper lobe In normal conditions has less diameter than lower lobe, but opposite in congestion) - Congestion grades 2 = Interstitial pulmonary edema - Congestion grade 2 = Thick interlobular septa and septal line (kerley B lines) – chest x-ray - Congestion grade 2 = Also finding blurred vessel contours, peribronchial cuffing, pleural effusions, enlarged heart, widened upper mediastinum - Congestion grade 3 = alveolar pulmonary edema - Congestion grade 3 = Perihilar distribution (butterfly edema)
o Pulmonary embolism:
- Defined as a venous thrombus that has arrived into pulmonary arteries usually from deep veins in leg
- Usually occur in numbers
- Lower lobes mainly location (better circulation in this region)
- Pulmonary infarction only in about 15 % of cases
- Symptoms: dyspnea, chest pain, tachypnea, tachycardia, right ventricular load on ECG - D-dimer lab test before imaging
- Chest x-ray, multislice CT, ventilation/perfusion scintigraphy when CT is contraindicated, pulmonary angiography (rarely nowadays), MRI (only in selected cases)
- Chest x-ray usually first imaging procedure
- Chest x-ray not able to detect embolism, but is important to rule out pneumothorax or cardiac decompensation
- Indirect signs of PE on chest x-ray: hampton´s hump, atelectasis, pleural effusion, oligemia, enlarged hilar vessels
Features:
1. Thrombi close to the wall
2. Irregular diameter of the vessel
3. Discontinuation of vessel
4. Dilation of the right atrium
5. Wide central pulmonary veins
6. Hypodense on CT (see picture in book page 298)
- imaging of pleural diseases - mediastinum - chest wall
- pleural effusion
- pleural tumours
- pneumothorax
- mediastinal space occupying lesions
- tumours of anterior mediastinum
- tumours of posterior mediastinum
- chest wall
Pleural diseases:
o Effusion:
- Most common pleural pathology
- Increase in pleural fluid
- Hydrothorax (transudate), pyothorax (pus), hemothorax (blood), chylothorax (lymph) - Usually occurring in association with thoracic or extrathoracic diseases
- Causes: heart failure, hypoalbuminemia, inflammation, neoplasm, trauma (rib fracture) - Chest x-ray, ultrasound and CT
- Fluid collects first dorsolateral phrenicocostal sinus
- Effusion seen on chest x-ray in standing position from 150ml onward, and in supine 500ml onward
- Ultrasound and CT are markedly superior to chest x-ray
- Shadowing on CT
o Pleural tumors:
- Metastasis most common (95%)
- From lung or breast carcinoma
- Mesothelioma rare malignant tumor (asbestosis)
- Lesions on x-ray and CT (nodular)
o Pneumothorax:
- Air in pleural cavity
- Causes: spontanous, COPD, fibrosis, metastases, trauma, lung biopsy, puncture, surgery - Chest x-ray (separation of pleural fold where visceral pleura seen as a thin white line along chest wall, also vessels in area absent
- CT most sensitive method to image air in the chest
- Tension pneumothorax: flattened diaphragm, displacement of mediastinum, wide intercostal spaces
o Mediastinum:
- Most important pathologies in the mediastinum includes:
1. Tumors
2. Aneurysm of aorta
3. Acute or chronic mediastinitis
4. Mediastinal abscesses - These may occur during surgical or endoscopic interventions or post traumatically - Especially happening during injury to esophagus
o Mediastinal space-occupying lesions:
- Chest x-ray first investigation
- CTA and MRA
- DSA Is important in cases of vascular disease and interventional procedures (stent graft for thoracic aneurysm, embolization for hemoptysis
- Mediastinum is divided into anterior, middle and posterior compartment (each associated with typical pathologies)
o Tumors of anterior mediastinum
- 4 T´s (thymus, thyroid, teratoma, terrible lymphoma)
- Hodkin´s disease, Thymus lymphoma/carcinoma, Thyroid, Germ-cell tumor (dermoid/teratoma)
o Space-occuping lesions in the middle mediastinum:
- Cysts of bronchogenic cysts, pericardial cyst, aneurysm of aorta, lymphoma
o Tumors of posterior mediastinum
- Neurogenic (schwannoma, neurofibroma, meningocele)
- Non-neurogenic (spondylitis, extramedullary, hematopoisesis)
o Chest wall:
- Consists of soft tissue, ribs and spine
- Bony skeleton assessed by x-ray (dislocated rib fractures, destruction due to metastasis, compressed vertebra in thoracic spine
- Physiologically the ventral cartilaginous portion of ribs tend to calcify with advancing age
- chest trauma
- imaging techniques
- rib fractures
- injury to tracheobronchial system
- Injury to Thoracic aorta
o Introduction: Book page 252 - 254
- Injuries of chest organs occur in 50-60 % of all patients experiencing multiple trauma - Cause is blunt trauma due to road accidents or falls in 90% of cases
- Rib fracture, pneumothorax and hemothorax most common
o Imaging procedure:
- Initial imaging = conventional x-ray
- CT permits much more sensitive detection of the following injuries:
1. Pneumomediatinum
2. Aorta, tracheobronchial system
3. Pneumothorax
4. Pleural fluid collection (hemotorax – blood, serous fluid)
- Ultrasound of little value. Primarily used in cases of involvement of heart in chest trauma (myocardial contusion or hematopericardium)
Typical chest injuries:
o Rib fractures:
- Most common type of fracture (60 % of blunt chest injuries)
- 4th to 9th rib most common
- Complications: injury to vessels, pneumothorax and hemothorax, lung injury - Serial rib fracture: resulting instability of chest and respiratory failure
o Injury to tracheobronchial system:
- Less than 2 % of chest injuries
- Cause: asudden compression of the chest with a closed epiglottis 🡪 increased pressure in tracheobronchial system 🡪 rupture
- Most common locations: Cricoid (80 %), central main bronchi, lobar bronchi - Radiological signs: Cervical emphysema, mediastinal emphysema, pneumothorax o Injury to thoracic aorta:
- 2 % of all blunt chest injuries
- Cause: usually deceleration trauma accompanied by the effect of shear forces or deceleration trauma with additional mechanical compression of the chest
- Location: most commonly distal to the left subclavian artery
- Radiological signs:
1. wide of the upper mediastinum (hematoma)
2. Extrapleural collection of blood
3. Hemothorax
- MDCT! Is currently the imaging method of choice for rapid investigation of traumatic rupture of the aorta. CT angiography is much faster than angiography and has the additional advantage of being non-invasive
- breast imaging techniques
- READ ABOUT IMAGE GUIDED BREAST INTERVENTIONS ON EARLIER QS!
o Mammography:
- Use a low-dose x-ray system to examine breasts
- Takes pictures of fat, fibrous tissue, ducts, lobes and blood vessels
- Primary modality used for imaging breast
- Digital mammography replaced x-ray film by solid-state detectors that convert x-rays into electrical signals
- These signals are used to produce images that can be displayed on a computer screen - Mammography can show changes in the breast up to two years before a physician can feel them
Indications:
1. All women over 40
2. Women at increased risk (over age 30)
3. Women who had previous breast cancer diagnosis
4. Lump found
-Before 40 years: Suspection for breast cancer based on USG/physical examination or MTS finding of unknown origin
- Nipple discharge – visualization of mammary ducts after injection of contrast medium Screening:
- 40-49, to identify at an early and curable stage
- Standard view – CC + MLO
Diagnostic:
- Imaging perfomed on a symptomatic patient or to work an abnormality found on screen - Additional views: magnification view, true lateral view, rolled view, sport compression, axillary view
- Shows masses and microcalcification (tiny flecks of calcium and can sometimes indicate early cancer)
- Sensitivity: 85 – 90 % in fatty replacement breasts and 65 % in dense breasts
o Ultrasonography:
- Most important supplementary investigation of the breast
- Women older than 40 does not substitute MMG!
- Inappropriate for screening (MIC cannot be assessed)
- Initial test in women younger than 40 years (dense breast tissue)
- Investigation is performed with high-frequency linear transducters (8-15MHZ) - Poor differentiation between fat tissue and solid tumor
- Guided biopsy
o Supplementary imaging modalities:
MRI: (dynamic contrast-enhanced breast MRI):
- Problem-solving tool for inconclusive MMG/USG findings
- Preoperative evaluation of local extent of newly diagnosed BC (exclusion of multifocality and multicentricity)
- Patients with implants (implant defect – no contrast medium needed)
- Monitoring of the response to neoadjuvant chemotherapy
- Breast cancer screening in high risk women (BRCA+)
- Diff.dg. of recurrence of BC, scar, reparative changes
- Diagnosis of small TU in dense breast tissue
Tomosynthesis (DBT – digital breast tomosynthesis):
- 3-D image of breast
- Uses several low dose x-rays obtained at multiple angles
- Reconstruction leads to series of slices designed to distinguish each layer - Minimal overlap – reduction of false positivities
READ ABOUT IMAGE GUIDED BREAST INTERVENTIONS ON EARLIER QS!
- MMG and US
- characteristic features of benign lesions
o MMG benign signs: - Small oval opacity - Large oval smoothly contoured opacity - Lobular (can also be suspicious) - Quite fatty density - Low density - Isodensity (can also be suspicious) - Well defined margin - Microlobulated margin - Benign calcification in: 1. Vessels 2. Fibroadenoma 3. Milk ducts 4. Dystrophy 5. Microcysts Macrocalcifications: - Large white dots - Almost always noncancerous and require no further follow-up Microcalcifications: - Very fine white specks - Usually noncancerous but can be a sign of cancer - Size, shape and pattern important to measure - Can appear anywhere in a breast and often show up on a mammogram - Most women have one or more areas of microcalcifications of various size - Majority are harmless! - Small percentage can be precancerous or cancer (biopsy sometime recommended) o US benign signs: - Round/oval (elliptical) shape - Well circumscribed, hyperchoic tissue - Homogenous echostructure - Mass orientation – wider than deep (-D/W ratio < 1) long axis parallel to skin - Gently curving smooth lobulations (< 3) - Thin echogenic pseudocapsule - Compressible, movable - CFM without intratumoral vascularization
- MMG and US
- characteristic features of malignant lesions
o MMG malignant signs: Primary signs: - MASS – dense, inhomogenous, speculated/stellar, surrounded by a light peripheral halo - MICROCALCIFICATIONS (detection of early stages of cancer – DCIS, LCIS) Secondary signs: - Nipple inversion - Architectural distortion - Skin thickening - Axillary lymphadenopathy - Skin retraction - Tissue asymmetry Other: - Stellate radiating opacity - Diffuse opacity - Halo sign - Stellate opacity with the retraction of the nipple Summary: - Lobular shape (may be suspicious) - Irregular shape (highly suspicious) - Iso density (may be suspicious) - High density (highly suspicious) - Indistinct and ill-defined margin (highly suspicious) o USG malignant signs: - Irregular shape, speculation - Non-circumscribed margins - Mass orientation – taller than wide - Microlobulations - Thick hyperchoic halo - Hypochoic - Sonographic posterior acoustic shadowing - Duct extension - Heterogeneous echostructure - Non-compressibility – malignant lesions displace the breast tissue without changing in height - CMF intratumoral vascularization present - Often fixed
- BIRADS classification
for findings in MMG, US and MR mammography
- solitary lesions : (shape, margins, acoustic pattern, dorsal acoustic, cm enhancement )
- calcifications :(micro/macro, benign/malignant features)
- architecture : appearance
- global asymmetry : glandular tissue (larger )
- focal asymmetry : smaller consolidations
- intramammary LN: (radioluscent, hyperechoic hilum of fat
- additional findings
BIRADS : 1-3 benign
BIRADS : 4-6 suspicious malignant
o Introduction:
- Important quality standard in breast diagnosis to align findings obtained from MMG, ultrasound and MR mammography
- Useful for establishing the subsequent procedure
- Findings can be described clearly by an evaluation system
- At a glance, clinician is able to decide about subsequent measures
- BI-RADS lexicon contains a description of all benign and malignant changes in the brest for MMG, ultrasound and MR MMG:
1. Solitary lesions: - Assessment of shape (round, oval, lobulated, irregular)
- Margins (smooth, blurred, microlobulated, speculated)
- Acoustic pattern (anechoic, hypoechoic, hyperechoic, complex)
- Dorsal acoustic characteristics (attenuation, obliteration)
- Uptake of contrast medium (slow, moderate, strong, wash-out)
2. Calcifications: - Typically benign
- Moderately suspicious
- Highly suspicious
3. Architetcural agitation: - Disturbance of the normal architecture of breast tissue without evidence of an obvious lesion
4. Global asymmetry: - Larger volume of glandular tissue at least in one quadrant of the breast
- Usually a variation from the normal condition; suspicious when detected on palpation
5. Focal asymmetry: - Smaller asymmetrical consolidation, often an islet of parenchyma
- Cause of greater concern than global asymmetry
6. Intramammary lymph nodes: - Oval, with radiolucent hyperechoic hilum of fat
- Typically in the upper outer quadrant
7. Additional findings: - Retraction of the skin
- Retraction of the mammilla
- Thickening of the skin
- Consolidation of fibrous septa
- Axillary lymphadenopathy
- At the end of the report, procedure is specified by stating one of seven assessment categories
- BI-RADS 0 = Reptort not concluded yet
- BI-RADS 1-3 = Benign (routine screening or follow-up if 3)
- BI-RADS 4-6 = Suspicious/malignant (biopsy or excision if 6)
