By Rebekah Moan, AuntMinnie.com staff writer
March 11, 2014

VIENNA - The fifth edition of the BI-RADS atlas has been released, and while there have been several changes, perhaps the most important is the uncoupling of the assessment category and management recommendation, according to presenters at an ECR 2014 session on Sunday afternoon.

It's been more than 10 years since the last BI-RADS edition came out. In this edition, released by the American College of Radiology (ACR) in February, radiologists are no longer shoehorned into management options. This is particularly useful for BI-RADS 3, easily the most troublesome category. For probably benign lesions, radiologists can now add additional information and specify, for instance, whether a biopsy should be conducted based on clinical circumstances.

"Sometimes you'll have a probably benign lesion where you decide to do biopsy, and in the old days you would have to decide whether you would raise the BI-RADS category into category 4 to be able to biopsy it," said Dr. Ulrich Bick, a radiology professor and vice chairman in the radiology department at Charité University in Berlin, who presented changes to the BI-RADS atlas on mammography. "Now you still call it probably benign but have a management recommendation based on some additional information that you want to biopsy it."

Other differences in the mammography section include how dense tissue is named. In the old BI-RADS edition, breast composition was segregated into categories 1 through 4. In the new edition, breast composition categories are A, B, C, or D. "A" is entirely fatty and "D" is extremely dense.

In addition to changes in the nomenclature, radiologists may also omit the specific percent density (i.e., 25%, 50%, or 75%). The density categories depend on the densest part of the mammogram, so even if the mammogram is more than 50% fatty, if it has a very dense area behind the nipple, the breast would be categorized as C or maybe D, but the percentages do not have to be specified, according to Bick.

Radiologists are encouraged to describe regional differences where cancer is likely to be missed and where additional ultrasound may be helpful, he said. The emphasis is on the masking effect of dense fibroglandular tissue of mammographic depiction on calcified lesions and is not meant as a predictor of breast cancer risk.

Another big change is that suspicious calcifications are no longer separated into intermediate concern and higher probability of malignancy.

"All calcifications need the same management: biopsy; it doesn't matter if they're higher or lower probability of malignancy, they're all clearly above the threshold of 2% and you need tissue diagnosis," he said.

There are other small changes in the new BI-RADS edition -- "cleanup," Bick calls them -- including changing the term "isodense" to "equal density." "Lobulated" to describe shape was also removed because it was confused with margin characteristics, so now the options are only oval, round, or regular.

Mammography was not the only section to be altered; ultrasound and MRI experienced some changes too.

For ultrasound, there were updates in lexicon descriptors such as masses, calcifications, associated features (now constituting surrounding tissue with stiffness assessment), and special cases.

There is also guidance on how to link BI-RADS descriptors with management recommendations.

For breast MRI, the changes were also primarily "cleanup." For instance, nonmass-like enhancement has been changed to nonmass enhancement and internal enhancement characteristics no longer include central enhancement and enhancing septa.

There is also a section on implant assessment: whether they're saline or silicone, subpectoral or pectoral, etc.

The new edition is a hefty tome: "It weighs 4 kg [9 lb]," Bick said. "I brought it to ECR and it was so heavy the airline almost didn't let me carry it on."

Volpara backs BI-RADS changes
Volpara Solutions is calling recent changes in the breast density reporting categories a significant step toward more accurate density measurement.
ACR releases new BI-RADS atlas
The American College of Radiology (ACR) has introduced the fifth edition of its BI-RADS atlas.

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Last Updated hh 3/12/2014 2:14:36 PM

8 comments so far ...
3/11/2014 5:04:32 PM
LisandroArriagada
[:'(]

3/11/2014 5:33:45 PM
Dr.Sardonicus
Quote from

"Sometimes you'll have a probably benign lesion where you decide to do biopsy, and in the old days you would have to decide whether you would raise the BI-RADS category into category 4 to be able to biopsy it," said Dr. Ulrich Bick, a radiology professor and vice chairman in the radiology department at Charité University in Berlin, who presented changes to the BI-RADS atlas on mammography. "Now you still call it probably benign but have a management recommendation based on some additional information that you want to biopsy it."

 
As with all classification schemes, this just grows more complex and confusing with time. 
 
They say they want to allow modification of the recommendation based on the "clinical criteria". Such as what?
 
Now for Prof Bick, let me suggest something that would help: If you talk to a patient and she is freaked out about coming back every 6 months with some tiny suspicion of cancer still being present (BTW - would this qualify as "clinical criteria"??)   then simply raise the birds to 4 and biopsy it. It isn't as if the birads classification is, you know, ACCURATE. It's a seat of the pants guess. Treat it that way. Do what is right, and just change the birads to reflect what needs to happen. 
 
That is all.
 
 

3/11/2014 5:35:39 PM
vonbraun
Birads 4 was technically always vague because the possibility of malignancy is 2-95%.

"All calcifications need the same management: biopsy; it doesn't matter if they're higher or lower probability of malignancy, they're all clearly above the threshold of 2% and you need tissue diagnosis," he said."
 
I guess he doesn't buy into the assertion that we are overdiagnosing low grade DCIS.

Great, more biopsies of BIRADS 3? What is the additional information that would move one to biopsy a lesion that has an imaging appearance of less than 2% possibility of malignancy?
 
 

3/11/2014 9:38:37 PM
RogerL
Birads is pseudo scientific claptrap
 
3 - might be cancer but we will wait 6months- how silly and stressful is that.
Bet no female radiologists or wives accept that.
They have a core biopsy and move on with their lives

3/11/2014 10:08:50 PM
IGotKids2Feed
Quote from vonbraun

What is the additional information that would move one to biopsy a lesion that has an imaging appearance of less than 2% possibility of malignancy?




Pt. anxiety. 98% is almost certain. But some don't think 98% is good enough. Particularly in this culture of 110%. And GPAs of > 4.0 (better than perfect). Mammography is far from perfect. But I've always thought categorizing a finding as BIRADS 3 is pretty damn good. I would take a BIRADS 3 on one of my relatives any day.