1. Breast MRI:Updates to
BI-RADS Lexicon
T Pousse
JFIM 2013 HONG KONG

2. Aims
• Recall and illustrate new synthetic
items of BI-RADS MRI
• Insist on changes to the BI-RADS
MRI lexicon in this third edition

3. Technical parameters
• Dedicated breast coil, pulse sequence,
(T2/T2 fat sat), IVC
• Diffusion weighted or spectroscopy
optional
• T2 weigthed recommanded before IVC

5. Background Parenchymal
Enhancement ( BPE)
• 5 categories
- none
- minimal
- mild
- moderate
- marked

6. minimal
moderate
mild
marked

7. Influence of Background
Parenchymal Enhancement
• Greater BPE may negatively influence breast
MRI performances (DeMartini, AJR 2012 536 patients
versus 200 patients)
– Decreasing specificity : increase of abnormal exam (30% vs 23%)
– No significant difference in positive rate of biopsy, cancer yield
• In the analysis of breast cancers not diagnosed
at MRI : less misdiagnosis of detection than caraterisation
Mistakes detection not influenced by BPE (Bouic-Pages Radiology
2012)
• BPE influenced by
hormonal fluctuation ,HRT, or Tamoxifen

9. Lesions characteristics
• Morphology
– Masses
– Non-masse enhancement
– Foci (≤ 5mm)
• Enhancements Kinetics

10. Masses
• Space occupying 3D lesions > 5 mm
- shape ( 2D )
- margin
- internal rehaussement characteristics
- T1-T2 weighted pulses sequences pre/
post contrast

12. Masse shape
SHAPE
Rond
Oval (replace macrolobulated)
Irrégular
macrolobulated

16. Mass margins
Margins
Régular
Irregular
circumscribed replaced smooth
Irrégular : combined shape+margins
Spiculated

23. Mass internal enhancement
patterns
Homogeneous
Heterogeneous
Central enhancement
Enhancing internal septation
Rim enhancement
Dark internal septa

26. Rim Enhancement value
• Bénign
– Inflammatory cyst
– Cytosteatonecrosis
• Malignant
– Triple negative Cancer

28. RIM ENHANCEMENT
K Triple négative

29. T2- weighted signal
intensity on non-contrast
images : new mass feature
in the revised lexicon!
• Hypersignal T2 ?
– T2 :
• > Parenchyma
• ≥ FAT
– T2 fat sat:
• > Parenchyma
• ≥ WATER , VESSEL

30. T2 Hypersignal : mechanism
Bénign
• Cystic and microcystic comp.
• Altered fat
• Fibroadenoma, intrammary lymph node,
phyllodes tumor
Malignant
• Tumor necrosis
• Mucinous subtype cancer

31. Family juvenile papillomatosis

32. Mucinous cancer

33. CCI grade 3

34. Non-Mass Enhancement
Enhancing area that is not a mass , separate
from background parenchymal enhancement
may contain interspersed fat
– Distribution (symetric or asymetric)
– Internal enhancement characteristics
– T2 weighted signal intensity

35. Fat area or normal parenchyma inside enhancement

36. NME distribution
•
•
•
•
•
•
•
Focal area ( <25% Q)
Linear
Branching linear : replace ductal
Segmental
Regional
Multiple regions >2
Diffuse
• Symetric or not

37. Focal zone
Often mixed with fat or normal matrix
<25% Q

38. Distribution : linear enhancement

39. Distribution : linear enhancement
DUCTAL

40. Benign NME linear
enhancement

41. Linear branching

42. Segmental

44. Symetric or asymetric
Diffuse bilateral
symetric
enhancement

45. Symetric or asymetric
• Asymetric
Regional, bilateral and asymetric enhancement

46. NME internal enhancement
•
•
•
•
•
Homogeneous
Heterogeneous
Stippled ( multiple punctuate foci : benign BPE)
Clumped (cobblestone ,beaded enhancement )
Clustered ring enhancement
Reticular /dendritic
Clustered ring (ductal carcinoma in situ)
Stippled :BPE

48. Ring enhancement

49. Ring Enhancement
PPV of malignancy = 70-100%
Ductal carcinoma
invasive cancer associated with
ductal carcinoma in situ
Uematsu AJR 2012 Non masse 3T
Tozaki AJR 2006

50. T2 Signal

51. Kinetic curve assessment
S0
St0"
S1
3
Rapid (intense)"
Medium"
Persistent "
2
St1"
S
S2
t2"
Persistent
Plateau
Wash out
1
ROI > 3 pixels
More suspicious area
t0= 0
t1= 2.5
IV contrast"
t2= 7.5
Time
(min)

52. Kinetic enhancement
2
3
2
Persistent
Plateau
1
ROI > 3 pixels
More
suspicious area
Wash out
Temps
(min)

53. Kinetic curve assessment
• Initial Phase (2 mns) (intensity + speed)
- slow : < 50%
- medium : 50-100%
- rapid : > 100%
• Delayed Phase
- persistent
- plateau
- Wash out
Qualitative appreciation
No quantitative cut – off
Menopausis status impact / kinetic curve enhancement (Milllet Radiology 2013)

54. Associated findings
•
•
•
•
•
•
•
Nipple or skin retraction
Skin thickening ( focal or diffuse)
Edema
Lymphadenopathy
Pectoralis muscle involvement
Precontrast increased ductal signal intensity
Susceptibility artifact related to surgical clips

58. Implants
• Material type : silicone, saline
• Location: retro-glandular or retropectoral
• Intra or extra-capsular rupture

59. Using new lexicon
• PPV for malignancy:mass
– Irregular shape and margin
– Spiculated
– Ring sign
– Heterogeneous
– Wash out kinetics
• PPV for malignancy : non mass
– Distribution : linear branching and segmental
– Internal enhancement : clumped and
clustered ring

60. Breast MRI interpretation
• BI-RADS IRM
– 0 : if suspicion of benign lesion (ex : FA)
– 4 : biopsy recommended ( even if US performed for
choice of the guidance)
– 3 (PPV variable in MRI)
• Global BI-RADS : combined reporting with
mammography / US

61. Conclusion
• T2 weighted sequence
• Background parenchymal enhancement
• Masses / non masses enhancement :
simplification
• Breast implant
• Management / facilitation patient care : BIRADS
0, 4, 3
• BIRADS global

62. Thanck you Patrice