1. The document outlines updates to the BI-RADS MRI classification system from 2013, including standardized terminology for describing findings like masses and non-mass enhancements. 2. It describes the steps for analyzing breast MRI findings, including assessing morphology, kinetics, diffusion imaging, and synthesizing the results. Characteristics like mass shape, margins, internal enhancement and time-signal intensity curves are evaluated. 3. New sections were added to BI-RADS 2013 for describing breast density, background parenchymal enhancement, associated features, non-enhancing lesions, and findings related to breast implants. The changes aim to make MRI interpretation and reporting more practical and consistent.

1. BI-RADS MRI :
Update New
Version 2013
Dr Corinne Balleyguier
Radiology, Gustave Roussy,
Villejuif, France
Hanoi nov 2015

3. Breast MRI in 2015
— Aims of breast MRI :
— 1- To detect a suspicious contrast uptake
— 2- To characterize a suspicious contrast uptake
— Morphological analysis
— Kinetics analysis
— DWI imaging
— Comparison enhanced images and T2w images
— Combined morphological and kinetics
analysis :
— MR BI-RADS interpretation

4. 4 Basic Rules in Breast MRI
— 1- To analyse radiological documents :
— History
— Mammogram, ultrasound
— 2- To perform an accurate protocol :
— Good Indication
— Patient positionning
— To choose adequate sequences according :
— Indication
— Type of MRI
— 3- To apply interpretation criteria based mainly on morphological
analysis
— 4- To correlate MR images to medical history, clinical examination
and imaging

5. New BI-RADS
Standardize Terminology
Mass Non mass
IDC
DCIS ILC

6. BI-RADS Interpretation :
Guidelines

7. Message 1
Step 1
First sequences to analyze:
Subtraction after injection
NB : be careful to movements artifacts, if so,
analyze non subtracted injected images

8. Step 1 : Mass or non Mass?
MASS NON MASS
Enhancement
?

9. Step 2 : Characteristics
Shape Margins Internal
enhancement
FOCUSDistribution Internal
MASS NON MASS
Enhancement
T2

10. Signal Intensity
Time
Progressive
Plateau
Washout
P0
(na3ve)
P1
(1st.
measurement
a8er
CA)
P2
(last
measurement)
T1
T0
Step 3: kinetics
Morphology > Kinetics!

11. Clinical case 1
— 35 yo woman
— Palpable suspicious mass, BI-RADS 5
— Breast biopsy : ILC
— MR for staging

13. T1 FS Gd

14. Step 1 : Mass or non Mass?
— A mass on MRI:
— Occupies a volume:
— Visible in 3D
— Input of isotropic acquisition and 3D reconstructions, MIP
— Usually seen on T1w or T2w without IV

15. Masse Non massMass

16. T1 T2 FatSat
MIP
IV

17. Step 2 : Mass Analysis
— First sequence after injection
— Maximal malignant enhancement ≈1’30s
— Analysis :
— Shape
— Margins
— Internal enhancement

18. Shape and Margins
Round Oval Irregular
SHAPE
Circumscribed Indistinct Spiculated
MARGINS

19. Shape and Margins
— BI-RADS 5
— Irregular shape
— Spiculated margins

20. Shape and Margins
— Benign lesion (BI-RADS 2 or 3) :
— Oval or round shape
— Circumscribed margins
Lymph Node
Fibroadenoma

21. Internal Mass Enhancement
Homogeneous Heterogeneous Rim enhancement Dark internal
septation

22. Internal Mass Enhancement
— Malignant lesion
— Heterogeneous

23. Internal Mass Enhancement
— Benign lesion:
— Homogeneous

24. Benign lesion :
Internal Dark Septation (Fibroadenoma)
Fibroadenoma

25. Signal Intensity
Time
Progressive
Plateau
Washout
P0
(na3ve)
P1
(1st.
measurement
a8er
CA)
P2
(last
measurement)
T1
T0
Step 3: kinetics
Morphology > Kinetics!

26. Benign lesion, Type 1 curve

27. Type 3, PPV malignant >90%

28. Type 2
Fibroadenoma

29. STEP 4 : ADC and DWI
— b600 or b800
— Hyperintense on DWI
— And < 1.10-3 mm2/ s : high specificity of
malignancy

30. b850 ADC
IV T2 Fat Sat
2 hyperintense masses on T2w
1 Cancer, 1 Fibroadenoma…

31. Raisonner sur une masse en IRM
SHAPE
T2
MARGINS
INTRERN
ENH
CURVE
ADC?
ROUND
HYPER
CIRCUMSCRIBED
Dark
Septa
1
High
>
1.
10-­‐3
OVAL
ISO
IRREGULAR
Homogeneous
2
IRREGULAR
SPICULATED
Heterogeneous
Rim
3
Low
<1.10-­‐3
BI-RADS 5
Synthesis : STEPS 1 to 5
BI-RADS 2

32. NON MASS ENHANCEMENT (NME)
Distribution
— Focal area
— Linear
— Segmental
— Regional
— Multiple Regions
— Diffuse
Internal characteristics
— Homogeneous
— Heterogeneous
— Clumped
— Clustered ring

33. NON MASS ENHANCEMENT (NME)
1. To eliminate subtraction artifact :
— Ckeck on non subtracted images
2. Symmetric ?
— Yes: background enhancement-> benign
— No : suspicious
3. Non dependant on breast density
4. Always check distribution in another plan!

34. Symmetric Asymmetric
Non Mass Enhancement

35. NME Focal Area
— Focal area:
— < 25 % of a breast
quadrant
— Unique or multiple
— Not oriented towards
the nipple
Focal area :
papillomatosis
BI-RADS TM

36. NME Linear
— Enhancement
arrayed in a line
— This distribution
may elevate
suspicion for
malignancy
because it
suggests
enhancement
within or around a
duct
BI-RADS TM

37. NME Linear

38. NME Segmental
— Enhancement that is
triangular or cone shaped
with the apex at the
nipple
— Highly suggestive of
DCIS

39. NME Segmental
— Enhancement within
or around a duct
raising the possibility
of extensive or
multifocal breast
cancer in a lobe or
segment of the breast
DCIS
BI-RADS TM

40. — Enhancement that
occupies a large
portion of breast
tissue, at least a
quadrant.
NME Regional
IDC
BI-RADS TM

41. FOCUS
— Focus :
— Specific tiny enhancing dot that cannot otherwise be
characterized < 5 mm
— Not seen without IV
— « Foci » has been eliminated as it was used to
describe several such tiny dots separated
widely by normal tissue and is a pattern of BPE
that can be diffuse or focal.
— .

42. FOCUS

43. Focus : LCIS

44. Focus
— Bilateral, symmetric : benign
— Unilateral, unique : high risk?
— Intermediate: 6 months
— High: 3 months
— Before surgery : biopsy
— Be careful, to differenciate Focus and Small
mass….
— Compare to T2w
— Check hyperintense signal on T2w

45. T2FS IV FST1
Mass ≠ Focus
(Intramammary LN)

46. BI-RADS 2013
— Describe breast density and background
enhancement
— Some criteria have been modified
— Added sections:
— Associated features
— Non-enhancing findings
— Fat-containing leions

47. Summary of Changes
Images Reisions
Background enhancement New
Mass New + suppressions
Non mass New + suppressions
Implants New
BI-RADS 0, 3 and 4 categories Clarifications

48. D
D
C
A
MR BI-RADS
BREAST DENSITY
Breast density (≠ breast enhancement)

49. BPE
Le rehaussement glandulaire peut masquer un cancer.
Courtesy : Pr C.De Bazelaire

50. Mass : Shape
1. Round
2. Oval shape
3. Irregular
Lobulated à oval shape ( ≤3 lobulations )
Irregular : shape and margins

51. Mass : Margins
1. Circumscribed
2. Indistinct
3. Spiculated
Smooth->circumscribed
Irregular : both shape and margins

52. Mass : internal enhancement
1. Homogeneous
2. Heterogeous
3. Rim
4. Dark septations
Central enhancement
Enhancing septations

53. Non-Mass : distribution
1. Symmetric or non symmetric
2. Focal area
3. Linear
4. Segmental
5. Regional
6. Multiple regions
7. Diffuse
Ductal

54. Non mass
— Non Mass
— Distribution :
— Linear
— Internal enhancement
— Clustered ring
— Stippled (included now in
BPE)

55. Non-Mas : Internal enhancement
1. Homogeneous
2. Heterogeous
3. Clumped
4. Clustered ring
Reticular
Dendritic

56. Associated features
— Nipple retraction
— Nipple invasion
— Skin retraction
— Skin invasion
— Pectoralis invasion
— Pectoralis edema

57. Non-enhancing Lesions
— Ductal ectasia (hyperT1)
— Simple cyst
— Complex cyst
— Edema
— Non enhancing mass
— Skin thickening
— Distorsion
— Clip, foreign body
T2 T1

58. — Normal/abnormal LN
— Steatonecrosis
— Hamartoma
— Collection
Fat-containing Lesions

59. MR BI-RADS IRM
ADDED SECTIONS
Implants
— Implant material : saline, silicone, other,
lumen type
— Location (retroglandular, retropectoral)
— Abnormal implant contour
— Intracapsular findings: folds,
subcapsular line, keyhole sign, linguine
sign..
— Extracapsular Silicone
— Water droplets
— Peri-implant fluid

60. BI-RADS 0 : Avoid!
— Technically unsatisfactory MRI
— If more information is needed to interpret the images
— Describe the subsequent diagnostic imaging workup
« Every effort should be made not to use
category 0 »

61. BI-RADS 3 : Avoid!
— 1- BPE : not completely assessed, or if we are not
confident if it is an hormonal variation or not
— Short interval follow-up (2-3 months)
2- Patient scanned in a non optimal phase
3- Patient on HRT : Stopping HRT for several weeks and
repeating the MRI
BI-RADS 3 frequency : 10 %

62. Take Home Messages
— Standardization MG, US, MR
— More practical
— Less BI-RADS 0 or BI-RADS 3
— Differentiation :
— Assessment
— Management