Follow-up results of BI-RADS 3 lesions on magnetic resonance imaging: a retrospective study

PURPOSE

The categorization of Breast Imaging Reporting and Data System (BI-RADS) 3 lesions is not as clear in magnetic resonance imaging (MRI) as it is in mammography (MG). With the increasing number of MRI scans currently being conducted globally, incidentally detected lesions falling into the probably benign category are frequently being observed. In this study, our aim was to investigate the imaging characteristics and follow-up results of BI-RADS 3 lesions detected by MRI and to determine their malignancy rates.

METHODS

Breast MRI scans performed between January 2010 and January 2020 and classified as BI-RADS 3 lesions were retrospectively analyzed. The study included 216 lesions with known biopsy or surgical excision results or with at least one year of radiological follow-up. We assessed the patients' age, the presence of breast cancer, the follow-up interval, and the imaging findings at the beginning and during the follow-up. Lesions that remained stable, disappeared, or decreased in size and had a benign histopathological diagnosis were classified as benign. Lesions with the histopathological diagnosis of malignancy, identified by either biopsy or surgical excision, were classified as malignant. We determined the malignancy rate based on the histopathology and follow-up results.

RESULTS

Considering the follow-up results of all cases, 8% of lesions were excised, 0.5% decreased in size, 1.4% became enlarged, 17.1% disappeared, and 73% remained stable. The malignancy rate was 2.8%. A significant relationship was found between lesion shape and malignancy, as progression to malignancy was more likely in round lesions than in other types. An irregular margin, heterogeneous enhancement, and kinetic curve (type 2) features were significant for lesion upgrade to malignancy.

CONCLUSION

The malignancy rate in BI-RADS 3 lesions detected by MRI is low and falls within the accepted cancer rate for MG and sonography. Changes in size, morphology, and enhancement pattern should be considered in terms of malignancy development during follow-up. The follow-up intervals should be determined on a case-by-case basis.

The Impact of Mammographic, Radiologist, and Patient Factors on the Likelihood of Probably Benign (BI-RADS 3) Assessment at Diagnostic Mammography

OBJECTIVE

To evaluate the association of mammographic, radiologist, and patient factors on BI-RADS 3 assessment at diagnostic mammography in patients recalled from screening mammography.

METHODS

This Institutional Review Board-approved retrospective study of consecutive unique diagnostic mammography examinations in asymptomatic patients recalled from screening mammography March 5, 2014, to December 31, 2019, was conducted in a single large United States health care institution. Mammographic features (mass, calcification, distortion, asymmetry), breast density, prior examination, and BI-RADS assessment were extracted from reports by natural language processing. Patient age, race, and ethnicity were extracted from the electronic health record. Radiologist years in practice, recall rate, and number of interpreted diagnostic mammograms were calculated. A mixed effect logistic regression model evaluated factors associated with likelihood of BI-RADS 3 compared with other BI-RADS assessments.

RESULTS

A total of 12 080 diagnostic mammography examinations were performed during the study period, yielding 2010 (16.6%) BI-RADS 3 and 10 070 (83.4%) other BI-RADS assessments. Asymmetry (odds ratio [OR] = 6.49, P <.001) and calcification (OR = 5.59, P <.001) were associated with increased likelihood of BI-RADS 3 assessment; distortion (OR = 0.20, P <.001), dense breast parenchyma (OR = 0.82, P <.001), prior examination (OR = 0.63, P = .01), and increasing patient age (OR = 0.99, P <.001) were associated with decreased likelihood. Mass, patient race or ethnicity, and radiologist factors were not significantly associated with BI-RADS 3 assessment. Malignancy rate for BI-RADS 3 lesions was 1.6%.

CONCLUSION

Asymmetry and calcifications had an increased likelihood of BI-RADS 3 assessment at diagnostic evaluation with low likelihood of malignancy, while radiologist features had no association.

Application of computer-aided diagnosis to predict malignancy in BI-RADS 3 breast lesions

Purpose

To evaluate the ability of computer-aided diagnosis (CAD) system (S-Detect) to identify malignancy in ultrasound (US) -detected BI-RADS 3 breast lesions.

Materials and methods

148 patients with 148 breast lesions categorized as BI-RADS 3 were included in the study between January 2021 and September 2022. The malignancy rate, accuracy, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and area under the curve (AUC) were calculated.

Results

In this study, 143 breast lesions were found to be benign, and 5 breast lesions were malignant (malignancy rate, 3.4 %, 95 % confidence interval (CI): 0.5-6.3). The malignancy rate rose significantly to 18.2 % (4/22, 95 % CI: 2.1-34.3) in the high-risk group with a "possibly malignant" CAD result (p = 0.017). With a "possibly benign" CAD result, the malignancy rate decreased to 0.8 % (1/126, 95 % CI: 0-2.2) in the low-risk group (p = 0.297). The AUC, sensitivity, specificity, accuracy, PPV, and NPV of the CAD system in BI-RADS 3 breast lesions were 0.837 (95 % CI: 77.7-89.6), 80.0 % (95 % CI: 73.6-86.4), 87.4 % (95 % CI: 82.0-92.7), 87.2 % (95 % CI: 81.8-92.6), 18.2 % (95 % CI: 2.1-34.3) and 99.2 % (95 % CI: 97.8-100.0), respectively.

Conclusions

CAD system (S-Detect) enables radiologists to distinguish a high-risk group and a low-risk group among US-detected BI-RADS 3 breast lesions, so that patients in the low-risk group can receive follow-up without anxiety, while those in the high-risk group with a significantly increased malignancy rate should actively receive biopsy to avoid delayed diagnosis of breast cancer.

Frequency and Outcomes of BI-RADS Category 3 Assessments in Patients With a Personal History of Breast Cancer: Full-Field Digital Mammography Versus Digital Breast Tomosynthesis

BACKGROUND. Studies establishing the validity of BI-RADS category 3 excluded patients with personal history of breast cancer (PHBC). Use of category 3 in patients with PHBC may be impacted not only by this population's increased breast cancer risk, but also by adoption of digital breast tomosynthesis (DBT) over full-field digital mammography (FFDM). OBJECTIVE. The purpose of this article was to compare the frequency, outcomes, and additional characteristics of BI-RADS category 3 assessments between FFDM and DBT in patients with PHBC. METHODS. This retrospective study included 14,845 mammograms in 10,118 patients (mean age, 63 years) with PHBC who had undergone mastectomy and/or lumpectomy. Of these, 8422 examinations were performed by FFDM from October 2014 to September 2016, and 6423 examinations by FFDM with DBT from February 2017 to December 2018, after interval conversion of the center's mammography units. Information was extracted from the EHR and radiology reports. FFDM and DBT groups were compared in the entire sample and among index category 3 lesions (i.e., earliest category 3 assessment per lesion). RESULTS. The frequency of category 3 assessment was lower for DBT than FFDM (5.6% vs 6.4%; p = .05). DBT, compared with FFDM, showed a lower malignancy rate for category 3 lesions (1.8% vs 5.0%; p = .04), higher malignancy rate for category 4 lesions (32.0% vs 23.2%; p = .03), and no difference in malignancy rate for category 5 lesions (100.0% vs 75.0%; p = .24). Analysis of index category 3 lesions included 438 and 274 lesions for FFDM and DBT, respectively. For category 3 lesions, DBT, compared with FFDM, showed lower PPV3 (13.9% vs 36.1%; p = .02) and a more frequent mammographic finding of mass (33.2% vs 23.1%; p = .003). CONCLUSION. The malignancy rate for category 3 lesions in patients with PHBC was less than the accepted limit (2%) for DBT (1.8%), but not FFDM (5.0%). A lower malignancy rate for category 3 lesions but higher malignancy rate for category 4 lesions for DBT supports more appropriate application of category 3 assessment in patients with PHBC through use of DBT. CLINICAL IMPACT. These insights may help establish whether category 3 assessments in patients with PHBC are within benchmarks for early detection of second cancers and reduction of benign biopsies.

A Single-Center Audit of BI-RADS 3 Assessment Category Utilization in Mammography and Breast Ultrasound

Purpose: To evaluate outcomes of breast lesions assessed at our institution as probably benign (Breast Imaging Reporting and Data System [BI-RADS] category 3) with an expected malignancy rate of less than or equal to 2 %. Methods: Average-risk women with a BI-RADS 3 assessment following mammographic and/or ultrasound evaluation at our institution between January 1 and December 31, 2017 were included. Cancer yield was calculated within 90 days and at 6-month intervals up to 36 months. Results: Among 517 women (median age, 52 years; range, 13-89 years) with a BI-RADS 3 assessment, 349 (67.5 %) underwent biopsy or completed follow-up imaging up to 36 months. One hundred and 68 (32.5 %) were lost to follow-up. Thirty of 349 (8.6 %) had their imaging upgraded and underwent biopsy, yielding six cancers (cancer yield, 6 of 349 women [1.7 %]). Among 569 lesions assessed as BI-RADS 3, 92 (16.2 %) were characterized by morphologic features other than those validated as probably benign in prospective clinical studies. Fifty three of 517 women (10.3 %) had follow-up beyond 24 months, and 24 (4.6 %) had follow-up beyond 36 months. Conclusion: Overall utilization of the BI-RADS 3 assessment category at our institution is appropriate with a 1.7 % cancer yield. However, the rate of loss to follow-up, percentage of non-validated findings assessed as probably benign, and redundancy in follow-up protocols are too high, and warrant intervention. A patient handout explaining the BI-RADS 3 assessment category and automatic scheduling of follow-up studies have been implemented at our center to address loss to follow-up.

Disparities Associated With Patient Adherence to BI-RADS 3 Assessment Follow-up Recommendations for Mammography and Ultrasound

OBJECTIVE

To assess the relationship between sociodemographic factors and adherence rates in patients with a BI-RADS 3 assessment.

METHODS

This retrospective cohort study reviewed data from all patients with a BI-RADS 3 assessment on mammography and ultrasound examinations at a single, multisite academic institution, which serves a diverse urban-suburban population, from January 1, 2015, to December 13, 2017. Appropriate follow-up was defined as returning for the first follow-up examination 3 to 9 months after the index examination. Associations between BI-RADS 3 adherence rates and patient sociodemographic characteristics were evaluated using logistic regression.

RESULTS

There were 4,038 patients in our study period; 2,437 patients (60%) had appropriate follow-up, 765 (19%) patients had delayed follow-up, and 836 patients (21%) were lost to follow-up. The overall malignancy rate was 1.4% (46 of 3,202). Older age, retired employment status, and Medicare insurance status were associated with increased adherence to BI-RADS 3 follow-up recommendations. Black race, single relationship status, Medicaid and self-pay insurance status, and living in a top 15% disadvantaged zip code were associated with decreased adherence. On multivariate analysis, older age remained associated with increased adherence and Medicaid insurance status with decreased adherence. Time between index examination and cancer diagnosis was shorter in patients who had timely follow-up (202 days [interquartile range 183-358] versus 392 days [interquartile range 365-563], P ≤ .001), although there was not a significant difference in stage at diagnosis (P = .46).

DISCUSSION

Multiple sociodemographic factors are associated with low adherence to BI-RADS 3 follow-up recommendations suggesting that more frequent and targeted interventions are needed to close disparity gaps.

Value of BI-RADS 3 Audits

Objectives

BI-RADS 3 is an established assessment category in which the probability of malignancy is equal to or less than 2%. However, monitoring adherence to imaging criteria can be challenging and there are few established benchmarks for auditing BI-RADS 3 assignments. In this study, we explore some parameters that could serve as useful tools for quality control and clinical practice management.

Materials and Methods

This retrospective study covered a 4-year period (Jan 2014-Dec 2017) and included all women over 40 years who were recalled from a screening exam and had an initial assignment of BI-RADS 3 (probably benign) category after diagnostic workup. A follow-up period of 2 years following the assignment of BI-RADS 3 was used for quantitative quality control metrics.

Results

Among 135,765 screening exams, 13,453 were recalled and 1,037 BI-RADS 3 cases met inclusion criteria. The follow-up rate at 24 months was 86.7%. The upgrade rate was 7.4% (77/1,037) [CI: 5.9-9.2%] and the PPV3 was 33.8% (26/77) [CI: 23.4-45.5%]. The cancer yield was 2.51% (26/1,037) [CI: 1.64-3.65%] and did not differ (p=0. 243) from the 2% probability of malignancy. The initial BI-RADS3 per screening exam and per recall from screening were 0.76% (1,037/135,765) [CI: 0.72-0.81%] and 7.7% (1,037/13,453) [CI: 7.26-8.17%], respectively.

Conclusion

Regular audit of BIRADS 3 metrics has the potential to provide additional insights for clinical practice management. Data from varied clinical settings with input from an expert committee could help establish benchmarks for these metrics.

ACR BI-RADS Category 3 Lesions in Women Younger Than 30: Follow-up Outcomes and Factors Associated With Biopsy

OBJECTIVE

Investigate imaging follow-up patterns and assessment of malignancy rate of BI-RADS 3 lesions in women younger than 30 years.

METHODS

We retrospectively reviewed consecutive studies between January 1, 2013 and January 1, 2015 with BI-RADS 3 assessment in women <30 years. Lesion size, follow-up rate, and biopsy rate were recorded. Completion of 24-month imaging follow-up or biopsy determined the endpoint. Statistical analysis of follow-up rates and biopsy timing was performed.

RESULTS

Of 2525 BI-RADS 3 lesions, 278 were identified in 215 women <30 years. Fifty-two (24%) women underwent a biopsy which was more frequently done at patient request than for lesion growth [33 (63.4%) versus 19 (36.5%), P <.01]. The odds of having biopsy upfront was significantly higher in lesions >2 cm in diameter (OR: 4.4 [95% CI 2.1-9.4], P <.01). The malignancy rate in our cohort was 0% (95% CI 0-1.7%). Of the 188 women expected for follow-up imaging, 58 (30%) were lost to follow-up, while 103 (55%) had 6-month follow-up, 74 (39%) 12-month follow-up, and 56 (30%) 24-month follow-up.

CONCLUSIONS

BI-RADS 3 lesions identified in our cohort had high biopsy rates and low compliance with no cancers. Our findings suggest that probable fibroadenomas in young women may only warrant abbreviated short-term follow-up at 6-months.

BI-RADS 3 on Screening Breast Ultrasound: What Is It and What Is the Appropriate Management?

US is widely used in breast imaging for diagnostic purposes and is also used increasingly for supplemental screening in women with dense breasts. US frequently depicts masses that are occult on mammography, even after tomosynthesis, and the vast majority of such masses are benign. Many masses seen only on screening US are easily recognized as benign simple cysts. Probably benign, BI-RADS 3, or low suspicion, BI-RADS 4A masses are also common and often prompt short-interval follow-up or biopsy, respectively, yet the vast majority of these are benign. This review details appropriate characterization, classification, and new approaches to the management of probably benign masses seen on screening US that can reduce false positives and, thereby, reduce costs and patient anxiety.

Synchronous BI-RADS category 3 lesions detected by preoperative breast MRI in patients with breast cancer: may follow-up be adequate?

OBJECTIVE

The purpose of this study was to analyze the rate of malignancy of synchronous Breast Imaging Reporting and Data System (BI-RADS) category 3 lesions identified by preoperative magnetic resonance imaging (MRI) in patients with breast cancer that were followed up rather than biopsied.

METHODS

From electronic medical records, we identified 99 patients treated in our institution for whom preoperative breast MRI identified synchronous BI-RADS 3 lesions. Lesion characteristics, rate of second-look ultrasonography (US), rate of collegial decision-making, and rate of biopsies performed during the period of monitoring were analyzed.

RESULTS

Second-look US was performed in 96 of 99 patients and did not reveal any lesion. Collegial decision-making for follow-up validation was asked in 32%. The median time to last MRI was 24.4 months (interquartile range [IQR] [19.3; 36.3]). The median follow-up was 39 months (IQR [28; 52]). Two cancers were diagnosed, one at 5 months and one at 26 months of follow-up. The incidence of malignancy of followed up synchronous BI-RADS category 3 lesions was 1.0% (95% CI [0.1%; 7.1%]) at 6 months and 2.2% (95% CI [0.6%; 8.6%]) at 30 months.

CONCLUSION

Monitoring could be proposed for synchronous BI-RADS category 3 lesions detected in preoperative breast cancer patients. A continued follow-up beyond 2 years could be of benefit.

KEY POINTS

• Follow-up can be proposed for MRI BI-RADS category 3 lesions not detected at second-look ultrasound, possibly after a collegial decision. • Follow-up should be continued annually since cancer may occur beyond 2 years.

Image-guided Procedure Versus 2-year Follow-up for a BI-RADS 3 Probably Benign Lesion: A Cost Comparison Analysis

OBJECTIVE

Perform a comparison between the costs of image-guided breast procedures versus 2-year imaging follow-up for findings classified as BI-RADS assessment category 3-probably benign.

METHODS

The national payment amount costs at non-facility locations were obtained from the Centers for Medicare and Medicaid Services physician fee schedule for breast imaging-related Current Procedural Terminology codes. Total costs were calculated and compared for management algorithms of 2-year imaging follow-up of a BI-RADS 3 lesion from 2018 through 2019 versus performing an image-guided procedure of the lesion in 2018 after the initial diagnostic imaging.

RESULTS

Two-year mammographic follow-up of a BI-RADS 3 finding costs $484. This was less than a stereotactic-guided breast biopsy, which cost at least $1055. Two-year follow-up for a probably benign US finding cost $615 compared to $1173 for the least expensive US-guided breast biopsy scenario. For breast MRI, 2-year imaging follow-up cost $1510, which was also less than most MRI-guided breast biopsy scenarios. The one exception in which biopsy costs less than 2-year imaging follow-up was in the setting of an MRI-guided biopsy in the average-risk population without a post-benign biopsy follow-up breast MRI; in this setting, MRI biopsy cost $1235.

CONCLUSION

In 2018-2019, 2-year imaging follow-up of a BI-RADS 3 finding continues to be less costly than an immediate procedure, except for MRI-guided breast biopsy in the average-risk population without a post-benign biopsy follow-up MRI.

Effect of Quantitative and Semi-quantitative Elastography Methods for the Management of Borderline Lesions on Ultrasonography

BACKGROUND

Elastography (strain or shear-wave) is a method that estimates tissue stiffness.

INTRODUCTION

The aim of this study is to evaluate the quantitative and semi-quantitative ultrasound elastography methods for the diagnosis of BI-RADS 4a and BI-RADS 3 lesions, which are borderline for biopsy and follow-up.

MATERIALS AND METHODS

175 consecutive women with 193 ultrasound-visible breast lesions were classified on Conventional B-mode Ultrasonography (CUS) according to the BI-RADS scoring system. Quantitative and semiquantitative values from ultrasound elastography in the form of strain Elastography Ratio (SER), shear Wave Elastography (SWE) and Shear Wave Elastography Ratio (SWER) were obtained. The lesions categorized as BI-RADS 4a and BI-RADS 3 on ultrasound were subsequently re-categorized according to the elastography values.

RESULTS

Except for the 13 BI-RADS 2 lesions, the remaining 180 lesions were biopsied. Pathology showed 83 lesions to be benign and 97 to be malignant. The sensitivity and specificity of the CUS were 96.9% and 75.0%, respectively with an accuracy of 86.0%. Cut-off points calculated based on ROC curves were 56.8 kPa for SWE, 3.53 for SWER and 3.81 for SER. When we downgraded BIRADS 4a lesions based on elastography results, the specificity (CUS+SER 96.9%, CUS+SWE 91.7%, and CUS+SWER 90.6%) and the accuracy (CUS+SER 95.3%, CUS+SWE 92.7%, and CUS+SWER 92.2%) were shown to be better than CUS. When we upgraded BI-RADS 3 lesions based on elastography results, the sensitivity of combined sets of SWE (99,0%) and SWER (100,0%) was better than CUS.

CONCLUSION

The rate of false-negative biopsies can be decreased with the combined use of elastography and ultrasonography.

BI-RADS 3 (short-interval follow-up) assessment rate at diagnostic mammography: Correlation with recall rates and utilization as a performance benchmark

The purpose of this study was to identify a correlation between the screening BI-RADS 0 (recall) rates and diagnostic BI-RADS 3 (short-interval follow-up) rates of individual interpreting radiologists, with the goal of utilizing the BI-RADS 3 rate as an acceptable performance metric in the diagnostic population. A multicenter retrospective analysis of medical audit statistics was conducted on annual radiologist performance data collected over a 14-year period in a community hospital-based practice. Mixed regression models were used to estimate the association between screening BI-RADS 0 and diagnostic BI-RADS 3 examinations while adjusting for calendar year, annual radiologist screening volume, annual radiologist diagnostic volume, and diagnostic examination indication. A moderate statistically significant positive correlation was established between the screening BI-RADS 0 rates and Diagnostic BI-RADS 3 rates (Pearson correlation coefficient + 0.349, P ≤ .001). Furthermore, when utilizing a national benchmark range of 8%-12% as an acceptable BI-RADS 0 rate within a screening population, the correlative BI-RADS 3 assessment rate was demonstrated to be approximately 16%. We propose that this BI-RADS category 3 rate may represent an additional acceptable performance metric in the diagnostic population. Routine inclusion of an interpreting mammographer's diagnostic BI-RADS 3 rate in the annual medical audit may help reduce inappropriate and/or excess use of the BI-RADS 3 category, which may lead to significant potential reductions in follow-up examinations with their associated healthcare-related costs, resource expenditure, and induced patient anxiety.

Variability in Individual Radiologist BI-RADS 3 Usage at a Large Academic Center: What's the Cause and What Should We Do About It?

RATIONALE AND OBJECTIVES

Although the breast imaging reporting and data system (BI-RADS) lists specific criteria for designating a lesion as BI-RADS category 3 (probably benign), there are no target benchmarks for BI-RADS 3 usage rates. This study investigates the variability of BI-RADS 3 rates among a group of academic breast imagers, with the goal of defining more precise utilization.

MATERIALS AND METHODS

We retrospectively reviewed all diagnostic mammograms performed between July 1, 2013 and August 8, 2017 at our academic institution. The percentage of diagnostic mammograms given a BI-RADS 3 assessment was compared between radiologists using the Chi-square test. We then evaluated for correlation between BI-RADS 3 rate and individual clinical metrics (eg, radiologist experience, cancer detection rate [CDR] and recall rate) using univariate linear regression.

RESULTS

The study included 13 breast imagers and 24,051 diagnostic breast examinations. There was significant variability in BI-RADS 3 rates between radiologists, ranging from 8.0% to 19.3% (p < 0.001). Increased BI-RADS 3 rates negatively correlated with BI-RADS 1 or 2 rate (p < 0.001) and positively correlated with recall rate (p = 0.03). There was no association between BI-RADS 3 rate and the radiologist's level of experience, BI-RADS 4 or 5 rate, or CDR.

CONCLUSION

We found significant variability in BI-RADS 3 usage, which seems to be used in place of BI-RADS 1 or 2 findings rather than to avoid biopsy recommendation. BI-RADS 3 rates also directly correlated with recall rate, suggesting a greater degree of uncertainty among specific radiologists. Importantly, increased usage of BI-RADS 3 did not correlate with provider experience or improved CDR.

Probably Benign Breast Nodular Lesions (BI-RADS 3): Correlation between Ultrasound Features and Histologic Findings

The purpose of this retrospective study was to determine the validity of the BI-RADS system in ultrasound findings assigned to BI-RADS 3 category, using cytologic and histologic results as a benchmark. Our study population consisted of 122 ultrasound nodular lesions in 122 women who underwent fine-needle aspiration cytology and biopsy for probably benign lesions (Breast Imaging Reporting and Data System [BI-RADS] category 3). Contrary to what was previously reported in the literature (risk of malignancy of BI-RADS 3 <2%), malignancy was the outcome in seven of 122 cases (5.7%). Our study also found that the presence of a cellular component with a mobile fluid-fluid level in a cystic lesion and small (<3 mm) anechoic components in solid lesions is not always an indication of benignity. Our experience seems to indicate the need to consider the presence of non-homogeneous echoes in the corpuscular cyst and solid nodular lesions with cystic components as suspicious, especially in lesions with large dimensions. Therefore it would be necessary to conduct further studies to establish a dimensional criterion in the assessment of the malignant nature of the mentioned lesions. The management of probably benign nodular lesions should not only be guided by BI-RADS classification; it is also necessary to include clinical and anamnestic data and apply a multidisciplinary approach to select cases that require histologic verification instead of the usual follow-up.

Breast tomosynthesis for the clarification of mammographic BI-RADS 3 lesions can decrease follow-up examinations and enables immediate cancer diagnosis

Background The limited sensitivity of mammography in case of a high breast density often produces unclear or false-positive findings, so-called BI-RADS 3 lesions, which have to be followed up to prove benignity. Digital breast tomosynthesis (DBT) was developed to reduce such summation effects. Purpose To evaluate the influence of an additional DBT on the management of mammographic BI-RADS 3 findings and whether DBT can decrease the time to definitive diagnosis or not. Material and Methods We analyzed 87 patients with a mammographic non-calcified BI-RADS 3 lesion who underwent an additional DBT of the affected breast. A follow-up two-dimensional (2D) examination or a histological result of the lesion had to be available. The images were analyzed especially for the BI-RADS category and incremental diagnostic accuracy. Moreover, the inter-reader reliability and the radiation dose were evaluated. Results The BI-RADS category has been changed by the addition of DBT: 57.1% were assessed as BI-RADS 1 or 2, 4.6% as BI-RADS 4, and only 38.3% remained as BI-RADS 3. The intraclass correlation coefficient for the three readers showed a good agreement for inter-reader reliability. No false-negative examination was found in the follow-ups. Nine lesions were biopsied (seven benign, two malignant). Both malignant lesions were suspicious in the DBT (BI-RADS 4). A significant higher glandular dose was necessary for the DBT. Conclusion DBT has the potential to reduce the recall-rate of BI-RADS 3 lesions and to find and diagnose malignant lesions earlier than 2D mammography alone.

BI-RADS 3: Current and Future Use of Probably Benign

PURPOSE OF REVIEW

Probably benign (BI-RADS 3) causes confusion for interpreting physicians and referring physicians and can induce significant patient anxiety. The best uses and evidence for using this assessment category in mammography, breast ultrasound, and breast MRI will be reviewed; the reader will have a better understanding of how and when to use BI-RADS 3.

RECENT FINDINGS

Interobserver variability in the use of BI-RADS 3 has been documented. The 5th edition of the BI-RADS atlas details the appropriate use of BI-RADS 3 for diagnostic mammography, ultrasound, and MRI, and discourages its use in screening mammography. Data mining, elastography, and diffusion weighted MRI have been evaluated to maximize the accuracy of BI-RADS 3.

SUMMARY

BI-RADS 3 is an evolving assessment category. When used properly, it reduces the number of benign biopsies while allowing the breast imager to maintain a high sensitivity for the detection of early stage breast cancer.

First ultrasound diagnosis of BI-RADS 3 lesions in young patients: Can 6-months follow-up be sufficient to assess stability?

OBJECTIVES

To evaluate the outcome of repeated short-term follow-up with ultrasound in no high-risk young patients with a BI-RADS3 lesion at first examination.

METHODS

In this IRB-approved study 492 women, aged 18-34 years (mean±standard deviation, 28±4.5years) with first breast ultrasound examination in 2012-2014 were retrospectively evaluated. Inclusion criteria were: at least one BI-RADS3 lesion and (a) biopsy/surgical excision or (b) follow-up of at least 18 months (including a 6-month follow-up). BI-RADS category assigned during follow-up and pathologic findings in cases undergoing biopsy/surgical excision were collected. At the 6- and 18-month follow-up the recommended biopsy rates (RBR) and the corresponding positive predictive value (PPV) were calculated.

RESULTS

In 97 patients, 151 BI-RADS3 lesions were identified. Biopsy/surgical excision was initially performed in 25/151 (16.5%) lesions. After 6-month, category was downgraded to BI-RADS1/2 in 23/126 (15.3%) and upgraded to BI-RADS4 in 9/126 lesions (7.1%). Pathological diagnosis of these lesions was fibroadenoma in 5 and benign phyllodes tumor in 4 cases (RBR 7%, PPV_bio 44.4%). After 18-month one lesion was classified BI-RADS4 and pathological diagnosis was fibroadenoma (RBR 1.1%, PPV_bio 0%).

CONCLUSIONS

Our preliminary data show that follow-up imaging performed after 18 months from a first BI-RADS3 diagnosis does not affect clinical treatment and 6-month follow-up may be sufficient to assess the stability of probably benign lesions.

Clinical Outcomes of Mammographic BI-RADS 3 Lesions in the Community Hospital Setting

OBJECTIVES

Per the Breast Imaging Reporting and Data System (BI-RADS) manual, a lesion designated as BI-RADS 3 should have less than a 2% chance of becoming malignancy. With this study, we evaluated the outcome of patients given a BI-RADS 3 designation in the community hospital. Specifically, whether our cancer detection rate for BI-RADS 3 lesions was less than 2% and comparable to rates obtained at other institutions.

METHODS

The records of 1037 patients given a BI-RADS 3 on screening mammogram were reviewed over a 1-year period between May 2007 and May 2008. A total of 142 of these patients were lost to follow-up, leaving 885 patients. Some of these patients had more than 1 BI-RADS 3 lesion during this study period, yielding a total of 923 BI-RADS 3 lesions to evaluate out of the 885 patients remaining. Of these, 478 of the patients' lesions were biopsied. The pathology was then reviewed to determine whether the lesions were cancerous.

RESULTS

Only 6 of the 882 lesions initially classified as a BI-RADS 3 were later diagnosed as cancer, or 0.65% of the study population. The positive predictive value of receiving a BI-RADS 3 was 99.3%, which demonstrates a high accuracy in predicting that a lesion is not cancerous.

CONCLUSION

Most lesions that are diagnosed as a BI-RADS 3 have a very low probability of eventually being diagnosed as cancer. The findings from this study are comparable to studies performed at other institutions.

BI-RADS 3 for magnetic resonance imaging

A BI-RADS (Breast Imaging Reporting and Data System) 3, or probably benign, assessment is given in approximately 7% to 12% of breast magnetic resonance (MR) images. However, the imaging features of probably benign lesions on MR imaging have not been well defined. As with mammography and ultrasonography, a BI-RADS 3 assessment should be used only when there is a less than 2% likelihood of malignancy. The use of BI-RADS 3 for classically benign findings should be avoided. Certain masses, foci, and areas of nonmass enhancement may be categorized as probably benign on baseline MR imaging.