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BI-RADS 3 Indications on MRI – Summary

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So while BI RADS 3 is a challenging topic overall, I think that

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MRI is really the hardest topic with BI RADS 3 because it's a

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newer field and the data is a lot less robust than on mammogram

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and ultrasound. I did show a few examples of some cases that there

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is some data to support the use of BI RADS 3 and I

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just want to go over those. So just to start, like I said,

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this is really an evolving area and I think we want to be

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flexible with our use of BI RADS 3 on MRI and be following

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the literature because I think that this is going to be really clarified

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over the next couple of years. The fifth edition of BI RADS was

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published in 2013 and MRI has, the technology itself has improved since

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2013. We're also just doing a lot more breast MRI

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now than we were in 2013. So this is becoming more and more

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relevant. But the 2013 atlas, this is what it lists for reasons to

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give a BI RADS 3 on MRI. So first it includes background parenchymal enhancement.

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In the atlas it says to consider giving a BI RADS 3 when

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there's suboptimal timing based on menstrual status or for postmenopausal

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patients on hormone replacement therapy. They include a

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dominant focus that is T2 hypo intense on baseline MRI

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and for masses and oval around circumscribed mass on a baseline MRI.

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And then they say that in the atlas it says that there's insufficient evidence

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for non mass enhancement. So there's emerging data that, you know, this

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is not in BI RADS yet. And hopefully when a new BI RADS comes

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out, there'll be better guidance. But the more updated literature suggests

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that we don't need to use BI RADS 3 for background parenchymal enhancement.

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There is with the newer contrast agents, we have not shown that there's

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large variations in the timing based on menstrual status.

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And we should really, if we see a diffuse pattern of background parenchymal

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enhancement, we should be able to assess that as a BI RADS 2. If

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there's any areas that stand out and look separate,

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we should give it a BI RADS 4 and do a biopsy.

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But that the space for really doing a short term follow up for

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background parenchymal enhancement has really gone away. The foci in mass,

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the data has continued to support those two, and I showed examples of

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these two findings that are reasonable for a BI RADS 3 assessment. So

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just to repeat again, we see a dominant focus, so this should be

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a single focus that stands out compared to the rest of the background

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parenchymal enhancement. And it should be T2 hypo intense, and it should

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be on a baseline MRI or one with less than two years of

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follow up. We're going to follow it for two years. If it's T2 bright, then

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we can consider that benign. And if it's a new or increasing

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enhancing focus, then we want to give it a BI RADS 4 and biopsy.

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For masses, as I showed that kind of similar to mammogram and ultrasound

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when there is an oval or round circumscribed mass on a baseline MRI, it's

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reasonable to give that a BI RADS 3 and follow.

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Again, we really want to be careful looking for any changes in size

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and have a low threshold to change that to a BI RADS 4 and

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do a biopsy. And non mass enhancement continues to be a really challenging

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topic. There's very limited data on this, but there is some small studies

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and there's also some expert opinion that suggests that focal regional homogenous

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non mass enhancement without associated T2 hyperintensity may be appropriate

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for a BI RADS 3 assessment. So I did show an example of

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that, but I just want to emphasize that there's not really robust data

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to support this. And we'll really need to continue following the literature

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and studying this topic to clarify which cases of non mass enhancement we

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can safely give a BI RADS 3 to

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and follow rather than biopsy and which cases we can consider to be

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just part of the normal background enhancement and give a BI RADS 2.

Report

Description

Faculty

Emily B. Ambinder, MD

Assistant Professor - Breast Imaging Division

The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medicine

Tags

Women's Health

Trauma

Neoplastic

MRI

Breast

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