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Follow Up Probably Benign Findings- BI-RADS 3 - Overview

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So we often see patients for a follow-up

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of probably benign findings.

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So these are the BI-RADS 3 patients.

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And the rationale for BI-RADS 3 is that

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some findings are known to have a less

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than 2 percent likelihood of malignancy.

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So using BI-RADS 3 should decrease the number

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of biopsies for false-positive findings,

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while also maintaining sensitivity for

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detection of breast cancer, because we're

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following these patients more closely.

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The protocol for BI-RADS 3 follow-up is

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that we will perform a full diagnostic

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workup before assigning a BI-RADS 3 assessment.

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16 00:00:40,785 --> 00:00:43,785 So we don't do this from a screening mammogram.

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We have the patient come back,

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have the finding evaluated, and then

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assigned the BI-RADS 3 category.

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Then we follow up with diagnostic imaging

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at six months, 12 months, and 24 months,

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and the finding is categorized as

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BI-RADS 3 until it's stable for treatment,

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at least two years.

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If the finding is stable at that final

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24-month follow-up, then we'll change

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the assessment to BI-RADS 2 and then

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perform routine follow-up going forward.

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We want to be sure that we're reassessing

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the finding and the rest of the breast

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tissue at each of the follow-up exams.

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And it's important to try and figure out

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whether it's possible to downgrade this finding

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to BI-RADS 2 if it truly is benign or has

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resolved or whether it's necessary to upgrade

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to BI-RADS 4 and actually biopsy the area.

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So for follow-up at six months,

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this is the Hopkins protocol.

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If it's a mass, if it's well seen on

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ultrasound, then we'll do ultrasound

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only at the six-month follow-up.

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There's no need to do the mammogram.

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If the mass was only seen on mammography, then we

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would do a unilateral full CC and MLO views,

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and we wouldn't necessarily repeat an ultrasound if

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it didn't show anything on the previous workup.

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For asymmetries, we'll do a unilateral

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mammogram, full CC and MLO views, and for

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calcifications, we'll do full CC and MLO views,

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unilateral, and then magnification views of the

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calcifications in the CC and lateral projection.

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If we're coming up to the 12 or 24

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month follow-up, if it's a young person,

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where we're following a mass seen on

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ultrasound, we'll only do ultrasound.

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Um, so we'll do ultrasound

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at six, 12, and 24 months.

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If the patient is age-appropriate for

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screening, then we'll do a bilateral

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mammogram at the 12 and 24-month follow-up

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because they would need to have that anyway.

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So CC and MLO views of both breasts and then

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ultrasound of the mass or the ultrasound finding.

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For asymmetry, we would do

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bilateral CC and MLO views.

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Um, so we're following the asymmetry and

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screening the rest of the breast tissue.

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And then for follow-up of calcifications,

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we would do the bilateral CC and MLO views

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as well as magnification views of the

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area of calcifications in CC and lateral.

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So there are only a few findings on

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mammography that are eligible for BI-RADS

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Category 3, and that is a solitary group

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of round or punctate calcifications.

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Non-calcified circumscribed solitary

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mass and a focal asymmetry without

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calcification or distortion.

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And really those things should be areas that

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we're seeing on a baseline screening mammogram.

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And there is room, you know, the BI-RADS atlas

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does give room for radiologist discretion,

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if there's something that you feel in

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your estimation is, um, a probably benign

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finding and could be categorized as such.

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You could use BI-RADS 3 for that finding as well.

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And some of the things that I think really

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fit nicely into that are calcifications

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that are likely to be early fat necrosis

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and calcifications that are likely

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to be early vascular calcifications.

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So some things we, we have an idea

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that these are going to be benign.

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And we don't need to biopsy

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them or in the case of

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early arterial calcifications,

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we really don't want to biopsy them.

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On ultrasound, um, BI-RADS 3 findings include

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masses with an oval shape, circumscribed

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margin, parallel orientation, hypoechoic

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echo texture, and no posterior features

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or posterior acoustic enhancement.

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And examples of this would be a classic

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fibroadenoma, a solitary complicated

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cyst, or clustered microcysts.

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And there has been some evolution in

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thinking about clustered microcysts.

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Um, these probably will be

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considered by Red's team

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to in the future.

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I mean, certainly if there are multiple

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groups, we would consider them by reds too.

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But particularly in an older woman, post-

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menopausal woman not on hormone therapy.

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If we have a solitary clustered microcysts,

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we would probably still give that a BI-RADS 3

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follow-up designation.

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And then, um, suspected fat necrosis or hematoma

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may be followed in a shorter time interval because

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evolution of the finding or resolution is likely.

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So we might follow that at four to eight

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weeks, or maybe even three months, um,

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something shorter than the six-month follow-up.

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So when would we downgrade to BI-RADS 2?

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So if we have a mass or complicated

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cyst and it goes away completely,

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You know, we can't find it anymore.

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That's it.

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That should be a BI-RADS 2.

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And I think also if a mass or complicated cyst

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really decreases a lot in size, it's unlikely

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to be a breast cancer calcifications that are

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clearly milk of calcium on magnification views.

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Maybe it wasn't so obvious on the on the previous

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exam, but now it is, that could be downgraded.

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Um, if the calcifications are definitely

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vascular, or the grouped calcifications form

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a circle consistent with calcification in

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the wall of an oil cyst, those could all be

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things that could be downgraded to BI-RADS 2.

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When do we upgrade to BI-RADS 4?

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Well, you know, if we're following a

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mass and there's a significant increase

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in size, I'd say more than a percentage.

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You know, more than a few millimeters,

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we would upgrade to BI-RADS 4 if there's

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development of a more suspicious feature.

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For example, if we're following a circumscribed

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mass, and then, um, you know, when we follow

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up one part of the mass looks more irregular

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or has irregular margins, we might, uh, upgrade

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to BI-RADS 4 in that situation, or following

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a group of calcifications, but the number of

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calcifications increases significantly as we're

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following, um, We may recommend biopsy of that.

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Um, and then there's also the issue that

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the rest of the breast tissue, um, is also

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being evaluated when we do these follow-ups.

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So a different suspicious finding may be noted.

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And that might require a BI-RADS 4 designation.

Report

Faculty

Lisa Ann Mullen, MD

Assistant Professor; Breast Imaging Fellowship Director

Johns Hopkins Medicine

Tags

Women's Health

Ultrasound

Non-infectious Inflammatory

Mammography

Breast

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