0:00

So we often see patients for a follow-up

0:03

of probably benign findings.

0:05

So these are the BI-RADS 3 patients.

0:10

And the rationale for BI-RADS 3 is that

0:12

some findings are known to have a less

0:14

than 2 percent likelihood of malignancy.

0:18

So using BI-RADS 3 should decrease the number

0:21

of biopsies for false-positive findings,

0:24

while also maintaining sensitivity for

0:26

detection of breast cancer, because we're

0:28

following these patients more closely.

0:31

The protocol for BI-RADS 3 follow-up is

0:34

that we will perform a full diagnostic

0:36

workup before assigning a BI-RADS 3 assessment.

0:40

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

0:43

We have the patient come back,

0:46

have the finding evaluated, and then

0:47

assigned the BI-RADS 3 category.

0:52

Then we follow up with diagnostic imaging

0:54

at six months, 12 months, and 24 months,

0:57

and the finding is categorized as

0:59

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

1:02

at least two years.

1:03

If the finding is stable at that final

1:06

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

1:09

the assessment to BI-RADS 2 and then

1:11

perform routine follow-up going forward.

1:15

We want to be sure that we're reassessing

1:17

the finding and the rest of the breast

1:19

tissue at each of the follow-up exams.

1:22

And it's important to try and figure out

1:25

whether it's possible to downgrade this finding

1:27

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

1:30

resolved or whether it's necessary to upgrade

1:34

to BI-RADS 4 and actually biopsy the area.

1:38

So for follow-up at six months,

1:41

this is the Hopkins protocol.

1:44

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

1:46

ultrasound, then we'll do ultrasound

1:48

only at the six-month follow-up.

1:50

There's no need to do the mammogram.

1:53

If the mass was only seen on mammography, then we

1:56

would do a unilateral full CC and MLO views,

2:01

and we wouldn't necessarily repeat an ultrasound if

2:04

it didn't show anything on the previous workup.

2:07

For asymmetries, we'll do a unilateral

2:09

mammogram, full CC and MLO views, and for

2:13

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

2:16

unilateral, and then magnification views of the

2:19

calcifications in the CC and lateral projection.

2:24

If we're coming up to the 12 or 24

2:26

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

2:30

where we're following a mass seen on

2:32

ultrasound, we'll only do ultrasound.

2:35

Um, so we'll do ultrasound

2:36

at six, 12, and 24 months.

2:38

If the patient is age-appropriate for

2:40

screening, then we'll do a bilateral

2:42

mammogram at the 12 and 24-month follow-up

2:45

because they would need to have that anyway.

2:47

So CC and MLO views of both breasts and then

2:50

ultrasound of the mass or the ultrasound finding.

2:54

For asymmetry, we would do

2:55

bilateral CC and MLO views.

2:58

Um, so we're following the asymmetry and

3:00

screening the rest of the breast tissue.

3:02

And then for follow-up of calcifications,

3:04

we would do the bilateral CC and MLO views

3:07

as well as magnification views of the

3:09

area of calcifications in CC and lateral.

3:13

So there are only a few findings on

3:16

mammography that are eligible for BI-RADS

3:19

Category 3, and that is a solitary group

3:22

of round or punctate calcifications.

3:25

Non-calcified circumscribed solitary

3:28

mass and a focal asymmetry without

3:31

calcification or distortion.

3:33

And really those things should be areas that

3:35

we're seeing on a baseline screening mammogram.

3:38

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

3:40

does give room for radiologist discretion,

3:43

if there's something that you feel in

3:45

your estimation is, um, a probably benign

3:48

finding and could be categorized as such.

3:50

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

3:53

And some of the things that I think really

3:55

fit nicely into that are calcifications

3:58

that are likely to be early fat necrosis

4:02

and calcifications that are likely

4:03

to be early vascular calcifications.

4:06

So some things we, we have an idea

4:08

that these are going to be benign.

4:10

And we don't need to biopsy

4:11

them or in the case of

4:13

early arterial calcifications,

4:15

we really don't want to biopsy them.

4:19

On ultrasound, um, BI-RADS 3 findings include

4:23

masses with an oval shape, circumscribed

4:26

margin, parallel orientation, hypoechoic

4:30

echo texture, and no posterior features

4:32

or posterior acoustic enhancement.

4:34

And examples of this would be a classic

4:36

fibroadenoma, a solitary complicated

4:39

cyst, or clustered microcysts.

4:42

And there has been some evolution in

4:44

thinking about clustered microcysts.

4:47

Um, these probably will be

4:49

considered by Red's team

4:51

to in the future.

4:52

I mean, certainly if there are multiple

4:55

groups, we would consider them by reds too.

4:58

But particularly in an older woman, post-

5:01

menopausal woman not on hormone therapy.

5:04

If we have a solitary clustered microcysts,

5:07

we would probably still give that a BI-RADS 3

5:09

follow-up designation.

5:11

And then, um, suspected fat necrosis or hematoma

5:15

may be followed in a shorter time interval because

5:18

evolution of the finding or resolution is likely.

5:21

So we might follow that at four to eight

5:24

weeks, or maybe even three months, um,

5:27

something shorter than the six-month follow-up.

5:31

So when would we downgrade to BI-RADS 2?

5:34

So if we have a mass or complicated

5:36

cyst and it goes away completely,

5:38

You know, we can't find it anymore.

5:40

That's it.

5:40

That should be a BI-RADS 2.

5:42

And I think also if a mass or complicated cyst

5:45

really decreases a lot in size, it's unlikely

5:47

to be a breast cancer calcifications that are

5:51

clearly milk of calcium on magnification views.

5:53

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

5:56

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

6:00

Um, if the calcifications are definitely

6:02

vascular, or the grouped calcifications form

6:06

a circle consistent with calcification in

6:08

the wall of an oil cyst, those could all be

6:10

things that could be downgraded to BI-RADS 2.

6:14

When do we upgrade to BI-RADS 4?

6:16

Well, you know, if we're following a

6:18

mass and there's a significant increase

6:20

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

6:22

You know, more than a few millimeters,

6:24

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

6:27

development of a more suspicious feature.

6:29

For example, if we're following a circumscribed

6:32

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

6:35

up one part of the mass looks more irregular

6:39

or has irregular margins, we might, uh, upgrade

6:42

to BI-RADS 4 in that situation, or following

6:45

a group of calcifications, but the number of

6:47

calcifications increases significantly as we're

6:50

following, um, We may recommend biopsy of that.

6:53

Um, and then there's also the issue that

6:55

the rest of the breast tissue, um, is also

6:58

being evaluated when we do these follow-ups.

7:00

So a different suspicious finding may be noted.

7:03

And that might require a BI-RADS 4 designation.