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Hello and welcome to Noon Conference, hosted by Modality

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Noon Conference connects the global radiology community

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through free live educational webinars that are accessible

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for all and is an opportunity

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to learn alongside top radiologists from around the world.

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Today we are honored to welcome Dr.

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Emily Ann Binder for a lecture on the BIRADS 2025 update.

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Dr. Ann Binder completed radiology residency

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and her breast imaging fellowship at Johns Hopkins Hospital.

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She specializes in all aspects of breast imaging,

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including screening, diagnostics

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and procedures, utilizing mam mammography,

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ultrasound, and MRI.

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Her research interests include improving access

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to breast imaging and new technologies

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for early detection of breast cancer.

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At the end of her lecture, please join her in a q

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and a session where she will answer questions you may

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have on today's topic.

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Please remember to use that q

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and a feature to submit your questions so we can get to

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as many as we can before our time is up.

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With that, we are ready to begin today's lecture. Dr.

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Ann Binder, please take it from here.

1:03

Thank you so much, Ashley, for that introduction.

1:05

I'm so happy to be here

1:06

and really so honored to have been asked to give this talk.

1:09

Um, in all honesty, this was a great chance for me

1:11

to make sure that I went through the new by Rads Atlas that,

1:14

um, I have a good understanding it for my own practice.

1:17

Um, so let's go ahead and get started.

1:21

So I have no disclosures to share.

1:22

So this is the, uh, the, the cover of the new birads Atlas

1:26

that we're very excited about.

1:27

Um, so the, uh, BIRADS stands

1:29

for the Breast Imaging Reporting and Data System.

1:32

I just wanna start off with some, um, history about birads

1:36

before we get into the changes in this new, uh, version,

1:40

just to understand like, what, what is virus?

1:42

Why do we use it? So these are,

1:43

this is really the purpose of VIR rads.

1:46

Um, so first, I think that probably the most important

1:49

and what we're gonna really focus, focus on today is

1:52

that it provides, is standardized breast imaging

1:54

terminology, and also, um, allows for clear

1:59

communication of results using assessment categories.

2:02

Um, it requires specific management

2:04

recommendations for every study.

2:07

And because of the way that, uh, the RES is set up

2:09

and the way that we're required to put in all of our report,

2:12

it really supports education

2:13

and research in breast imaging,

2:15

which has been really helpful for the field to progress.

2:21

Um, I, I think it's important just to understand the history

2:24

of RADS before we get into the changes, just to see like

2:26

where we're, where we're coming from.

2:27

So what RADS was first published in 1993,

2:31

and this was published in response to the, uh,

2:34

mammography Quality State Standards Act,

2:36

or MQSA, um, by having a standardized lexicon,

2:41

which was what was, uh, really included in

2:42

that first edition just from mammography, it made it easier

2:45

for, uh, sites all across the country to, uh, adhere

2:50

to the MQSA rules.

2:53

These, uh, were updated every couple of years over,

2:56

uh, the time since then.

2:57

You can see second edition was published just a few years

2:59

later, a third edition in 1998.

3:02

The fourth edition in 2003 was the first time that, um,

3:05

ultrasound and MRI were included in the Atlas.

3:08

Um, it was then another 10 years

3:10

before the fifth edition was published in 2013,

3:13

and that's the edition that we've been using

3:15

for, for quite a while.

3:16

It's been 12 years. Um, this is the longest

3:19

that we've gone without an update to IRAs, which made this,

3:22

um, current version really highly anticipated.

3:25

There's been a lot that has happened in breast

3:27

imaging since 2013.

3:29

Um, and we're all really excited

3:30

to have this, this new atlas.

3:32

Um, instead of calling this the sixth edition,

3:34

they are now calling it version 2025.

3:37

So that is a change. Um,

3:39

and it's going to be more of a living document

3:41

where it won't be of these huge updates to changes in, uh,

3:44

new additions in the future, but they'll be changing it over

3:47

time as more of a living document.

3:49

So we won't get, we won't have another 12 years

3:51

before we get another update.

3:55

Um, I wanted to, um, first actually just think I know this,

3:58

this was a lot of work by a lot of people to, to, um,

4:01

put together this version 2025.

4:03

I was not at all involved in working on it.

4:05

Um, and I know it was a lot to go through.

4:08

I know there's a lot of research in breast imaging,

4:10

and they wanted to make sure that they were, um, taking in,

4:13

uh, everything that was being done.

4:14

So definitely wanted to thank everyone

4:16

that worked on this, this update.

4:18

Um, I also wanted to say that the point of this,

4:21

this talk is really to go over the changes to the lexicon.

4:24

That's what I'm gonna focus on. So the goal is not to,

4:26

to really, um, teach breast imaging.

4:29

I'm gonna show some samples, some examples, um,

4:32

but I'm not gonna show examples of every single, um,

4:35

finding, uh, because we just don't quite have time for that.

4:37

I'm gonna go through all three modalities.

4:39

I'm gonna go through mammography, ultrasound,

4:41

and MRI, um, with the main changes that, uh,

4:44

the main updates that were included in this,

4:46

uh, version 2025.

4:50

So one, one thing, uh, that is, uh,

4:53

modality neutral is that the, this new birads

4:58

has a emphasis on,

4:59

on including structured clinical indications

5:02

for every single study.

5:04

And this is really pretty, uh, should be pretty easy for us

5:07

to implement because it is just three choices.

5:09

Every breast imaging study, a mammogram, an ultrasound,

5:12

or an MRI, we should start off with a major indication.

5:17

The three choices are asymptomatic screening,

5:20

diagnostic workup, and diagnostic current breast cancer.

5:25

So any patient that comes in at the beginning of our study,

5:27

we should lump it into one of these three categories.

5:32

There are then options to include subcategories, um,

5:37

which I think is probably most important

5:39

for the diagnostic workup.

5:40

But these are some of the examples that, uh, that are

5:42

provided for what these subcategories might be.

5:44

So for a patient coming in for asymptomatic screening,

5:47

it may be important

5:49

to include in the indication if they have an elevated risk

5:51

for breast cancer, they have done breast tissue,

5:54

or if they have a history of breast cancer, these are sort

5:56

of pertinent additional information.

5:58

Um, they're still an asymptomatic screening patient,

6:01

but it might be important to know that information in order

6:03

to interpret the study for the diagnostic workup.

6:07

I, I think that these subcategories,

6:08

although they're called optional,

6:09

I think are probably more important

6:11

because if someone's coming in for a diagnostic workup,

6:13

we really wanna know what they're,

6:15

what they're presenting for.

6:16

So, um, somebody has coming in for a palpable lump,

6:19

that would be a clinical finding.

6:21

It may be, um, they were called back from a screening

6:24

mammogram or a focal asymmetry.

6:26

That would be an imaging finding.

6:28

It could be a bi rad three follow up or a biopsy follow up.

6:31

So I think if, um, I think in that this diagnostic

6:34

of it really, this optional subcategory is probably very

6:36

helpful to, um, to include when, uh,

6:40

when writing the indication for the study.

6:44

Uh, then they have, um,

6:45

an optional additional relevant history.

6:48

Um, so some examples that they give that might, this might,

6:50

um, entail would be the specific gene mutation,

6:54

the specific imaging finding, and the location

6:56

and the size of the cancer in

6:58

a patient with a known breast cancer.

7:00

Um, so this should be,

7:01

every breast imaging study should have, um, kind

7:05

of followed this light up when we're writing the indication.

7:08

Um, so I'm gonna get into our three, um,

7:13

main, uh, modalities in, in, um, breast imaging.

7:16

And the first one is, is mammography.

7:18

This is our main modality in breast imaging.

7:21

Um, so first is that they have a whole section

7:23

for digital breast tomosynthesis.

7:24

So the fifth edition was published in 2013, right

7:27

around the time that tomosynthesis is being FDA approved.

7:30

It did not have tomosynthesis included.

7:33

Um, so it also includes what the benefits

7:36

of digital breast tomosynthesis have been.

7:39

So really, um, we know from many studies

7:42

that tomosynthesis increases cancer detection rate

7:45

and lowers recall rate.

7:47

And I just have just a, a quick example.

7:48

This isn't a, a nice case with a, this, um, distortion

7:52

that is circled, that's in the central part of the CCC view

7:56

On the 2D view, this sort

7:57

of just looks like the normal tissue,

7:58

but when you scroll through,

7:59

and this is a single slice of the tomo, so this is a,

8:02

it really, um, you can see that those margins

8:04

and that that distortion really jumps out, um,

8:06

and becomes very, uh, much more obvious.

8:09

Uh, and SOIs is really a win-win

8:11

with both finding more cancers

8:13

and allowing us to, uh, um,

8:17

have a lower recall rate.

8:21

Um, so breast sensation was not changed in the fifth, uh,

8:24

in this, uh, version 2025.

8:26

I just wanted to point out that in the the fifth edition,

8:28

there was a pretty major change.

8:30

I know that has, that was, you know, over 10 years ago.

8:32

But just wanted to remind people that the,

8:34

the breast density is really classified on

8:36

how likely the tissue is.

8:38

The tissue that's there will obscure a cancer.

8:41

Um, in previous versions, it was just what the percentage

8:44

of dense tissue was.

8:47

Um, but,

8:49

but they, uh, uh, what they have changed is

8:52

that if there's one area that's very dense, that's really

8:54

what we should, we should be basing the breast density on,

8:56

not looking at the whole breast.

8:57

Overall. Um, why is breast density important?

9:02

Well, really there's two reasons.

9:03

So, one is that we know that it affects mammo, uh,

9:06

mammographic accuracy.

9:08

So higher breast tissue density, uh,

9:11

decreases the sensitivity of mammography.

9:12

It's just harder to see cancers when you have a

9:14

lot of dense breast tissue.

9:16

Um, and many studies have shown

9:17

how the sensitivity really goes down with increased,

9:20

um, breast density.

9:22

And second, we also know that increased breast density is,

9:26

uh, is a, um, is an independent

9:27

risk factor for breast cancer.

9:29

So it's really a, it's really, um, both sides

9:31

that make it important.

9:33

Um, and because of this, we are required

9:35

to document the breast density

9:36

for every mammogram that we read.

9:37

And I just have examples of the four categories.

9:40

This wording is, is very imp is very specific.

9:43

The FDA requires this specific wording.

9:46

A small change in the new birads is that they do allow, um,

9:51

changing when it's a unilateral study

9:53

to have a unilateral wording.

9:55

This is a kinda an issue with the, the prior FDA wording

9:59

or the, the requirements was, um, was plural.

10:02

And so if it was a unilateral study,

10:03

that was always a little bit awkward.

10:04

So that was a small change.

10:06

But this, this wording is, um, is standard.

10:13

I'm getting into, um, specific findings.

10:16

So I always, when I was teaching these, uh, um, the lexicon,

10:21

I used to always have to kind of re rethink this.

10:23

I would always say for shape, you can remember ROI like a,

10:27

an a VI region of interest.

10:28

That's how I would always remember it.

10:29

But now it's, um, we have added a fourth shape.

10:33

So we have oval, round, irregular,

10:36

and a new shape, um, is lobulated.

10:38

And, uh, you'll see this very similar slide when I go

10:41

to ultrasound and MRI,

10:43

because this lobulated shape option was added

10:46

for all three of the modalities.

10:48

So they describe a lobbyist sheep is, that is a mass

10:52

that has one or more indentations resulting in

10:55

an undulating contour.

10:57

This is usually benign,

10:58

but slightly more suspicious than oval sheep.

11:01

Um, kind of on the, on the flip side,

11:06

they got rid of one of the margin terms.

11:08

So another thing I'm gonna have to rethink of my,

11:11

um, you know, how I'm teaching this.

11:12

So they used to always say, okay, the margin, you remember s

11:15

but now we lost that m.

11:17

So for the mammographic mass, the choices

11:19

for margin are circumscribed, obscured,

11:22

indistinct, or speculated.

11:25

So for that, what we used to call micro lobulated,

11:27

they suggested that is usually be reclassified

11:30

as indistinct, um, with the new, um, the new birads atlas.

11:38

Um, and then another, uh, I think a very important change is

11:43

that a mammographic mass is, um, now only needs

11:46

to be seen on one view if it has the

11:48

characteristic features of a mass.

11:49

And I just copied this as the specific wording, um, for

11:53

that, uh, on this section from the, uh, virus version 2025.

11:58

Um, in the past, uh, one view finding was always had

12:01

to be considered an asymmetry, even if it,

12:03

if it really looked like a mass.

12:05

Um, but we, we know we, it's possible that the,

12:08

the finding may not be included on the image on the second

12:11

view, potentially for a bar posterior finding,

12:14

or might be obscured by, um, fiber glandular tissue.

12:18

Uh, and I think tomosynthesis can help show

12:21

that a finding really truly is a mass, like really has the,

12:25

um, has this, the sheep in the, the other requirements

12:29

of a mass, even if it's only seen on one view.

12:33

Uh, so this is definitely, this is a another change

12:36

that I'll have to get, get used to, uh, being allowed to do.

12:39

And I just have an example here.

12:41

This is a small mass that we see on a, this is a spot

12:44

CC view, and this is a single tomosynthesis slice.

12:47

When I scrolled through this on the tomosynthesis, it,

12:51

I could clearly see that it represented a mass,

12:53

it had a definite 3D shape, um,

12:56

but I was not, did not have a correlate on the other view.

12:59

We went to ultrasound. This did, um, uh, have a correlate

13:02

of an irregular math on ultrasound.

13:04

This is also, um, in example

13:07

that in the past I may have used micro lobulated

13:09

to describe this margin.

13:11

Um, I think it has like little bumps on the edge of it.

13:14

So in this new, uh, version of birads,

13:16

I would use the margin as indistinct instead.

13:20

Um, the overall shape, I think in the o birads,

13:23

I would've called this oval,

13:24

but it does have some gentle undulations in this.

13:27

And so this may be a, a good example

13:29

of also a lobulated key.

13:30

So this is a kind of, kind of, that is one that we may,

13:33

I would, um, opt to use a lot

13:35

of the new language in Rads calling this a lobulated mass

13:38

with indistinct margins,

13:40

even though it's only seen on one view.

13:46

Um, so there are a few changes

13:48

to the mammographic calcifications.

13:51

Um, I think a lot, I think fewer than the

13:53

changes to the mass section.

13:54

So just go over them.

13:56

Um, so I just crossed off the wording that was removed,

14:00

and then I have the purple, the, the findings that were the,

14:03

that were added, um, so many other the same.

14:06

So we still have skin vascular, coarse,

14:08

round rim and suture.

14:10

Those were all in the fifth edition

14:12

and are, again, in version 2025,

14:16

the term popcorn like was removed.

14:19

So what we used to call popcorn like

14:20

that would just now fall under the course category.

14:22

Those remove the term dystrophic,

14:24

that should also now be categorized as coarse.

14:28

And then the term milk of calcium was removed

14:32

and, um, instead just, um, changed to layering.

14:35

And that's because milk of calcium is really what's causing

14:38

the calcifications where rather than the,

14:41

um, the appearance of it.

14:43

So we're changing it to describe the appearance

14:45

of it rather than what is causing it.

14:48

Um, which it seems very reasonable, reasonable to me.

14:51

I think we'll also, maybe I'll have

14:52

fewer questions from patients.

14:54

I think that milk calcium, I think did, uh,

14:56

I know in my anecdotal experience sometimes would lead

14:59

to questions from patients, and

15:00

that term was a little bit confusing.

15:02

Um, so layering calcifications is what we would use

15:04

to de try to deter to, um, describe those now.

15:07

So I just have one example

15:09

of calcifications I may have called popcorn calcific.

15:11

Oh, there's one other change actually I forgot to, uh,

15:13

to go over here is that the term punctate was removed, um,

15:18

in version, uh, five round

15:20

or punctate were grouped together.

15:22

But, um, we were supposed to use the distinction

15:24

of whether the individual calcifications were less than

15:27

or equal to 0.5 millimeters.

15:30

So around calcification was larger

15:33

and a punty calcification was smaller than 0.5 millimeters.

15:36

And I know in one of the, the lectures that I went

15:38

to about the new birads, I remember clearly the,

15:40

the person giving the talk, um,

15:42

explaining why the changes made.

15:44

They said, no one's pulling out a ruler

15:46

and measuring calcifications and it,

15:47

and it doesn't matter round

15:49

or puncti, they were treated the same.

15:51

Um, uh, you know, grouped round

15:53

or puncti calcifications on a baseline.

15:55

That is something that can be a birads three that has not

15:58

changed, but it doesn't matter if it's under

16:01

or over 0.5 millimeters.

16:02

If that distinction made a difference in outcomes,

16:04

then we would have kept it.

16:06

But because it doesn't make a difference

16:07

that term punk date has been removed.

16:09

So what we used

16:10

to call punk date should just now all be

16:12

called round calcifications.

16:16

This is just an example of calcifications

16:18

that may have been, um, called course, uh, called, um,

16:20

popcorn calcifications in the past.

16:22

And now we would call course calcifications.

16:27

There are no changes to the suspicious falsifications.

16:29

I just have the four categories listed here.

16:32

Amorphous course, heterogeneous fine amorphic

16:35

and fine linear or fine linear branching.

16:37

And like I said before, I don't,

16:38

I'm not gonna show examples.

16:39

This is not a, a talk to teach you what these all look like.

16:42

But, um, just to go over the lexicon, so these are have,

16:44

are, are unchanged in the, um, version 2025

16:50

compared to the fifth edition.

16:54

Um, so I think, uh, uh, uh, sort of another, uh,

16:58

big change is that within the asymmetry category

17:02

by rads version 2025 has removed the term

17:04

developing asymmetry.

17:05

And that's because the temporal change is for sure important

17:09

and it should be described,

17:10

but there's not, not other findings in our lexicon

17:12

that have a temporal component.

17:14

So this was removed to be consistent.

17:16

Um, and I think that makes a lot of sense.

17:18

So developing asymmetry is a new

17:20

or increasing focal asymmetry.

17:22

So this is just an example.

17:25

Um, this, this patient has a,

17:28

a focal asymmetry in the, uh, upper outer, uh,

17:32

breast can see had circled in the red that was, uh, new

17:36

or at least is increasing compared to the prior.

17:38

So, and I used, I would've in the past called this a

17:40

developing asymmetry.

17:43

Um, but now we call this a focal asymmetry,

17:45

but it's a suspicious focal asymmetry

17:47

because it's new or increasing.

17:52

Um, so just to point out that, so a focal asymmetry,

17:55

the birads is really dependent on, on looking at, uh,

18:00

the study in the context of, of

18:03

what was, what happened before.

18:05

So on a baseline mammogram, a focal asymmetry is appropriate

18:09

to be a birads three in recommending a six month follow up,

18:13

a new or increasing focal asymmetry.

18:15

What we used to call a developing asymmetry

18:17

would be a Birads four.

18:19

So this would still be called a vocal asymmetry, but

18:21

because we have priors and it's new

18:23

or increasing, we're gonna, um, give it a rads four.

18:26

I mean, this patient should have an ultrasound

18:27

to see if there's a correlate,

18:29

but we know that developing asymmetries,

18:31

even without an ultrasound correlate have a high

18:35

positive predictive value for cancer.

18:36

So these should be biopsied.

18:38

A stable focal asymmetry typically over two years

18:41

would be a birad strain.

18:47

Um, solitary dialect.

18:49

The duct in the prior edition were described as suspicious

18:53

and biopsy was recommended.

18:54

And this was really based on like a single small study.

18:58

Um, there has been a lot more studies on this topic since

19:01

the prior, uh, version of birads.

19:04

And it's, uh, realized

19:05

that these solitary dilate ducts are usually benign.

19:08

So unless the patient is symptomatic

19:10

or there are other associated with suspicious findings such

19:14

as microcalcifications, a mass

19:16

or architectural distortion, they can be called benign.

19:23

Um, in the past, the lymph nodes were not its own section.

19:25

So now lymph nodes for, um, all

19:27

of the modalities have their own section

19:29

and it's, it's just organized as normal

19:32

or, uh, whether it's an inter mammary lymph node

19:34

or an axillary lymph node

19:36

and whether it's normal or abnormal.

19:40

Um, and they also provide the management guidelines.

19:43

So these are to check for symmetry

19:45

to review the medical red record for a potential reason

19:48

to have enlarged lymph nodes.

19:49

And if you have unexplained, uh, adenopathy, then we would,

19:53

um, call that patient back and do an ultrasound.

19:55

Um, ultrasound is really the best modality to, um,

19:58

evaluate the lymph nodes.

20:04

Um, this new rads goes into detail, um,

20:07

differentiating a primary finding, a secondary finding

20:10

and associated features.

20:13

Um, so the primary finding is gonna be the abnormality

20:15

that drives the birads in management.

20:20

This is, um, distinct from a secondary finding.

20:23

So these are additional imaging findings

20:25

that are associated with the primary finding.

20:27

So some examples, and these are, um,

20:29

probably the most common examples would be if you have a

20:31

mass that is the, really the main suspicious finding,

20:33

but if there's calcifications associated with it, um,

20:38

on the flip side, you may have calcifications

20:40

that are the primary finding that are driving this,

20:42

the level of suspicion, but there's an associated fo

20:44

asymetry, so that would be a secondary finding.

20:47

So these are imaging findings associated

20:49

with the primary finding, these,

20:52

this distinct from associated features.

20:54

Now associated features are changes to the breast

20:57

that happen due to the primary and secondary findings.

21:00

And the, the main examples that they include are skin

21:02

retraction or skin thickening, um, that we see in response

21:06

to, uh, findings in the breast.

21:10

And, um, these are very clearly laid out in the new by rad.

21:12

These, uh, the difference between primary, secondary

21:15

and associated features.

21:20

Um, another, this is sort of a, um,

21:22

I think a difficult topic or unresected high risk lesions.

21:26

So this has been an area that has, um,

21:29

been evolving over the past several years.

21:32

And there is a recognition in the new Bio-Rad Atlas

21:35

that different institutions have different protocols

21:38

and they are very clear

21:39

that the institutional protocols should be followed.

21:42

Um, so it's, uh, finding that in the past were

21:47

documented as being high risk, have sort of shifted

21:50

and are not always excised.

21:51

And this would might include something like a papilloma, um,

21:54

which may be just even called benign by some surgery groups,

21:58

um, or a LH.

22:00

Uh, so based on the institutional protocol, it is okay

22:06

to, um, fall to follow these findings

22:10

and change the virus to

22:11

after a period of time that's decided on by

22:14

between like the radiologist and the surgeon.

22:15

So typically two years.

22:17

So we do this in our group when we have one of these,

22:19

um, high risk lesions.

22:21

And I know this, even this term lesion has been sort

22:24

of changed and we try not to actually use

22:25

that term anymore in our institution.

22:28

Um, we have those patients see a breast surgeon.

22:31

If they see a breast surgeon and it's decided not to do

22:34

a surgical excision, then, um, we will, uh,

22:39

do inter um, imaging follow up for two years.

22:42

And after two years, we will give the patient a ires two.

22:50

Um, so that's the end of the, um, uh, mammography section.

22:53

I'm gonna move on to the ultrasound section now.

22:59

Um, so the first thing they talk about in the ultrasound

23:01

section is test tissue composition.

23:02

So the tissue pattern is unchanged from the fifth edition.

23:05

There are three options, a homogeneous background,

23:08

EQU architecture, fat homogeneous background,

23:09

echo architecture, fibro, glandular,

23:11

and a heterogeneous background architecture.

23:13

And this is primarily for ultrasound screening exams,

23:16

but they also add a new, um, tissue composition category,

23:21

and that is a glandular tissue component.

23:23

And this is the qualitative assessment of how much

23:26

of the tissue is five angular tissue versus fat.

23:29

So this is, um, similar to the breast density.

23:33

Um, and similar to the breast density,

23:35

we have four categories, minimal, mild, moderate,

23:38

and march with, um, percentages of how much

23:40

of the breast tissue is that angular tissue.

23:44

It's very similar to the

23:46

how the breast density was categorized

23:48

before this, the fifth edition came out,

23:50

which was the percentage of dense versus non-ED tissue.

23:54

Um, so it'd be interesting if this ends of getting changed

23:56

to more, to more similarly, um, follow

23:59

how we're now now using density.

24:00

But for now it's based on the percentage of, of each, um,

24:05

so less than 25% would be minimal

24:07

and then marked would be greater than

24:08

or equal to 75% of the fibro glandular tissue compared

24:11

to the fat fatty tissue.

24:13

So this is just, um, um, a single example.

24:16

This patient has a cyst in her breast,

24:17

but what we see is that most of the, the,

24:19

the tissue on the ultrasound is fatty and that,

24:22

but I do see this band of dense tissue

24:24

and say she has, um, uh, 20 0 20,

24:28

over 25% of this, um,

24:31

fiber glandular tissue compared to the fatty tissue.

24:33

So we put her in the mild category

24:36

and we look at her mammogram and it's sort of similar,

24:37

I would put her into a scattered fibro glandular

24:40

densities category on her mammogram.

24:42

So those two things usually go together.

24:47

So this is, again, similar.

24:49

I like, uh, like I mentioned when I talked about this, on,

24:51

on mammogram, we're gonna see this, this slide three times.

24:54

So ultrasound mass, this, the, um,

24:57

shape ovulated has been added.

25:00

Same description, um, here as for, um, as I'm mammogram,

25:04

again, usually benign

25:05

but slightly more suspicious than oval sheep.

25:09

Um, they also just very slightly change the wording

25:13

for para parallel.

25:15

It's now parallel versus non parallel.

25:18

In the prior version, it was not parallel.

25:19

I mean, these are small changes,

25:20

but just, um, you know, to be aware that this is

25:23

how it is now worded in the new manual.

25:27

Um, for echo pattern, um, the term complex cystic

25:31

and solid has been changed to mixed solid and cystic.

25:35

And the reason for this is that it's the solid component of

25:39

of the, these mixed masses that really drives the birad.

25:43

So wanna have that be the first at the beginning

25:45

of the wording rather than at the end.

25:48

So this is gonna take me a little bit of getting used to.

25:50

I'm so used to saying complex cystic and solid mass,

25:53

but now we'll be changing that

25:55

to calling these findings mixed solid and cystic masses.

26:02

Uh, the posterior features,

26:03

the term combined pattern was removed.

26:06

So now the three choices are no posterior features

26:10

enhancement or shadowing.

26:13

So I just have a couple of examples.

26:16

This is a little, uh, mass

26:17

and, um, in the prior version of virus,

26:19

I may have used the term micro lobulated to describe this,

26:23

um, margin, but now we would use the word, um,

26:26

indistinct to describe it.

26:31

This is a, um, a math that previously would've described

26:35

as a complex cystic and solid mass.

26:37

I see an area that's, um, anti coic with, uh, fluid.

26:41

And then there's a solid component that I'm showing,

26:43

showing in the right image has blood flow within it.

26:47

Um, and so this would now be called a mixed solid

26:51

and cystic mass rather than a complex cystic and solid mass.

26:58

Um, now a non mass, non mass lesion is a whole new, um,

27:03

category that was a now included on ultrasound.

27:06

Um, I think this is very helpful to include, uh,

27:10

'cause I have seen this before.

27:11

So this, the definition that's given in

27:13

by RADS is a sonographic finding

27:15

that is identified in at least two imaging planes,

27:18

but lacks the 3D dimensionality

27:20

or conspicuity of a mass, such

27:22

as characterizable margin or shape.

27:25

So it may be primarily visualized in only one plane.

27:28

It's often subtle, the size may be difficult to determine.

27:32

And segmental distribution is predictive of malignancy.

27:37

I'm gonna go through the these, um, these are the,

27:40

the biris terminologies that are, um,

27:44

that we should be using when we're describing them.

27:46

And it, the, the, the distribution, it, it's very similar

27:49

to non mass enhancement on MRI.

27:52

So can we describe this regional focal linear

27:54

or segmental with segmental really having the highest

27:58

positive predictive value for malignancy.

28:00

We describe the echo pattern of he hyper coic,

28:04

hypo coic or heterogeneous.

28:06

And then the posterior features, they're the same

28:07

as the mass findings,

28:09

no posterior features enhancement or shadowing.

28:12

So these different categories are similar to other, um,

28:15

other finding that it's kind

28:17

of copied over from either the ultrasound mass

28:19

or the MRI non mass enhancement finding.

28:24

Um, they've added calcifications

28:28

for under on ultrasound in the new version of birads.

28:32

Um, so these are, they used to just have, um,

28:35

the only way they health patients were only included if they

28:38

were associated with a mass, either in a mass

28:40

or outside of a mass.

28:41

But now they're also, um, included on their own.

28:44

And then they've also added, they could also be associated

28:46

with a non mass lesion.

28:52

They have added a few associated features.

28:55

So these are some of the new, or at least

28:57

or changed, um, associated features

29:00

that are included in this new birad.

29:01

So an echogenic, pseudo-real and echogenic rind.

29:06

And they've also changed some

29:07

of the wording for vascularity.

29:08

So the three choices for vascularity are avascular,

29:11

internal vascularity and peripheral vascularity.

29:17

These are the unchanged associated factors, features

29:20

that have been present on the live,

29:21

the prior aversion architectural distortion, duct changes,

29:25

skin changes, edema,

29:26

and an elasticity assessment

29:28

if that's something that you were doing.

29:33

Um, so lymph nodes, uh, it really in all three modalities,

29:36

the lymph node section was really expanded.

29:38

Um, so on ultrasound they've had had differentiated

29:42

intra memory, axillary

29:44

and, uh, to differentiate what level it is, level one, two,

29:47

or three and supraclavicular.

29:49

And, um, the morphology, this is unchanged,

29:51

the cortical thickness of three

29:53

millimeters, which are cutoff for normal.

30:00

I am now gonna move on to the, um, the MRI section.

30:03

I know we have a couple of questions.

30:04

I will, um, come back to them at the end,

30:06

but if anybody else has questions, feel free

30:08

to put them in the, in the chat

30:09

and I'll do my best to answer them at the end.

30:14

Um, so m MRI several changes to the MRI section.

30:17

So I think this is probably a, a big one for me.

30:19

I think I've, I use this term focus pretty regularly,

30:22

and this term focus, um,

30:24

has been removed from the by rises atlas.

30:26

So focus was previously described

30:28

as a small dot of enhancement.

30:30

Um, but the by rise version 2025 suggests

30:34

that these should not be described as either a small mass

30:36

or a small focal non-math enhancement,

30:38

or they shouldn't be described at all

30:39

because they're just part

30:41

of the background parenchymal enhancement.

30:46

Um, again, for, uh, the, um, uh, I'm sorry, this is the,

30:50

this is the shape, the shape brown og,

30:52

irregular lobulated has been added just like the other

30:55

modalities for margins.

30:58

There's also a change.

30:59

Um, so they have circumscribed and then non circumscribed.

31:04

The two choices used to be speculated and irregular.

31:07

Um, I always thought it was a little bit awkward

31:09

that you could have an irregular shape

31:10

and an irregular margin.

31:12

When I was describing a mass on MRI,

31:15

now you can no longer do that because the eye

31:17

is now indistinct.

31:18

So, um, that word irregular for margin has been removed.

31:22

Um, so you can have an irregular shape

31:26

with an indistinct margin,

31:27

but you can't have an irregular shape

31:28

with an irregular margin anymore.

31:33

And there was a new descriptor added

31:35

for masses, and that's T two hypertensive.

31:36

I'm gonna show an example of that with the reference being,

31:39

um, lymph node bright

31:41

for what's considered T two right on MRI.

31:47

Um, and they also added, um, another, another feature,

31:51

peritumoral edema.

31:52

This is T two hyper signal

31:54

and the tissue surrounding a known cancer

31:56

or suspicious finding.

31:57

This is typically considered suspicious,

32:00

although it can also be related to post biopsy ft change, if

32:02

that binding was recently biopsied.

32:06

There were no changes to the, um,

32:08

terminology from, um, the fifth edition.

32:10

In terms of non for non mass enhancements,

32:12

really the changes were, um, that we've talked about

32:15

so far were related to the removal of focus

32:17

and then, um, some changes to the lexicon for masses.

32:19

So, um, again, lymph nodes,

32:23

some changes for lymph nodes.

32:25

Now it has its own section. We're gonna be clear about

32:28

what the location, is it intra memory,

32:29

axillary or internal memory.

32:32

And, um, describe the that lymph nodes

32:35

as either normal or abnormal.

32:37

On MRI. This is a subjective assessment.

32:39

We're looking for asymmetric asymmetry compared

32:42

to other lymph nodes, um,

32:45

and subjective cortical thickening.

32:46

So that three millimeter cutoff

32:48

that we use on ultrasound is really not, uh,

32:50

doesn't work on MRI.

32:52

Um, a lot of little lymph nodes will, um, seem

32:56

to have over a three millimeter cutoff just

32:58

because of the way that the imaging is done.

33:01

Um, asymmetric rounding

33:02

or absence of hila also, our, um,

33:04

shouldn't be the sole criteria,

33:05

especially the absence of hila.

33:07

Some, um, small lymph nodes will look like they don't have a

33:10

hilum on MRI that can be normal for them.

33:13

So this should be, um, in, in combination

33:16

with other findings on the lymph nodes.

33:21

How do we, um, report the lymph nodes?

33:23

So it really depends on the clinical scenario.

33:25

Is it, has it already been biopsied?

33:27

Does the patient have a known cancer?

33:30

Um, so if, if somebody has lymph node that's already biased,

33:34

we know that it's cancer, that's gonna be a birad six.

33:36

That's should be easy. If the patient has a known cancer,

33:40

then could, um, give the lymph nodes a birads four

33:43

and recommend a, a biopsy or could.

33:45

Um, uh, and if the patient does not have a, a known, uh,

33:50

and you could also say whether it would,

33:52

if it would affect clinical management

33:54

and the, the patient does not have a known cancer

33:56

with unilateral adenopathy without a known reason,

33:59

he would give this a virus four

34:01

and recommend ultrasound with intent to biopsy.

34:05

So just gonna have a couple of examples here.

34:08

Um, this is a T one, uh, subtraction image.

34:11

The first subtraction, the first, um,

34:13

post contrast subtraction.

34:16

Um, I have the yellow arrows are pointing to two small, uh,

34:19

m findings in the right breast.

34:22

I would have described these as small, uh,

34:24

of enhancing foci.

34:26

So now, and then with that, the removal of the term focus,

34:29

I would describe these as small masses

34:30

and give them the measurement for them.

34:35

This is a, uh, a finding that in a prior version,

34:38

I would've called this an irregular shaped mass within an,

34:43

uh, with an irregular margin, with a new version of birads.

34:48

I, um, would think that the shape, I think would

34:52

could call it irregular.

34:53

I think it also could potentially fit into the category of,

34:56

um, lobulated and the, the margin.

34:58

And I would not call, I would call indistinct in, um,

35:01

using the new mar, using the new Birads lexicon.

35:08

Um, so now, uh, T two hyperintensity, this is something

35:10

that we've been describing, um, uh,

35:15

on our MRIs, you know,

35:19

but it just, it just wasn't something

35:20

that was included in the by rad atlas as an,

35:22

as a as a category.

35:24

Uh, so this is really not something

35:25

that's probably gonna change our practice,

35:27

but just to, uh, it's this new in, in the RADS atlas.

35:29

So I'm showing here a T two weight image on the left,

35:33

A T one subtraction image on the right there is an enhancing

35:37

mass in the inner left breast,

35:38

which the arrow is pointing to.

35:40

And on the T two, this is T two bright,

35:42

what we're comparing it to is a, a lymph node.

35:44

I don't have a lymph node on this image,

35:45

but this is really light bulb, right?

35:46

It's very bright. So this would be a T

35:48

two hyper enhance math.

35:51

Um, and this is a, we're, I'm gonna talk about this Mina,

35:55

but this is actually the only finding a a, um, an oval math

36:00

that's ttu, right, that has shown to have a, um, appropriate

36:05

for a BI-RADS three assessment.

36:06

I'm gonna get actually into that in just a minute.

36:09

The, the birads, um,

36:10

new birads goes into more detail about the BIRADS category.

36:14

So I'm gonna talk a little bit about, about this here.

36:18

Um, so they,

36:19

they have a whole section on bio RADS three on MRI.

36:22

And I think this, this first line

36:24

that I keep had here was, was surprising to me.

36:26

And I think this is very aspirational in my

36:29

own practice and in my groups practice.

36:30

So it's, they say that should be used in less than, uh,

36:34

or equal to 5% of examination.

36:36

So this should really be used rarely.

36:39

Um, it should rarely be used in non baseline exams.

36:43

It should never be used in current cancer patients.

36:46

And there's only one specific imaging finding

36:49

that has been shown to have the appropriate criteria

36:52

for a S3, and that's a mass that is oval circumscribed

36:56

with homogeneous internal enhancement

36:57

or dark internal citations.

36:59

It's T two hyper enhance that's not new or increasing.

37:01

So that, that example that I just gave

37:03

of a T two hyper enhance

37:04

mass really meets all this criteria.

37:05

That's a great, that would be a great example on a,

37:08

if you saw that on a baseline study,

37:09

that would be a birads three.

37:12

Um, but they really discouraged the use of IRADs three

37:14

for other findings

37:16

or for, um, for cases that are not baseline,

37:20

we should be making assessments as the finding stable

37:23

and then that would be negative.

37:24

Or is the finding new or increasing and

37:25

therefore suspicious and should be biopsied?

37:28

Um, I think this is very challenging, challenging to do,

37:30

and I think something that we're all working on trying

37:32

to, to hone this skill.

37:36

Um, BIO RADS four, um, in the prior version,

37:40

the subgroupings of four A, B,

37:42

and C were only, um, previously listed

37:45

for mammography and ultrasound.

37:46

They have been now added for MRI, um, seem, uh,

37:51

PPVs as what we had in, um, on the other modalities with

37:56

a positive predictive value of two to 10% falling into

37:59

that four a category, 10 to 50%, four B,

38:02

and over 50% in the four C category.

38:05

And I really find this the most helpful in

38:07

talking with patients.

38:09

Um, I think kind of having these subgroups you can say,

38:13

you know, we're being, if you're, it's a four a maybe

38:15

that we're being very cautious

38:16

and recommending if you're in a four C category, might want

38:19

to do a little bit more time counseling the patient

38:22

about the concern that this, um, has a good chance

38:25

of being a breast cancer.

38:27

Um, so I think it's, it it makes sense to have this as, um,

38:30

consistent across all of the modalities.

38:32

Uh, um, there is some, uh,

38:37

also wording, I think this is kind of helpful guidance

38:41

for those patients that come in for an MRI

38:43

for extensive disease.

38:45

Uh, when do we use a birads six

38:48

and when do we use a birads four or five?

38:50

Um, and these are the guidelines that are given in the, um,

38:54

in the 20, uh, 25 IRADs atlas.

38:57

So when you have a, a vi, when you have, um,

39:00

additional findings that are contiguous

39:02

with the known cancer, um, when it is less than

39:06

or equal to two centimeters from when there's additional

39:08

finding that's less than or equal

39:09

to two centimeters from the known cancer,

39:11

or they increases the total extent of the finding

39:15

by less than two centimeters

39:17

and would not change clinical management

39:19

by getting additional tissue,

39:20

then those additional findings should all be described

39:24

as part of the known cancer

39:25

and that patient should be given a BIRAD six.

39:29

This, uh, should be separate from, um, cases

39:33

where the additional findings are over two centimeters from

39:36

the cancer or when those additional findings would increase

39:38

the extent of disease by greater than two centimeters,

39:41

which is a cutoff

39:42

that we use that'll likely impact clinical management.

39:45

They also, um, suggest avoiding the term satellite

39:48

because that term doesn't have a specific meaning

39:51

and maybe different things to different people.

39:53

So instead just to describe the finding in the relationship,

39:56

um, to the known cancer

39:59

and have those guide what the, the BioRad

40:01

and the management recommendation would be.

40:05

I just have an example here.

40:06

This is a patient, um, that was present me

40:08

for extensive disease on the, the image on the left.

40:12

I'm showing the biopsy proof and malignancy.

40:13

This is a large irregular mass with speculated margins.

40:17

The image on the right, the patient had, um, this large area

40:20

of non mass enhancement in a segmental distribution

40:23

extending between the known cancer and the nipple.

40:26

It was, um, about five centimeters in, uh, in a span.

40:32

So this really, uh, would, would change the,

40:34

the patient's surgical, uh, planning.

40:37

It increases the span by well over two centimeters.

40:40

So this patient was given, uh, a bio RADS five

40:43

with a recommendation to do additional tissue sampling.

40:46

So we biopsy the anterior margin of

40:48

that non mass enhancement.

40:50

It was DCIS, we had a clip there.

40:52

We're able to include that whole span in the patient's,

40:55

in the patient's, um, surgical planning.

41:00

Um, the last, um, thing I wanted to talk about is that the

41:05

buyers does, um, also, uh, just point out that the

41:11

BYS assessment, this is a modality neutral,

41:13

should always match the imaging findings.

41:15

And this is actually similar to the prior additions.

41:17

Nothing new. I think it's just something to, to remind,

41:20

um, everyone about.

41:22

So the BYS assessment should match the imaging findings,

41:24

but the recommendation should match the patient, which means

41:28

that there can be a mismatch in your birads

41:30

and your recommendation.

41:32

Um, so these are just some, I think some

41:33

of the common examples that we'll see here, which is like a,

41:37

a simple cyst that's painful.

41:38

We know that's not a cancer, that is a BYRES two finding,

41:41

but the recommendation is to do an aspiration.

41:45

Um, we sometimes will have a patient

41:46

with a known breast cancer who has, um, an ultrasound study

41:51

schedule from the of the axilla.

41:53

And if the lymph nodes are normal, since the imaging on

41:56

that patient today is the axilla

41:58

and we're imaging normal, um, lymph nodes, we're gonna give

42:01

that study a IRADs two.

42:03

But the recommendation is not annual screening mammogram.

42:05

The recommendation is to be continue

42:07

their surgical consultation.

42:10

Um, so that is the, the last line of my talk.

42:13

Uh, I wanted to thank everyone for their attention.

42:14

I have a couple of questions. If anybody else has questions,

42:16

feel free to type them in.

42:18

I will, um, do my best to reply, respond to the questions

42:22

that are in here.

42:23

So the first one was to repeat the primary

42:25

and secondary finding so I can go back to that section.

42:29

This was under mammography.

42:33

Um, so just to repeat, so the, these are, they have kind

42:36

of three different lumping of, of, of, uh,

42:39

what you're describing as a, either a primary finding,

42:42

a secondary finding, or an associated feature.

42:44

So the primary finding is gonna be your abnormality

42:47

that drives the birads in management.

42:48

So this is the main finding that you're describing.

42:51

A secondary finding are gonna be other imaging findings

42:54

that are associated with a primary finding.

42:56

And I think sometimes it can be difficult.

42:57

Maybe you have a mass with associ,

42:59

like very suspicious calcifications

43:00

and you know, maybe it's hard

43:02

to decide which one is the primary,

43:03

which one's the secondary.

43:05

But I would step back and think what is really the finding

43:07

that's driving my, my level of suspicion?

43:09

And that's gonna be your primary finding.

43:11

And then you're still gonna describe the other findings,

43:14

but those would be secondary findings.

43:16

Now this, these two primary

43:19

and secondary findings, these are like calcifications,

43:22

asymmetries masses.

43:23

These are, um, these like discrete mammography, um,

43:27

categories, which is distinct from the associated features.

43:30

And these are changes to the breath that happen due

43:33

to primary and secondary findings.

43:36

So that answers that question.

43:38

The second question is, how are we calculating percentage

43:42

of tissue component on ultrasound?

43:44

So I think this is, um, a little bit tough for me to answer.

43:47

This is, this is new in by, this is not something

43:50

that we have been doing in our group,

43:52

but this is partic it should be used, um,

43:54

in my understanding from reading in the, the

43:56

by atlas should be done on screening ultrasounds where,

43:59

where, um, scanning the entire breast

44:02

and then you're making a subjective, um, estimate of

44:06

how much of the ti tissue is fibro glandular, which is going

44:10

to be that more whitish, um,

44:12

the lighter colored gray versus, um, the fat,

44:15

which is gonna be the darker colored gray.

44:17

So it's, you're gonna, when you're doing

44:18

that screening ultrasound, you look, you make a decision of

44:21

how much, um, falls into each of those categories.

44:24

And I, I do show this example,

44:25

I mean it's just a single slice, so it's not a great,

44:28

I can't, you know, show you a full screening ultrasound.

44:30

But when we, if we scroll through the whole breast

44:32

for this patient, we see that, um, there is about a quarter

44:35

of the tissue is that more white fibro glandular tissue.

44:40

And about three quarters is more of this darker gray color,

44:42

which is the fatty tissue.

44:44

And therefore we put her into that mild category.

44:47

A couple of questions about lymph nodes,

44:54

um, which I think is, I think they kind of popped up

44:57

during the MRI slide on lymph nodes.

45:00

So lemme go back to that.

45:03

So every, so, uh, one is, the first question was about

45:07

what assessment should we be giving lymph nodes in general?

45:12

Um, and it is, we still would give

45:18

a, a RADS four when it's a suspicious lymph node.

45:21

Um, we don't wanna give an A zero, a rad zero on an MRI.

45:26

Uh, if we wanna give, what, what I always try to think

45:30

and what I was, was taught, I think is still consistent

45:32

with the new rads is you wanna give the assessment, um,

45:36

based on like if, if you didn't really,

45:38

if you didn't see the finding on the next modality.

45:41

Um, so for, for a lymph node,

45:43

if you see a suspicious lymph node, it's appropriate

45:44

to give it as a RADS four with the recommendation

45:47

for ultrasound and attempt biopsy.

45:50

Um, we, uh, it's similar to the prior version.

45:55

Individual findings can have what can have,

45:58

you can give it a birads,

45:59

but the overall study will get a single birads.

46:02

So, um, I mean there's so many different, uh, situations.

46:06

It's like, you know, I can go through all of them,

46:08

but I think a common, um, situation

46:12

that comes up is a patient with a known cancer

46:14

and then on their MRI,

46:16

they have enlarged lymph nodes

46:17

unilateral to the, the cancer.

46:19

What RADS would you give it?

46:21

So that would be a BIRADS four

46:22

because they have, um, a suspicious finding

46:24

and that's really the most actionable is

46:25

to find out what's going on with the lymph nodes.

46:28

Um, and so that would trump the RAD six of the cancer

46:33

patients should get an ultrasound and, um,

46:35

and biopsy at the lymph node if

46:37

that would affect her, their treatment.

46:39

I'm just reading this question.

46:44

Yeah, I think one of this question is should we be assigning

46:47

RADS for each finding?

46:48

And my understanding is it, it's still okay to,

46:50

to give each finding its own rads,

46:52

but we, what's most important is

46:53

to give the study overall a rads, which is going

46:55

to be the most actionable, actionable, um, rads of any

47:00

of the findings that are described.

47:01

So if you have a known cancer, that's a six,

47:03

but there's another finding that's a RADS four

47:05

or five, the overall RADS category for the study is going

47:09

to be the four or five.

47:12

I think I have one more question that I will, uh, can try

47:16

to address, which is asking about a DC value

47:19

and ultra fast enhancement on MRI.

47:22

Um, that is a question. I actually am not sure the answer to

47:24

that we are not, um, doing this at my institution

47:28

and I, I don't recall whether this is included in the new

47:32

by outlet, so I don't, I don't know the answer to that.

47:34

Um, but I know that's,

47:36

that's something that we're currently doing.

47:38

So I am, I'm not sure, but it's a, it's a good question

47:41

and I, uh, will try to look up the answer for that.

47:44

Well, thank you so much for your attention.

47:46

Really happy, happy to be here.

47:49

Um, and, uh, everyone have a, have a nice day.

47:53

Thank you so much Dr. Bin for that review

47:55

and for answering all those questions.

47:57

I'm sure there will be tons more about this

47:59

as people dive into the full update.

48:01

So appreciate you being here and starting this conversation.

48:04

And thank you for everyone else

48:05

for participating in our noon conference

48:07

and asking such great questions.

48:09

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48:11

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48:14

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48:17

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48:19

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48:22

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48:25

Anatomy of Knee Joint With Common Pathologies.

48:28

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48:34

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