0:01

So those were some really good examples of

0:04

good indications for BI-RADS 3 on ultrasound.

0:07

And now I just want to go through

0:08

those in a little bit more detail

0:12

to emphasize what we were just looking at.

0:16

So our first indication for BI-RADS 3

0:19

on ultrasound is a circumscribed

0:22

oval, solid, parallel, hypoechoic mass.

0:26

This is robust data.

0:27

Most of these represent fibroadenomas.

0:31

And we can safely call them a

0:33

BI-RADS 3 and follow for two years.

0:37

Now when the lesion is palpable, there's

0:40

really only good data for women under age 40.

0:43

So if it's a palpable mass in a woman

0:47

over age 40, it actually doesn't really

0:49

fall into this BI-RADS 3 category.

0:51

And we would recommend biopsy; you know, as any finding

0:56

in BI-RADS 3, we want to make sure we're assessing

0:58

it at the six-month period to look for changes.

1:00

And that's especially true for masses.

1:03

And one of the main things we're looking

1:04

at for these is a change in size.

1:07

So if a mass decreases in size, we're going to

1:09

feel really confident that it's not a cancer.

1:12

And we could change that BI-RADS 3 to a

1:14

BI-RADS 2. However, if it increases in size, and when

1:18

we say increase, we use a 205 cut-off

1:21

at 6 months, then we're going to want to do a

1:24

biopsy, and we showed one case of that where

1:27

a mass increased in size and led to a biopsy.

1:30

And we want to make sure that we're not

1:33

missing any quickly growing cancers.

1:35

And so that's why we want to do this

1:37

6-month follow-up, be very careful

1:39

in assessing for changes in size.

1:41

And then biopsy when we see that. I also want to

1:46

point out this case: when there are multiple bilateral

1:49

masses, at least we say when there's at least three

1:52

overall, and at least one at each breast, then we can

1:55

assess as benign and we don't need to do a BI-RADS 3.

2:01

Our second indication for BI-RADS 3

2:04

on ultrasound is a complicated cyst.

2:07

These should be isolated complicated

2:09

cysts with low-level echoes.

2:11

There's multiple studies showing that these have a

2:14

low rate of malignancy greater than 0%

2:17

but still less than or equal to 2%

2:20

And just like, you know, with the solid masses,

2:22

if there are multiple bilateral complicated

2:24

cysts, we can assess those as benign.

2:27

Like we showed in one example, sometimes

2:29

these will resolve at the 6-month follow-up.

2:31

And then, of course, if we don't

2:32

see the finding anymore, then we no

2:34

longer need to continue following it.

2:39

The third indication for BI-RADS 3 on

2:42

ultrasound are clustered microcysts.

2:45

We want to make sure we're differentiating

2:47

a cluster of simple cysts because

2:49

these can be assessed as a BI-RADS 2.

2:52

So BI-RADS 3 should be used when

2:53

their individual cysts are

2:55

small or deep, or they're not definitely simple.

2:58

The data supporting BI-RADS 3 for clustered

3:02

microcysts is definitely less robust than it

3:04

is for the solid mass or complicated cysts.

3:07

There's only been a small number of studies

3:09

specifically evaluating clustered microcysts,

3:12

but in those small studies, the risk of

3:16

malignancy is less than or equal to 2%.

3:18

And so that is considered an

3:20

appropriate indication for BI-RADS 3.

3:24

Now in the BI-RADS atlas, there's a few other

3:28

indications that are listed based on expert opinion.

3:32

So the first one is a hyperechoic mass

3:36

with central hypoechoic to anechoic

3:38

component suggestive of fat necrosis.

3:41

And this can do a short-term follow-up to

3:45

make sure it's changing in a way that is

3:47

appropriate for fat necrosis or resolving.

3:50

That's something that we do in clinical practice.

3:52

And I showed an example of fat necrosis

3:55

that we gave a BI-RADS 3 to.

3:59

The other two that are listed in BI-RADS 3 are

4:01

a posterior shadowing seen in two projections

4:04

without a definite mass or architectural

4:07

distortion thought to be due to post-surgical scar.

4:10

These are not findings that in my group that we give

4:13

a BI-RADS 3 to, and I think that it's likely that in

4:17

a new BI-RADS that these will no longer be listed.

4:20

But again, posterior shadowing

4:22

in two projections, you know, if we hope that we'd

4:27

be able to find a mass associated with that and then

4:29

would just do a biopsy, if we're able to clarify

4:33

it's related to a dense calcification, we would

4:35

want to just call that benign, and similar too in

4:38

mammography, when we see architectural distortion,

4:40

we get very worried, and we will only see a not

4:44

biopsy it if we're sure that it's due to a scar.

4:46

So we're very careful with looking at post-surgical

4:49

scars and trying to be confident in either calling the

4:53

distortion benign because we believe it's related to

4:57

the scar or suspicious, and then we want to do a biopsy.

5:00

But if you're unsure and you think it's probably

5:03

due to a scar, like aren't a hundred percent

5:05

certain, then it's possible that a BI-RADS 3

5:08

could be a reasonable follow-up plan.

5:15

I also want to bring up the use of

5:17

BI-RADS 3 for axillary adenopathy,

5:19

and this is sort of a timely topic right now.

5:23

Unilateral adenopathy is rare and

5:25

typically considered suspicious.

5:28

However, with the COVID-19 vaccine, we've been

5:30

seeing a lot of unilateral reactive adenopathy.

5:35

This is... it can be seen with other

5:37

vaccines, but it's just a lot more

5:39

pronounced with the COVID-19 vaccination.

5:43

And so this has been really a current topic,

5:45

and there's been a lot of literature and breast

5:47

imaging related to this to try to figure out what

5:50

we should do to make sure we're not over-biopsying

5:52

these women but also not missing malignancies.

5:57

The Society of Breast Imaging

5:59

gave a recommendation published in March 2021 that

6:04

we should be recommending a short-term follow-up

6:07

four to twelve weeks after the second vaccine dose.

6:10

And if the adenopathy persists, we should do a biopsy.

6:14

And I showed one example of this where

6:17

we did not see that adenopathy resolved,

6:19

and it did turn out to be a malignancy.

6:21

So we want to make sure we are following

6:24

these women and letting that adenopathy

6:27

go away before we assess them as benign.

6:30

Because although we know that the

6:32

vaccine can cause adenopathy, we also

6:35

know that cancer can cause adenopathy.

6:37

And we want to make sure that the

6:38

reason is just a reactive lymph node

6:41

and not something else that's going on.