0:01

Hi, I am Emily Ambinder, I'm an assistant professor

0:04

in radiology and oncology at Johns Hopkins,

0:08

and I'm really excited to be here today to talk

0:10

about BI-RADS 3 and multimodality breast imaging.

0:14

Now, BI-RADS 3 is a really challenging topic for

0:17

breast imagers, and I'm hoping that this talk will

0:20

help to clarify things and make it more accessible.

0:22

Make it a topic that you don't dislike as much

0:24

as you might at the beginning of the talk.

0:27

So I just want to start by

0:29

talking about the BI-RADS Atlas.

0:32

This is something that I,

0:34

I love about breast radiology.

0:36

This is a lexicon that breast radiologists use to

0:41

describe findings on mammogram, ultrasound, and MRI.

0:46

And with it, any breast imaging

0:49

study should be reported the same way regardless

0:52

of which breast radiologist is looking at it.

0:56

Every breast imaging report is

0:59

given an assessment category.

1:02

And I know this will, will probably be a review,

1:04

but I just want to set the stage for the BI-RADS

1:06

3 category before we get into more details on it.

1:10

And with each of these categories,

1:13

comes a recommendation for what

1:14

the patient should do to follow up.

1:16

So the first two I just want to mention

1:19

are BI-RADS categories one or two.

1:22

And that's when the study is either negative or benign.

1:25

And when we use those terms, the breast radiologist

1:28

is indicating that there is a zero percent

1:31

chance that there is a cancer in that study.

1:34

And we're recommending a follow-up in one year.

1:37

Now on the flip side, when we use the BI-RADS

1:39

terms four or five, we're saying that we see

1:42

something on the breast imaging study that

1:45

is suspicious and will recommend a biopsy.

1:48

Within these four or five

1:49

categories, we have subcategories.

1:51

So four A indicates a two to 10% chance of

1:54

malignancy, four B up to 50%, four C up to 95%.

2:00

And when we use a category five, we're

2:01

saying that we're very suspicious.

2:03

We believe that there's over a 95% chance

2:06

that the finding represents a cancer.

2:09

Regardless, with any of those

2:12

BI-RADS assessment scores, we'll be recommending

2:14

a biopsy to get a tissue diagnosis.

2:18

A BI-RADS 6 means that there is a

2:21

biopsy-proven malignancy on the imaging.

2:25

A BI-RADS assessment category 0 means

2:28

that the study is inconclusive and we

2:31

need to do additional diagnostic workup.

2:34

And finally, our favorite category, BI-RADS

2:37

3, and we use this term "probably benign," meaning

2:41

that there's greater than a 0 percent chance of

2:43

cancer, so it doesn't fall into that category

2:46

of BI-RADS 1 or 2 categories, but there's a very

2:50

small chance of cancer, less than or equal to 2%.

2:53

So we, it doesn't reach our threshold to recommend

2:56

a biopsy, and we'll do a follow-up in six months.

3:02

So BI-RADS 3, this "probably benign,"

3:04

this is just a, it's a really challenging topic,

3:07

and that's what we're gonna be focusing on

3:09

during this talk.

3:12

Like I said, this means that there

3:14

is a low chance of malignancy.

3:15

It's not 0 percent, but it's very

3:18

small, less than or equal to 2 percent.

3:20

So it doesn't reach our threshold to be recommending

3:23

a biopsy, but we do want to keep a close eye on

3:25

the finding because we know there's at least a

3:28

small chance that it could represent a cancer.

3:32

When we give something a BI-RADS

3:35

3 assessment,

3:36

we recommend having surveillance imaging

3:38

at six months after the initial study.

3:41

So that would be halfway in between

3:43

a normal screening schedule.

3:47

That would be an extra appointment.

3:49

Then they would come back at 12 months.

3:51

So that should be the time that usually that patient

3:53

would be coming for their screening mammogram.

3:55

Instead, they would be coming in for a

3:56

diagnostic appointment to follow up this study

4:00

finding. And then at 24 months,

4:04

similarly, that should be at the time that they

4:06

would be coming in anyway for their annual imaging.

4:09

There is an optional follow-up at 36 months.

4:15

We should only use the BI-RADS 3 category

4:17

after we've done a full diagnostic workup,

4:20

and that's really for two separate reasons.

4:23

So first, we want to limit unnecessary follow-ups

4:27

for findings that could have been assessed as benign,

4:29

and I'm going to show some examples of that.

4:32

Something that may have met BI-RADS 3

4:34

criteria on mammogram, but then when we

4:37

do an ultrasound, we see that it's clearly

4:39

a benign finding, such as a simple cyst.

4:42

We also want to make sure we're not

4:44

delaying diagnosis of small cancers that could

4:46

have been diagnosed with a full diagnostic workup.

4:51

So we never give a BI-RADS 3 assessment

4:53

directly from a screening exam.

4:54

We always want to bring that patient back, do

4:56

a full diagnostic workup before using this

4:59

category.

5:02

I want to stress that BI-RADS 3 is not

5:04

just an intermediate category that we

5:06

should use when we're unsure what to do.

5:08

I think this is tempting when we're seeing

5:11

a patient and it's maybe a confusing case,

5:13

and we think, well, let's just give

5:14

it a BI-RADS 3 because we're not sure.

5:16

And that's not how we should be

5:18

using BI-RADS 3. BI-RADS 3

5:20

should really be reserved for specific findings

5:23

that we know with evidence-based data have a

5:26

low chance of malignancy, and we're going to

5:29

go over these today to help show what those

5:32

findings are and go over some of the data that

5:34

supports the use of BI-RADS 3 for these cases.

5:39

The benefit of using BI-RADS 3 is to reduce the

5:43

number of benign biopsies performed while maintaining

5:47

a high sensitivity for early-stage breast cancer.

5:51

So when we're thinking about using BI-RADS 3,

5:53

we really want to think that we're using it to

5:56

remove cases that might have been recommended for

5:58

biopsy because they have a very, very low chance

6:02

of malignancy, less than that 2 percent number.

6:06

We don't want to be using it for cases, instead

6:08

of giving something a BI-RADS 2 that

6:11

could be safely assessed as being benign.

6:13

We really want to be finding these, these

6:16

very specific imaging findings that have a low

6:18

likelihood of malignancy to give this assessment.

6:24

I want to just note that there are definitely

6:26

challenges with BI-RADS 3, and I think anybody

6:28

who's done any breast imaging can relate to this.

6:32

The two main ones are, first, that there's

6:35

quite a high inter-observer variability

6:39

with using BI-RADS 3.

6:41

And I'm hoping that this talk will help to

6:43

maybe decrease that among the people that

6:45

are watching, because we really should only

6:48

be using it for specific imaging findings.

6:50

But there's been several studies showing

6:53

that even among breast radiologists,

6:55

there's a lot of variability in how it's used.

7:00

Second is that we're asking patients to

7:03

come back for this extra appointment when

7:05

they wouldn't have needed to come back for

7:07

breast imaging if we had given something a

7:09

BI-RADS 1 or 2, this six-month appointment.

7:11

And we found that there's

7:13

very low compliance with that

7:15

BI-RADS 3 recommendation.

7:18

That's another day that the, that woman is going

7:20

to have to take off work or find childcare.

7:23

There's a cost associated with an extra appointment.

7:27

And I think we should kind of keep that in mind

7:28

when we're making this recommendation and make

7:31

sure we're really using it when it's appropriate.

7:34

And you know, when it's appropriate, we do want

7:37

to be using it to make sure that we're catching

7:39

the few of those cases that are actually cancers,

7:43

but we don't want to be overusing it because

7:46

we know that there's a challenge with having

7:47

patients come back for this extra appointment.