Document sans-titre

The sonographic solid nodules algorithm
The BIRADS characterization
Ph Vignal Paris
Th Stavros, Denver

The BIRADS categories

* A realistic goal for US : identify a short interval follow up group with low risk of malignancy : BIRADS 3 *

* Not all the solid nodules can be characterized : large overlap in sonographic findings between benign and malignant nodules *

* Use multiple findings because cancer is heterogeneous *

* In a strict algorithm approach *

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BIRADS :
Breast Imaging Reporting And Data System

Only for solid nodules

* BIRADS 2 : certainly benign : lipoma, lymph node___________________

* BIRADS 3 : probably benign ( less than 2% of malignity) : fibroadenoma

* BIRADS 4 : suspicious (a,midly and b, moderetly) ___________________

* BIRADS 5 :malignant: > 90%___________________________________

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BIRADS 2

Hyperechoic mass ( lipomas)

Lymph node

Silicon granuloma

BIRADS 3
the benign sets

* Elliptical, wider than tall and completely encompassed by a thin echogenic capsule

* Gently lobulated, wider than tall and completely encompassed by a thin echogenic capsule

* A partial capsule is inadequate proof of benignity : special manoeuvers are required

Gently lobulated, wider than tall completely encompassed by a thin echogenic capsule

Elliptical, wider than tall completely encompassed by a thin echogenic capsule

Video
Click on the image below (1.03Mb)

A complete ( long and short axis) thin echogenic capsule must be present.

A partial capsule is inadequate proof of benignity

Where is the capsule ?

BIRADS 4 and 5 : the suspicious findings

* Spiculation or thick echogenic halo

* Angular margins

* Microlobulations

* Taller than wide

* Duct ectension

* Branch pattern

* Shadowing

* Calcifications

* Markedly hypoechoic

Supicious findings

* Surface characteristics : findings 1-3 Spiculation or thick echogenic halo,angular margins ,microlobulations

* Shape characteristics : findings 4-6: Taller than wide,duct ectension,branch pattern

* Internal characteristics: findings 7-9: Shadowing,calcifications,markedely hypoechoic

Another look

1. hard findings ( signs of invasive malignancy) : spiculation or thick echogenic halo,angular margins, shadowing

2.soft findings (signs of intraductal components): microlobulation, duct extension, branch pattern, calcifications

3. hard and soft findings (with both DCIS and invasion) : taller than wide, markedly hypoechoic.

Sensitivity specificity

* None of the individual findings have the desired sensitivity of 98% or greater

* A single suspicious finding enables a sensitivity of 99% But most often more than 5 or 6 suspicious findings are present.

* The specificity of soft findings is less than that of hard findings

Microlobulations Se 71% PPV 40%

Angular margins Se 28% PPV 80%


Markedly hypoechoic Se 48 VPP 41%

Branch pattern Se 3.6% PPV 14%


duct extension Se 3.6 PPV 100

Echogenic halo (h: 35%)

Echogenic halo: value of harmonics
Click on (1.4Mb)


	Spiculations Se 43% PPV 97%


	Taller than wide Se 14 PPV 80%

Why taller than wide is specific of malignancy ?
	Because the breast vasculature is perpenducular to the skin

Shadowing Se 64% PPV 29%

Attention : false positive


Move the probe …	heeling and toeing in the long axis, rocking In the short axis

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Sensitivity : Stavros study’s
( 1211 nodules)

* Sensitivity : 99.8% 1 FN /287 birads 3

* SPE 32% ( due to soft findings)

* PPV 44% .

* The negative to positive biopsy rate is 1.9 to 1

* Far less than before the use of the sonographic algorithm ( 5 to 1) in 1995

Conclusion

* The BIRADS classification must be used in all BUS reports

* To achieve a very high sensitivity without an excess of biopsies

* It helps to communicate with the pathologist.

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