European Journal of Radiology 61 (2007) 195201

BIRADSTM mammography: Exercises

Corinne Balleyguier a, , Francois Bidault a , Marie Christine Mathieu b , Salma Ayadi a ,
Dominique Couanet a , Robert Sigal a
a

Radiology Department, Institut de Cancerologie Gustave-Roussy, 39 rue Camille Desmoulins, 94805 Villejuif Cedex, France
b Biopathology Department, Institut de Canc
erologie Gustave-Roussy, 94805 Villejuif, France
Received 18 August 2006; received in revised form 21 August 2006; accepted 24 August 2006

Abstract
Some radiological cases are presented in this article to train the reader to the BIRADSTM classification in mammography. Each case is described
according to the fourth American version of the BIRADSTM lexicon. Some classifications difficulties will also be presented, in order to show the
complexity and the observer variability, commonly encountered in BIRADSTM 3 and 4 categories.
2006 Published by Elsevier Ireland Ltd.
Keywords: BIRADSTM classification; BIRADSTM 3 category; Mammography; Training; Microcalcifications; Breast

1. Illustrating cases of BIRADSTM mammography

classication
An oval shape mass is visible on this view. Contours are well
circumscribed (arrows), a mixed content with fat and glandular
tissue is visible within the mass. The diagnosis is an hamartoma.
This is a typical example of the BIRADSTM 2 classification in
mammography. No further examination is necessary (Fig. 1).
Macrocalcifications are dense, linear and needle-shape, following the ducts and oriented toward the nipple, which is very
suggestive of a plasma cell mastitis (arrows). This a typically
benign disease of the breast which can be classified in the
BIRADSTM 2 category (Fig. 2).
Multiple round calcified masses are visible in the right breast.
The peripheral calcifications are typical of calcified fibroadenoma. No further examination is necessary. BIRADSTM 2
category (Fig. 3).
This view shows at least three microcalcifications clusters.
All microcalcifications are round, homogeneous, isodense and
monomorphous. These microcalcifications do not look like milk
or calcium calcifications, because of their round shape on the ML
view.
If they are recently detected, it is recommended to perform a
short follow-up at 6, 12, 24 and 48 months to insure of their stability. They are classified in the BIRADSTM 3 category (Fig. 4).

Corresponding author. Tel.: +33 1 42 11 60 74; fax: +33 1 42 11 52 79.

E-mail address: balleyguier@igr.fr (C. Balleyguier).

0720-048X/$ see front matter 2006 Published by Elsevier Ireland Ltd.

doi:10.1016/j.ejrad.2006.08.034

An oval, homogeneous mass is visible in the right breast.

Contours are well circumscribed and lobulated (arrow). Ultrasonography showed an homogeneous solid mass. Because of
the solid content, the classification is BIRADSTM 3. The first
follow-up should be performed 4 months later, conversely to
microcalcifications (Fig. 5).
An extended area of thin and amorphous microcalcifications
is visible in the upper and outer quadrant of the left breast
(arrows). These microcalcifications were stable since 5 years.
The BIRADSTM category is BIRADSTM 4 and as the calcifications are not evolutive, the attended result is benign: BIRADSTM
4a. Vacuum macrobiopsy revealed benign lobular microcalcifications (Fig. 6).
This oval mass is partially well circumscribed. The inferior
border of the mass is indistinct (ill-defined) (arrow). Ultrasound
showed a solid, homogeneous mass. Because of the contours, the
mass is categorized in BIRADSTM 4b. A biopsy is recommended
and the radiologist has to compare the histologic results to the
mammographic features. Ultrasound guided biopsy revealed a
cellular adenofibroma (Fig. 7).
An architectural distorsion is visible in the upper and outer
quadrant of the right breast (arrows). Ultrasound was normal.
This image is suspicious of malignancy and can be classified
as BIRADSTM 4c. Stereotactic biopsy revealed a 7 mm DIC
(Fig. 8).
A cluster of microcalcifications is visible in the upper quadrant of the left breast. Microcalcifications are homogenous and
some look like milk calcifications (arrows). Categorization is

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Fig. 1. 53-Year-old woman. No palpable mass. Cranio-caudal (CC) view of the

left breast. Hamartoma.

Fig. 3. 60-Year-old women. ML view of the right breast. Multiple calcified

fibroadenoma.

Fig. 2. 55-Year-old woman. Medio-lateral (ML) view of the right breast. Plasma
cell mastitis.

Fig. 4. 45-Year-old woman. Magnification ML view of the right breast. Lobular

benign microcalcifications.

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Fig. 7. 53-Year-old woman. Spot compression view of the left breast. Adenofibroma.

Fig. 5. 48-Year-old woman. Spot compression view of the right breast. Adenofibroma.

Fig. 6. 72-Year-old woman. CC (a) and ML (b) views of the left breast. Lobular calcifications.

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Fig. 8. 69-Year-old woman. CC (a) and MLO (b) views of the right breast. Ductal invasive carcinoma (DIC).

Fig. 9. 53-Year-old woman. Magnification view of the left breast. Typical ductal
hyperplasia.

Fig. 10. 55-Year-old woman. Magnification view of the right breast. Ductal
carcinoma in situ (DCIS).

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Fig. 11. 47-Year-old woman. CC (a) and MLO (b) views of the left breast. Ductal invasive carcinoma.

BIRADSTM 4b due to the linear distribution. Biopsy revealed

benign microcalcifications, with typical ductal hyperplasia. A 6
months follow-up mammogram is recommended in this case to
avoid false negative cases of biopsy (Fig. 9).
Multiple dense, irregular and heterogeneous microcalcifications in a microcalcifications cluster. Due to the localized round
distribution, the final classification is not BIRADSTM 5 but
BIRADSTM 4c. Biopsy revealed a DCIS (Fig. 10).
A 15 mm spiculated mass (arrows) is visible in the inner and
inferior part of the left breast. The mammographic features are
typically malignant: BIRADSTM 5 (Fig. 11).
Typically malignant fine linear branching microcalcifications
(arrows) are suggestive of malignancy: BIRADSTM 5. Biopsy
revealed a DCIS (Fig. 12).

2. Difcult cases
Multiple amorphous microcalcifications are suspicious in this
case due to pleomorphism (arrows): BIRADSTM 4b. Macrobiopsy revealed only benign microcalcifications and atrophic
glandular tissue. No surgery was performed (Fig. 13).
An ill-defined mass is visible in the outer quadrant of
the right breast (arrow, Fig. 14a): BIRADSTM 4b. Ultrasonography confirmed the suspicious features of this lesion:
solid content, microlobulated mass but a posterior enhancement is visible. Biopsy (Fig. 14c) revealed a benign lesion,
pseudo-tumoral adenosis, with multiple round epithelial cells
(arrows) which can be frequently misdiagnosed as a breast

Fig. 12. 52-Year-old woman. Magnification view of the right breast. DCIS.

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Fig. 13. Magnification view of the right breast (a); biopsy (HES) (b). Lobular microcalcifications.

Fig. 14. CC view of the right breast (a); ultrasound (b); biopsy (HES) (c). Pseudo-tumoral adenosis.

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Fig. 15. ML view of the left breast (a); magnification view (b). DCIS and diffuse milk microcalcifications.

carcinoma on mammogram. In this case, biopsy could not be

avoided.
Typically benign, milk microcalcifications are visible in the
entire breast (arrowheads, Fig. 15a): BIRADSTM 2.
A different cluster of microcalcifications is visible in the
posterior inferior quadrant of the left breast (arrows). These cal-

cifications are suspicious due to the irregular shape and high

density: BIRADSTM 4c.
When there are two types of microcalcifications, the final
category is the most suspicious. In this case, a biopsy was recommended and revealed a DCIS.