ACR BI-RADS Atlas Fifth Edition

QUICK REFERENCE

ULTRASOUND MAMMOGRAPHY
Tissue a. Homogeneous background echotexture fat Breast a. The breasts are almost entirely fatty
composition composition
b. Homogeneous background echotexture fibroglandular b. There are scattered areas of fibroglandular density
(screening
only) c. Heterogeneous background echotexture c. The breasts are heterogeneously dense, which
may obscure small masses
d. The breasts are extremely dense, which lowers
the sensitivity of mammography
Masses Shape Oval Masses Shape Oval
Round Round
Irregular Irregular
Orientation Parallel Margin Circumscribed
Not parallel Obscured
Margin Circumscribed Microlobulated
Not circumscribed Indistinct
- Indistinct Spiculated
- Angular Density High density
- Microlobulated Equal density
- Spiculated Low density
Echo pattern Anechoic Fat-containing
Hyperechoic Calcifications Typically Skin
Complex cystic and solid benign Vascular
Hypoechoic Coarse or popcorn-like
Isoechoic Large rod-like
Heterogeneous Round
Posterior features No posterior features Rim
Enhancement Dystrophic
Shadowing Milk of calcium
Combined pattern Suture
Calcifications Calcifications in a mass Suspicious Amorphous
Calcifications outside of a mass morphology Coarse heterogeneous
Intraductal calcifications Fine pleomorphic
Associated Architectural distortion Fine linear or fine-linear branching
features Duct changes Distribution Diffuse
Skin changes Skin thickening Regional
Skin retraction Grouped
Edema Linear
Vascularity Absent Segmental
Internal vascularity Architectural distortion
Vessels in rim Asymmetries Asymmetry
Elasticity Soft Global asymmetry
assessment Intermediate Focal asymmetry
Hard Developing asymmetry
Special cases Simple cyst Intramammary lymph node
Clustered microcysts Skin lesion
Complicated cyst Solitary dilated duct
Mass in or on skin Associated Skin retraction
features
Foreign body including implants Nipple retraction
Lymph nodes intramammary Skin thickening
Lymph nodes axillary Trabecular thickening
Vascular AVMs (arteriovenous malformations/ Axillary adenopathy
abnormalities pseudoaneurysms) Architectural distortion
Mondor disease Calcifications
Postsurgical fluid collection Location of Laterality
Fat necrosis lesion Quadrant and clock face
Depth
Distance from the nipple

For the complete Atlas, visit acr.org/birads

 MAGNETIC RESONANCE IMAGING
Amount of a. Almost entirely fat Associated Nipple retraction
fibroglandular b. Scattered fibroglandular tissue features Nipple invasion
tissue (FGT) c. Heterogeneous fibroglandular tissue Skin retraction
d. Extreme fibroglandular tissue Skin thickening
Background Level Minimal Skin invasion Direct invasion
parenchymal Mild Inflammatory cancer
enhancement
Moderate Axillary adenopathy
(BPE)
Marked Pectoralis muscle invasion
Symmetric or Symmetric Chest wall invasion
asymmetric Asymmetric Architectural distortion
Focus Fat containing lesions Lymph nodes Normal
Masses Shape Oval Abnormal
Round Fat necrosis
Irregular Hamartoma
Margin Circumscribed Postoperative seroma/hematoma with fat
Not circumscribed Location of lesion Location
- Irregular Depth
- Spiculated Kinetic curve Initial phase Slow
Internal assessment
Homogeneous Medium
enhancement Signal intensity
Heterogeneous (SI)/time curve Fast
characteristics
Rim enhancement description Delayed phase Persistent
Dark internal septations Plateau
Washout
Non-mass Distribution Focal Implants Implant material and Saline
enhancement Linear lumen type
(NME) Silicone
Segmental - Intact
Regional - Ruptured
Multiple regions Other implant material
Diffuse Lumen type
- Single
- Double
- Other
Internal Homogeneous Implant location Retroglandular
enhancement Heterogeneous Retropectoral
patterns
Clumped Abnormal implant Focal bulge
Clustered ring contour
Intramammary lymph node Intracapsular silicone Radial folds
Skin lesion findings Subcapsular line
Non-enhancing Ductal precontrast high signal on T1W Keyhole sign (teardrop, noose)
findings Cyst Linguine sign
Postoperative collections Extracapsular
Breast
(hematoma/seroma) silicone
Post-therapy skin thickening and Lymph nodes
trabecular thickening Water droplets
Non-enhancing mass Peri-implant fluid
Architectural distortion
Signal void from foreign bodies, clips, etc.

BI-RADS ASSESSMENT CATEGORIES

Category 0: Mammography: Incomplete Need Additional Imaging Evaluation and/or Prior Mammograms for Comparison
Ultrasound & MRI: Incomplete Need Additional Imaging Evaluation
Category 1: Negative
Category 2: Benign
Category 3: Probably Benign
Category 4: Suspicious Mammography Category 4A: Low suspicion for malignancy
& Ultrasound: Category 4B: Moderate suspicion for malignancy
Category 4C: High suspicion for malignancy
Category 5: Highly Suggestive of Malignancy
Category 6: Known Biopsy-Proven Malignancy
For the complete Atlas, visit acr.org/birads 07.15