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1203

BREAST IMAGING |
BI-RADS 5: More than Cancer

RADIOGRAPHICS FUNDAMENTALS
Kimberly A. Dao, MD The full digital presentation is available online.
Anna F. Rives, MD, PhD
Liza M. Quintana, MD Imaging evaluation of the breast relies on the American College of Ra-
Michael A. Kritselis, DO diology Breast Imaging Reporting and Data System (BI-RADS), which
Michael D. C. Fishman, MD
offers a standard lexicon for describing, assessing, and managing breast
Rutuparna Sarangi, MD
imaging findings. The BI-RADS 5 assessment category is used when
Priscilla J. Slanetz, MD, MPH
the likelihood of malignancy is estimated to be greater than or equal to
95% on the basis of imaging findings. However, according to Yao et al,
Abbreviation: BI-RADS = Breast Imaging Re-
porting and Data System the actual positive predictive value for a BI-RADS 5 assessment ranges
RadioGraphics 2020; 40:1203–1204
from 78% to 97.5%. Hence, not all BI-RADS 5 lesions are malignant.
There are several benign entities affecting the breast that may manifest
https://doi.org/10.1148/rg.2020200054
with highly suspicious imaging features and BI-RADS 5 categoriza-
Content Code: tion. In this online presentation, we review the imaging features used
From the Departments of Radiology (K.A.D., in a BI-RADS 5 assessment, a range of benign entities that can mimic
A.F.R., M.D.C.F., R.S., P.J.S.) and Pathology malignancy, the importance of radiologic-pathologic correlation, and
(M.A.K.), Boston University Medical Center,
Boston University School of Medicine, 830 the management of a discordant biopsy result.
Harrison Ave, Moakley Building Ste 1300, Bos- There are specific imaging features of BI-RADS 5 malignancies
ton, MA 02118; and Department of Pathology,
Beth Israel Medical Center, Harvard Medical depicted at mammography, US, and MRI. Typical mammographic
School, Boston, Mass (L.M.Q.). Presented as features that warrant BI-RADS 5 assessment include an irregular mass
an education exhibit at the 2019 RSNA Annual
Meeting. Received March 28, 2020; revision re-
with spiculated margins with or without associated distortion, fine
quested May 22 and received June 13; accepted linear branching or pleomorphic calcifications, segmental pleomorphic
June 17. M.D.C.F. and P.J.S. have provided calcifications, or some combination of these findings (Figure). At US,
disclosures (see end of article); all other au-
thors have disclosed no relevant relationships. typical imaging features of a BI-RADS 5 mass include irregular shape,
Address correspondence to K.A.D. (e-mail: nonparallel orientation, hypoechoic echo pattern, spiculated margin,
[email protected]).
ductal extension, echogenic halo, or posterior shadowing. Imaging
©
RSNA, 2020 features that warrant a BI-RADS 5 assessment at MRI include an
irregular enhancing mass with noncircumscribed margins and type II
(plateau) or III (washout) kinetics.
The Table lists the various benign processes that can mimic malig-
nancy at mammography, US, or MRI and consequently could result in
a BI-RADS 5 assessment. For each entity, we review its clinical mani-
festations, imaging features, histologic findings, and management. The
more common benign processes include chronic and inflammatory
mastitis, granulomatous mastitis, fat necrosis, complex sclerosing lesion
or radial scar, granular cell tumor, and infection. The less common
benign processes include lymphocytic (diabetic) mastopathy, atypical
infection, fibromatosis or desmoid tumor, and myofibroblastoma.

TEACHING POINTS
„ A BI-RADS category 5 assessment is used when the likelihood of malignancy is believed to
be greater than or equal to 95% on the basis of the imaging findings. Not all BI-RADS 5
lesions are found to be malignant.
„ A benign percutaneous biopsy result for a BI-RADS 5 assessment warrants repeat percu-
taneous biopsy or excision.
„ A variety of benign entities may be categorized as BI-RADS 5 because of suspicious imag-
ing features. The most common BI-RADS 5 mimics are chronic and inflammatory mastitis,
granulomatous mastitis, fat necrosis, complex sclerosing lesions, granular cell tumors, and
infection.
1204  September-October 2020 radiographics.rsna.org

Figure.  Focal asymmetry seen at mammo-

graphic screening in a 47-year-old woman.
Mediolateral oblique (a) and craniocaudal (b)
spot compression mammograms show an ir-
regular high-density mass with a spiculated
margin. This imaging finding was classified
as BI-RADS 5. The results of a core biopsy re-
vealed invasive ductal carcinoma.

When a lesion is assessed as BI-RADS 5, the

Benign Entities Possibly Classified as BI-RADS 5
first step in management is percutaneous biopsy.
When a benign pathologic test result is obtained, Atypical infection
this most often is considered discordant, and in Complex sclerosing lesion and radial scar
these cases, repeat biopsy or surgical excision Fat necrosis
Fibromatosis or desmoid tumor
would then be recommended. Delving into the
Granular cell tumor
clinical history of the patient can sometimes aid
Granulomatous mastitis
in the diagnosis of a suspicious lesion and, in
Inflammatory mastitis (autoimmune)
rare circumstances, possibly even help avoid the
Lymphocytic (diabetic) mastopathy
need for repeat biopsy. For example, a history
Mastitis
of surgery or accidental trauma to the breast
Myofibroblastoma
may support the diagnosis of fat necrosis. If the
Other benign entities (amyloidosis)
patient has a history of diabetes, the diagnosis of
lymphocytic mastopathy may be reasonable. A
clinical history of systemic lupus erythematosus
can explain a diagnosis of inflammatory mastitis. not related to the present article: received royalties from
After reviewing this presentation, the reader UpToDate. Other activities: treasurer and fund-raising
will become familiar with the imaging features liaison for the Association of University Radiologists.
and management of benign entities that can
demonstrate BI-RADS 5 imaging characteristics. Suggested Readings
Recognizing these imaging features, correlating Cho SH, Park SH. Mimickers of breast malignancy on breast
sonography. J Ultrasound Med 2013;32(11):2029–2036.
them with the clinical history, and being aware of Heller SL, Moy L. Imaging features and management of high-risk
benign entities that may mimic malignancy will lesions on contrast-enhanced dynamic breast MRI. AJR Am
help radiologists provide optimal patient care. J Roentgenol 2012;198(2):249–255.
Kim YR, Kim HS, Kim HW. Are irregular hypoechoic breast
masses on ultrasound always malignancies?: a pictorial essay.
Disclosures of Conflicts of Interest.—M.D.C.F. Ac- Korean J Radiol 2015;16(6):1266–1275.
tivities related to the present article: disclosed no relevant Mario J, Venkataraman S, Dialani V, Slanetz PJ. Benign breast
relationships. Activities not related to the present article: lesions that mimic cancer: determining radiologic-pathologic
advisory board member for Hologic; consultant to Ze- concordance. Appl Radiol 2015;44(9):28–32. https://ap-
bra Medical Vision; provided expert witness case review pliedradiology.com/articles/benign-breast-lesions-that-mimic-
for Abramson, Brown and Dugan; institution received cancer-determining-radiologic-pathologic-concordance.
Spruill L. Benign mimickers of malignant breast lesions. Semin
a Strategic Alignment Grant from the Association of Diagn Pathol 2016;33(1):2–12.
University Radiologists. Other activities: disclosed no Yao MMS, Joe BN, Sickles EA, Lee CS. BI-RADS category 5 as-
relevant relationships. P.J.S. Activities related to the pres- sessments at diagnostic breast imaging: outcomes analysis based
ent article: disclosed no relevant relationships. Activities on lesion descriptors. Acad Radiol 2019;26(8):1048–1052.