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Breast Imaging Reporting and Data System

Inter- and Intraobserver Variability in Feature Analysis and Final Assessment

¹ Department of Radiology, University of Maryland School of Medicine, 22 S. Greene St., Baltimore, MD 21201.
² The Greenebaum Cancer Center, University of Maryland School of Medicine, Baltimore, MD 21201.
³ Department of Epidemiology and Preventive Medicine, University of Maryland School of Medicine, Baltimore, MD 21201.

View larger version (114K): [in a new window]   Fig. 1A. —57-year-old woman with lesion variably termed "focal asymmetric density" versus "indistinct" mass. Bilateral routine craniocaudal (A) and mediolateral oblique (B) mammograms show focal normal variant asymmetric parenchyma (arrows) that was unchanged for 5 years.

View larger version (109K): [in a new window]   Fig. 1B. —57-year-old woman with lesion variably termed "focal asymmetric density" versus "indistinct" mass. Bilateral routine craniocaudal (A) and mediolateral oblique (B) mammograms show focal normal variant asymmetric parenchyma (arrows) that was unchanged for 5 years.

View larger version (122K): [in a new window]   Fig. 1C. —57-year-old woman with lesion variably termed "focal asymmetric density" versus "indistinct" mass. Spot compression mammogram was provided with comparison films. Three observers described finding as focal asymmetric density, considered normal (BI-RADS category 1, two observers), or needing sonography (BI-RADS category 0, one observer). Remaining two observers viewed finding as mass with indistinct borders and suspicious, needing biopsy (BI-RADS category 4). This distinction of focal asymmetric density from indistinct mass is one of the most problematic in mammographic interpretation, as was also seen in study of Baker et al. [7].

View larger version (156K): [in a new window]   Fig. 2. —65-year-old woman with infiltrating ductal (colloid) carcinoma. Spot magnification mammogram shows mass considered circumscribed and lobulated by three observers, microlobulated by one observer, and circumscribed and round by fifth observer. Sonography was recommended by three observers describing mass as circumscribed; the other observers assessed mass as suspicious (BI-RADS category 4).

View larger version (83K): [in a new window]   Fig. 3A. —57-year-old woman with infiltrating ductal carcinoma. Craniocaudal (A) and mediolateral oblique mammograms (B) show focal density (arrows). From screening images alone, one observer deemed this negative (BI-RADS category 1) although lesion was marked on films.

View larger version (81K): [in a new window]   Fig. 3B. —57-year-old woman with infiltrating ductal carcinoma. Craniocaudal (A) and mediolateral oblique mammograms (B) show focal density (arrows). From screening images alone, one observer deemed this negative (BI-RADS category 1) although lesion was marked on films.

View larger version (166K): [in a new window]   Fig. 3C. —57-year-old woman with infiltrating ductal carcinoma. Spot magnification mammogram in mediolateral projection reveals spiculated mass, considered highly suggestive of malignancy (BI-RADS category 5) by all observers.

View larger version (125K): [in a new window]   Fig. 4. —77-year-old woman with calcifications caused by ductal carcinoma in situ (DCIS). Global magnification mammogram in true lateral projection shows several groups of calcifications (arrows) due to multifocal DCIS. One observer considered these coarse in morphology, multiple groups in distribution, and probably benign (short-term follow-up recommended, BI-RADS category 3). Another considered these to be punctate, multiple groups, and suspicious (biopsy recommended, BI-RADS category 4). Three observers considered these pleomorphic (one clustered, one linearly distributed, and one multiple groups) with assessments suspicious (BI-RADS category 4), highly suggestive of malignancy (BI-RADS category 5), and needs additional evaluation (BI-RADS category 0), respectively.

View larger version (116K): [in a new window]   Fig. 5. —56-year-old woman with recurrent carcinoma manifesting as unusual microcalcifications (arrows) on spot magnification mammogram. At histopathology, calcifications were in necrotic center of infiltrating ductal carcinoma that developed at site of lumpectomy 8 years earlier for ductal carcinoma in situ. Four observers considered these calcifications to be coarse: three assessed them as benign (BI-RADS category 2) and one as probably benign (BI-RADS category 3). One observer described these as amorphous and benign (BI-RADS category 2).

View larger version (130K): [in a new window]   Fig. 6A. —57-year-old woman with microcalcifications in apocrine metaplasia. Spot magnification mammograms in craniocaudal (A) and mediolateral oblique (B) projections show several clusters of microcalcifications (arrows) due to fibrocystic changes, with microcysts and apocrine metaplasia. Observers variably described these as milk of calcium, benign (BI-RADS category 2), punctate or pleomorphic in multiple clusters and suspicious (BI-RADS category 4), or pleomorphic in segmental distribution and highly suggestive of malignancy (BI-RADS category 5).

View larger version (142K): [in a new window]   Fig. 6B. —57-year-old woman with microcalcifications in apocrine metaplasia. Spot magnification mammograms in craniocaudal (A) and mediolateral oblique (B) projections show several clusters of microcalcifications (arrows) due to fibrocystic changes, with microcysts and apocrine metaplasia. Observers variably described these as milk of calcium, benign (BI-RADS category 2), punctate or pleomorphic in multiple clusters and suspicious (BI-RADS category 4), or pleomorphic in segmental distribution and highly suggestive of malignancy (BI-RADS category 5).

View larger version (146K): [in a new window]   Fig. 7. —53-year-old woman with fibroadenoma shown on spot magnification mammogram. Variability was great with this patient. On initial interpretation, two observers considered this a focal asymmetric density (one as highly suspicious of malignancy [BI-RADS category 5], and one as probably benign [BI-RADS category 3]). Another three observers considered this an indistinct mass and suspicious (n = 2, BI-RADS category 4) or highly suggestive (n = 1, BI-RADS category 5) of malignancy. Three observers described associated pleomorphic calcifications. On second interpretation, all observers changed their description. Two observers considered mass circumscribed and lobulated; one considered it obscured; one, spiculated; and one, microlobulated. Final assessment changed for one observer who initially classified the mass as indistinct and highly suggestive of malignancy (BI-RADS category 5,) then reclassified it as circumscribed and benign (BI-RADS category 2).

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