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BIRADS III

BIRADS III is an intermediate category in the breast imaging reporting and data system. While it is usually classified as benign or probably benign, a finding placed in this category should have a very high probability of being benign. The risk of malignancy in a BIRADS III lesion is considered at ~0.3-2%.

The role of BIRADS III in a screening programme

This is a contentious issue and this discussion is to generate some thought and not necessarily to be used as the last word. There are differences of opinion on this issue all over the senology world.

In a screening setting a lesion you should probably not be using BIRADS III as an option. In every day imaging if you are reading screening studies and a lesion is not clearly BIRADS II you should ideally default to a BIRADS 0 and get the patient back for workup. There are many good reasons why screening programmes around the world have excluded BIRADS III from options for their readers to choose.

Confusion and BIRADS III

All other factors being equal, a lesion called BIRADS III should have a high probability of being benign. There is considerable misunderstanding about this in both the medical and lay communities. It can be used safely and appropriately in the diagnostic breast setting and has a place in avoiding unnecessary workups. This category should never be used to delay the diagnosis of  a breast malignancy for reasons other than imaging characteristics.

BIRADS III does not mean a lesion has suspicious characteristics. If the lesion is indeterminate or has troubling imaging findings or there are red flags, you should go to BIRADS IV.

In practice

Depending on where you work and your level of comfort you indications for using BIRADS III will differ. Personal opinion (Dr Garth Kruger): in practice we use the category for small rounded densities in pre menopausal women that are likely small fibroadenomas or small cysts/foam cysts with low level internal echos. The lesion is overtly innocuous and simply does not justify the intervention. Another group of patients I bring back for short term follow up are those small overtly benign calcifications that have increased minimally over previous mammograms. The short term follow up buys me time to be satisfied I am not dealing with an early DCIS but obviates what is likely an unnecessary intervention. Other authors will differ and have other uses for BIRADS III; this is the nature of senology.

Remember that you have an obligation to track your BIRADS III lesions and make sure they are not lost to follow up.

Any post menopausal breast that develops anything other than vascular calcifications is a red flag. Be vary careful of using BIRADS III in the post menopausal breast or a breast that has had a previous cancer. Be aware that fat necrosis, radiation changes and post surgical scarring can and do change with time.

The reader with low reading volumes and/or low levels of experience should be using BIRADS III only after consultation with an experienced breast imager. This is true as well for those reading on their own in geographically isolated locations where volumes may be low. This is really important in the real world of imaging: if you are not an experienced breast image reader you should not be using BIRADS III. 

Reporting recommendations

It is not expected to change over the follow-up interval, but the radiologist would prefer to establish its stability. Often a 6 month follow up is recommended 2,7

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