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1 Journal of Breast Cancer ISSN J Breast Cancer 2008; September 11 (3): ORIGINAL ARTICLE 초음파로진단된유방영상보고데이터체계범주 4a 질환의조직병리학적분석 조백현 1,2 ㆍ김의정 5 ㆍ장소용 3 ㆍ김희정 4 ㆍ문희정 3 ㆍ박양순 4 ㆍ이일균 1,2 ㆍ김도일 1,2 ㆍ이원흥 1,2 ㆍ류정규 3 ㆍ최문혜 3 ㆍ이영란 3 윤회수 3 ㆍ윤세옥 1,2 1 미즈메디병원유방센터 2 외과 3 진단방사선과 4 병리과, 5 국민건강보험공단일산병원병리과 Histopathologic Analysis of BI-RADS Category 4a Breast Lesions Diagnosed by Ultrasonography Baik-Hyeon Jo 1,2, Yee Jeong Kim 5, So Yong Chang 3, Hee Jung Kim 4, Hee Jung Moon 3, Yangsoon Park 4, Il-Kyun Lee 1,2, Doy Il Kim 1,2, Won Hung Lee 1,2, Jungkyu Ryu 3, Moon-Hae Choi 3, Young Rahn Lee 3, Hoi Soo Yoon 3, Sei-Ok Yoon 1,2 1 Breast Center, Departments of 2 General Surgery, 3 Diagnostic Radiology, and 4 Pathology, MizMedi Hospital, Seoul; 5 Department of Pathology, National Health Insurance Corporation Ilsan Hospital, Goyang, Korea Purpose: We analyzed the histopathologic findings of the patients with ultrasongraphic Breast Imaging Reporting and Data System (BI-RADS) Category 4a breast lesions to determine which patient can be excluded from any invasive, diagnostic procedure in the future. Methods: Of the 180 cases of BI-RADS Category 4a breast lesions that were diagnosed with ultrasonography during a 6 month-period, 132 cases were pathologically confirmed and these were analyzed retrospectively. Four benign cases that did not undergo any further procedure after fine needle biopsy and 6 malignant cases (4.5%) were excluded from this study. Results: Of the 122 cases, 77 cases (63.1%) showed homogeneous benign finding, and 45 cases (36.9%) showed heterogeneous finding that was made up of two or more different pathologic lesions. Fibroadenoma (55.8%) was the most frequent pathologic finding in the cases with homogeneous finding, followed by fibrocystic change (14.3%), and fibrosis (7.8%). The cases with heterogeneous finding presented fibrocystic change (55.5%), microcalcification (48.8 %), ductal hyperplasia (42.2%), and fibroadenoma (31.1%) in the order of frequency. Conclusion: Lesion with heterogeneous histopathologic nature was the most frequent finding defined as category 4a in breast ultrasonography, followed by fibrodenoma, fibrocystic change, microcalcification, and ductal hyperplasia. Refining more specific ultrasonographic findings of these lesions would guarantee that radiologists exclude more benign lesions from category 4a. Key Words : BI-RADS, Breast, Ultrasonography 중심단어 : 유방영상보고데이터체계, 유방, 초음파검사 서 론 책임저자 : 조백현 서울시강서구내발산동 701-4, 미즈메디병원외과 Tel: , Fax: drjo514@yahoo.co.kr 접수일 : 2007 년 8 월 6 일게재승인일 : 2008 년 8 월 29 일 * 본논문의요약을 2006 년 16th Annual National Interdisciplinary Breast Conference, Las Vegas, Nevada 에서포스터로발표되었음. 유방암진단을위한영상검사법은유방촬영술과유방초음파검사가가장널리이용되고있다. 일반적으로 30 세이상의여성에서유방촬영술이유방검사의일차적검사로시행되고있으나, 폐경기이전의여성이나치밀유방을가진여성에서는민감도가떨어져유방암중 10-30% 정도는발견되지않을수도있다.(1) 특 139

2 140 Baik-Hyeon Jo, et al. 히한국여성에서는서양여성에비해젊은여성의유방암비율이높고치밀유방이많기때문에유방암진단시유방초음파검사의필요성이높다.(2) 1992년미국방사선의학회 (American College of Radiology) 에서는유방영상검사의표준화를위해유방영상보고데이터체계 (Breast Imaging Reporting and Data System, BI-RADS) 를개발하였는데,(3) 2003년 4판에는유방초음파분야를새롭게추가하였다.(4) 현재대부분의의료기관에서유방초음파검사후판정을위해 BI-RADS에제시된판독용어 (lexicon) 를사용하여병변을표현하고, 0부터 6까지의 7가지범주중한가지를선택하여최종판정을하게된다. 이에따르면, 범주 4는유방암으로확진할만한소견은아니지만유방암일가능성이 3-94% 이므로생검이필요하다. 범주 4의악성가능성의범위가넓기때문에, 임상의사에게좀더구체적인영상정보를제공하기위해범주 4를범주 4a ( 하위 ), 4b ( 중간 ), 4c ( 중등도 ) 의세범주로세분하였다. 범주 4a 는약 3-5% 의악성가능성을가지며조직검사대상이다. 반면, 양성일가능성이높은범주 3의판정을받은병변의경우악성일가능성이 2% 이하이기때문에조직검사가필수적이지않고 6개월간격의추적검사를권고한다. 따라서, 이두범주의판정차이는침습적검사와비침습적추적검사중하나를선택하게되므로, 환자는그결과에따라상당한심리적또는육체적부담의차이를느끼게된다. 저자들은유방초음파검사에서범주 4a 로진단받은환자와같은기간에유방초음파검사에서범주 3으로판정된예중조직검사를시행한예를분석함으로써, 범주 4a 로진단된양성병변과그조직병리학적특성을조사하기로하였다. 1. 연구대상 방 2005년 1월 1일부터 5월 31일까지미즈메디병원유방센터에서유방초음파검사를시행받은 3,239예중, 범주 4a로판정된것은 180 예였다. 유방촬영술에서미세석회화소견으로범주 4a 의판정을받았지만, 그와일치하는초음파의이상소견이없이정상인예는제외하였다. 30 세미만여성의유방초음파검사에서단순결절로범주 4a 로판정받아추가적인유방촬영술이필요하지않다고판 Table 1. Indications of biopsy for the patients with category 3 lesion 1. When a lesion is palpable and is larger than 2 cm in diameter 2. When patient complains of a growing palpable mass 3. When patient wants to make it sure what a lump is 4. When patient had ever been recommended to undergo biopsy for a lesion 법 단된경우는본연구에포함하였다. 180 예모두조직검사를권유받 았으며, 이중조직검사를시행받은 132 예를대상으로조사하였다. 2. 방법 1) 초음파검사 2) 조직검사 유방초음파검사를시행받은환자는판정결과범주 4a 의소견을보인 180 예였으며, 모두에게조직검사를권유하여 132 예에서조직검사를시행하였다. 같은기간에유방초음파검사를시행받은환자중 710 예가범주 3으로판정받았다. 이중 79 예에서조직검사를시행하였고, 적응증은 Table 1에기술하였다. 절침생검 (core-needle biopsy) 이나맘모톰 (Mammotome, Johnson & Johnson, Cincinnati, USA) 검사상비정형증식증 (atypical ductal hyperplasia) 의소견을보인경우는절제생검술을시행하여상피내암이나침윤성암의병존여부를확인하였다. 세침흡 Table 2. Methods of biopsy and pathologic patterns of benign lesions defined as Category 4a in ultrasonography Diagnostic methods Pathologic patterns 연구전 6개월간 (2004년 6월 1일부터 12 월 31일까지 ) 한명의연구자 ( 책임연구자 ) 가본연구와같은방법으로범주 4a 의양성예측도 (positive predictive value) 를측정하였다. 책임연구자를제외한유방초음파검사자들과다른연구자들은연구에관하여모르는상태 (blinded) 에서연구를시행하였다. 연구기간동안 5명의방사선과의사가동일한기종의초음파기기 (ATL HDI 5000, Phillips, Bothwell, USA) 로검사하였으며, 7.5 MHz 의탐침자를사용하였다. 검사의판독은 2003년미국방사선의학회에서편찬된 BI-RADS (Appendix) 에따랐다. 범주의판정은초음파를시행하는사람의결정에따라맡겼으며, 이들의결과는조사결과양성예측도가 3에서 5% 범위내에존재하여본연구에있어서판정의적절성을확인하였다. 유방초음파검사자들은검사가시작되기전 6 개월이상그리고, 검사기간중, 월 1 회이상 BI- RADS에따른유방초음파검사판정에관하여회의를하였다. Homogeneous Heterogeneous Total CNB* Mammotome Excision Total (%) 77 (63.1) 45 (37.9) 122 (100) *CNB is an abbreviation for core needle biopsy, which was done with 14-gauge automated biopsy gun under the guidance of ultrasonography; Mammotome biopsy was done with 11-gauge vacuum-assisted probe under the guidance of ultrasonography.

Histopathologic Analysis of BI-RADS Category 4a Breast Lesions 141 인생검 (fine-needle aspiration biopsy, FNAB) 으로양성병변으로판정되었으나, 추가적으로절침생검, 맘모톰검사, 절제생검술중한가지를시행받지않은 4예는조직검사결과분석에서제외하였다.

절침생검은 14-gauge core needle 이장착된생검총 (a rapid-fire, spring-loaded, automated biopsy gun, MD TECH, Gainsville, USA) 을사용하여 3내지 5절편을채취하였다.

조직검사두가지이상이질적인병리학적소견 (Fig 2) 을보인경우에는한명의연구자가각병리소견의구성비율을다시조사하였다. 전체소견에서가장많은비율로구성된병리조직소견을제1 (the first) 소견으로정의하고, 이어서제2 (the second), 제3 (the third), 그리고제4 (the fourth) 소견으로정의하고각병변의빈도를조사하였다. Fig 1.

But its axis is parallel and it has posterior enhancement without peripheral thickening. The picture was scanned with ATL HDI 5000, Phillips, USA. (B) The picture was taken from the above lesion.

4) 범주 3 질환의조직소견연구대상기간중조직검사를시행한범주 3예중에서절침생검, 맘모톰검사, 절제생검술로조직검사를시행한 79 예의조직병리소견을분석하여, 범주 4의결과와비교하였다. 결과 A 조직검사를시행한 132 예중 6예 (4.5%) 가악성으로판정되었다.

Malignant lesions defined as category 4a in ultrasonography B Fig 2. Heterogeneous lesion defined as Category 4a.

3 Histopathologic Analysis of BI-RADS Category 4a Breast Lesions 141 인생검 (fine-needle aspiration biopsy, FNAB) 으로양성병변으로판정되었으나, 추가적으로절침생검, 맘모톰검사, 절제생검술중한가지를시행받지않은 4예는조직검사결과분석에서제외하였다. 본연구의대상인 122 예의조직검사방법은절침생검이 84 예로가장많았고, 맘모톰검사가 23 예, 절제생검술이 15 예의순이었다 (Table 2). 절침생검은 14-gauge core needle 이장착된생검총 (a rapid-fire, spring-loaded, automated biopsy gun, MD TECH, Gainsville, USA) 을사용하여 3내지 5절편을채취하였다. 맘모톰검사는조직검사를목적으로시행하였으며, 11-gauge vacuum-assisted biopsy probe가장착된맘모톰을사용하여최소한 3절편이상의조직을채취하였다. B A C 3) 조직검사의판정병리조직검사의판정은최초의병리보고서를참고하였다. 단일병리소견 (Fig 1) 으로구성된예에서는각질환의빈도를조사하였다. 조직검사두가지이상이질적인병리학적소견 (Fig 2) 을보인경우에는한명의연구자가각병리소견의구성비율을다시조사하였다. 전체소견에서가장많은비율로구성된병리조직소견을제1 (the first) 소견으로정의하고, 이어서제2 (the second), 제3 (the third), 그리고제4 (the fourth) 소견으로정의하고각병변의빈도를조사하였다. Fig 1. Fibroadenoma categorized as Category 4a. (A) The mass shows heterogeneous and low internal echo and it has microlobulated and angular margin. But its axis is parallel and it has posterior enhancement without peripheral thickening. The picture was scanned with ATL HDI 5000, Phillips, USA. (B) The picture was taken from the above lesion. Its stromal component shows marked fibrosis and lack of cellularity. (C) Cystically dilated ducts and tubular glands are seen in loose mixoid stroma (H&E, 100). 4) 범주 3 질환의조직소견연구대상기간중조직검사를시행한범주 3예중에서절침생검, 맘모톰검사, 절제생검술로조직검사를시행한 79 예의조직병리소견을분석하여, 범주 4의결과와비교하였다. 결과 A 조직검사를시행한 132 예중 6예 (4.5%) 가악성으로판정되었다. 범주 4a 중악성으로판정된 6예중 3예가맘모톰검사, 3예가절침생검으로진단되었는데, 미세침윤을동반한상피내암이 2예, 침윤성유관암이 1예, 그리고나머지 3예는조직학적으로특수형 (special type) 암이었다 (Table 3). 세침흡인생검에서 Table 3. Malignant lesions defined as category 4a in ultrasonography B Fig 2. Heterogeneous lesion defined as Category 4a. (A) The mass shows heterogeneous and low internal echo and it has microlobulated margin. It also has posterior acoustic shadowing in part. There is no secondary sign on the surrounding tissue, like architectural distortion, Cooper s ligament thickening or cutoff, peripheral thickening. The picture was scanned with ATL HDI 5000, Phillips, USA. (B) Several foci of ductal hyperplasia are seen on the top. Fibrocystic change is also seen on the bottom. (C) Microcalcification is in the dilated duct on the left of a large component of adenosis (H&E, 100). C Patient Age/ sex Pathologic finding Method of biopsy 1 43/F Invasive ductal carcinoma CNB* 2 33/F Intraductal papillary carcinoma mammotome 3 75/F Tubular carcinoma with LCIS mammotome 4 56/F Adenoid cyctic carcinoma CNB 5 47/F DCIS with microinvasion mammotome 6 60/F Invasive ductal carcinoma CNB LCIS=lobular carcinoma in situ; DCIS=ductal carcinoma in situ. *CNB is an abbreviation for core needle biopsy, which was done with 14-gauge automated biopsy gun under the guidance of ultrasonography; Mammotome biopsy was done with 11-gauge vacuum-assisted probe under the guidance of ultrasonography.

4 142 Baik-Hyeon Jo, et al. 양성으로판명된후추가적인방법의조직검사를시행하지않는 4 예와악성으로판명된 6예를제외한 122 예의양성중, 77예 (63.1%) 는단일병리소견을가졌으며, 45 예 (36.9%) 에서는두가지이상의이질적인병리소견을보였다. 단일병리조직소견을보인 77 예중, 섬유선종이 43 예 (55.8%) 로가장많았고, 이어서섬유낭종성변화 11예 (14.3%), 섬유화 6예 (7.8%) 등의순이었다 (Table 4). 두가지이상의이질적인병리소견을보인 45 예중 25예 (55.5%) 에서섬유낭종성변화를보였으며, 이어서미세석회화 22 예 (48.8 %), 유관증식증 19 예 (42.2%), 그리고섬유선종 14 예 (31.1%) 등의순서로빈도를보였다 (Table 4). 두가지이상의이질적병리소견을보인 45 예에서, 제1소견은섬유선종이 14 예로가장많았고, 섬유낭종성변화 9예, 관내유두종 (7 예 ), 섬유선종성증식증 (fibroadenomatous hyperplasia) Table 4. Pathologic findings of homogeneous benign lesions defined as Category 4a Pathologic findings Number (%) Fibroadenoma 43 (55.8) Fibrocystic change 11 (14.3) Fibrosis 6 (7.8) Fibroadenomatous change 4 (5.2) Duct ectasia 3 (3.9) Adenosis 2 (2.6) Inflammatory 2 (2.6) Ductal hyperplasia* 2 (2.6) Others 4 (5.2) Total 77 (100) *Ductal hyperplasia includes 1 atypical ductal hyperplasia. Table 5. Pathologic analysis of heterogeneous benign lesions defined as category 4a The order of compositional proportion Lesions First Second Third Fourth Total (%) Fibroadenoma (31.1) Fiborcystic change (55.5) Ductal papilloma 7 7 (15.6) FAH 6 6 (13.3) Ductal hyperplasia* (42.2) Duct ectasia (13.3) Fibrosis (11.1) Apocrine metaplasia (15.6) Microcalcification (48.8) Others (13.3) Total FAH is an abbreviation for fibroadenomatous hyperplasia. *Ductal hyperpalsia includes 1 atypical ductal hyperplasia; Stromal fibrosis is included in fibrosis. 6예등의순이었다. 반면, 분포비율에관계없이가장많이보인병리학적소견은섬유낭종성변화로 25 예 (55.5%) 에서나타났다. 그리고미세석회화 22 예 (48.8%), 유관증식증 19 예 (42.2%), 이어서섬유선종 14 예 (31.1%) 등의순서로빈발하였다 (Table 5). 범주 3 중조직검사를시행한 79예중 3예 (3.8%) 가악성으로판정되었다. 조직검사방법으로는절제생검술이 41 예 (51.9%) 에서시행되어가장많이이용되었다. 양성으로판명된 76 예중 60 예 (78.9%) 가단일병리조직소견을보였으며, 16 예 (21.1%) 에서 2 가지이상의이질적병리조직소견을보였다 (Table 6). 고 유방초음파검사는 1951년 15-MHz A-mode 탐촉자 (transducer) 를이용하여 3 mm의종양을형상화하는데처음으로사용되었다.(5) 초기에유방초음파검사는미세석회화를검사할수없고고형종양의악성여부의감별이불가능했기때문에유방검사에서큰역할을할수없었다.(6) 그러나최근탐촉자와영상소프트웨어의발달로고형종양의악성가능성에대한등급별분류가가능해졌다.(7) 현재유방초음파검사는유방진찰소견및유방촬영술과함께유방검사에있어서필수적인검사이며, 유방검사 Table 6. Method of biopsy and pathologic patterns of Category 3 Lesions Diagnostic methods CBN* (41.8) Mammotome (6.3) Excision (51.9) Total in the benign (%) 60 (78.9) 16 (21.1) Total (%) 60 (75.9) 16 (20.3) 3 (3.8) 79 (100) 찰 Heterogeneous Pathologic patterns (%) Benign Malignant Homogeneous Total *CNB is an abbreviation for core needle biopsy, which was done with 14-gauge automated biopsy gun under the guidance of ultrasonography; Mammotome biopsy was done with 11-guage vacuumassisted probe under the guidance of ultrasonography. Table 7. Indications of breast ultrasonography 1. Identification and characterization of palpable and nonpalpable abnormalities and the further evaluation of clinical and mammographic findings 2. Guidance of interventional procedures 3. Evaluating problems associated with breast implants 4. Treatment planning for radiation therapy 5. Initial imaging technique to be used for young (under 30), lactating, and pregnant women

5 Histopathologic Analysis of BI-RADS Category 4a Breast Lesions 143 에있어서다양한적응증을가진다 (Table 7).(8) 특히최근보고에따르면세가지검사가모두음성일경우음성예측도 (negative predictive value for cancer) 는 99.9% 에이른다.(9) 그러나유방의방사선학적검사에서악성이의심스러운병변은침습적인검사인조직검사로반드시악성여부를감별해야한다. 조직검사방법은절개생검술또는절제생검술등수술적인방법이외에 FNAB, 절침생검, 맘모톰검사등이있다. 조직검사시어떤방법이사용되더라도조직검사를시술받는환자는여러가지불편한점에직면하게된다. 조직검사자체에대한불안감, 조직검사에따른불편함, 그리고초기방사선검사에서부터조직검사가결과가나올때까지사회생활의위축을초래한다. 이런이유로임상의사들이환자에게조직검사를권유할때신중한판단이요구되는데, 이때가장중요한것이방사선검사의판정시악성에대한위양성률 (false negative rate) 을최소화하는것이다. 유방초음파검사에서발견된결절이보이는소견중악성을예측할수있는소견들이다양하게주장되고있으며각각의소견들이악성도를예측하는정도도조금씩다르다. 고형 (solid) 성분이없는단순낭종 (cyst) 일경우 BI-RADS 범주 2로판정하여조직검사대상에서제외하며, 반면낭종성병변내부에뚜렷한고형병변이보이는복합낭종 (complex cyst) 일경우반드시조직검사를해야한다.(10) 따라서초음파검사상발견된고형병변에서보이는다양한소견을분석하여각각의소견이암에대한양성예측도를조사하는것이유방초음파검사의판독에중요한근거를제시한다. 이를위해먼저초음파검사소견을표현하는용어의표준화가이루어져야하는데, 미국방사선의학회가개발한 BI-RADS 이 2003년에 4판으로개정되면서유방초음파소견의표준화된용어를제시하였다. Duke 대학의 Hong 등 (11) 은유방초음파검사에서발견된종양에대하여초음파 BI-RADS에서제시한용어들을사용해서각각의용어에대한양성예측도를조사한연구결과를발표하였다. 이결과에따르면, 종양변연 (mass margin) 이침상형 (spicualted) 이거나각짐형 (angular), 종양의방향 (mass orientation) 이평행하지않음 (not parallel), 병변경계 (lesion boundary) 의고에코달무리 (echogenic halo), 불규칙한 (irregular) 종양모양 (mass shape) 등의소견을보일때각각의소견에대한악성의빈도가 60% 이상으로높았다. 그러나현재이러한소견을종합하여판정하는 BI-RADS에서조직검사를권고하는범주 4a 의경우양성예측도가 3-5% 이므로, 범주 4a 로판정된경우암양성예측도 (Positive Predictive Value for cancer) 를더높일필요가있으며, 이로써불필요한침습성검사를피할수있다. 이를위해먼저범주 4a으로판정된양성질환의빈도를조사하고빈발하는질환의병리학적소견과방사선검사를대조해볼필요가있다. 저자들은범주 4a 로판정된예의병리조직학적소견을분석하여그특징을찾고, 같은기간에조직검사를시행한범주 3의예들을분석하였다. 범주 4a 의소견을보인모든환자에게조직검사를권유한반면, 범주 3의환자에서는경우매우선택적 (Table 1) 으로조직검사가시행되었다. 따라서, 본연구에서두환자군의소견을비교하는하는것은통계학적으로의미가없다. 다만, 범주 3의예에서조직검사는방사선학검사소견에관계없이임상적으로암이의심되거나, 병변의크기가큰경우에시행되었으며, 전체병변의조직소견을알수있는절제생검술의의한검사의비율이범주 4a 에서보다압도적으로높았음에도불구하고, 범주 3의경우 78.9% 에서단일병리소견을보인반면, 범주 4a 의경우 63.1% 의환자가단일병리학적소견을보였다. 따라서, 조직병리학적으로이질적인질환들이복합적으로구성된병변의경우에유방초음파검사에서범주 3보다는범주 4a 로판정될가능성이높다고할수있겠다. 특히, 주병변 (main lesion) 이아닌부수적인조직소견인미세석화가이질적소견으로보인양성환자중약절반 (48.8%) 에서나타났다. 이는부수적으로동반된미세석회가유방초음파검사의판정에영향을미친다고추정할수있다. 그러므로유방초음파검사에서범주 4a 로판정된환자는반드시유방엑스선검사를시행하여미세석회의특성을조사함으로써위양성률 (false positive rate) 을줄일수있을것으로기대된다. 향후본연구에서조사된범주 4a 에서흔히보이는양성병변의병리조직소견과유방초음파소견을분석함으로써, 각양성병리소견에대한초음파검사에서의특징을확립할수있을것으로기대된다, 또한, 악성으로진단된 6예중 3예 (50%) 가특수형유방암이었는데, 이는일반적인통계에서전체유방암에서특수형이차지하는비율 (20-30%) 보다높았다.(12) 본연구에서는조사대상숫자가적어비록통계적의미는없으나, 이러한특수형유방암은범주 4b, 4c, 범주 5에포함되기보다하위범주, 즉범주 4a 나범주 3에포함될가능성이있음을시사한다. 따라서, 저자들은이에대한추가적인연구결과가나오기를기대한다. 결론유방초음파검사에서발견되어범주 4a 로판정되는결절중가장흔한것은두가지이상의병리소견을가진결절이다. 단일병리소견을결절들중에서는섬유선종, 섬유낭종성변화, 미세석회, 유관증식증등의순서로흔히판정된다. 특히, 이러한병변의조직소견과초음파검사소견을비교분석하면추가적으로음성예측도가높은초음파소견을정립할수있으며, 궁극적으로침습적인조직검사의빈도를줄일수있다.

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7 Histopathologic Analysis of BI-RADS Category 4a Breast Lesions 145 Appendix MizMedi Breast Center BI-RADS Lexicon Patient s name : Patient s PIN : Date of assessment :,,. Lesions I. (Rt, Lt)-, - cm FN II. (Rt, Lt)-, - cm FN Size : cm Size : cm A. Mass a. Shape (oval, round, irregular) (oval, round, irregular) b. Orientation (parallel, not parallel) (parallel, not parallel) c. Margin 1. circumscribed 1. circumscribed 2. not circumscribed 2. not circumscribed (indistinct, angular, microlobulated, spiculated) (indistinct, angular, microlobulated, spiculated) d. Boundary (abrupt interface, echogenic halo) (abrupt interface, echogenic halo) e. Echo pattern (anechoic, hyperechoic, complex, hypoechoic) (anechoic, hyperechoic, complex, hypoechoic) f. Posterior (No, enhancement, acoustic feature shadowing, (No, enhancement, shadowing, combined) combined) g. Surrounding tissue (identifiable effect: select all that apply) 1. Duct changes ( ) ( ) 2. Cooper s ligament changes ( ) ( ) 3. Edema ( ) ( ) 4. Architectural distortion ( ) ( ) 5. Skin thickening ( ) ( ) 6. Skin retraction/irregularty ( ) ( ) B. Calcifications (select all that apply) a. Macrocalcifications ( ) ( ) b. Microcalcifications out of mass ( ) ( ) c. Microclacifications in mass ( ) ( ) C. Special cases (a unique diagnosis or findings: select all that apply) a. Clustered microcysts ( ) ( ) b. Complicated cysts ( ) ( ) c. Mass in or on skin ( ) ( ) d. Foreign ( ) ( ) e. Lymph node-intra mammary ( ) ( ) f. Lymph node-axillary ( ) ( ) D. Vascularity (select all that apply) a. Not present or assessed ( ) ( ) b. Present in lesion ( ) ( ) c. Present immediately adjacent ( ) ( ) to lesion d. Diffusely increased vascularity ( ) ( ) in surrounding tissue E. Assessment Category: I: Category II: Category III: -, cm FN, Size: cm, (Category ) IV: -, cm FN, Size: cm, (Category ) V: -, cm FN, Size: cm, (Category ) VI: -, cm FN, Size: cm, (Category ) VII: -, cm FN, Size: cm, (Category ) Examiner s Signature: F. Final diagnosis (Pathologic Report) I. II. III. MizMedi Breast Center, Seoul, Korea *The breast imaging reporting and data system (BI-RADS) lexicon developed by the American college of radiology.

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Kbcs002.hwp Does Real-time Compound Imaging Improve Evaluation of reast Cancer Compared to Conventional Sonography? o Kyoung Seo, M.D., Yu Whan Oh, M.D., Kyu Ran Cho, M.D., Young Hen Lee, M.D., Hyung Joon Noh, M.D.,