BI-RADS, C-RADS, CAD-RADS, LI-RADS, Lung-RADS, NI-RADS, O-RADS, PI-RADS, TI-RADS: Reporting and Data Systems Julie Y. An, MD Kyle M.L. Unsdorfer, MD.

BI-RADS, C-RADS, CAD-RADS, LI-RADS, Lung-RADS, NI-RADS, O-RADS, PI-RADS, TI-RADS: Reporting and Data Systems Julie Y. An, MD Kyle M.L. Unsdorfer, MD Jeffrey C. Weinreb, MD An earlier incorrect version of this presentation appeared online. This presentation was corrected on September 12, 2019.

Address correspondence to: J.Y.A.
Author Affiliations From the Department of Medicine, Akron, Ohio (J.Y.A.); Department of Radiology, Mayo Clinic, Rochester, Minn (K.M.L.U.); and Department of Radiology, Yale University School of Medicine, New Haven, Conn (J.C.W.). Address correspondence to: J.Y.A. Current address: Department of Radiology, University of California San Diego 200 W Arbor Drive, San Diego, CA 92103 ( 2018 RSNA Educational Exhibit: MS101 Acknowledgments.—The authors would like to thank Philip Araoz, MD, Chi Wan Koo, MD, and Baris Turkbey, MD for their guidance and review of this presentation. Disclosures of Conflicts of Interest.—J.C.W. Activities related to the present article: member of the ACR LI-RADS and PI-RADS committees; received reimbursement for travel expenses for committee meetings from the ACR. Activities not related to the present article: disclosed no relevant relationships. Other activities: disclosed no relevant relationships.

Recognize the systematic scoring and modifiers of RADS.
Review the overview of the current American College of Radiology (______)* Reporting and Data Systems (RADS). Recognize the systematic scoring and modifiers of RADS. Review the general themes and key imaging components of each system. Identify additional resources for more in-depth training and education. Note.—*Reprinted, with permission, from the ACR.

Why Standardized Reporting?
Unifies the language between radiologists and clinicians Allows consistent data collection and improvement of diagnostic parameters Helps to standardize care Adds value by providing clinical recommendations and guidance

What is ______RADS? RADS include systems with standardized terminology, assessment, and reporting endorsed by the ACR. The predominant focus is on cancer imaging (breast, colon, head and neck, liver, lung, ovarian, prostate, and thyroid cancers), with additional systems focusing on coronary artery disease and head injuries (pending publication). Systems were devised by expert consensus and may be updated periodically.

“The goal of the________ RADS is to reduce the variability of terminology in reports and to ease communication between radiologists and referring physicians.”1

ACR RADS Abbreviations
BI-RADS = Breast Imaging Reporting and Data System C-RADS = CT Colonography Reporting and Data System CAD-RADS = Coronary Artery Disease Reporting and Data System LI-RADS = Liver Imaging Reporting and Data System NI-RADS = Neck Imaging Reporting and Data System O-RADS = Ovarian-Adnexal Reporting and Data System PI-RADS = Prostate Imaging Reporting and Data System TI-RADS =Thyroid Imaging Reporting and Data System

TI-RADS NI-RADS Lung-RADS BI-RADS LI-RADS CAD-RADS C-RADS O-RADS
Thyroid cancer Head and neck cancer Lung-RADS BI-RADS Lung cancer Breast cancer LI-RADS Hepatocellular carcinoma CAD-RADS Coronary artery disease C-RADS Colon cancer O-RADS PI-RADS Ovarian and adnexal mass Prostate cancer

TI-RADS NI-RADS Lung-RADS BI-RADS LI-RADS CAD-RADS C-RADS O-RADS
*Cancer Specific TI-RADS NI-RADS Thyroid cancer Head and neck cancer Lung-RADS BI-RADS Lung cancer Breast cancer LI-RADS Hepatocellular carcinoma CAD-RADS Coronary artery disease C-RADS Colon cancer O-RADS PI-RADS Ovarian and adnexal mass Prostate cancer

_______Reporting and Data Systems
Pathologic Condition Score or Category Score Assignment Modalities BI-RADS Breast cancer 0–6 (4A-C) Patient based Mammography, MRI, US C-RADS Colon cancer Colonic findings (C0–4); extracolonic findings (E0–4) Lesion based CT colonography CAD-RADS Coronary artery disease 0–5, N CT angiography LI-RADS Liver cancer (HCC) 1–5, TIV, NC, M, TR CT, MR, CEUS: lesion based; US: patient based CT, MRI, CEUS, US Lung-RADS Lung cancer (screening) 0–4 (4A, B, X), S, C Low-dose CT NI-RADS Head and neck cancers (diagnostic system) 0–4 (2A, B) PET, CT, MRI O-RADS Ovarian-adnexal masses NA US PI-RADS Prostate cancer 1–5 Multiparametric MRI TI-RADS Thyroid cancer (incidental lesions) Note.—C = prior lung cancer, CEUS = contrast material–enhanced US, HCC = hepatocellular carcinoma, M = malignant but not HCC, NA = not applicable, N, NC = inadequate study, S = clinically significant or potentially clinically significant findings (nonlung cancer), TIV = tumor in vein, TR = treated.

The Systematic Scoring of______RADS1

1____2____3____4____5____6 Increased likelihood of disease
RADS Scoring Scale Pathologic Condition Score or Category Score Assignment Modalities BI-RADS Breast cancer 0–6 (4A-C) Patient based Mammography, MRI, US C-RADS Colon cancer C0-4, E0-4 Lesion-based CT Colonography CAD-RADS Coronary artery disease 0-5, N Patient-based CTA LI-RADS Liver cancer: HCC 1-5, TIV, NC, M, TR CT, MR, CEUS: Lesion, US: Patient-based CT, MRI, CEUS, US Lung-RADS Lung cancer: screening 0-4 (4A,B,X), S, C Low-dose CT NI-RADS Head & neck cancers: diagnostic 0-4 (2A,B) PET, CT, MRI O-RADS Ovarian-Adnexal masses N/A Ultrasound PI-RADS Prostate cancer 1-5 Multiparametric MRI TI-RADS Thyroid cancer: incidental lesions 1____2____3____4____5____6 Increased likelihood of disease

Increased likelihood of disease
RADS Scoring Scale Increased likelihood of disease Pathologic Condition Score or Category Score Assignment Modalities BI-RADS Breast cancer 0–6 (4A-C) Patient-based Mammo, MRI, Ultrasound (US) C-RADS Colon cancer C0–4, E0–4 Lesion-based CT Colonography CAD-RADS Coronary artery disease 0–5, N CTA LI-RADS Liver cancer (HCC) 1–5, TIV, NC, M, TR CT, MR, CEUS: Lesion, US: Patient-based CT, MRI, CEUS, US Lung-RADS Lung cancer (screening) 0–4 (4A,B,X), S, C Low-dose CT NI-RADS Head and neck cancers (diagnostic) 0–4 (2A,B) PET, CT, MRI O-RADS Ovarian-adnexal masses NA N/A Ultrasound PI-RADS Prostate cancer 1–5 Multiparametric MRI TI-RADS Thyroid cancer (incidental lesions) C C2 C3 C4 A B X A B

Nondiagnostic Scores 0,N,NC BI-RADS C-RADS CAD-RADS* LI-RADS Lung-RADS
Pathologic condition Score or Category Score Assignment Modalities BI-RADS Breast cancer 0–6 (4A-C) Patient-based Mammo, MRI, Ultrasound (US) C-RADS Colon cancer C0–4, E0-4 Lesion-based CT Colonography CAD-RADS* Coronary artery disease 0–5, N CTA LI-RADS Liver cancer (HCC) 1–5, TIV, NC, M, TR CT, MR, CEUS: Lesion, US: Patient-based CT, MRI, CEUS, US Lung-RADS Lung cancer (screening) 0–4 (4A,B,X), S, C Low-dose CT NI-RADS Head and neck cancers (diagnostic) 0–4 (2A,B) PET, CT, MRI O-RADS Ovarian-adnexal masses NA N/A Ultrasound PI-RADS Prostate cancer 1–5 Multiparametric MRI TI-RADS Thyroid cancer (incidental lesions) 0,N,NC Inadequate study, requires repeat or additional imaging *CAD-RADS 0 = Exception, not an inadequate study

Subscores BI-RADS C-RADS CAD-RADS LI-RADS Lung-RADS NI-RADS O-RADS
Pathologic condition Score or Category Score Assignment Modalities BI-RADS Breast cancer 0–6 (4A-C) Patient-based Mammo, MRI, Ultrasound (US) C-RADS Colon cancer C0–4, E0–4 Lesion-based CT Colonography CAD-RADS Coronary artery disease 0–5, N CTA LI-RADS Liver cancer (HCC) 1–5, TIV, NC, M, TR CT, MR, CEUS: Lesion, US: Patient-based CT, MRI, CEUS, US Lung-RADS Lung cancer (screening) 0–4 (4A,B,X), S, C Low-dose CT NI-RADS Head and neck cancers (diagnostic) 0–4 (2A,B) PET, CT, MRI O-RADS Ovarian-adnexal masses NA N/A Ultrasound PI-RADS Prostate cancer 1–5 Multiparametric MRI TI-RADS Thyroid cancer (incidental lesions) 4A - Low suspicion 4B - Intermediate suspicion 4C - Moderate suspicion 4A - Smaller, less solid 4B - Larger, more solid 4X - Has additional findings that raise suspicion 2A - Superficial lesion 2B - Deep lesion

Score Modifiers BI-RADS C-RADS CAD-RADS LI-RADS Lung-RADS NI-RADS
Pathologic condition Score or Category Score Assignment Modalities BI-RADS Breast cancer 0–6 (4A-C) Patient-based Mammo, MRI, Ultrasound (US) C-RADS Colon cancer C0–4, E0–4 Lesion-based CT Colonography CAD-RADS Coronary artery disease 0–5, N CTA LI-RADS Liver cancer (HCC) 1–5, TIV, NC, M, TR CT, MR, CEUS: Lesion, US: Patient-based CT, MRI, CEUS, US Lung-RADS Lung cancer (screening) 0–4 (4A,B,X), S, C Low-dose CT NI-RADS Head and neck cancers (diagnostic) 0–4 (2A,B) PET, CT, MRI O-RADS Ovarian-adnexal masses NA N/A Ultrasound PI-RADS Prostate cancer 1–5 Multiparametric MRI TI-RADS Thyroid cancer (incidental lesions) C - Colonic findings E - Extracolonic findings M - Malignant but not HCC TR - Treated TIV - Tumor in vein C - Prior lung cancer S - Significant findings, not lung cancer

Imaging Examples of ______RADS1

BI-RADS2 BI-RADS is appropriate to use for patients undergoing screening, diagnostic, or posttreatment follow-up imaging for breast cancer. First system proposed in 1993, and the first RADS to gain widespread clinical adoption Integrated with the American Society of Breast Surgeons guidelines Pathologic condition: Breast cancer (screening and diagnostic) Imaging modalities: Mammography, MRI, US Scoring: Patient score 0–6 (4A-C) Version: 5 (2015)

Modalities or Technique
BI-RADS Pathologic Condition Score or Category Assignment Modalities or Technique Breast cancer 0–6 (4AC) Patient-based Mammography, MRI, US Category Features and Imaging Findings Management Mammo MRI US BI-RADS 1 Negative: no visible abnormalities, no well-formed mass, asymmetric glandular structure, no change from prior examination No additional actions BI-RADS 2 Benign: calcified fibroadenomas, cysts, and fatty densities such as lipomas, galactoceles, oil cysts, hamartomas, surgical scars, secretory ductal ectasia, vascular calcifications, breast implants, silicone granulomas, etc BI-RADS 3 Probably benign: risk of malignancy is lower than 2%; includes noncalcified solid nodules (arrow), clusters of round or oval calcifications (circle), fibroglandular densities, dilated duct or postbiopsy architectural distortion without central density, etc Initial short-interval (6 months) follow-up BI-RADS 4 Suspicious: risk of malignancy is 2%–94%; 4A = low suspicion, 4B = moderate suspicion, 4C = high suspicion; includes asymmetric, localized, and evolving areas of high density with convex contours, noncystic opacities with obscure contours, etc Biopsy should be considered BI-RADS 5 Highly suspicious: risk of malignancy is >94%; includes microcalcifications with linear branching, clusters with segmental galactophorous distribution, evolving lesions with architectural distortion, poorly circumscribed opacities with irregular contours, speculation, etc Appropriate action should be taken Additional Categories BI-RADS 0: Incomplete assessment  Need to perform repeat imaging or to review prior mammograms for comparison BI-RADS 6: Known biopsy-proven malignancy  Appropriate action should be taken

C-RADS3 C-RADS is used for patients undergoing screening CT colonography. From the Working Group on Virtual Colonoscopy, which includes members of the ACR Colon Cancer Committee Reports colorectal neoplasia and extracolonic findings Pathologic condition: Colon cancer Imaging modality: CT colonography Scoring: Lesion score C0–4, E0–4 Version: 1 (2005)

C-RADS Pathologic Condition Score or Category Assignment Modalities or Technique Colon cancer C0–4, E0–4 Lesion based CT colonography Category and Colorectal findings Management CT C1: Normal colon or benign lesions: no visible abnormalities, no polyps ≥6 mm, lipoma, diverticula Continue routine screening every 5–10 years per guidelines C2: Intermediate finding: <3 polyps (arrow) of 6–9 mm size, cannot exclude ≥6 mm in technically adequate examinations Surveillance or colonoscopy; evidence suggests surveillance can be delayed for at least 3 years C3: Polyp of possibly advanced adenoma (arrow): polyp ≥10 mm, ≥3 polyps of 6–9 mm Follow-up colonoscopy, communicate with referring physician; subject to local practice, possible biopsy C4: Colonic mass (arrow), likely malignant: lesion compromises bowel lumen, demonstrates extracolonic invasion Surgical consultation recommended Extracolonic findings Management CT E1: Normal examination or anatomic variant: retroaortic left renal vein No workup indicated E2: Clinically unimportant finding: liver or kidney cyst, cholelithiasis without cholecystitis, vertebral hemangioma E3: Likely an unimportant finding: minimally complex or homogeneously hyperattenuating kidney cyst Workup may be indicated, depending on the clinical scenario E4: Potentially important finding: solid renal mass, lymphadenopathy, large aortic aneurysm, suspicious lung nodule Communicate to referring physician per practice guidelines Retroaortic left renal vein Simple renal cyst Minimally complex renal cyst Portal thrombus and metastasis Additional Categories.—C0: Inadequate study: inadequate preparation, insufflation, awaiting prior studies for comparison  Repeat examination and review prior studies E0: Limited examination: artifact, evaluation of extracolonic soft tissue is severely limited  Alternative workup indicated

CAD-RADS4 CAD-RADS is used for patients with stable or acute chest pain. Additional inclusion criteria: Negative first troponin test results Negative or nondiagnostic electrocardiogram (EKG) Thrombolysis in myocardial infarction (TIMI) score less than 4 (low-intermediate mortality risk of unstable angina/non–ST-segment elevation myocardial infarction [NSTEMI]) Graded by the patient’s highest- risk coronary lesion Pathologic condition: Coronary artery disease Imaging modality: Coronary CT angiography Scoring: Patient score 0–5, N Version: 1 (2016)

CAD-RADS Pathologic Condition Score or Category Assignment Modalities or Technique Coronary artery disease 0–5, N Patient based CT angiography Category Features and Imaging Findings Management CT angiography CAD-RADS 0 ACS highly unlikely: 0% stenosis or no plaque; absence of CAD No further evaluation of ACS required CAD-RADS 1 ACS highly unlikely: 1%–24% minimal stenosis or plaque with no stenosis; minimal nonobstructive CAD Consider a non-ACS cause if there are normal troponin levels and no EKG changes CAD-RADS 2 ACS unlikely: 25%–49% mild stenosis; mild nonobstructive CAD If the clinical suspicion of ACS is high or if high-risk plaque has manifested, consider hospital admission and cardiology consultation Category Features and Imaging Findings Management CT angiography CAD-RADS 3 ACS possible: 50%–69% stenosis; moderate CAD Consider hospital admission, cardiology consultation, functional testing, intervention CAD-RADS 4 ACS likely: 4A: 70%–99% stenosis 4B: >50% left main or ≥70% three-vessel stenosis; severe CAD Consider hospital admission, cardiology consultation, or intervention CAD-RADS 5 ACS very likely: 100% stenosis (arrow), complete coronary occlusion Consider expedited ICA and revascularization if there is acute occlusion Normal LAD >50% narrowing proximal to a stent. CAD-RADS 3S (S = stent) Noncalcified plaque in mid LAD without stenosis Severe 80%–90% stenosis Proximal left main calcified plaque leading to a 25% stenosis Additional Category.—CAD-RADS N – Nondiagnostic study. CAD cannot be excluded. ACS cannot be excluded  Additional and/or alternative evaluation for ACS needed Note.—ACS = acute coronary syndrome, ICA = invasive coronary angiography, LAD = left anterior descending coronary artery.

LI-RADS5–7 LI-RADS applies to patients at high risk for HCC (eg, those patients with hepatitis B or C, cirrhosis from nonalcoholic steatohepatitis [NASH], alcohol, or prior HCC Excludes patients younger than 18 years of age, those with no risk factors and/or cirrhosis, vasculopathies, or Budd-Chiari syndrome Integrated with the American Association for the Study of Liver Diseases (AASLD) guidelines Pathologic condition: HCC Imaging modalities: CT, MRI, US, contrast-enhanced US Scoring: CT, MRI, contrast-enhanced US = lesion score, 1–5, TIV, NC, M, T US = Patient score,1–3 Version: 3 (2017–2018)

LI-RADS CT/MRI Pathologic Condition Score or Category Assignment Modalities or Technique HCC 1-5, TIV, NC, M, T Lesion based MRI, CT Note.—LR-5 threshold growth = 50% diameter increase over 6 months. Reprinted, with permission, from reference 5.

LI-RADS CT/MRI Pathologic Condition Score or Category Assignment Modalities or Technique HCC 1-5, TIV, NC, M, T Lesion based MRI, CT Category Features and Imaging Findings Management MRI CT LR 1 Definitely benign: definite cyst, hemangioma, focal scar Routine surveillance (6 months) LR 2 Probably benign: probable cyst, hemangioma, focal scar. Routine surveillance (6 months), or consider earlier follow-up LR 3 Intermediate probability for HCC: regenerative and/or dysplastic nodules, FNH, HC adenoma Short-interval (3–6 months) follow-up LR 4 Probably HCC: 80% malignant, 74% HCC Biopsy, ≤3 months follow-up, or multidisciplinary discussion LR 5 Definitely HCC: 97% malignant, 94% HCC Multidisciplinary discussion for management Additional Diagnostic Categories LR TIV - TIV Multidisciplinary discussion, may need to perform a biopsy LR NC – Nondiagnostic owing to image degradation or omission Repeat or perform alternative imaging in 3 months or less LR M - Probably malignant, not necessarily HCC Multidisciplinary discussion, may need to perform a biopsy Additional Treatment Response (TR) Categories TR Nonevaluable - Inadequate imaging technique and/or quality TR Nonviable - Low likelihood of viable tumor TR Nonviable - Moderate likelihood of viable tumor TR Equivocal - High or definite likelihood of viable tumor PVP Delayed 7 mm. No APHE, WO, or capsule. Definitely a cyst. Definitely hemangioma PVP PVP 8 mm with APHE. No WO or capsule. Possible cavernous hemangioma. Probably hemangioma PVP PVP 6 mm with APHE and WO. No capsule. Possible HCC. 10 mm with APHE. No WO or capsule. Possible HCC. PVP Delayed 14 mm with APHE and WO. No capsule. Probably HCC. 17 mm with APHE and WO. No capsule. Probably HCC. Note.—APHE = arterial phase hyperenhancement, FNH = focal nodular hyperplasia, HC = hepatocellular, PVP = portal venous phase, WO = washout. Delayed PVP Delayed 16 mm with APHE, WO, and capsule. HCC. 23 mm with APHE, WO, and capsule. HCC.

Modalities or Technique US Visualization Score Features
LI-RADS US Pathologic Condition Score or Category Assignment Modalities or Technique HCC surveillance 1–3 Patient based US Category US Score and Imaging FIndings Management US LI-RADS US 1 Negative: No US evidence of HCC; no observations or definitely benign observations Continue surveillance every 6 months LI-RADS US 2 Probably benign: Observations <10 mm in diameter, not definitely benign May warrant short-term (every 3–6 months) US surveillance LI-RADS US 3 Intermediate probability for HCC: Observations ≥10 mm in diameter, not definitely benign, or new thrombus in vein May warrant multiphase imaging Score US Visualization Score Features A No or minimal limitations, unlikely to meaningfully affect sensitivity B Moderate limitations that may obscure small masses C Limitations: significantly lower sensitivity for focal liver lesions 9-mm hyperechoic observation in superior left lobe 17-mm heterogeneous mass in segment VIII

Lung-RADS8 Lung-RADS is used for screening examinations of adults ages 55–80 (per the U.S. Preventive Services Task Force) with 30 pack-year (pkyr) smoking history and those who quit within 15 years. Recommended annual repeat screening Patient level score determined based on the nodule with the highest degree of suspicion Pathologic condition: Lung cancer (screening) Imaging modality: Low-dose CT Scoring: Patient score 0–4 (4A,B,X), S, C Version: 1 (2014)

Lung-RADS Pathologic condition Score or Category Assignment Modalities or Technique Lung cancer 0–4 (4 A, B, X), S, C Patient based Low-dose CT Category Features and Imaging Findings Management Low-dose CT Lung-RADS 1 Negative: No nodules or definitely benign nodules (calcifications: complete, central, popcorn, concentric rings, and fat containing) Routine low-dose CT in 12 months Lung-RADS 2 Benign: <1% risk of malignancy Nodules with low likelihood of becoming clinically active owing to size or lack of growth. Solid nodule: <6 mm, new <4 mm Part-solid nodule: <6 mm Nonsolid nodule: <20 mm, ≥20 mm, and unchanged or slow growing; category 3 or 4 nodules unchanged for ≥3 months Lung-RADS 3 Probably benign: 1%–2% risk of malignancy Solid nodule: ≥6 to <8 mm at baseline, new at 4–6 mm Part-solid nodule: 6 mm with solid component that is <6 mm, new <6 mm Nonsolid nodule: ≥20 mm on baseline or new nodule Low-dose CT in 6 months Lung-RADS 4 Suspicious: 5% to >15% risk of malignancy 4A = Solid ≥8 to <15-mm, growing <8-mm, or new 6- to <8-mm nodule; part solid ≥6-mm nodule with ≥6-mm to <8-mm solid component or a new or growing <4-mm solid component 4B = Solid ≥15-mm or new growing ≥8-mm nodule; part-solid nodule with a ≥8-mm solid component or a new or growing ≥4-mm solid component 4X: Category 3 or 4 nodules with additional suspicious features (eg, spiculation, ground-glass nodule that doubles in size in 1 year, lymphadenopathy) 4A: Low-dose CT in 3 months, ± PET/CT if there is a ≥8-mm solid component; 4B, X: Chest CT with and without contrast material, ± biopsy, ± PET/CT if there is a ≥8-mm solid component Part-solid 5-mm nodule Solid 7-mm nodule 4X solid ≥ 15-mm nodule with spiculation Additional Categories: Lung-RADS 0 - Incomplete: Prior chest CT examinations being located for comparison, part or all of lungs cannot be evaluated Lung-RADS S - Other: Clinically significant or potentially clinically significant findings that are nonlung cancer Lung-RADS C - Prior lung cancer: Patient with prior diagnosis who is returning for screening

NI-RADS9 NI-RADS is used for patients with a new neck mass and those with a known and/or treated mass undergoing surveillance Provides recommendations regarding surveillance, direct inspection, short-term follow-up, additional imaging, and performing biopsy. Pathologic condition: Head and neck cancers (diagnostic and surveillance system) Imaging modalities: PET, CT, MRI Scoring: Patient score 0–4 (2A-B) Version: 1 (2016)

NI-RADS Pathologic condition Score or Category Assignment Modalities or Technique Head and neck cancer 0–4, 2A-B Patient based PET, CT, MRI Category Features and Imaging Findings Management CT PET NI-RADS 1 No evidence of recurrence: expected posttreatment change, non–masslike distortion, low-attenuating mucosal edema, no fluorodeoxyglucose (FDG) uptake, diffuse linear enhancement after radiation therapy Routine surveillance (6 months) NI-RADS 2A Low suspicion (superficial): focal mucosal enhancement but non–masslike, focal mild-to-moderate mucosal FDG uptake Direct visual inspection NI-RADS 2B Low suspicion (deep): ill-defined soft tissue, little to no enhancement, mild-to-moderate FDG uptake Short interval follow-up (3 months), repeat PET NI-RADS 3 High suspicion: new or enlarging primary mass or lymph node, discrete nodule or mass with differential enhancement, intense focal FDG uptake Image-guided or clinical biopsy NI-RADS 4 Pathologically proven or definite radiographic progression Proceed with appropriate clinical management All images reprinted, with permission, from reference 9. Additional Categories NI-RADS 0 – Incomplete: New baseline study and knowledge of prior imaging exists and will be available for interpretation Assign score in addendum after prior imaging becomes available

O-RADS10 O-RADS is a standardized lexicon, not a scoring system.
Discourages the use of colloquial terms such as complex, ring of fire, etc Evaluation by laterality Pending expansion of the lexicon for MRI Pathologic condition: Ovarian and adnexal masses Imaging modality: Transvaginal US Scoring: Not scored Version: 1 (2018)

Ovarian and adnexal finding Major categories Physiologic Follicle Corpus Luteum Lesion IOTA classification Unilocular cyst, no solid components Subtype: simple cyst Subtype: hemorrhagic cyst Subtype: dermoid cyst Incomplete septum Irregular inner wall Internal echoes Unilocular cyst with solid components Multilocular cyst, no solid components Multilocular cyst, with solid components Solid (≥80%) Subtype: purely solid (100% solid) Size Vascularity Circumrenal Doppler flow in cyst wall Internal color Doppler flow Color score (IOTA Classification) O-RADS Pathologic Condition Score or Category Assignment Modalities or Technique Ovarian-adnexal masses NA US Color score 1 – no blood flow Color score 2 – minimal flow Color score 3 – moderate flow Color score 4 – marked flow Note.—IOTA = International Ovarian Tumor Analysis.

PI-RADS uses multiparametric MRI sequences, T2-weighted imaging, diffusion-weighted imaging (DWI), apparent diffusion coefficient (ADC) mapping, and dynamic contrast-enhanced (DCE) imaging, for the detection, surveillance, and biopsy planning of prostate lesions. Dominant sequences performed for scoring is based on the lesion location: PI-RADS11 Pathologic condition: Prostate cancer Imaging modality: Multiparametric MRI Scoring: Lesion score 1–5 Version: 2 (2015) D T Peripheral Zone (PZ) = DWI Transition Zone (TZ) = T2-weighted imaging Artwork reprinted and adapted, with permission, from reference 11.

PI-RADS Pathologic Condition Score or Category Assignment Modalities or Technique Prostate cancer 1–5 Lesion based Multiparametric MRI Category Imaging Features T2-weighted ADC DWI DCE PI-RADS 1 Negative study without suspicious lesions. Clinically significant cancer is highly unlikely. PI-RADS 2 Clinically significant cancer (arrows) is unlikely to be present. PZ lesion: DWI score = 2 TZ lesion: T2 score = 2 PI-RADS 3 Presence of clinically significant cancer (arrows) is equivocal. PZ lesion: DWI score = 3 (and DCE lesion) TZ lesion: T2 score = 3 (and DWI score <5) PI-RADS 4 Clinically significant cancer (arrows) is likely to be present. PZ lesion: DWI score = 3 (positive DCE) or DWI score = 4 (negative DCE) TZ lesion: T2 score = 3 (DWI score = 5) or T2 score = 3 (DWI score <5) PI-RADS 5 Clinically significant cancer (arrows) is highly likely; includes the same features as those found in PI-RADS 4, with the addition of a ≥15-mm lesion or evidence suggestive of extraprostatic extension (curvilinear contact length of 1.5 cm or capsular bulge and irregularity) Right-mid PZ: DWI score = 2 Right mid-PZ: DCE score = negative Right-mid PZ: DWI Score = 3 Right-mid PZ: DCE = negative Right Apical-mid PZ: DWI score = 3 Right Apical-mid PZ: DCE = positive Left TZ: T2 score = 5 Left TZ: DWI score = 5

TI-RADS12 TI-RADS is used for risk stratification in patients with thyroid nodules and offers guidance on fine-needle aspiration (FNA) and follow-up Scored by the summation of points given to imaging characteristics suggestive of malignancy Free online calculators are available. Pathologic condition: Thyroid cancer Imaging modality: US Scoring: Lesion score 1–5 Version: 1 (2017)

TI-RADS Pathologic Condition Score or Category Assignment Modalities or Technique Thyroid cancer 1–5 Lesion based US Category Points Management US TI-RADS 1 0 = benign No FNA TI-RADS 2 2 = not suspicious TI-RADS 3 3 = mildly suspicious If ≥1.5 cm, then follow-up; if ≥2.5 cm, then perform FNA TI-RADS 4 4–6 = moderately suspicious If ≥1.0 cm, then follow-up; if ≥1.5 cm, then perform FNA TI-RADS 5 ≥ 7 = highly suspicious If ≥0.5 cm, then follow-up; if ≥1.0 cm, then perform FNA Feature Score and Imaging Findings Composition [0] completely or almost completely cystic, spongiform [1] mixed cystic and solid [2] solid or almost completely solid Echogenicity [0] anechoic [1] hyperechoic or isoechoic [2] hypoechoic [3] very hypoechoic Shape [0] wider than tall [3] taller than wide Margin [0] smooth, ill defined [2] lobulated or irregular [3] extrathyroid extension Echogenic foci [0] none or large comet-tail artifact [1] macrocalcifications [2] peripheral rim calcifications [3] punctate echogenic foci Sum points from each category

Future Direction of ______RADS1

Current Limitations Adoption varies from institution to institution, as does experience among radiologists Lack of consistency in terminology and structure. For example: lesion or observation category, score, or level category ranges: 0,1–4, 5, 6 Nondiagnostic findings represented by 0, N, or NC May be improved by Combining oncology RADS to five main types to avoid confusion. For example: 1 = benign, 2 = likely benign, 3 = indeterminate, 4 = likely malignant, 5 = malignant Standardizing the terminology used for nondiagnostic and negative studies Limiting RADS to cancer imaging

Future Direction ACR is currently changing the organization and approval process for RADS efforts in order to deal with growing demands. Additional RADS are in varying stages of development. The Myeloma Response Assessment and Diagnosis System (MY-RADS)13 (whole-body MRI for myeloma), Vesical Imaging-Reporting and Data System (VI-RADS)14 (MRI for bladder cancer), Metastasis Reporting and Data System for Prostate Cancer (MET-RADS)15 (whole-body MRI for metastatic prostate cancer) are recent non–ACR endorsed systems. Incorporation of standardized templates and terminology with vendor-provided ACRassist Integration with clinical society guidelines to increase adoption For example, LI-RADS with the AASLD and BI-RADS with the American Society of Breast Surgeons guidelines

Publication Trends BI-RADS and PI-RADS have had the greatest number of publications. Suggests these systems have the greatest clinical and research interest Data obtained from reference 16. Note: BI-RADS and PI-RADS publication frequency ranges from 0 to 300 articles vs 0 to 30 articles for all other systems.

Publication Trends Growing number of articles published on LI-RADS, TI-RADS, Lung-RADS, and CAD-RADS Data obtained from reference 16. Note: BI-RADS and PI-RADS publication frequency ranges from 0 to 300 articles vs 0 to 30 articles for all other systems.

Publication Trends C-RADS, O-RADS, and NI-RADS have not had as much research interest. Notably, these three systems have not been updated since their initial release Data obtained from reference 16. Note: BI-RADS and PI-RADS publication frequency ranges from 0 to 300 articles vs 0 to 30 articles for all other systems.

Additional Resources for ______RADS1

______Website Free, detailed, and up-to-date resources for new systems and recent changes1 Ex: Head Injury Imaging Reporting and Data System (HI-RADS) is currently being developed for imaging traumatic brain injury Reprinted, with permission, from reference 1.

Video Resources TI-RADS LI-RADS
Three-part ACR TI-RADS Webinar ACR TI-RADS Steering Committee 17 18 19 ACR TI-RADS Series Jenny Hoang, MD 20 21 22 Images reprinted, with permission, from references 20–22. Images reprinted, with permission, from references 17–19. LI-RADS Introduction to LI-RADS, Claude Sirlin, MD 23 2017 Version of LI-RADS for CT and MR Imaging: An Update RadioGraphics 24 Image reprinted, with permission, from reference 23.

Video Resources BI-RADS PI-RADS Breast Cancer Review Series:
BI-RADS 5th Edition Leonardo Valentin, MD Image reprinted, with permission, from reference 25. Prostate MRI Using PI-RADS Andrew Rosenkrantz, MD PI-RADS Prostate MRI: Common Imaging Pitfalls Art Rastinehad, DO Image reprinted, with permission, from reference 26. Image reprinted, with permission, from reference 27.

Interactive Cases Lung-RADS BI-RADS LI-RADS PI-RADS
Lung Cancer Screening eLearning Program (ACR login required) Interactive Cases Image reprinted, with permission, from reference 28. BI-RADS Mammography Case Review (ACR MC7 forthcoming) LI-RADS LI-RADS teaching and case-based module, Montefiore/Albert Einstein, (ACR login required) Image reprinted, with permission, from reference 29. Learn Prostate MRI Andrew Rosenkrantz, MD PI-RADS Image reprinted, with permission, from reference 31. Image reprinted, with permission, from reference 30.

Summary The ACR-endorsed RADS are a set of guidelines for the evaluation and interpretation of disease-oriented imaging studies. Systems may be periodically updated to improve diagnostic parameters, and new systems are in various stages of development. Clinical adoption of ACR RADS varies. BI-RADS, followed by PI-RADS and LI-RADS, have the greatest acceptance. Integration of RADS into multidisciplinary guidelines has the potential to increase the field of radiology’s impact on clinical care.

Suggested Readings BI-RADS C-RADS CAD-RADS LI-RADS Lung-RADS NI-RADS
Citation Ver Yr BI-RADS D’Orsi CJ, Sickles EA, Mendelson EB et al. ACR BI-RADS atlas, Breast Imaging Reporting and Data System. Reston, Va: American College of Radiology, 2013. v5 2015 C-RADS Zalis ME, Barish MA, Choi JR et-al. CT colonography reporting and data system: a consensus proposal. Radiology. 2005; 236 (1):3–9. v1 2005 CAD-RADS Cury RC, Abbara S, Achenbach S, et al. CAD-RADS Coronary Artery Disease: Reporting and Data System—An expert consensus document of the Society of Cardiovascular Computed Tomography (SCCT), the American College of Radiology (ACR) and the North American Society for Cardiovascular Imaging (NASCI): Endorsed by the American College of Cardiology J Cardiovasc Comput Tomogr. 2016;10(4):269–281. 2016 LI-RADS American College of Radiology. Liver Reporting and Data Systems (LI-RADS). Accessed June 4, 2019. v3 2017/8 Lung-RADS Lung Imaging Reporting and Data System (Lung-RADS). Amer College of Radiology. CC BY-NC-ND 4.0. 2014 NI-RADS Cavazuti B, Hudgins P, Rath T, et al. Neck Imaging Reporting and Data System: An Atlas of NI-RADS Categories for Head and Neck Cancer. American College of Radiology. Accessed June 4, 2019. O-RADS Andreotti RF, Timmerman D, Benacerraf BR., et al. (2018). Ovarian-Adnexal Reporting Lexicon for Ultrasound: A White Paper of the ACR Ovarian-Adnexal Reporting and Data System Committee. Journal of the American College of Radiology. 15 (10), 1415–1429. 2018 PI-RADS Weinreb JC, Barentsz JO, Choyke PL, Cornud F, Haider MA, Macura KJ, Margolis D, Schnall MD, Shtern F, Tempany CM, et al. PI-RADS Prostate Imaging: Reporting and Data System: 2015, Version 2. Eur Urol. 2016;69(1):16–40. v2 TI-RADS Tessler FN, Middleton WD, Grant EG, Hoang JK, Berland LL, et al. ACR Thyroid Imaging, Reporting and Data System (TI-RADS): White Paper of the ACR TI-RADS Committee. Journal of the American College of Radiology. 2017; 14 (5): 587–595. 2017

References ACR. Reporting and Data Systems. Accessed June 4, 2019. D’Orsi CJ, Sickles EA, Mendelson EB et al. ACR BI-RADS atlas, Breast Imaging Reporting and Data System. Reston, Va: American College of Radiology, 2013. Zalis ME, Barish MA, Choi JR et-al. CT colonography reporting and data system: a consensus proposal. Radiology. 2005; 236 (1):3–9. Cury RC, Abbara S, Achenbach S, et al. CAD-RADS Coronary Artery Disease: Reporting and Data System—An expert consensus document of the Society of Cardiovascular Computed Tomography (SCCT), the American College of Radiology (ACR) and the North American Society for Cardiovascular Imaging (NASCI): Endorsed by the American College of Cardiology J Cardiovasc Comput Tomogr. 2016;10(4):269–281. American College of Radiology. CT/MRI LI-RADS v Published July Accessed June 4, 2019. American College of Radiology. Ultrasound LI-RADS v Published Accessed June 4, 2019. American College of Radiology. CEUS LI-RADS v Published Accessed June 4, 2019. American College of Radiology. Lung Imaging Reporting and Data System (Lung-RADS). Accessed June 4, 2019.

References Cavazuti B, Hudgins P, Rath T, et al. Neck Imaging Reporting and Data System: An Atlas of NI-RADS Categories for Head and Neck Cancer. American College of Radiology. Accessed June 4, 2019. Andreotti RF, Timmerman D, Benacerraf BR., et al. Ovarian-Adnexal Reporting Lexicon for Ultrasound: A White Paper of the ACR Ovarian-Adnexal Reporting and Data System Committee. J Am Coll Radiol. 2018;15(10):1415–1429. Weinreb JC, Barentsz JO, Choyke PL, Cornud F, Haider MA, Macura KJ, Margolis D, Schnall MD, Shtern F, Tempany CM, et al. PI-RADS Prostate Imaging: Reporting and Data System: 2015, Version 2. Eur Urol. 2016;69(1):16–40. Tessler FN, Middleton WD, Grant EG, Hoang JK, Berland LL, et al. ACR Thyroid Imaging, Reporting and Data System (TI-RADS): White Paper of the ACR TI-RADS Committee. Journal of the American College of Radiology. 2017;14(5): 587–595. Messiou C, Hillengass J, Delorme S, et al. Guidelines for Acquisition, Interpretation, and Reporting of Whole-Body MRI in Myeloma: Myeloma Response Assessment and Diagnosis System (MY-RADS). Radiology. 2019;291(1):5–13. Panebianco V, Narumi Y, Altun E et al.Multiparametric magnetic resonance imaging for bladder cancer: development of VI-RADS (Vesical Imaging-Reporting and Data System). Eur Urol 2018;74(3):294–306. Padhani AR, Lecouvet FE, Tunariu N. METastasis Reporting and Data System for Prostate Cancer: Practical Guidelines for Acquisition, Interpretation, and Reporting of Whole-body Magnetic Resonance Imaging-based Evaluations of Multiorgan Involvement in Advanced Prostate Cancer. Eur Urol 2017;71(1):81–92. National Institutes of Health: Office of Portfolio Analysis. iCite. Accessed June 4, 2019. RadiologyACR. ACR TI-RADS Webinar Part I: This Is How We Do It. YouTube. Published March 8, Accessed June 4, 2019.

References RadiologyACR. ACR TI-RADS Webinar Part II: Case Based Review and Frequently Asked Questions. YouTube. Published April 9, Accessed June 4, 2019. RadiologyACR. TI-RADS Thyroid Imaging Reporting and Data System Webinar Part III. YouTube. Published May 30, Accessed June 4, 2019. Hoang J. ACR TI-RADS Overview and Approach. YouTube. Published September 2, Accessed June 4, 2019. Hoang J. ACR TI-RADS Structured reporting template. YouTube. Published September 3, Accessed June 4, 2019. Hoang J. ACR TI-RADS DRAH Jan YouTube. Published January 10, Accessed June 4, 2019. UCSD Liver Imaging Group. Claude-athon 2018 (pt 7): Introduction to LI-RADS. YouTube. Published April 17, Accessed June 4, 2019. RadioGraphics Version of LI-RADS for CT and MR Imaging: An Update. YouTube. Published November 3, Accessed June 4, 2019. Valentin, L. Breast Cancer Review Series: BIRADS 5th Edition. YouTube. Published October 23, Accessed June 4, 2019. Rosenkrantz, A. Prostate MRI Using PI-RADS. YouTube. Published September 11, Accessed June 4, 2019.

References Rastinehad, A. 8 Prostate MRI: Common Imaging Pitfalls. YouTube. Published March 1, Accessed June 5, 2019. American College of Radiology. Lung Cancer Screening Education. Accessed June 4, 2019. American College of Radiology. Mammography Case Review. Accessed June 4, 2019. American College of Radiology. LI-RADS teaching and case-based module. Accessed June 4, 2019. Rosenkrantz, A. Learn prostate MRI. Learnprostatemri.com Accessed June 4, 2019.

BI-RADS, C-RADS, CAD-RADS, LI-RADS, Lung-RADS, NI-RADS, O-RADS, PI-RADS, TI-RADS: Reporting and Data Systems Julie Y. An, MD Kyle M.L. Unsdorfer, MD.

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Presentation on theme: "BI-RADS, C-RADS, CAD-RADS, LI-RADS, Lung-RADS, NI-RADS, O-RADS, PI-RADS, TI-RADS: Reporting and Data Systems Julie Y. An, MD Kyle M.L. Unsdorfer, MD."— Presentation transcript:

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BI-RADS, C-RADS, CAD-RADS, LI-RADS, Lung-RADS, NI-RADS, O-RADS, PI-RADS, TI-RADS: Reporting and Data Systems Julie Y. An, MD Kyle M.L. Unsdorfer, MD.

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Presentation on theme: "BI-RADS, C-RADS, CAD-RADS, LI-RADS, Lung-RADS, NI-RADS, O-RADS, PI-RADS, TI-RADS: Reporting and Data Systems Julie Y. An, MD Kyle M.L. Unsdorfer, MD."— Presentation transcript:

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