Breast Imaging Reporting - 2nd STU ballot
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Breast Imaging Reporting - 2nd STU ballot, published by HL7 International - Clinical Interoperability Council. This is not an authorized publication; it is the continuous build for version 0.3.0). This version is based on the current content of https://github.com/HL7/fhir-breast-radiology-ig/ and changes regularly. See the Directory of published versions

CodeSystem: RadLex CDE's (Experimental)

Official URL: http://hl7.org/fhir/us/breast-radiology/CodeSystem/RadLexCDE Version: 0.3.0
Active as of 2022-12-07 Computable Name: RadLexCDE

Copyright/Legal: This value set includes content from ACR RadElement, which is Copyright© 2022, Radiological Society of North America. ALL RIGHTS RESERVED.

ACR Common Data Element (CDE) code system

This Code system is referenced in the content logical definition of the following value sets:

This code system http://hl7.org/fhir/us/breast-radiology/CodeSystem/RadLexCDE defines the following codes:

LvlCodeDisplayDefinition
1RDES241 Breast CalcificationBreast Calcification
1RDES243 Breast CystBreast Cyst
1RDES245 BI-RADSBreast Mass Detection on Mammography
1RDES246 Breast MassBreast Mass
1RDE1556 PresenceAbnormalcalcificationobservation
2  RDE1556_present presentRDE1556_present
2  RDE1556_absent absentRDE1556_absent
2  RDE1556_indeterminate indeterminateRDE1556_indeterminate
2  RDE1556_unknown unknownRDE1556_unknown
1RDE1557 SideBreastlateralityofabnormalityobserved
2  RDE1557_right rightRDE1557_right
2  RDE1557_left leftRDE1557_left
2  RDE1557_bilateral bilateralRDE1557_bilateral
1RDE1558 LocationClockpositionsoftheabnormalityobserved
2  RDE1558_oneOclockPosition oneo'clockpositionRDE1558_one o'clock position
2  RDE1558_twoOclockPosition twoo'clockpositionRDE1558_two o'clock position
2  RDE1558_threeOclockPosition threeo'clockpositionRDE1558_three o'clock position
2  RDE1558_fourOclockPosition fouro'clockpositionRDE1558_four o'clock position
2  RDE1558_fiveOclockPosition fiveo'clockpositionRDE1558_five o'clock position
2  RDE1558_sixOclockPosition sixo'clockpositionRDE1558_six o'clock position
2  RDE1558_sevenOclockPosition seveno'clockpositionRDE1558_seven o'clock position
2  RDE1558_eightOclockPosition eighto'clockpositionRDE1558_eight o'clock position
2  RDE1558_nineOclockPosition nineo'clockpositionRDE1558_nine o'clock position
2  RDE1558_tenOclockPosition teno'clockpositionRDE1558_ten o'clock position
2  RDE1558_elevenOclockPosition eleveno'clockpositionRDE1558_eleven o'clock position
2  RDE1558_twelveOclockPosition twelveo'clockpositionRDE1558_twelve o'clock position
1RDE1559 DepthAnteriordepthistheoutermostdepthclosesttothenippleofthebreastMiddledepthinbetweentheanteriorandposteriorportionofthebreastPosteriordepthclosesttothechestwallofthebreast
2  RDE1559_anterior anteriorRDE1559_anterior
2  RDE1559_middle middleRDE1559_middle
2  RDE1559_posterior posteriorRDE1559_posterior
1RDE1560 Breast body landmarkBreastlandmarkvalueset
2  RDE1560_nipple nippleRDE1560_nipple
2  RDE1560_chestWall chestwallRDE1560_chest wall
2  RDE1560_skinStructure skinstructureRDE1560_skin structure
1RDE1561 Distance from landmarkDistancefrombodylandmarktobodylocationofabnormality
1RDE1562 Laterality from landmarkRDE1562
2  RDE1562_rightAndLeft rightandleftRDE1562_right and left
2  RDE1562_midline midlineRDE1562_midline
2  RDE1562_structureOfRightHalfOfBody structureofrighthalfofbodyRDE1562_structure of right half of body
2  RDE1562_structureOfLeftHalfOfBody structureoflefthalfofbodyRDE1562_structure of left half of body
1RDE1563 QuadrantQuadrant of breast
2  RDE1563_lowerInner lowerinnerRDE1563_lower inner
2  RDE1563_lowerOuter lowerouterRDE1563_lower outer
2  RDE1563_upperInner upperinnerRDE1563_upper inner
2  RDE1563_upperOuter upperouterRDE1563_upper outer
1RDE1564 RegionRegion of breast
2  RDE1564_axilla axillaThe axilla (also, armpit, underarm or oxter) is the area on the human body directly under the joint where the arm connects to the shoulder. It also contains many sweat glands.
2  RDE1564_axillaryTail axillarytailRDE1564_axillary tail
2  RDE1564_axillaOne axillaoneThere are three levels of axillary lymph nodes (the nodes in the underarm or 'axilla' area): Level I is the bottom level, below the lower edge of the pectoralis minor muscle.
2  RDE1564_axillaTwo axillatwoThere are three levels of axillary lymph nodes (the nodes in the underarm or 'axilla' area):Level II is lying underneath the pectoralis minor muscle.
2  RDE1564_axillaThree axillathreeThere are three levels of axillary lymph nodes (the nodes in the underarm or 'axilla' area): Level III is above the pectoralis minor muscle.
2  RDE1564_inframammaryFold inframammaryfoldThe mass/lesion is located in the inframammary crease where the lower boundary of the breast and the chest meet.
2  RDE1564_inSkin inskinLocated within skin.
2  RDE1564_centralToNipple centraltonippleCentral to the nipple (central portion of the breast-behind the nipple).
1RDE1565 TypeRDE1565
2  RDE1565_amorphous amorphousRDE1565_amorphous
2  RDE1565_coarse coarseRDE1565_coarse
2  RDE1565_dystrophic dystrophicRDE1565_dystrophic
2  RDE1565_eggshell eggshellRDE1565_eggshell
2  RDE1565_fine fineRDE1565_fine
2  RDE1565_generic genericRDE1565_generic
2  RDE1565_coarseHeterogeneous coarseheterogeneousRDE1565_coarse heterogeneous
2  RDE1565_indistinct indistinctRDE1565_indistinct
2  RDE1565_largeRoadlike largeroadlikeRDE1565_large roadlike
2  RDE1565_layering layeringRDE1565_layering
2  RDE1565_fineLinear finelinearRDE1565_fine linear
2  RDE1565_lucentCentered lucentcenteredRDE1565_lucent centered
2  RDE1565_milkOfCalcium milkofcalciumRDE1565_milk of calcium
2  RDE1565_finePleomorphic finepleomorphicRDE1565_fine pleomorphic
2  RDE1565_punctate punctateRDE1565_punctate
2  RDE1565_rim rimRDE1565_rim
2  RDE1565_round roundRDE1565_round
2  RDE1565_skin skinRDE1565_skin
2  RDE1565_spherical sphericalRDE1565_spherical
2  RDE1565_sature satureRDE1565_sature
2  RDE1565_vascular vascularRDE1565_vascular
1RDE1567 CountRDE1567
1RDE1568 DistributionRDE1568
2  RDE1568_fineLinearBranching finelinearbranchingRDE1568_fine, linear, branching
2  RDE1568_clustered clusteredRDE1568_clustered
2  RDE1568_diffuse diffuseRDE1568_diffuse
2  RDE1568_grouped groupedRDE1568_grouped
2  RDE1568_linear linearRDE1568_linear
2  RDE1568_regional regionalRDE1568_regional
2  RDE1568_segmental segmentalRDE1568_segmental
1RDE1569 Distribution widthSizeoftheentireregionaffectedbyabnormalityinmm
1RDE1570 SizeSizeofasinglefindingobservedinmm
1RDE1571 Associated featuresRDE1571
2  RDE1571_architecturalDistortion architecturaldistortionf the mass blurs a tissue plane between fat and fibroglandular tissue or if the mass produces distortion of the ducts, these findings may be termed architectural distortion.
2  RDE1571_axillaryAdenopathy axillaryadenopathyEnlarged axillary (under the armpit) lymph nodes. Additional evaluation is needed to determine the cause.
2  RDE1571_biopsyClip biopsyclipTissue marker placement after image-guided breast biopsy has become a routine component of clinical practice. Marker placement distinguishes multiple biopsied lesions within the same breast, prevents re-biopsy of benign lesions, enables multi-modality correlation, guides pre-operative localization and helps confirm surgical target removal.
2  RDE1571_brachytherapyTube brachytherapytubeBrachytherapy may be temporary or permanent. Temporary brachytherapy places radioactive material inside a catheter for a specific amount of time and then it is removed. It is given at a low-dose rate (LDR) or high-dose rate (HDR). Permanent brachytherapy is also called seed implantation. It puts radioactive seeds (about the size of a grain of rice) in or near the tumor permanently. After several months, the seeds lose their radioactivity.
2  RDE1571_chestWallInvasion chestwallinvasionA tumor of the lung that has invaded the chest wall.
2  RDE1571_cooperDistorted cooperdistortedCooper's ligaments support the breasts on the chest wall, maintain their contour, and keep them in position. Breasts become distorted if cancerous tumors grow on the ligaments.
2  RDE1571_cooperThickened cooperthickenedCooper's ligaments support the breasts on the chest wall, maintain their contour, and keep them in position. These support breast tissue; and can become contracted in cancer of breast, producing dimples in overlying skin. Thickening occurs when there are skin changes usually associated with the presence of a mass, benign or malignant, that causes shortening in the Coopers ligaments due to fibrosis.
2  RDE1571_edema edemaEdema (swelling of the breasts) may be due to blockage of subdermal lymphatics by tumor cells or an inflammatory process within the breast or axilla.
2  RDE1571_edemaAdj edemaadjThis is swelling of one or both breasts. A mammographic pattern of skin thickening, increased parenchymal density, and interstitial marking.
2  RDE1571_goldSeed goldseedTiny, gold seeds, about the size of a grain of rice, that are put in and/or around a tumor to show exactly where it is in the body. The tumor can then be directly targeted and be given higher doses of radiation with less harm to nearby healthy tissue. Also called gold fiducial marker seeds, gold fiducial markers, and gold-seed fiducial markers.
2  RDE1571_hematoma hematomaA hematoma is a localized bleeding outside of blood vessels, due to either disease or trauma including injury or surgery and may involve blood continuing to seep from broken capillaries.
2  RDE1571_nippleRetraction nippleretractionRetracted nipples lie flat against the areola. The condition can be the result of inflammation or scarring of the tissue behind the nipple, and caused by numerous conditions, not just cancer. In the case of breast cancer, nipple retraction occurs when the tumor attacks the duct behind the nipple, pulling it in.
2  RDE1571_noChestWallInvasion nochestwallinvasionThe mass has not attached itself to the chest wall.
2  RDE1571_pectoralisMuscleInvasion pectoralismuscleinvasionPectoralis muscle invasion is when a tumor has become large enough to invade into the pectoralis muscle.
2  RDE1571_pectoralisMuscleInvolvement pectoralismuscleinvolvementPectoralis muscle involvement of the tumor has been detected on the MRI by muscle enhancement with obliteration of the fat plane between the tumor and the muscle.
2  RDE1571_pectoralisMuscleTenting pectoralismuscletentingThe tent sign is a term referring to a characteristic appearance of the posterior edge of the breast parenchyma when a mass (usually an infiltrating lesion) causes its retraction and forms an inverted 'V' that resembles the tip of a circus tent.
2  RDE1571_postSurgicalScar postsurgicalscarPost surgical scarring happens because of the incisions needed to surgically remove tumor, cells, etc. The amount of scarring is connected to the different stages of wound healing. Surgical scar care should be continued for a year.
2  RDE1571_seroma seromaA breast seroma is a collection (pocket) of serous fluid that can develop after trauma to the breast or following procedures such as breast surgery or radiation therapy. Serous fluid is a pale yellow, transparent fluid that contains protein, but no blood cells or pus.
2  RDE1571_skinInvolvement skininvolvementThe mass or lesion has attached itself to the skin of the breast. There are several layers of skin that the mass or lesion can penetrate and that is what determines the level of skin invasion.
2  RDE1571_skinLesion skinlesionA skin lesion is a part of the skin that has an abnormal growth or appearance compared to the skin around it.In order to diagnose a skin lesion, a full physical exam is necessary.
2  RDE1571_skinRetraction skinretractionSkin retraction (or inversion) or Skin retraction. Breast cancers that are located near the skin or nipple may cause scarring within the breast that pulls at the nipple or nearby skin. Skin and nipple retraction are more obvious when a woman raises her arms above her head or leans forward.
2  RDE1571_skinThickening skinthickeningThe presence of skin thickening on mammography is variably defined, usually being more than 2 mm in thickness. It can result from a number of both benign and malignant causes.
2  RDE1571_surgicalClip surgicalclipMost surgical clips are currently made of titanium, and as many as 30 to 40 clips may be used during a single surgical procedure. Surgical clips may remain inside the patient's body after the wounds are healed.
2  RDE1571_trabecularThickening trabecularthickeningTrabecular thickening-thickening of the Cooper's ligaments and fibrous stroma-is an imaging finding of breast edema, usually secondary to dilated lymphatics. Skin thickening and trabecular thickening often occur together, and they have similar differential diagnoses.
2  RDE1571_calcificationInMass calcificationinmassCalcifications usually can't be felt, but appear on a mammogram. Depending on how calcifications are clustered; shape, size, and number, further tests may be necessary. Larger 'macrocalcifications' are usually not associated with cancer.
2  RDE1571_calcificationNotOnMammogram calcificationnotonmammogramCalcifications usually can't be felt, but appear on a mammogram. Calcifications can be clustered and their shape, size, and number. Large 'macrocalcifications' are usually not associated with cancer.
2  RDE1571_calcificationOnMammogram calcificationonmammogramCalcifications are small deposits of calcium that show up on mammograms as bright white specks or dots on the soft tissue background of the breasts. The calcium readily absorbs the X-rays from mammograms
2  RDE1571_calcifications calcificationsCalcifications are small deposits of calcium that show up on mammograms as bright white specks or dots on the soft tissue background of the breasts.
2  RDE1571_microCalcifications microcalcificationsMicro-calcifications show up as fine, white specks in a mammogram, similar to grains of salt; usually noncancerous, but certain patterns can be an early sign of cancer.
2  RDE1571_milkOfCalcium milkofcalciumThe term milk of calcium (MOC) is given to dependent, sedimented calcification within a cystic structure or hollow organ. This sort of colloidal calcium suspension layering can occur in various regions.
2  RDE1571_rimCalcifications rimcalcificationsThese are very thin benign calcifications that appear as calcium is deposited on the surface of a sphere. Although fat necrosis can produce these thin deposits, calcifications in the wall of cysts are the most common 'rim' calcifications.
1RDE1576 ShapeRDE1576
2  RDE1576_irregular irregularRDE1576_irregular
2  RDE1576_lobular lobularRDE1576_lobular
2  RDE1576_oval ovalRDE1576_oval
2  RDE1576_round roundRDE1576_round
1RDE1577 TypeRDE1577
2  RDE1577_complex complexComplex cysts have irregular or scalloped borders, thick walls, and some evidence of solid areas and/or debris in the fluid. These solid areas echo back the sound waves from the ultrasound. A complex cyst is sometimes aspirated, or drained with a fine needle, so that the fluid inside can be tested. If blood or any unusual cells are present, further testing may be needed to rule out breast cancer.
2  RDE1577_complicated complicatedComplicated cysts are 'in between' simple and complex. Although they share most of the features of simple cysts, they tend to have some debris inside them and echo back some of the ultrasound waves. However, they don't have the thick walls or obvious solid components that a complex cyst has.
2  RDE1577_micro microA microcyst Is a sac-like pocket of tissue that contains fluid, air, or other substances. A Microcyst is small and less than 2-3 mm and are often in clusters and only show up on a mammogram or ultrasound.
2  RDE1577_oil oilOil cysts are filled with fluid that may feel smooth and soft/squishy. Oil cysts are caused by the breakdown of fatty tissue.
2  RDE1577_simple simpleA simple cyst is a sac-like pocket of membranous tissue that only contains clear fluid.
2  RDE1577_withDebris withdebrisA cyst that is filled with debris and fluid substance. It Is either considered a complex or complicated cyst. The type of debris determines what kind of cyst.
2  RDE1577_cyst cystRDE1577_cyst
1RDE1578 DensityRDE1578
2  RDE1578_equal equalRDE1578_equal
2  RDE1578_fatContaining fatcontainingRDE1578_fat containing
2  RDE1578_high highRDE1578_high
2  RDE1578_low lowRDE1578_low
1RDE1579 MarginRDE1579
2  RDE1579_angular angularSome or all of the margin has sharp corners, often forming acute angles. The margin of the mass is not circumscribed.
2  RDE1579_circumscribed circumscribedA circumscribed margin is one that is well defined, with an abrupt transition between the lesion and the surrounding tissue. For US, to describe a mass as circumscribed, its entire margin must be sharply defined. Most circumscribed lesions have round or oval shapes.
2  RDE1579_indistinct indistinctThere is no clear demarcation of the entire margin, or of any portion of the margin, from the surrounding tissue. For mammography, this descriptor should not be used when the interpreting physician believes it is likely due to immediately adjacent breast tissue. Use of this descriptor usually implies a suspicious finding.
2  RDE1579_intraductalExtension intraductalextensionIntraductal tumor extension is a characteristic feature of primary breast carcinoma, and is an important consideration in patients undergoing breast conservative surgery.
2  RDE1579_irregular irregularEdges around the soft tissue that don't look smooth. Indicative of some sort of growth or mass rather than a cyst.
2  RDE1579_lobulated lobulatedThe edge of the mass has broad bulges. Much like a 6 or 8 leaf clover. The edge of all of the leaves would be considered lobulated.
2  RDE1579_macrolobulated macrolobulatedSmooth margin with distinct separation between the mass and the surrounding border. Macrolobulaed margins are oval-shaped and have a wide rather than tall formation.
2  RDE1579_microlobulated microlobulatedThe margin is characterized by short-cycle undulations or scalloped appearance, and the margin of the mass is not circumscribed.
2  RDE1579_nonCircumscribed noncircumscribedThe mass has one or more of the following features: indistinct, angular, microlobulated, or spiculated in any portion of the margin There is not a clear demarcation between the mass and the surrounding tissue.
2  RDE1579_obscured obscuredIt is hidden by superimposed or adjacent fibroglandular tissue. This is used primarily when some of the margin of the mass is circumscribed, but the rest (more than 25%) is hidden.
2  RDE1579_smooth smoothThe edges of the mass have a smooth appearance and distinct separation between the mass and surrounding tissue.
2  RDE1579_spiculated spiculatedThe margin is characterized by sharp lines radiating from the mass, often a sign of malignancy, but the significant feature is that the margin of the mass is not circumscribed.
1RDE1580 OrientationRDE1580
2  RDE1580_parallelToSkin paralleltoskinRDE1580_parallel to skin
2  RDE1580_perpendicularToSkin perpendiculartoskinRDE1580_perpendicular to skin
2  RDE1580_tallerThanWide tallerthanwideRDE1580_taller than wide
2  RDE1580_widerThanTall widerthantallRDE1580_wider than tall
1RDE1586 Assessment categoryRDE1586
2  RDE1586_category0IncompleteNeedAdditionalImaging category0needadditionalimagingRDE1586_category 0, incomplete - need additional imaging
2  RDE1586_category1Negative category1,negativeRDE1586_category 1, negative
2  RDE1586_category2BenignFinding category2,benignfindingRDE1586_category 2, benign finding
2  RDE1586_category3ProbablyBenignFinding category3,probablybenignfindingRDE1586_category 3, probably benign finding
2  RDE1586_category4SuspiciousAbnormality category4,suspiciousabnormalityRDE1586_category 4, suspicious abnormality
2  RDE1586_category4ASuspiciousAbnormalityLowLikelihoodOfBeingCancer category4A,suspiciousabnormalitylowlikelihoodofbeingcancerRDE1586_category 4A, suspicious abnormality - low likelihood of being cancer
2  RDE1586_category4BSuspiciousAbnormalityModerateLikelihoodOfBeingCancer category 4B,suspiciousabnormality-moderatelikelihoodofbeingcancerRDE1586_category 4B, suspicious abnormality - moderate likelihood of being cancer
2  RDE1586_category4CSuspiciousAbnormalityHighLikelihoodOfBeingCancer category4C,suspiciousabnormality-highlikelihoodofbeingcancerRDE1586_category 4C, suspicious abnormality - high likelihood of being cancer
2  RDE1586_category5HighlySuggestiveOfMalignancy category5,highlysuggestiveofmalignancyRDE1586_category 5, highly suggestive of malignancy
2  RDE1586_category6KnownBiopsyProvenMalignancy category6,knownbiopsy-provenmalignancyRDE1586_category 6, known biopsy - proven malignancy
1RDE1587 Breast composition categoryRDE1587
2  RDE1587_categoryATheBreastsAreAlmostEntirelyFatty categorya,thebreastsarealmostentirelyfattyRDE1587_category a, the breasts are almost entirely fatty
2  RDE1587_categoryBThereAreScatteredAreasOfFibroglandularDensity categoryb,therearescatteredareasoffibroglandulardensityRDE1587_category b, there are scattered areas of fibroglandular density
2  RDE1587_categoryCTheBreastsAreHeterogeneouslyDense categoryc,thebreastsareheterogeneouslydenseRDE1587_category c, the breasts are heterogeneously dense
2  RDE1587_categoryDTheBreastsAreExtremelyDense categoryd,thebreastsareextremelydenseRDE1587_category d, the breasts are extremely dense
1RDE1588 Breast lateralityRDE1588
2  RDE1588_right rightRDE1588_right
2  RDE1588_left leftRDE1588_left
2  RDE1588_bilateral bilateralRDE1588_bilateral
1RDE1589 Implant presenceRDE1589
2  RDE1589_left leftRDE1589_left
2  RDE1589_right rightRDE1589_right
2  RDE1589_bilateral bilateralRDE1589_bilateral
2  RDE1589_none noneRDE1589_none
1RDE1590 Prior mastectomyRDE1590
2  RDE1590_right rightRDE1590_right
2  RDE1590_left leftRDE1590_left
2  RDE1590_bilateral bilateralRDE1590_bilateral
2  RDE1590_none noneRDE1590_none
1RDE1602 TypeRDE1602
2  RDE1602_mass massRDE1602_mass
2  RDE1602_intraductal intraductalRDE1602_intraductal
2  RDE1602_partiallySolid partiallysolidRDE1602_partially solid
2  RDE1602_solid solidRDE1602_solid