| Code | Display |
| yes |
Yes |
| no |
No |
| unknown |
Unknown |
| acr-a |
ACR A – Almost entirely fatty |
| acr-b |
ACR B – Scattered areas of fibroglandular density |
| acr-c |
ACR C – Heterogeneously dense |
| acr-d |
ACR D – Extremely dense |
| birads-0 |
BI-RADS 0 – Incomplete examination |
| birads-1 |
BI-RADS 1 – No changes found |
| birads-2 |
BI-RADS 2 – Benign changes found |
| birads-3 |
BI-RADS 3 – Possibly benign changes |
| birads-4 |
BI-RADS 4 – Suspicious malignant finding |
| birads-5 |
BI-RADS 5 – Highly probable malignant finding |
| finding-formation |
Formation (mass) |
| finding-calcification |
Calcification |
| finding-deformation |
Architectural deformation |
| finding-asymmetry |
Focal asymmetric tissue |
| dynamics-none |
Image without negative dynamics |
| dynamics-negative |
Negative dynamics observed |
| biopsy-us-guided |
Biopsy under ultrasound guidance |
| biopsy-xray-guided |
Biopsy under X-ray guidance |
| parenchyma-fatty |
Homogeneous adipose tissue |
| parenchyma-fibroglandular |
Homogeneous fibroglandular |
| parenchyma-heterogeneous |
Heterogeneous |
| nature-cyst |
Cyst |
| nature-lymph-node |
Breast lymph node |
| nature-fibroadenoma |
Fibroadenoma |
| nature-papilloma |
Papilloma |
| nature-lipoma |
Lipoma |
| nature-malignant |
Tumor (malignant) |
| nature-abscess |
Abscess |
| nature-other |
Other (free text) |
| ducts-normal |
Ducts not expanded |
| ducts-expanded |
Ducts expanded |
| right |
Right |
| left |
Left |
| ln-level-n1 |
N1 |
| ln-level-n2 |
N2 |
| ln-level-n3 |
N3 |
| fixation-formalin |
Fixed (10% formalin buffered solution) |
| fixation-unfixed |
Unfixed |
| proc-none |
No important information |
| proc-biopsy |
Biopsy |
| proc-excision |
Excision |
| proc-other-operation |
Other operation |
| proc-chemotherapy |
Chemotherapy |
| proc-radiation |
Radiation (breast) |
| proc-immunotherapy |
Immunotherapy |
| op-thick-needle-biopsy |
Thick needle biopsy |
| op-excision |
Excision |
| op-other |
Other (free text) |
| ihc-negative |
Negative |
| ihc-weak |
Weak (+) |
| ihc-moderate |
Moderate (++) |
| ihc-strong |
Strong (+++) |
| her2-negative |
HER2: expression absent (0) |
| her2-low |
HER2: low immunohistochemical expression (1+) |
| her2-borderline |
HER2: expression borderline (2+) |
| her2-positive |
HER2: expression positive (3+) |
| her2-eval-0 |
HER2 evaluation: 0+ |
| her2-eval-1 |
HER2 evaluation: 1+ |
| her2-eval-2 |
HER2 evaluation: 2+ |
| her2-eval-3 |
HER2 evaluation: 3+ |
| fish-amplified |
FISH: HER2 amplified |
| fish-amplified-clusters |
FISH: amplified (clusters) |
| fish-co-amplified |
FISH: co-amplified (HER2>=6, HER2/CEP17<2) |
| fish-borderline |
FISH: borderline (4<=HER2<6, HER2/CEP17<2) |
| fish-monosomic |
FISH: monosomic (HER2<4, HER2/CEP17>=2) |
| fish-negative |
FISH: negative (HER2<4, HER2/CEP17<2) |
| fish-not-evaluated |
FISH: not to be evaluated |
| cish-amplified |
CISH/SISH: HER2 amplified |
| cish-not-amplified |
CISH/SISH: HER2 not amplified |
| cish-not-evaluated |
CISH/SISH: not to be evaluated |
| grade-g1 |
G1 (well-differentiated) |
| grade-g2 |
G2 (moderately differentiated) |
| grade-g3 |
G3 (poorly differentiated) |
| grade-gx |
Gx (degree of differentiation undetermined) |
| lvi-0 |
pLVI-0: not detected |
| lvi-1 |
pLVI-1: spreading, otherwise unclassified |
| lvi-2 |
pLVI-2: only in lymphatic vessels and small blood vessels |
| lvi-3 |
pLVI-3: only in veins (large, thick-walled blood vessels) |
| lvi-4 |
pLVI-4: present in both lymphatic vessels and veins |
| lvi-9 |
pLVI-9: undetectable/unknown |
| uoq |
Upper outer quadrant |
| uiq |
Upper inner quadrant |
| loq |
Lower outer quadrant |
| liq |
Lower inner quadrant |
| rec-mammographic-control |
Mammographic control |
| rec-additional-mammography |
Additional mammography |
| rec-spot-compression |
Local compression with magnification |
| rec-ultrasound |
Ultrasound examination |
| rec-breast-specialist |
Breast specialist consultation |
| rec-consultation |
Consultation with breast specialist |
| rec-biopsy-ultrasound |
Biopsy under ultrasound |
| rec-biopsy |
Biopsy indicated |
| rec-stereotactic-biopsy |
Stereotactic biopsy |
| rec-mri |
MRI examination |
| rec-next-mammography |
Next mammography after N months |
| rec-follow-up-6m |
Follow-up in 6 months |
| rec-biopsy-indicated |
Biopsy indicated |