乳腺癌专栏读者来信和回复

尊敬的Daniel Kopans教授：

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我是中国**大学附属医院乳腺影像学专业的年轻医生。抱歉打扰您，我有一个问题困扰了我很长时间：您能解释一下第五版BI-RADS分类中的"grouped calcifications"和第四版BI-RADS分类中的"clustered calcifications”之间的区别吗？这两个词在中文中没有太大区别，所以我说不出这一变化的原因。非常感谢您抽出时间！

您忠实的，***医生

Dr. Kopans回复译文

*医生：

谢谢你的提问。虽然我是最初的BIRADS标准委员会的联合主席，BIRADS是基于我在麻省总医院为我部门开发的计算机报告系统，但我不再是委员会的成员，所以我把问题转发给现任BIRADS委员会的Dr. Ed Sickles，他的回复如下：

“我可以向你解释当时决定将“clustered calcifications”替换为“grouped calcifications”的实际原因，无论你是否认同这个理由，但事实的确如此。英语中的“grouped”和 “clustered”几乎没有什么区别。BI-RADS的改变是因为多年来，人们一直使用“clustered”作为判断可疑恶性钙化灶的描述词，许多转诊临床医生和患者对这一乳腺X射线摄影发现的恶性可能性做出了不准确的高估计，认为恶性可能性比良性可能性大得多。而实际上恶性可能性约为30%，这些钙化很可能是良性的，而不是恶性的，尽管它足够可疑，并且进行进一步的组织诊断是恰当的。BI-RADS委员会决定更改术语，以便在第5版BI-RADS首次发布恶性概率百分比时，用术语“clustered”取代“grouped”，借此消除对“clustered”的误解，明确表示其恶性可能性只有约30%。”

换句话说，Dr. Sickles解释说这两个词之间没有真正的区别。委员会希望结束“clustered”意味着癌症高风险的想法。事实上，正如他所写，大多数“grouped”或“clustered”钙化与癌症无关，但它们具有足够高的风险（30%）需要进行活检。在美国，我们会使用局部麻醉进行图像引导下的穿刺活检。我不知道委员会为什么要做出改变，因为他们所要做的仅仅是说明小钙化“grouped”或“clustered”在一起时的风险。当然，正如我回信给Dr. Sickles，他也同意，决定是否需要活检的不仅仅是“grouped”（或clustered），还有钙化的形态。例如：我从未见过空心环形的“group”或“cluster”的钙化灶是癌。

如果描述在1立方厘米乳腺组织中存在5个或更多钙化很重要，但并没有恶性风险疑虑时，我个人喜欢使用“a group”这一术语，这样读报告的人就会明白我看到了这些钙化，但觉得可以不做任何处理。当我认为这些钙化灶需要进行活检时，我仍然会使用“clustered”一词。

BIRADS对于组织我们的想法、报告和跟踪结果非常重要，但我不同意其中的一些部分。当我想要活检时，我会使用“clustered”；当我只想描述而不必处理它们时，我会使用“a group”一组圆形的、空心环形的钙化”。

关于判定“圆形钙化”顺便说一句，以前一位同事描述“圆形”就像一个球，当你弹起它，它会回到你的手上。如果钙化看上去不是真正圆滑可弹的感觉，那么它就不是“圆形”，也不应该被描述为“圆形”。

我希望这些对你有所帮助。如果你还有其他问题，请告诉我。

Dan Kopans

Dr. Kopans回复原文

**:

Thanks for your question.  Although I was Co-Chairman of the original BIRADS Committee, and BIRADS was based on the computer reporting system that I developed for my group at the Massachusetts General Hospital, I am no longer on the committee, so I posed it to Dr. Ed Sickles who was on the BIRADS committee and he wrote the following:

“Having been "on the inside" when the decision was made to replace "clustered" with "grouped", I can explain it to you. You may or may not agree with the rationale, but here it is.

There is very little difference between "grouped" and "clustered" in the English language.  The change in BI-RADS was made because over the many years of having used "clustered" as a descriptor of calcifications judged suspicious for malignancy, many referring clinicians and patients developed an inaccurately high estimate of the likelihood of malignancy for this mammographic finding, much more likely malignant than benign.  The actual likelihood is approximately 30%, hence these calcifications are much more likely benign than malignant, albeit sufficiently suspicious that tissue diagnosis is appropriate.  The BI-RADS Committee decided to change terminology so that when the actual percentage likelihoods of malignancy were published in BI-RADS for the first time (5th edition), misconceptions about "clustered" would be eliminated when this term was replaced with the term "grouped", explicitly stated to have a likelihood of malignancy of only about 30%.”

In other words Dr. Sickles is explaining that there is no real difference between the two words.  The Committee wanted to end the idea that “clustered” implied a very high risk of being due to cancer.  In fact, as he writes, most “grouped” or “clustered” calcifications are not related to cancer, but have a high enough risk (30%) that they need to be biopsied.  In the U.S. we would perform an image guided needle biopsy using local anesthesia.  I don’t know why the committee made the change since all they had to do was explain the risk when there are small calcifications “grouped” or “clustered” close together.  Of course, as I wrote back to Dr. Sickles, and he agreed, it is not just the grouping (or clustering) that determines the need for a biopsy, but the morphology of the calcifications.  For example: I have never seen a “group” or “cluster” of calcifications that were “round with lucent centers” that was associated with breast cancer. 

I personally like to use the term “a group” of calcifications if I feel it is important to describe 5 or more in a cubic centimeter of tissue, when I am NOT concerned about the “group” so that someone looking at the study will understand that I saw them and felt they could be left alone.  I would still use the term “clustered” when I am concerned that they need to be biopsied. 

BIRADS is very important to organize our thoughts, reports, and track our results, but there are some parts of it with which I do not agree.  I would continue to use “clustered” when I want a biopsy and “a group of round, lucent centered calcifications” when I just want to describe them, but leave them alone.

By the way, as one of my former fellows explained, “round” is like a ball.  When you bounce it, it comes back to your hand.  If a calcification will not come directly back, then it is not “round” and should not be described as “round”.

I hope this helps.  Let me know if you have any other questions. 

Dan Kopans