Breast Imaging Report Templates 

The templates that comprise the Breast Imaging Report are interconnected as in Figure A-10.

Breast Imaging Report Template Structure

Figure A-10. Breast Imaging Report Template Structure


TID 4200 Breast Imaging Report

This template forms the content tree that allows a Breast Imaging Report device to describe the results of a radiologist's diagnostic interpretation of Breast Imaging (e.g., X-Ray mammography or breast ultrasound) evidence. This template, together with its subordinate templates, describes the results for presentation to clinicians, or for consumption by Breast Imaging Report devices for subsequent Breast Imaging Reports.

This template shall be instantiated at the Root node only.

See Figure Q.1-1 “Top Level of Breast Imaging Report Content Tree” in PS3.17 .

Type:

Non-Extensible

Order:

Significant

Root:

Yes

Table TID 4200. Breast Imaging Report

NL

Rel with Parent

VT

Concept Name

VM

Req Type

Condition

Value Set Constraint

1

CONTAINER

EV (111400, DCM, "Breast Imaging Report")

1

M

Root node

2

>

HAS CONCEPT MOD

INCLUDE

DTID 1204 “Language of Content Item and Descendants”

1

M

3

>

CONTAINS

INCLUDE

DTID 4202 “Breast Imaging Report Narrative”

1

M

4

>

CONTAINS

INCLUDE

DTID 4208 “Breast Imaging Report Supplementary Data”

Breast Imaging Report Supplementary Data

1

U


TID 4201 Breast Imaging Procedure Reported

A procedure that is reported in a Breast Imaging Report is expressed in this template. The results of more than one procedure may be included in a single report instance (see TID 4208 “Breast Imaging Report Supplementary Data”).

See Figure Q.1-2 “Breast Imaging Procedure Reported Content Tree” in PS3.17 .

Type:

Non-Extensible

Order:

Significant

Table TID 4201. Breast Imaging Procedure Reported

NL

Rel with Parent

VT

Concept Name

VM

Req Type

Condition

Value Set Constraint

1

CODE

EV (121058, DCM, "Procedure reported")

1

M

DCID 6050 “Breast Procedure Reported”

2

>

HAS CONCEPT MOD

CODE

EV (111464, DCM, "Procedure Modifier")

1-n

U

DCID 6058 “Procedure Modifiers for Breast”

3

>

HAS CONCEPT MOD

CODE

EV (G-C171, SRT, "Laterality")

1

M

DCID 6022 “Side”

4

>

HAS PROPERTIES

CODE

EV (111401, DCM, "Reason for procedure")

1

U

DCID 6051 “Breast Procedure Reason”

5

>>

HAS CONCEPT MOD

CODE

EV (G-D709, SRT, "Relative time")

1

U

DCID 12102 “Temporal Periods Relating to Procedure or Therapy”

6

>>

HAS CONCEPT MOD

CODE

EV (111402, DCM, "Clinical Finding")

1-n

UC

IFF row 4 value is "Clinical Finding"

DCID 6055 “Breast Clinical Finding Or Indicated Problem”

Breast Clinical Finding or Indicated Problem

7

>>>

HAS PROPERTIES

CODE

EV (G-C171, SRT, "Laterality")

1

U

DCID 6022 “Side”

8

>

HAS PROPERTIES

DATE

EV (111060, DCM, "Study Date")

1

U


Content Item Descriptions

Row 5 "Relative time"

This content item indicates whether the value of "Reason for procedure" (row 4) is modified with "pre-" or "follow-up".

TID 4202 Breast Imaging Report Narrative

This template contains the narrative text sub-tree of the content tree of a Breast Imaging Report. The narrative summary may be subdivided into sections with section headings.

See Figure Q.1-3 “Breast Imaging Report Narrative Content Tree” in PS3.17 .

Type:

Non-Extensible

Order:

Significant

Table TID 4202. Breast Imaging Report Narrative

NL

Rel with Parent

VT

Concept Name

VM

Req Type

Condition

Value Set Constraint

1

CONTAINER

EV (111412, DCM, "Narrative Summary")

1

M

2

>

CONTAINS

CONTAINER

BCID 6052 “Breast Imaging Report Section Title”

1-n

M

3

>>

HAS OBS CONTEXT

INCLUDE

DTID 1002 “Observer Context”

1-n

U

4

>>

CONTAINS

TEXT

BCID 6053 “Breast Imaging Report Elements”

1

M

5

>>>

INFERRED FROM

INCLUDE

DTID 350 “References to Supporting Evidence”

1

U


TID 4203 Breast Imaging Assessment

This template provides the content of a Breast Imaging Assessment, for an overall assessment section for the entire report (see TID 4208 “Breast Imaging Report Supplementary Data”) or an assessment of a particular finding (see TID 4206 “Breast Imaging Report Finding Section”). This template defines a code-based assessment of the interpretation results.

See Figure Q.1-5 “Breast Imaging Assessment Content Tree” in PS3.17 .

Type:

Non-Extensible

Order:

Significant

Table TID 4203. Breast Imaging Assessment

NL

Rel with Parent

VT

Concept Name

VM

Req Type

Condition

Value Set Constraint

1

CODE

EV (111005, DCM, "Assessment Category")

1

M

DCID 6026 “Mammography Assessment”

2

CODE

EV (111053, DCM, "Recommended Follow-up")

1-n

U

BCID 6028 “Mammography Recommended Follow-up”

3

>

HAS CONCEPT MOD

CODE

EV (G-C171, SRT, "Laterality")

1

U

DCID 6022 “Side”

4

>

HAS PROPERTIES

NUM

EV (111055, DCM, "Recommended Follow-up Interval")

1

U

UNITS = DCID 6046 “Units of Follow-up Interval”

Values = Integer ≥ 0, where 0 = immediate follow-up

5

>

HAS PROPERTIES

DATE

EV (111054, DCM, "Recommended Follow-up Date")

1

U

6

>

HAS PROPERTIES

INCLUDE

DTID 4207 “Breast Imaging Pathology Results”

1-n

U


TID 4204 Breast Imaging Report Intervention Section

This template defines a supplementary data section for an Intervention of the breast, for the Breast Imaging Report. It is included from TID 4208 “Breast Imaging Report Supplementary Data”.

Type:

Extensible

Order:

Significant

Table TID 4204. Breast Imaging Report Intervention Section

NL

Rel with Parent

VT

Concept Name

VM

Req Type

Condition

Value Set Constraint

1

CONTAINER

EV (111463, DCM, "Supplementary Data for Intervention")

1

M

2

>

CONTAINS

INCLUDE

DTID 4201 “Breast Imaging Procedure Reported”

1

M

3

>

CONTAINS

CODE

EV (A-00110, SRT, "Instrument")

1

U

4

>>

HAS PROPERTIES

TEXT

EV (111465, DCM, "Needle Gauge")

1

UC

XOR row 5

5

>>

HAS PROPERTIES

CODE

EV (111465, DCM, "Needle Gauge")

1

UC

XOR row 4

6

>>

HAS PROPERTIES

NUM

EV (111467, DCM, "Needle Length")

1

U

UNITS = EV (cm, UCUM, "centimeter")

7

>

CONTAINS

NUM

EV (111436, DCM, "Number of passes")

1

U

UNITS = EV ({passes}, UCUM, "passes")

8

>

CONTAINS

NUM

EV (111437, DCM, "Number of specimens")

1

U

UNITS = EV ({specimens}, UCUM, "specimens")

9

>

CONTAINS

CODE

EV (111431, DCM, "Instrument Approach")

1-n

U

DCID 6065 “Instrument Approach”

10

>

CONTAINS

CODE

EV (111438, DCM, "Needle in target")

1

U

DCID 230 “Yes-No”

11

>

CONTAINS

NUM

EV (111439, DCM, "Number of needles around target")

1

U

UNITS = EV ({needles}, UCUM, "needles")

12

>

CONTAINS

CODE

EV (F-04460, SRT, "Medication given")

1-n

U

13

>

CONTAINS

CODE

EV (111440, DCM, "Incision made")

1

U

DCID 230 “Yes-No”

14

>

CONTAINS

CODE

EV (111123, DCM, "Marker placement")

1

U

DCID 230 “Yes-No”

15

>

CONTAINS

CODE

EV (111442, DCM, "Confirmation of target")

1

U

DCID 6066 “Target Confirmation”

16

>

CONTAINS

CODE

EV (DD-60002, SRT, "Complication of procedure")

1-n

U

DCID 6062 “Interventional Procedure Complications”

17

>>

HAS PROPERTIES

CODE

EV (111466, DCM, "Severity of Complication")

1

U

DCID 251 “Severity of Complication”

18

>

CONTAINS

CONTAINER

EV (121027, DCM, "Specimen")

1-n

U

19

>>

HAS OBS CONTEXT

INCLUDE

DTID 1009 “Subject Context, Specimen”

1

U

20

>>

CONTAINS

CODE

EV (F-00E6D, SRT, "Color of fluid")

1

U

DCID 6067 “Fluid Color”

21

>>

CONTAINS

CODE

EV (111456, DCM, "Action on fluid")

1

U

DT (111457, DCM, "Sent for analysis")

DT (111458, DCM, "Discarded")

22

>>

CONTAINS

CODE

EV (111455, DCM, "Occult blood test result")

1

U

DCID 250 “Positive-Negative”

23

>>

CONTAINS

INCLUDE

DTID 4207 “Breast Imaging Pathology Results”

1-n

U

24

>

CONTAINS

INCLUDE

DTID 350 “References to Supporting Evidence”

1

U


TID 4205 Breast Composition Section

This template defines a Breast Composition section for the supplementary data sub-tree of the Breast Imaging Report. It is included from TID 4208 “Breast Imaging Report Supplementary Data”.

Type:

Non-Extensible

Order:

Significant

Table TID 4205. Breast Composition Section

NL

Rel with Parent

VT

Concept Name

VM

Req Type

Condition

Value Set Constraint

1

CONTAINER

EV (F-01710, SRT, "Breast composition")

1

M

2

>

CONTAINS

INCLUDE

DTID 4201 “Breast Imaging Procedure Reported”

1-n

U

3

>

CONTAINS

CODE

EV (F-01710, SRT, "Breast composition")

1-n

MC

At least one of row 3, 5 shall be present

DCID 6000 “Overall Breast Composition”

4

>>

HAS CONCEPT MOD

CODE

EV (G-C171, SRT, "Laterality")

1

M

DCID 6022 “Side”

5

>

CONTAINS

NUM

EV (111046, DCM, "Percent Fibroglandular Tissue")

1-n

MC

At least one of row 3, 5 shall be present

UNITS = EV (%, UCUM, "Percent")

6

>>

HAS CONCEPT MOD

CODE

EV (G-C171, SRT, "Laterality")

1

M

DCID 6022 “Side”

7

>

CONTAINS

CODE

EV (111350, DCM, "Breast background echo texture")

1-2

U

DCID 6151 “Background Echotexture”

8

>>

HAS CONCEPT MOD

CODE

EV (G-C171, SRT, "Laterality")

1

M

DCID 6022 “Side”


TID 4206 Breast Imaging Report Finding Section

This template defines a supplementary data section for the Findings of the Breast Imaging Report. It is included from TID 4208 “Breast Imaging Report Supplementary Data”.

Type:

Extensible

Order:

Significant

Table TID 4206. Breast Imaging Report Finding Section

NL

Rel with Parent

VT

Concept Name

VM

Req Type

Condition

Value Set Constraint

1

CONTAINER

EV (121070, DCM, "Findings")

1

M

2

>

HAS OBS CONTEXT

INCLUDE

DTID 1002 “Observer Context”

1-n

U

3

>

CONTAINS

INCLUDE

DTID 4201 “Breast Imaging Procedure Reported”

1

M

4

>

CONTAINS

CODE

EV (121071, DCM, "Finding")

1-n

M

DCID 6054 “Breast Imaging Findings”

5

>>

HAS CONCEPT MOD

CODE

EV (111405, DCM, "Implant type")

1-n

UC

May be present if value of row 4 is (A-04010, SRT, "Implant")

DCID 6059 “Breast Implant Types”

6

>>

HAS PROPERTIES

INCLUDE

DTID 4203 “Breast Imaging Assessment”

1

U

7

>>

HAS PROPERTIES

CODE

EV (111014, DCM, "Clockface or region")

1

U

DCID 6018 “Clockface Location or Region”

8

>>

HAS PROPERTIES

CODE

EV (111048, DCM, "Quadrant location")

1

U

DCID 6020 “Quadrant Location”

9

>>

HAS PROPERTIES

INCLUDE

DTID 1400 “Linear Measurement”

1-n

U

10

>>

HAS PROPERTIES

INCLUDE

DTID 1401 “Area Measurement”

1-n

U

11

>>

HAS PROPERTIES

INCLUDE

DTID 1402 “Volume Measurement”

1-n

U

12

>>

HAS PROPERTIES

CODE

EV (111020, DCM, "Depth")

1

U

DCID 6024 “Depth”

13

>>

HAS PROPERTIES

CODE

EV (111035, DCM, "Lesion Density")

1

U

DCID 6008 “Density Modifier”

14

>>

HAS PROPERTIES

CODE

EV (M-020F9, SRT, "Shape")

1-n

U

DCID 6004 “Mammography Characteristics of Shape”

15

>>

HAS PROPERTIES

CODE

EV (111037, DCM, "Margins")

1-n

U

DCID 6006 “Mammography Characteristics of Margin”

16

>>

HAS PROPERTIES

CODE

EV (111009, DCM, "Calcification Type")

1-n

U

DCID 6010 “Mammography Calcification Types”

17

>>

HAS PROPERTIES

CODE

EV (111008, DCM, "Calcification Distribution")

1

U

DCID 6012 “Calcification Distribution Modifier”

18

>>

HAS PROPERTIES

NUM

EV (111038, DCM, "Number of calcifications")

1

U

UNITS = EV ({calcifications}, UCUM, "calcifications")

Value = Integer 1 - n

19

>>

HAS PROPERTIES

CODE

EV (111407, DCM, "Implant finding")

1-n

U

DCID 6072 “Breast Implant Findings”

20

>>

HAS PROPERTIES

CODE

EV (G-C189, SRT, "Associated Finding")

1-n

U

DCID 6056 “Associated Findings for Breast”

21

>>

HAS PROPERTIES

NUM

EV (111406, DCM, "Number of similar findings")

1

U

UNITS = EV ({findings}, UCUM, "findings")

Value = Integer 2 - n

22

>>

HAS PROPERTIES

CODE

EV (F-01720, SRT, "Change since last mammogram")

1-n

U

DCID 6002 “Change Since Last Mammogram Or Prior Surgery”

23

>>

HAS PROPERTIES

CODE

EV (111354, DCM, "Orientation")

1

U

DCID 6152 “Orientation”

24

>>

HAS PROPERTIES

CODE

EV (111357, DCM, "Lesion boundary")

1

U

DCID 6153 “Lesion Boundary”

25

>>

HAS PROPERTIES

CODE

EV (111360, DCM, "Echo pattern")

1

U

DCID 6154 “Echo Pattern”

26

>>

HAS PROPERTIES

CODE

EV (111366, DCM, "Posterior acoustic features")

1

U

DCID 6155 “Posterior Acoustic Features”

27

>>

HAS PROPERTIES

CODE

EV (111371, DCM, "Identifiable effect on surrounding tissues")

1

U

DCID 6015 “Single Image Finding From BI-RADS®”

28

>>

HAS PROPERTIES

CODE

EV (111372, DCM, "Vascularity")

1

U

DCID 6157 “Vascularity”

29

>>

HAS PROPERTIES

CODE

EV (111380, DCM, "Correlation to Other Findings")

1-n

U

DCID 6158 “Correlation to Other Findings”

30

>>

INFERRED FROM

INCLUDE

DTID 350 “References to Supporting Evidence”

1

U


TID 4207 Breast Imaging Pathology Results

This template defines the pathology results for a procedure. It may be applied to a Breast Imaging Assessment (see TID 4203 “Breast Imaging Assessment”), or a Breast Imaging Intervention (see TID 4204 “Breast Imaging Report Intervention Section”).

Type:

Extensible

Order:

Significant

Table TID 4207. Breast Imaging Pathology Results

NL

Rel with Parent

VT

Concept Name

VM

Req Type

Condition

Value Set Constraint

1

CONTAINER

EV (111468, DCM, "Pathology Results")

1

M

2

>

CONTAINS

INCLUDE

DTID 4201 “Breast Imaging Procedure Reported”

1

U

3

>

CONTAINS

DATETIME

EV (111469, DCM, "Sampling DateTime")

1

M

4

>

CONTAINS

CODE

EV (122177, DCM, "Procedure Result")

1

M

DCID 6063 “Interventional Procedure Results”

5

>

CONTAINS

CODE

EV (111042, DCM, "Pathology")

1-n

U

BCID 6030 “Mammography Pathology Codes”

6

>>

HAS PROPERTIES

CODE

EV (111388, DCM, "Malignancy Type")

1

U

DCID 6159 “Malignancy Type”

7

>>

HAS PROPERTIES

NUM

DCID 6165 “Breast Linear Measurements”

1-n

U

UNITS = EV (mm, UCUM, "millimeter")

8

>>

HAS PROPERTIES

CODE

EV (F-02900, SRT, "Histological grade finding")

1

U

BCID 6069 “Nottingham Combined Histologic Grade”

BCID 6070 “Bloom-Richardson Histologic Grade”

9

>>>

HAS CONCEPT MOD

CODE

EV (R-00258, SRT, "Histologic grade")

1

U

BCID 6071 “Histologic Grading Method”

10

>>

HAS PROPERTIES

CODE

EV (R-00274, SRT, "Tumor margin status")

1

U

DT (111470, DCM, "Uninvolved"),

DT (111471, DCM, "Involved")

11

>>

HAS PROPERTIES

CODE

EV (111472, DCM, "Nipple involved")

1

U

DCID 230 “Yes-No”

12

>>

HAS PROPERTIES

NUM

EV (111473, DCM, "Number of nodes removed")

1

U

UNITS = EV ({nodes}, UCUM, "nodes")

13

>>

HAS PROPERTIES

NUM

EV (111474, DCM, "Number of nodes positive")

1

MC

Shall be present IFF value of row 12 is > 0

UNITS = EV ({nodes}, UCUM, "nodes")

14

>>

HAS PROPERTIES

CODE

EV (R-00465, SRT, "pT category finding")

1

U

DCID 6160 “Breast Primary Tumor Assessment From AJCC”

15

>>

HAS PROPERTIES

CODE

EV (R-00463, SRT, "Node stage finding")

1

U

DCID 6161 “Clinical Regional Lymph Node Assessment for Breast”

16

>>

HAS PROPERTIES

CODE

EV (R-00461, SRT, "Metastasis stage finding")

1

U

DCID 6162 “Assessment of Metastasis for Breast”

17

>>

HAS PROPERTIES

CODE

EV (R-00443, SRT, "Tumor stage finding")

1

U

BCID 6068 “Tumor Stages From AJCC”

18

>>

HAS PROPERTIES

CODE

EV (111475, DCM, "Estrogen receptor")

1

U

DCID 250 “Positive-Negative”

19

>>

HAS PROPERTIES

CODE

EV (111476, DCM, "Progesterone receptor")

1

U

DCID 250 “Positive-Negative”

20

>>

HAS PROPERTIES

NUM

EV (111477, DCM, "S Phase")

1

U

UNITS = EV (%, UCUM, "percent")


TID 4208 Breast Imaging Report Supplementary Data

This template forms a supplementary data sub-tree of the content tree of a Breast Imaging Report. Each subsection provides a specific type of supporting evidence to the narrative text sub-tree, for example, as coded and numeric data.

See Figure Q.1-4 “Breast Imaging Report Supplementary Data Content Tree” in PS3.17 .

Type:

Non-Extensible

Order:

Significant

Table TID 4208. Breast Imaging Report Supplementary Data

NL

Rel with Parent

VT

Concept Name

VM

Req Type

Condition

Value Set Constraint

1

CONTAINER

EV (111414, DCM, "Supplementary Data")

1

M

2

>

CONTAINS

INCLUDE

DTID 4201 “Breast Imaging Procedure Reported”

1-n

M

3

>

CONTAINS

CODE

EV (111403, DCM, "Baseline screening mammogram")

1

U

DCID 230 “Yes-No”

4

>

CONTAINS

CODE

EV (111404, DCM, "First mammogram ever")

1

U

DCID 230 “Yes-No”

5

>

CONTAINS

INCLUDE

DTID 4205 “Breast Composition Section”

1

U

6

>

CONTAINS

INCLUDE

DTID 4206 “Breast Imaging Report Finding Section”

1-n

U

7

>

CONTAINS

INCLUDE

DTID 4204 “Breast Imaging Report Intervention Section”

1-n

U

8

>

CONTAINS

CONTAINER

EV (111413, DCM, "Overall Assessment")

1

U

9

>>

CONTAINS

INCLUDE

DTID 4203 “Breast Imaging Assessment”

1

M