Breast Imaging Report Templates
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## Breast Imaging Report Templates

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

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 |  |

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