Pathological and radiological assessment of benign breast lesions with BIRADS IVc/V subtypes. should we repeat the biopsy?

Background: Timely diagnosis is a crucial factor in decreasing the death rate of patients with breast cancer. BI-RADS categories IVc and V indicate a strong suspicion of cancer. The categorisation of each group is determined by the characteristics of the lesion. Certain benign breast lesions might have radiological features indicative of malignancy; thus, biopsy is mandatory. This study aimed to identify the histopathological diagnosis of benign breast masses classified into BIRADS IVc and V subgroups, investigate the radiological characteristics of these masses, and identify ultrasound features that could lead to false positive results (benign lesions that mimic malignancy on imaging).

Methods: This was a retrospective cross-sectional study at a single facility. Breast lesions reported as BIRADS IVc and V that underwent needle core/stereotactic vacuum-assisted biopsy were reviewed. Patients with benign pathologic diagnoses were analysed, delineating pathological diagnoses. Radiological descriptors were compared to those of a matched control of 50 malignant cases with BIRADS IVc.

Results: A total of 828 breast lesions classified as BIRADS IVc or V were detected during the period spanning from 2015 to 2022. Forty-four lesions (44/828, 5.3%) were benign at initial biopsy, while 784 lesions (784/828, 94.7%) were malignant. After histopathological testing and repeat biopsy, 26/828 (3.14%) patients had discordant benign diagnosis. Half of the repeated biopsies (10/20, 50%) showed malignant pathology. Compared to that in the control group, the presence of an oval shape of the mass was significantly more common in patients with benign pathology (p = 0.035). Conversely, the presence of posterior shadowing was significantly less common (p = 0.050) in benign lesions. No significant differences were observed for the other radiological characteristics. The most common histopathological diagnosis was fibrocystic change.

Conclusion: This study highlights key findings regarding the sonographic imaging descriptors and histopathological diagnoses of benign breast lesions categorised as BIRADS IVc/V. The study recommends a correlation between clinical and radiological findings and encourages multidisciplinary decision-making among radiologists, pathologists, and clinicians to determine if a repeat biopsy is warranted. There is a need for continuous research to improve the diagnosis and treatment of breast lesions and reduce false-positive rates by incorporating other methodologies such as sonoelastography and incorporating deep learning and artificial intelligence in the decision-making to eliminate unnecessary procedures.