Management of BI-RADS Category 3 Lesions

Initial Management Decision

For solid lesions less than 2 cm with low clinical suspicion, observation is acceptable with physical examination and ultrasound or mammogram every 6 months for 1-2 years to assess stability, according to the National Comprehensive Cancer Network 2
Core needle biopsy is the preferred tissue sampling method if biopsy is elected for solid lesions less than 2 cm with low clinical suspicion, as recommended by the National Comprehensive Cancer Network 2
Surgical excision is also an option for solid lesions less than 2 cm with low clinical suspicion, though generally reserved for specific indications, as stated by the National Comprehensive Cancer Network 2
For complicated cysts, options include aspiration or short-term follow-up with physical examination and ultrasound or mammography every 6-12 months for 1-2 years, according to the National Comprehensive Cancer Network 3
If blood-free fluid is obtained on aspiration and the mass resolves, monitoring for recurrence is necessary for complicated cysts, as recommended by the National Comprehensive Cancer Network 2
Tissue biopsy is required if the cyst increases in size on follow-up for complicated cysts, according to the National Comprehensive Cancer Network 3

The American College of Radiology recommends performing unilateral diagnostic mammogram or ultrasound of the affected breast at 6 months for BI-RADS category 3 lesions 1
For women 40 years and older, bilateral mammography should be performed to ensure the contralateral breast is imaged at appropriate yearly intervals, as recommended by the American College of Radiology 1
Depending on the level of concern, subsequent follow-up may be either every 6 months for the affected breast or annual bilateral mammograms, according to the American College of Radiology 1

Any increase in lesion size on interval imaging requires mandatory biopsy, as recommended by the American College of Radiology 1
Change in benign characteristics or development of suspicious morphological features also requires mandatory biopsy, according to the American College of Radiology 1

Immediate biopsy with histologic sampling is reasonable in situations where return visits are uncertain or follow-up compliance is questionable, as recommended by the American College of Radiology 1
Upfront biopsy is also reasonable for patients who are highly anxious about the finding or have a strong family history of breast cancer, according to the American College of Radiology 1

If biopsy shows benign, image-concordant results, continue physical examination and ultrasound or mammogram every 6-12 months for 1-2 years before returning to routine screening, as recommended by the National Comprehensive Cancer Network and the American College of Radiology 2, 1
If the lesion increases in size during this period, repeat tissue sampling is necessary, according to the National Comprehensive Cancer Network 3
If biopsy shows benign but image-discordant results, surgical excision is mandatory, as recommended by the National Comprehensive Cancer Network 2