Breast imaging-reporting and data system (BI-RADS) assessment category 5

Last revised by Dr MT Niknejad on 30 Jul 2022

BI-RADS 5 lesions under the BI-RADS (breast imaging reporting and data system) refer to breast lesions that are highly suspicious for malignancy, requiring appropriate action to be taken (i.e. biopsy and management as appropriate). BI-RADS 5 lesions have the characteristic morphology of breast cancer with a ≥ 95% chance of being malignant1.

The implication of a BI-RADS 5 finding, in contrast to BIRADS 4, is that if the histology is benign, it should be considered discordant with imaging findings, and lesion excision is still advised.

Radiographic features

Mammography

A BI-RADS 5 lesion has the typical imaging features of breast malignancy. On a mammogram, any two of the following features are demonstrated:

  • spiculated or irregular mass
  • high density
  • fine linear or linear branching segmental calcifications

Nipple retraction, skin thickening and evidence of interval growth, if present, would support the diagnosis.

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Cases and figures

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  • Case 19: bilateral invasive lobular carcinoma
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