Returning to routine screening for BI-RADS 3 lesions on supplemental automated whole-breast ultrasound reduces the cancer recall rate "substantially," while also being unlikely to result in adverse outcomes, according to research published July 14 in the American Journal of Roentgenology.
Results from a prospective study led by Richard Barr, PhD, from Northeastern Ohio Medical University in Rootstown supports routine annual follow-up for BI-RADS 3 lesions at supplemental automated whole-breast ultrasound.
This method of ultrasound detects additional cancers in women with dense breasts, but it also identifies many BI-RADS 3 lesions that result in short-term follow-ups and biopsies, Barr and his team said. Researchers wanted to evaluate outcomes in patients recommended for return to routine screening for lesions assessed as BI-RADS 3.
The team looked at 2,257 women between 2013 and 2016 with an average age of 58 years old. Whole-breast ultrasound was scored as BI-RADS 1 in 1,186 of the women, BI-RADS 2 in 591, BI-RADS 3 in 395, and BI-RADS 0 in 85.
The study authors found that routine follow-up of BI-RADS 3 lesions detected on supplemental screening in women with dense breasts and any risk resulted in a recall rate of 3.8%, a biopsy rate of 0.5%, and a positive biopsy rate of 58.3%, with no missed cancers.
A total of 394 patients with BI-RADS 3 had a two-year follow-up, during which no cancer was diagnosed in the quadrant of the lesion.
The researchers also found that malignancy rates were not different between BI-RADS 1, 2, and 3, and the ultrasound recall rate was 3.8%. They also found that if short-term follow-up had been recommended for automated whole-breast ultrasound BI-RADS 3, the recall rate would have been 21.3%.
Barr and his team said that automated whole-breast ultrasound can help lessen variability by standardizing documentation, recording, and archiving of ultrasound images from the entire breast, except the axilla. They also said that images of similar quality can be obtained from adequately trained ultrasonographers and mammographers.
![Examples of ultrasound findings and techniques. (A) Images in a 39-year-old male patient with a mass in the left thigh. The mass is heterogeneous on the B-mode US image (compared with the patient in D) and showed increased microvascularity (superb microvascular imaging [SMI]) and shear-wave elastography (SWE) values. Undifferentiated pleomorphic sarcoma was diagnosed at biopsy (with pleomorphic rhabdomyosarcoma in surgical specimen). (B) Images in an 18-year-old male patient with a mass in the left leg. The mass is hypoechoic on the B-mode image, with no other findings suggestive of malignancy. The lesion is in contact with the cortex of the tibia, which is slightly irregular. CT revealed a doubtful anteromedial tibial erosion. The microvascular study demonstrated high vascularization, suggestive of malignancy. Periosteal Ewing sarcoma was diagnosed with both histologic and immunohistochemical confirmation. (C) Images in a 69-year-old female patient with a lump growing on the outside of the left leg. Multiple SWE examinations were performed (please note the high values obtained in the measurements, whereas the color map highlights the stiffness relative to adjacent tissues). SMI showed areas of increased vascularization to target for sampling. Undifferentiated spindle cell sarcoma was diagnosed at biopsy, with residual leiomyosarcoma in the surgical specimen after neoadjuvant therapy. (D) Images in a 56-year-old female patient with a mass in the right thigh. The mass is heterogeneous at both B-mode ultrasound (similar to patient A) and MRI (coronal T2-weighted spectral attenuated inversion recovery [SPAIR]; T1-weighted pre-contrast and postcontrast imaging), which even shows uptake after the administration of paramagnetic contrast material, which is traditionally suggestive of malignancy. Low values at SMI and elastography are suggestive of benignity. Spindle cell lipoma was diagnosed at biopsy, with atypical spindle cell lipomatous tumor in the surgical specimen.](https://img.auntminnie.com/mindful/smg/workspaces/default/uploads/2026/08/images-radiol250278fig2.APCFLSvX6p.jpg?auto=format%2Ccompress&fit=crop&h=100&q=70&w=100)
![Examples of ultrasound findings and techniques. (A) Images in a 39-year-old male patient with a mass in the left thigh. The mass is heterogeneous on the B-mode US image (compared with the patient in D) and showed increased microvascularity (superb microvascular imaging [SMI]) and shear-wave elastography (SWE) values. Undifferentiated pleomorphic sarcoma was diagnosed at biopsy (with pleomorphic rhabdomyosarcoma in surgical specimen). (B) Images in an 18-year-old male patient with a mass in the left leg. The mass is hypoechoic on the B-mode image, with no other findings suggestive of malignancy. The lesion is in contact with the cortex of the tibia, which is slightly irregular. CT revealed a doubtful anteromedial tibial erosion. The microvascular study demonstrated high vascularization, suggestive of malignancy. Periosteal Ewing sarcoma was diagnosed with both histologic and immunohistochemical confirmation. (C) Images in a 69-year-old female patient with a lump growing on the outside of the left leg. Multiple SWE examinations were performed (please note the high values obtained in the measurements, whereas the color map highlights the stiffness relative to adjacent tissues). SMI showed areas of increased vascularization to target for sampling. Undifferentiated spindle cell sarcoma was diagnosed at biopsy, with residual leiomyosarcoma in the surgical specimen after neoadjuvant therapy. (D) Images in a 56-year-old female patient with a mass in the right thigh. The mass is heterogeneous at both B-mode ultrasound (similar to patient A) and MRI (coronal T2-weighted spectral attenuated inversion recovery [SPAIR]; T1-weighted pre-contrast and postcontrast imaging), which even shows uptake after the administration of paramagnetic contrast material, which is traditionally suggestive of malignancy. Low values at SMI and elastography are suggestive of benignity. Spindle cell lipoma was diagnosed at biopsy, with atypical spindle cell lipomatous tumor in the surgical specimen.](https://img.auntminnie.com/mindful/smg/workspaces/default/uploads/2026/08/images-radiol250278fig2.APCFLSvX6p.jpg?auto=format%2Ccompress&dpr=2&fit=crop&h=167&q=70&w=250)
