Do I need to refer a patient with a RAD (Radiology Assessment Data) TI (Tissue Imaging) 4 finding for biopsy despite the radiologist's recommendation for a 1-year follow-up?

Management of RAD TI 4 Findings: Biopsy vs. Follow-up

For a RAD TI 4 finding, you should proceed with biopsy despite the radiologist's recommendation for 1-year follow-up, as TI-RADS 4 represents a suspicious finding that warrants tissue diagnosis. 1

Understanding TI-RADS 4 Classification

• TI-RADS 4 (or NI-RADS 4 for neck imaging) represents a finding that is suspicious or highly suggestive of malignancy 1
• This category reflects a high probability of malignancy that requires tissue confirmation before treatment decisions 1
• Unlike lower categories (TI-RADS 1-3), category 4 findings have imaging characteristics that strongly suggest malignancy 1

Recommended Management Approach

When Biopsy is Necessary:

• For BI-RADS category 4 or 5 (suspicious or highly suggestive of malignancy), tissue diagnosis using core needle biopsy (preferred) or needle localization excisional biopsy is necessary 1
• The ACR guidelines clearly state that for suspicious findings (category 4), tissue diagnosis is required rather than observation 1
• Even when radiologists recommend follow-up for category 4 findings, clinical practice should adhere to established guidelines requiring biopsy 2

Special Considerations:

• While NI-RADS 4 often represents definitive known recurrence that may not require biopsy in some contexts, this applies primarily to cases where recurrence is unequivocal or when patients are enrolled in clinical trials 1
• For initial diagnosis (rather than known recurrence), biopsy remains the standard of care for category 4 findings 1

Potential Reasons for Discordant Recommendations

• Radiologist experience (≥20 years) may lead to less adherence to guidelines for suspicious findings 2
• Variations in practice patterns exist, particularly for high-risk lesions 3
• Miscommunication between radiologists and referring physicians regarding terminology and follow-up recommendations occurs frequently 4
• Error and discrepancy rates in radiology practice are estimated at 3-5% of studies reported 5

Algorithm for Decision Making

1. Confirm the TI-RADS 4 classification in the radiology report 1
2. Discuss with the radiologist why they recommended follow-up despite the category 4 designation 4
3. If no compelling reason exists to deviate from guidelines, proceed with tissue diagnosis 1
4. Choose the appropriate biopsy method based on lesion characteristics:
   • Core needle biopsy (preferred) for most lesions 1
   • Consider image-guided biopsy for deep or difficult-to-access lesions 1
5. Ensure pathology-imaging concordance after biopsy 1
   • If discordant, consider repeat biopsy or surgical excision 1

Important Caveats

• Discordance between radiologist recommendations and imaging category should prompt further discussion rather than automatic acceptance of follow-up 4
• Delaying biopsy of a suspicious finding could result in delayed diagnosis and treatment of malignancy 1
• The risk of missing malignancy with observation alone outweighs the risks associated with biopsy for category 4 findings 6
• Document your clinical reasoning if you choose to deviate from guidelines based on specific patient factors 2