Is a histopathological examination (HPE) necessary for a patient with a Breast Imaging-Reporting and Data System (BIRAD) 2 classification?

BI-RADS 2 Does Not Require Histopathological Examination

No, histopathological examination (HPE) is not necessary for BI-RADS 2 lesions—these are definitively benign findings that require only routine screening mammography. 1

Understanding BI-RADS 2 Classification

BI-RADS 2 represents lesions that are definitively benign with essentially 0% malignancy risk, including simple cysts, intramammary lymph nodes, calcified fibroadenomas, and other clearly benign findings. 1, 2

• Research confirms that the frequency of malignancy in breast lesions classified as BI-RADS 2 is zero (0/192 lesions in one study), making breast biopsies unnecessary in these cases. 2
• The positive predictive value for malignancy in BI-RADS 2 is 0.04 (4%), which is below the threshold requiring tissue diagnosis. 3

Management Algorithm for BI-RADS 2

For Asymptomatic Simple Cysts (BI-RADS 2):

• Clinical breast examination and ultrasound results must be concordant before proceeding to routine screening. 1
• Therapeutic aspiration should only be performed if persistent clinical symptoms are present (e.g., pain, discomfort). 1
• If asymptomatic and imaging-concordant, return directly to routine age-appropriate screening intervals. 1

For Other BI-RADS 2 Findings:

• No biopsy, aspiration, or short-term follow-up is required. 1, 2
• Resume routine screening mammography according to standard age-appropriate intervals. 1

Critical Distinction: BI-RADS 1 vs BI-RADS 2

BI-RADS 1 indicates a completely negative examination with no findings to report, while BI-RADS 2 indicates definitively benign findings are present but require documentation. 1

• Both categories have the same clinical management: return to routine screening without biopsy or short-term follow-up. 1
• Neither category requires histopathological examination under any circumstances when imaging and clinical findings are concordant. 1, 2

Common Pitfalls to Avoid

• Do not perform biopsy on BI-RADS 2 lesions simply because a finding is documented—this represents unnecessary intervention with zero clinical benefit. 2
• Ensure clinical-radiological concordance before dismissing a palpable finding as BI-RADS 2; if a palpable mass exists but imaging shows only benign findings, further evaluation may still be warranted based on clinical suspicion. 1
• Do not confuse BI-RADS 2 with BI-RADS 3 (probably benign, requiring short-term follow-up)—these are fundamentally different categories with different management algorithms. 4, 5