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Purpose: The malignancy rates within the Breast Imaging Reporting and Data System (BI-RADS) category 4a and 4b lesions were examined, and the correlations with the histopathology results were analyzed. In addition, the positive predictive value (PPV) and clinical utility of BIRADS category 4a and 4b lesions for predicting a malignancy were assessed. Methods : : From January 2017 to December 2019, patients with BI-RADS category 4a and 4b lesions on breast ultrasonography (US) who underwent a subsequent core needle biopsy in the authors’ institution were evaluated. The clinical, pathological, and sonographic features were assessed to identify the malignancy rate and pathologic factors predictive of malignancy. The sensitivity, specificity, PPV, and negative predictive value (NPV) were calculated. A Binary logistic regression test was used to estimate the odds ratio (OR) and 95% confidence interval (CI). Results : : The study population included 314 lesions in 275 patients (mean age, 45.3 years; range, 21–78 years). The overall malignancy rate was 9.8% (31 of 314). The malignancy rates among the BI-RADS category 4a and 4b lesions were 9.3% (28 out of 300) and 21.4% (3 out of 14), respectively. Compared to the well-defined margins, ill-defined margins were associated with an increased risk of breast cancer with a corresponding OR (95% CI) of 1.880 (1.304-2.554). The sensitivity, specificity, PPV, and NPV of the C4a and C4b lesions were as follows: 90.3%, 3.9%, 9.4%, and 78.6%, respectively, for C4a lesions and, 9.7%, 96.1%, 21.4%, and 90.6%, respectively, for C4b lesions. Only the equivocal elasticity on ultrasonography was associated with an increased risk of breast cancer with an OR (95% CI) of 2.357 (1.004-5.532). Conclusion : : BI-RADS categories 4a and 4b are useful for predicting malignancy. Nevertheless, further studies will be needed to identify more predictive factors for breast cancer.

The concomitant presence of posterior mitral annular calcification and infectious mitral valve lesions poses a technical challenge with considerable perioperative risk when using previously proposed techniques for mitral valve surgery. Herein, we report a case of the use of a modified surgical technique to successfully treat a patient with mitral infective endocarditis complicated by a subendocardial abscess and extensive posterior mitral annular calcification.