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We developed a machine learning model based on radiomics to predict the BI-RADS category of ultrasound-detected suspicious breast lesions and support medical decision-making towards short-interval follow-up versus tissue sampling. From a retrospective 2015–2019 series of ultrasound-guided core needle biopsies performed by four board-certified breast radiologists using six ultrasound systems from three vendors, we collected 821 images of 834 suspicious breast masses from 819 patients, 404 malignant and 430 benign according to histopathology. A balanced image set of biopsy-proven benign (n = 299) and malignant (n = 299) lesions was used for training and cross-validation of ensembles of machine learning algorithms supervised during learning by histopathological diagnosis as a reference standard. Based on a majority vote (over 80% of the votes to have a valid prediction of benign lesion), an ensemble of support vector machines showed an ability to reduce the biopsy rate of benign lesions by 15% to 18%, always keeping a sensitivity over 94%, when externally tested on 236 images from two image sets: (1) 123 lesions (51 malignant and 72 benign) obtained from two ultrasound systems used for training and from a different one, resulting in a positive predictive value (PPV) of 45.9% (95% confidence interval 36.3–55.7%) versus a radiologists’ PPV of 41.5% (p &lt; 0.005), combined with a 98.0% sensitivity (89.6–99.9%); (2) 113 lesions (54 malignant and 59 benign) obtained from two ultrasound systems from vendors different from those used for training, resulting into a 50.5% PPV (40.4–60.6%) versus a radiologists’ PPV of 47.8% (p &lt; 0.005), combined with a 94.4% sensitivity (84.6–98.8%). Errors in BI-RADS 3 category (i.e., assigned by the model as BI-RADS 4) were 0.8% and 2.7% in the Testing set I and II, respectively. The board-certified breast radiologist accepted the BI-RADS classes assigned by the model in 114 masses (92.7%) and modified the BI-RADS classes of 9 breast masses (7.3%). In six of nine cases, the model performed better than the radiologist did, since it assigned a BI-RADS 3 classification to histopathology-confirmed benign masses that were classified as BI-RADS 4 by the radiologist.

A Machine Learning Ensemble Based on Radiomics to Predict BI-RADS Category and Reduce the Biopsy Rate of Ultrasound-Detected Suspicious Breast Masses