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Objectives: To calculate the positive predictive value of biopsies performed (PPV3) of the Ultrasound section of the American College of Radiology Breast Imaging Reporting and Data System (ACR BI-RADS US) atlas categories 4 and 5 in different age groups and to determine whether patient age influences the PPV3 of each category in the diagnosis of breast lesions.Methods: We identified 2,433 ACR BI-RADS US categories 4 and 5 lesions with a known pathological diagnosis in 2,433 women. The patients were classified into three age groups (<35, 35-50, and >50 years). The age-related PPV3 of each category in the three age groups were calculated based on the pathological diagnoses and compared using the chi-squared test.Results: The overall PPV3 of each category was within the reference range provided by the ACR in 2013. PPV3 gradually increased with increasing age in patients with category 4 lesions. PPV3 in the oldest group with subcategories 4A and 4B lesions were close to or exceeded the reference values.Conclusions: PPV3 and age were significantly associated in patients with category 4 lesions according to the newest edition of ACR BI-RADS US in the diagnostic setting. Closer attention should be given to older patients when assigning a final assessment category.Key Points: • In patients with category 4 lesions , the likelihood of malignancy is associated with age. • In patients with category 5 lesions, the association is not definite. • Closer attention should be given to older patients in applying the ACR BI-RADS US. [ABSTRACT FROM AUTHOR]