Background <p>Fibroadenomas are benign breast tumors composed of epithelial and stromal tissue. While most have consistent imaging features and are considered simple fibroadenomas, several histological variants exist. Differentiating these subtypes is clinically relevant due to their variable behavior, potential for malignancy, and differing treatment considerations. In our study, we focused on one of these variants, which is complex fibroadenomas, aiming to identify the imaging features that aid in their diagnosis and thus guide further management.</p> Methods <p>This retrospective observational study included 175 female patients with 182 solid breast lesions, prospectively categorized as BI-RADS 3 or 4a, and were referred for biopsy. All lesions were assessed by mammography with complementary ultrasound or by ultrasound alone. Imaging features were analyzed and correlated with the corresponding histopathological results.</p> Results <p>According to the histopathological results, 115/182 lesions (63.2%) were proved to be simple fibroadenomas, while 67/182 lesions (36.8%) were proved to be complex fibroadenomas, of which 5 cases were associated with ductal carcinoma in situ based on the final postoperative pathological results. On analyzing the imaging features of the studied lesions, a significant correlation was found between the presence of internal microcalcifications, cystic changes, and increased vascularity and the diagnosis of complex fibroadenoma.</p> Conclusion <p>Complex fibroadenomas show distinct imaging characteristics compared to simple fibroadenomas, including internal calcifications, cystic areas, and enhanced vascularity. Although the overall risk of malignancy is low, tissue sampling is recommended when these features exist. Therefore, identifying these distinct radiological features aids in their diagnosis and guides the management strategy.</p>