BI-RADS v2025: What Changed in the New Manual?

What changed in BI-RADS v2025?

BI-RADS v2025 changes the breast-imaging lexicon and report organization while adding contrast-enhanced mammography (CEM) as a fully integrated standalone section. It retains the mammography, ultrasound, MRI, and audit/outcomes-monitoring sections.

This article summarizes the changes that a radiology resident accustomed to the previous fifth edition should recognize first when transitioning to the new version. It does not replace the BI-RADS v2025 Manual; the official guidance is required for detailed category and terminology use.

The most fundamental change: “Manual” instead of “Atlas”

To reflect the scope of the content, the ACR changed the name from “BI-RADS Atlas” to “BI-RADS Manual.” Version naming also moved from edition number to publication year. As a result, the preferred term is BI-RADS v2025, rather than “sixth edition.”

The new version expanded from the previous 696-page structure to a more comprehensive 896-page resource and includes more clinical examples across different modalities.

Report organization is more consistent across modalities

One of the main goals of v2025 is to organize mammography, ultrasound, and MRI reports using a more consistent logic. The general sequence includes:

1. Indication
2. Comparison with prior examinations
3. Technique or acquisition parameters
4. Modality-specific tissue/density information
5. Findings
6. Assessment
7. Management recommendation

The practical implication for a resident is that the “findings paragraph” should be clearly separated from the “final assessment and recommendation.” Technical information becomes more visible, and comparison appears earlier in the report.

BI-RADS 0 now separates two different needs

In prior use, BI-RADS 0 could combine the need for additional imaging and/or prior images under a single statement. v2025 separates these into two clearer situations:

• Additional imaging evaluation is required
• Comparison with prior examinations is required

This distinction matters for patient recall and workflow. “Prior studies are pending” and “targeted ultrasound/additional mammographic views are required” do not have the same operational meaning.

BI-RADS 6 management language has broadened

The management language for category 6, used for a known biopsy-proven malignancy, has moved from wording focused only on surgical excision toward a broader framework of clinical management and definitive local treatment. This acknowledges that definitive local treatment may not always be limited to surgery.

The report should clearly state that the patient already has a diagnosis. Any new suspicious findings should be described separately.

Contrast-enhanced mammography is now a core section

In v2025, CEM has moved from supplemental material to a fully integrated section of the Manual. This means that the following are more clearly standardized:

• Acquisition and technical standards
• A shared lexicon for findings
• Report organization
• Assessment approach

Local templates used at a center that reports CEM should be compared with the official v2025 terminology.

Notable changes in mammography

Defining a mass on DBT

The previous approach emphasized seeing a mass in two projections. v2025 recognizes that, in digital breast tomosynthesis, the required features may be demonstrated in a single projection. This relates to the ability of DBT sections to show a lesion's three-dimensional characteristics more clearly.

The “microlobulated” margin term has been removed

The “microlobulated” margin term was removed from the margin options to reduce confusion with the “lobulated” shape term. When appropriate, this appearance is recommended to be described under an “indistinct” margin. The “lobulated” shape term, meanwhile, has returned to the lexicon.

Some calcification terminology has been simplified

v2025 includes changes that reduce food-based analogies and emphasize morphology. For example, “popcorn-like” is no longer separately emphasized and is grouped under “coarse”; “milk of calcium” is replaced by the appearance-based term “layering.” “Dystrophic” is no longer a separate term and is included within the coarse group.

The developing-asymmetry term has changed

“Developing asymmetry” was removed as a lexicon definition because it embeds temporal change within the lesion name. The morphology of the asymmetry and the fact that it is new or increased compared with prior imaging should be stated as separate elements in the report.

Notable changes in breast ultrasound

Tissue composition has been expanded

The ultrasound section adds subdescriptors such as tissue pattern and glandular-tissue component. This structure aims to describe the background tissue more consistently, especially in screening ultrasound.

“Non-mass lesion” has been added as a finding

v2025 introduces the concept of a non-mass lesion for an area that differs from normal tissue and can be identified in three dimensions but lacks a definite mass boundary and shape. The term should not be used casually to mean “an abnormal area that is not a mass”; it should be learned using the official definition and examples.

Terminology has been harmonized

Several terms have been updated to improve consistency across modalities:

• “Not parallel” → “Non-parallel”
• “Not circumscribed” → “Non-circumscribed”
• “Complex cystic and solid” → “Mixed solid and cystic”
• “Absent vascularity” → “Avascular”
• “Vessels in rim” → “Peripheral vascularity”

English-language templates should use the official terms consistently. In translated local templates, the institution should choose stable equivalents while allowing users to understand which English Manual term each expression represents.

Lymph nodes receive separate and more extensive coverage

The discussion of intramammary, axillary, internal mammary, and supraclavicular lymph nodes has been expanded in relation to morphology, reporting, and staging. Rather than compressing axillary adenopathy into an “associated features” line, it is increasingly important to document nodal morphology and clinical context explicitly.

Notable changes in breast MRI

“Focus” has been removed as a finding category

The separate “focus” finding category used in the prior version has been removed. Small enhancing findings should be handled using the appropriate categories and descriptors in the official v2025 lexicon.

T2 signal intensity has been added as a mass subfeature

Subdescriptors have been added for whether a mass is T2 hyperintense or not T2 hyperintense. This feature does not determine the assessment category by itself; it is interpreted together with morphology and enhancement characteristics.

Some MRI terms have been simplified

• “Kinetic curve assessment” has become “enhancement kinetics”
• “Initial phase” has become “early phase”
• “Rim enhancement” has become “thick rim enhancement”
• “Invasion” has become “involvement” in selected contexts

Peritumoral edema has also been added to the associated features.

Acquisition parameters are more visible

The MRI section includes new information on abbreviated protocols and diffusion-weighted imaging. When relevant, report templates are expected to carry acquisition parameters and background parenchymal enhancement explicitly.

What should change for the resident?

1. Do not use old smart text blindly

Macros that have remained unchanged for more than a decade may contain terms that have been removed or renamed. Breast imaging shortcuts should carry a version label.

2. Standardize report order

Make the separation between indication, comparison, technique, findings, assessment, and recommendation visible.

3. Describe the finding and temporal change separately

Instead of writing only “developing asymmetry,” describe the asymmetry's morphology and separately state that it is new or has increased compared with prior imaging.

4. Correlate the same lesion across modalities

Location details such as clock-face position, distance from the nipple, depth, and tissue layer facilitate mammography-ultrasound-MRI correlation.

5. Keep the BI-RADS category consistent with the findings list

When multiple findings are present, the final category is based on the most suspicious finding; the recommendation for each finding should remain understandable.

Example report organization

INDICATION Evaluation of a palpable left breast mass.

COMPARISON Compared with mammography dated March 15, 2025.

TECHNIQUE Bilateral digital mammography and tomosynthesis images were obtained.

BREAST DENSITY [BI-RADS v2025-compatible density statement]

FINDINGS In the upper outer quadrant of the left breast ...

ASSESSMENT BI-RADS 4 — suspicious finding.

RECOMMENDATION Ultrasound-guided core biopsy is recommended.

This structure is an example. The official Manual should be used for category wording and the detailed lexicon.

Frequently asked questions

Have the BI-RADS categories changed completely?

The basic 0–6 category structure has been retained, but terminology, report organization, modality sections, and selected management statements have been updated.

Can the old fifth edition no longer be used?

New reports and educational materials should be brought into alignment with v2025. The transition period and local implementation may be managed by each institution.

Is BI-RADS v2025 free?

The full Manual is sold by the ACR. The ACR has published a publicly accessible “What's New?” document summarizing the major updates.

References

1. American College of Radiology. Breast Imaging Reporting & Data System (BI-RADS). Source (opens in a new tab)
2. American College of Radiology. ACR BI-RADS v2025 Manual — What's New? November 2025. Source (opens in a new tab)
3. Newell MS, Destounis SV, Leung JWT, DeMartini WB, Lee CH, Eby PR. ACR BI-RADS v2025 Manual. Reston, VA: American College of Radiology; 2025.