Review the practical BI-RADS v2025 updates to report organization, mammography, ultrasound, MRI, and contrast-enhanced mammography.
Browse the other checklists, phrase sets, and systematic approaches in this topic.
The American College of Radiology substantially updated the breast imaging lexicon and report organization in the BI-RADS v2025 Manual. The new version retains the mammography, ultrasound, MRI, and audit/outcomes-monitoring sections while adding contrast-enhanced mammography (CEM) as a fully integrated standalone section.
The summary below focuses on the changes a radiology resident should recognize first when moving from the fifth edition to the new version. It does not replace the BI-RADS v2025 Manual; the official guidance is required for detailed category and terminology use.
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.
One of the main goals of v2025 is to organize mammography, ultrasound, and MRI reports using a more consistent logic. The general sequence includes:
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.
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:
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.
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.
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:
Local templates used at a center that reports CEM should be compared with the official v2025 terminology.
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 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.
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.
“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.
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.
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.
Several terms have been updated to improve consistency across modalities:
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.
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.
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.
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.
Peritumoral edema has also been added to the associated features.
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.
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.
Make the separation between indication, comparison, technique, findings, assessment, and recommendation visible.
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.
Location details such as clock-face position, distance from the nipple, depth, and tissue layer facilitate mammography-ultrasound-MRI correlation.
When multiple findings are present, the final category is based on the most suspicious finding; the recommendation for each finding should remain understandable.
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.
The basic 0–6 category structure has been retained, but terminology, report organization, modality sections, and selected management statements have been updated.
New reports and educational materials should be brought into alignment with v2025. The transition period and local implementation may be managed by each institution.
The full Manual is sold by the ACR. The ACR has published a publicly accessible “What's New?” document summarizing the major updates.
This content is educational and is not patient-specific medical advice. Every phrase, template, classification result, and recommendation must be verified and adapted by a physician using the complete examination, clinical context, current guidelines, and institutional protocol.
Use the relevant RadPhrases calculator, then verify the result against the official guideline and the complete examination.