Key terms retired in 2025: "Microlobulated margin" (mammography) · "Developing asymmetry" · "Complex cystic and solid" (US) · "Focus" (MRI) · "Irregular margin" (MRI) · "Multiple regions" NME distribution · "Rim enhancement" (→ thick rim enhancement) · "Invasion" (→ involvement)
Assessment Categories
| Feature | BI-RADS 5th Ed (2013) | BI-RADS 2025 | Clinical Impact |
|---|---|---|---|
| Category 0 | Single category: "Incomplete — Need Additional Imaging and/or Prior Imaging for Comparison" | Split into 0A (need additional imaging) and 0B — NEW — need prior mammograms for comparison | Reflects 2024 FDA MQSA amendments. 0B: must reach final assessment within 30 days. Do NOT use 0A/0B to recommend supplemental MRI — give final category instead. |
| Category 0 usage | — | 0B only when priors genuinely required to render Cat 1 or 2 and feasibly obtainable. Do NOT use 0A to defer biopsy on a suspicious finding — assign Cat 4/5. | Prevents inappropriate deferral of biopsy. |
| Category 6 | "Surgical excision when clinically appropriate" | "Clinical follow-up with surgeon and/or oncologist, and definitive local therapy (usually surgery) when clinically appropriate." Cat 6 may also apply to additional close findings (ACFs) within 2 cm of biopsy-proven malignancy. | Ablation and non-surgical therapies now acknowledged. ACF provision avoids over-classifying small adjacent suspicious findings. |
Report Organization (All Modalities)
All modalities standardized to the same structure:
- Indication
- Comparison to prior exams
- Technique / Acquisition parameters
- Breast density / composition
- Findings
- Assessment
- Management recommendations
Breast density is now a mandatory standalone section in reports for all modalities. Technique/acquisition parameters is now a required section. Comparison to priors moves to section 2 (before technique).
Mammography
| Feature | BI-RADS 5th Ed (2013) | BI-RADS 2025 | Clinical Impact |
|---|---|---|---|
| DBT — mass definition | Mass must be seen in 2 projections | A mass apparent on a single DBT projection is valid | Changes how masses are characterized on tomosynthesis; no longer requires 2-view confirmation |
| Synthetic mammogram (SM) | Not formally addressed | SM formally recognized; lower spatial resolution than true 2D; can produce pseudocalcifications not present on tomo slices | Calcifications seen on SM but absent on tomo slices = pseudocalcification artifact — confirm with true 2D or magnification views |
| Margin: Microlobulated | Distinct margin descriptor (intermediate suspicion) | REMOVED. Describe as indistinct margin instead. Removed to avoid confusion with the shape term "lobulated." | Do not use "microlobulated margin" — use "indistinct margin." One of the most impactful daily reporting changes. |
| Shape: Lobulated | Eliminated from 5th edition | RETURNED as "lobulated" (not "lobular") — term changed to avoid confusion with lobular histologic subtype. Valid across mammography, US, MRI, and CEM. | Lobulated shape is back. Use "lobulated" not "lobular." Applicable across all modalities. |
| Calcification: Popcorn-like / Dystrophic | Listed as distinct types | Both → coarse (simplify reporting; move away from food-related and histopathology-based terms) | Use "coarse" for former popcorn-like and dystrophic calcifications. |
| Calcification: Milk of calcium | Distinct type | → Layering (emphasizes morphologic appearance — sedimentation on lateral view) | Use "layering." Smudgy on CC view, layers dependently on true lateral. |
| Calcification: Punctate | Parenthetical subset of "round" | Parenthetical removed — "round" now subsumes punctate (both <0.5 mm round particles; not practical to distinguish) | Use "round." Do not separately report "punctate." |
| Vascular calcifications | Typically benign | Retained as typically benign; now noted to be associated with increased cardiovascular disease risk | Mention vascular calcifications in the report — clinically significant beyond breast imaging. |
| Calcification distribution table | Table 3: PPV by distribution | REMOVED. Distribution no longer has its own PPV reference table. | Morphology remains primary driver for biopsy decisions. Distribution provides context only. |
| Developing asymmetry | Distinct asymmetry subtype | REMOVED as a descriptor. Now described as: an asymmetry (focal or global) that is "enlarging, becoming denser, or more conspicuous." | Do not use "developing asymmetry." Describe the finding type (focal/global asymmetry) and characterize the change in the report narrative. |
| Lymph nodes | Intramammary and axillary addressed separately | Combined into a single Lymph Nodes section with sub-findings. Multiple dilated ducts added as new finding — considered typically benign. | Report intramammary and axillary nodes under unified heading. |
| Solitary dilated duct | Generally BI-RADS 4A | When not associated with suspicious features and in asymptomatic individuals → can be considered benign. Symptomatic or with suspicious associated findings → workup warranted. | No longer automatically 4A in asymptomatic patients with isolated finding and no suspicious features. |
| Secondary findings | Axillary adenopathy, architectural distortion, calcifications listed as "associated features" | "Secondary findings" introduced. Architectural distortion and calcifications recategorized as secondary (or primary) findings — no longer merely associated features. Axillary adenopathy → Lymph Nodes section. | Architectural distortion and calcifications can now stand as primary findings in their own right. |
| MLO depth | Determined by vertical imaginary lines | Determined by lines paralleling the angle of the pectoralis major muscle | MLO depth stratification (anterior/mid/posterior) now aligns with pec major angle. |
| Special cases | No explicit cases for gynecomastia, implants, or mastectomy | Added: Gynecomastia, Implants/augmentation, Mastectomy. Hormone-induced breast tissue in transfeminine patients should NOT be characterized as gynecomastia. | Dedicated guidance for gynecomastia, augmentation, and post-mastectomy imaging. |
Ultrasound
| Feature | BI-RADS 5th Ed (2013) | BI-RADS 2025 | Clinical Impact |
|---|---|---|---|
| Non-mass lesion | Not in lexicon | NEW finding: discrete finding distinctly different from normal tissue, seen in 3 dimensions, but lacking discrete margination of a mass and unable to be assigned specific shape. Analogous to NME on MRI. | Non-mass lesion is now a reportable US finding. Report location, size, and associated features. |
| Tissue composition | Single descriptor | Expanded to tissue pattern + glandular tissue component (GTC) as a separate sub-finding | Report GTC separately when applicable. |
| Posterior features: combined pattern | Listed as option | REMOVED. If any shadowing present → characterize as shadowing | Do not use "combined pattern." Any shadowing → report as shadowing. |
| Echo pattern | Complex cystic and solid | → Mixed solid and cystic | Use "mixed solid and cystic." Retire "complex cystic and solid." |
| Associated features | Architectural distortion, duct changes, skin changes, edema, vascularity, elasticity | Added: echogenic pseudocapsule and echogenic rind as new sub-findings. Vascularity: "absent" → avascular; "vessels in rim" → peripheral vascularity. | Report echogenic pseudocapsule and echogenic rind when present. Update vascularity terminology. |
| Special cases | — | Added: foreign body, abscess, post-traumatic (non-surgical) changes. Lymph node reporting expanded to include internal mammary and supraclavicular nodes. | Abscess and post-traumatic changes are now explicit US special case categories. |
MRI
| Feature | BI-RADS 5th Ed (2013) | BI-RADS 2025 | Clinical Impact |
|---|---|---|---|
| Focus | Distinct finding (<5 mm enhancing dot) | ELIMINATED from MRI lexicon entirely | Do not report "focus." Describe small enhancing dots within mass/NME descriptors, or note as too small to characterize. |
| Margin: Irregular | Non-circumscribed/irregular listed as margin sub-descriptor | "Irregular" → "indistinct" under non-circumscribed margins — avoids duplication with "irregular" as a shape descriptor; harmonizes with mammography. Applies to CEM as well. | Use "indistinct" not "irregular" for non-circumscribed MRI masses. |
| T2 signal intensity | Not a mass sub-finding | Added as mass sub-finding: hyperintense / not hyperintense | Report T2 signal: hyperintense (fibroadenoma, cyst, mucinous carcinoma) vs. not hyperintense. |
| NME distribution: multiple regions | Listed as distribution descriptor | REMOVED | Do not use "multiple regions." Describe each region separately or use diffuse/regional. |
| Enhancement kinetics | "Kinetic curve assessment" / "initial phase" | → "Enhancement kinetics" / "early phase" | Use "enhancement kinetics" and "early phase." Retire "kinetic curve" and "initial phase." |
| Rim enhancement | "Rim enhancement" | → "Thick rim enhancement" ("thick" added for precision) | Use "thick rim enhancement." Plain "rim enhancement" is retired. |
| Invasion → Involvement | Skin invasion, nipple invasion, muscle invasion, chest wall invasion | All changed to "involvement": skin involvement, nipple involvement, pectoralis muscle involvement, chest wall involvement. Peritumoral edema added as new descriptor. Architectural distortion removed from associated features. | Do not use "invasion" in MRI reports. Use "involvement." Report peritumoral edema when present. |
| BPE: minimal | Minimal/mild/moderate/marked | "Minimal" now explicitly includes no enhancement | Do not create a separate "none" BPE category — none = minimal. |
| BPE reporting | Optional/variable | BPE is now a mandatory standalone report section | Explicitly document BPE level in every breast MRI report. |
| MRI report structure | Variable | Standardized: Indication → Comparison → Acquisition parameters → FGT → BPE → Findings → Assessment → Management | "Breast composition" → FGT. Acquisition parameters (including abbreviated protocol or DWI use) now required. |
Audit and Outcomes
| Feature | BI-RADS 5th Ed (2013) | BI-RADS 2025 | Clinical Impact |
|---|---|---|---|
| Cancer definition for audit | DCIS or any primary invasive breast carcinoma | Updated to include pleomorphic or florid lobular carcinoma in situ (PLCIS/FLCIS) in addition to DCIS and invasive carcinoma | PLCIS and FLCIS now count as cancer for audit — important for tracking upgrade rates from high-risk lesions. |
| Category 3 outcomes | Not included in basic audit | Now included in basic clinically relevant audit | Track and report Category 3 outcomes (cancers found at follow-up) as part of standard quality metrics — not only Category 4/5. |