Thirteen Takeaways on BI-RADS v2025 Changes for Mammography, Ultrasound and Breast MRI Reporting

Whether it is changes with calcification descriptors for mammogram review, new guidance for lymph node reporting, non-mass lesions on breast ultrasound and peritumoral edema on breast MRI, leading breast radiologists offer practical insights on all of the changes for the BI-RADS v2025 manual in a newly published review in the American Journal of Roentgenology.

Here are 13 pertinent takeaways from the review.

What Were Key Mammography Changes for BI-RADS v2025?

1. Masses no longer require confirmation on two projections. BI-RADS v2025 explicitly allows a suspicious finding seen on a single digital breast tomosynthesis (DBT) projection to be described as a mass, reflecting DBT's depth resolution and its now central role in mammographic interpretation.

2. Mass and calcification descriptors were reorganized to reduce ambiguity. "Microlobulated" was removed as a margin descriptor and "lobulated" was added as a shape descriptor. Architectural distortion and lymph nodes are now described as separate associated features rather than being grouped together. "Developing asymmetry" was eliminated as a standalone category with interval change now described more narratively.

3. A new approach for calcification descriptors. Emphasizing morphology and distribution, the BI-RADS v2025 system reorganizes the terminology for calcification descriptors in order to facilitate improved clarity in risk stratification and enhance reproducibility among readers.

4. While retaining the four breast density categories, the BI-RADS v2025 system emphasizes more of a focus on the densest region of the breast as opposed to an overall fibroglandular percentage. The BI-RADS v2025 system also requires density reporting on certain post-procedure mammograms (e.g., after clip placement) when reported separately from other exams.

5. Improved clarity for the BI-RADS category 0 assessment. Identifying whether this assessment is due to a need foradditional imaging evaluation versus a need for prior images for comparison may help reduce ambiguity for technologists, referring clinicians, and in outcomes tracking as well.

6. Enhanced guidance for lymph node reporting. For mammography reporting, a separate section for nodal evaluation — instead of previous notation in the “associated feature” section — may facilitate more systematic description of nodal morphology and laterality.

7. An updated guidance on dilated ducts. Offering separate categories for solitary and multiple dilated ducts, the BI-RADS v2025 system also emphasizes differentiation between benign dilated ducts and ductal dilatation that appears suspicious based upon laterality, associated calcifications, or other concerning features.

What Are the Pertinent Breast Ultrasound Updates with BI-RADS v2025?

8. New shape, echo pattern, and elasticity descriptors were added.The BI-RADS v2025 system adds “lobulated” as a shape descriptor for ultrasound and replaces “complex cystic and solid” with “mixed solid and cystic” as the most suspicious echo pattern descriptor. Newly incorporated elasticity descriptors are also noted in the updated BI-RADS v2025 system.

9. Non-mass lesion has been added for ultrasound findings with an emphasis on distribution, echo pattern, and posterior feature descriptors. The BI-RADS v2025 system also recognizes segmental distribution of a non-mass lesion as prognostic for malignancy.

10. Expanded guidance on lymph node and tissue composition. Nodal discussion is now inclusive of internal mammary and supraclavicular nodes as well as intramammary and axillary nodes. The BI-RADS v2025 system also added a new descriptor with glandular tissue component (GTC), a quartile-based qualifier of fibroglandular tissue. A moderate to marked GTC is associated with a 50 percent increased cancer risk relative to minimal to mild GTC, according to the BI-RADS v2025 system.

11. Calcification and associated feature terminology were updated for ultrasound. Calcifications are now subdivided into macrocalcifications and microcalcifications in the BI-RADS v2025 system. A new descriptor, “echogenic rind,” was added for thick echogenic bands around a mass or non-mass lesion that carry a high positive predictive value for malignancy and should be included in lesion size measurements. The BI-RADS v2025 system also denotes clustered microcysts as a benign BI-RADS category 2 presentation based on data showing they are rarely malignant.

What Does BI-RADS v2025 Change About Breast MRI Reporting?

12. Key terminology changes. For mass presentations on breast MRI, the BI-RADS v2025 system added “lobulated” as a shape descriptor and changed “irregular” to “indistinct” for margin descriptions. Other changes included the addition of “thick” to denote uneven thick rim enhancement and the use of T2 signal intensity as a mass descriptor.

13. Revision of associated features. The BI-RADS v2025 system has removed architectural distortion as an associated feature for breast MRI and replaces “invasion” with “involvement” when describing extended enhancement into extended structures. A new associated feature is peritumoral edema with the BI-RADS v2025 system noting that extensive peritumoral edema is linked to increased risk of lymph node metastases.