A review in the American Journal of Roentgenology (30 September 2026) summarises the changes in the BI-RADS v2025 manual across mammography, tomosynthesis, ultrasound, MRI and contrast-enhanced mammography.
Across modalities, reports gain structured clinical indication categories, a standardised order, structured lesion location and lymph node reporting, and an expanded audit method. Categories 0 and 6 are clarified, and breast MRI now has a category 4 subdivision to match mammography and ultrasound. Calcification terms are revised, ultrasound recognises non-mass lesions and echogenic rims, MRI gains enhancement and T2 signal descriptors, and contrast-enhanced mammography is formally incorporated.
None of this changes the core logic of category-linked management, but templates, audit software and teaching sets will all need updating. Clinicians who receive breast reports will see an MRI category 4 with a letter for the first time, which carries a different likelihood of malignancy.
- Update reporting templates to the v2025 structure and indication categories.
- Use 4A, 4B or 4C for suspicious breast MRI findings, as with mammography and ultrasound.
- Report axillary lymph nodes in the structured way the new edition sets out.
- Tell referring surgeons and oncologists that MRI 4 subcategories are now in use.
- Check that your audit system can capture the expanded audit fields.
Why it matters
It changes what referrers read on every breast report, especially MRI, and how departments audit themselves.
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