BI-RADS v2025: Key Updates and Implications for Breast Imaging Practice

BI-RADS v2025 updates the established BI-RADS framework to reflect contemporary breast imaging practice across mammography, ultrasound, MRI, and contrast-enhanced mammography (CEM). This review summarizes the principal cross-modality and modality-specific changes introduced in the new Manual and discusses their implications for interpretation, reporting, multidisciplinary communications, and audits, with an emphasis on new descriptor terminology, assessment clarifications, and modality comparisons. Key cross-modality updates include structured clinical indication categories, revised and standardized report organization, harmonized terminology, refined morphologic descriptors, refined assessment categories (e.g., clarification of BI-RADS categories 0 and 6; introduction of BI-RADS 4 subclassification for breast MRI to mirror other modalities), structured lesion localization, tissue composition assessment, lymph node reporting, and expanded audit methodology. Modality-specific changes include refined mammographic characterization for digital breast tomosynthesis, revised calcification terminology, recognition of nonmass lesions and perilesional echogenic features for ultrasound, introduction of enhancement and T2-related descriptors for MRI, and formal incorporation of CEM into the BI-RADS reporting framework. Overall, BI-RADS v2025 preserves the core principles of prior editions of structured reporting, evidence-based assessment categories, and linkage between imaging findings and management recommendations while improving reporting consistency and reproducibility, cross-modality correlation, and auditability and performance monitoring across the full spectrum of breast imaging modalities.