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

[00:00:02][music] >> Hello.

[00:00:06]And thank you for joining us. We are pleased to present our review article, BI-RADS version 2025, key updates and implications for breast imaging practice. I'm speaking on behalf of my co-authors from the University of Udine.

[00:00:21]In this presentation, we will summarize the most relevant updates introduced in the new BI-RADS edition and discuss their implications for daily breast imaging practice.

[00:00:32]One of the first major changes introduced in BI-RADS version version 2025 is the adoption of a more standardized reporting structure across imaging modalities.

[00:00:42]The goal is to improve consistency and facilitate communication among radiologists, surgeons, oncologists, and other members of the multidisciplinary team.

[00:00:52]Comparison with prior imaging studies is now presented at the beginning of the report, highlighting the importance of temporal assessment in imaging interpretation.

[00:01:01]Furthermore, acquisition parameters and tissue composition are reported in dedicated sections, ensuring that key technical and contextual information is presented in a clear and consistent manner.

[00:01:15]BI-RADS version 2025 also introduces standardized clinical indication categories. Examinations are now categorized as screening, diagnostic evaluation, or imaging performed in patients with known breast cancer.

[00:01:29]By explicitly incorporating the clinical indication into the reporting framework, BI-RADS version 2025 strengthens the contextual interpretation, improves communication with referring physicians, and supports more meaningful audit and performance assessment.

[00:01:45]BI-RADS category 6 is assigned to lesions with unknown histopathologic diagnosis of malignancy prior to definitive treatment. In this setting, imaging plays a central role in defining disease extent, guiding treatment planning, and monitoring response to therapy.

[00:02:04]In breast MRI, contiguous or adjacent findings with similar morphology may be indicated near the index malignancy.

[00:02:13]These findings often represent extensions of the same disease process and are particularly relevant when located within 2 cm of the known cancer.

[00:02:25]BI-RADS version 2025 clarifies that when these adjacent findings do not alter clinical management, they may be incorporated within the same category 6 assessment rather than receiving separate assessment categories.

[00:02:38]In these situations, reporting should emphasize the overall extent of disease and the spatial relationship between findings, providing a more clinically meaningful description of tumor distribution.

[00:02:52]One of the most relevant ultrasound updates introduced in BI-RADS version 2025 is the glandular tissue component or GTC. But what exactly does GTC represent?

[00:03:04]Fibroglandular tissue is composed of different tissue components. One of these is hyperechoic fibrous tissue, which contributes to the overall architecture of the breast parenchyma.

[00:03:16]The glandular component consists of lobules and terminal ducts. Together, lobules and terminal ducts form the terminal ductal lobular units or TDLUs, which represent the glandular component of the fibroglandular tissue.

[00:03:33]BI-RADS version 2025 defines GTC as the ratio of these glandular structures to the total fibroglandular tissue expressed as a percentage.

[00:03:45]Minimal GTC corresponds to less than 25% glandular tissue and is characterized by predominantly fibrous breast parenchyma.

[00:03:55]Mild GTC corresponds to 25% glandular tissue and remains predominantly fibrous in composition.

[00:04:04]Moderate GTC reflects a progressive increase in glandular tissue representing 50% of total fibroglandular tissue.

[00:04:15]Marked GTC corresponds to at least 75% glandular tissue and represents the most glandular rich category.

[00:04:24]For reporting purposes, GTC can be grouped also into two broader categories.

[00:04:31]Low GTC which includes minimal and mild patterns and high GTC which includes moderate and marked patterns.

[00:04:41]Additionally, BI-RADS version 2025 introduces a standardized layer-based approach for ultrasound lesion localization.

[00:04:50]The most superficial layer corresponds to the echogenic skin. Beneath the skin lies the isoechoic subcutaneous fat. The central portion of the breast is composed of echogenic fibroglandular tissue.

[00:05:05]Posteriorly, the retroglandular fat separates the breast parenchyma from the chest wall.

[00:05:11]The deepest landmark is the pectoralis major muscle.

[00:05:15]Another important update in BI-RADS version 2025 is the introduction of lymph nodes as a dedicated reporting category across imaging modalities.

[00:05:25]BI-RADS version 2025 adopts a morphology-based approach to lymph node assessment. Key suspicious features include cortical thickening, loss of the fatty hilum, nodal rounding, internal change, and abnormal vascularity.

[00:05:43]BI-RADS version 2025 also incorporates regional nodal anatomy according to TNM staging.

[00:05:50]Assessment now includes intramammary, axillary, internal mammary, and supraclavicular lymph node stations.

[00:05:59]Within the axilla, levels 1, 2, and 3 are defined based on the location of the nodes to the pectoralis minor muscle, which serves as a principal anatomical landmark for standardized nodal localization and reporting.

[00:06:14]This structured approach improves communication and facilitates integration in multi-disciplinary clinical management.

[00:06:23]In mammography, BI-RADS version 2025 formally integrates digital breast tomosynthesis into the reporting framework, reflecting its central role in contemporary breast imaging practice.

[00:06:36]Mass characterization has been refined, allowing lesion classification based on a single DBT projection, and introducing updates to shape and margin descriptors.

[00:06:48]In addition, calcification terminology has been simplified. Descriptors such as popcorn-like and dystrophic are now incorporated within the broader category of coarse calcifications.

[00:07:02]The word punctate has been replaced by round, and milk calcium is now described as layering.

[00:07:11]Several ultrasound-specific were introduced in BI-RADS version 2025.

[00:07:16]These include the formal introduction of non-mass lesions as a distinct finding.

[00:07:21]Now, perilesional echogenic features, such as echogenic rind and pseudocapsule, a structured approach to calcification reporting, and replacement of the term complex cystic and solid lesion with mixed solid and cystic breast lesion, emphasizing the diagnostic importance of solid component.

[00:07:41]MRI-related updates in BI-RADS version 2025 primarily aim to reduce ambiguity in lesion characterization. Key changes include removal of the descriptor focus, replacement of rim enhancement and thick rim enhancement, and the introduction of supportive features such as T2 signal intensity and peritumoral edema, which may provide additional diagnostic and prognostic information.

[00:08:08]Moreover, subclassification of category 4, categories 4A, 4B, and 4C is explicitly introduced for breast MRI, aligning MRI assessment with mammography and ultrasound.

[00:08:24]Unlike other modalities, BI-RADS version 2025 introduces no major conceptual changes for contrast-enhanced mammography.

[00:08:32]However, its formal integration into the BI-RADS framework represents an important step towards cross-modality standardization.

[00:08:41]Enhancement descriptors are aligned with MRI terminology.

[00:08:45]Morphologic descriptors are harmonized with mammography, and CEM is now recognized as a routine component of breast imaging assessment rather than a complementary technique.

[00:08:58]Beyond standardizing terminology and reporting, BI-RADS version 2025 strengthens audit and performance monitoring by introducing standardized definitions of positive and negative examinations.

[00:09:11]This facilitates more reliable performance metrics, benchmarking, and quality assurance. The manual also provides dedicated audit recommendations for specific clinical settings, such as preoperative breast MRI, further integrating audit into routine breast imaging practice.

[00:09:32]Thank you for your attention. We hope this presentation has highlighted that BI-RADS version 2025 is more than an update. It is a shared language designed to improve consistency, communication, and patient care.

[00:09:46]We look forward to exploring future developments in breast imaging together.