How Does ACR BI-RADS® v2025 Change the Radiologist’s Approach? A Practical Guide Across Mammography, Ultrasound, and MRI: A Narrative Review

Twelve years after the 2013 fifth edition, the American College of Radiology has released BI-RADS® v2025, with substantial revisions across mammography, ultrasonography, MRI, and the newly independent contrast-enhanced mammography (CEM) section. This review compares the two editions and reads the main changes against the available evidence on diagnostic performance and reader agreement, rather than only cataloguing them. Examples featuring digital breast tomosynthesis, synthetic mammography, and automated whole-breast ultrasonography now appear throughout the modality sections. “Lobulated” has been added as a shape descriptor across all modalities, while “microlobulated” was dropped from the mammography margin list. Calcification terms shifted from etiology to morphology: “milk of calcium” became “layering,” “punctate” was folded into “round,” and “dystrophic” moved under “coarse.” Ultrasonography gained two new entries, “non-mass lesion” and “echogenic rind,” and on MRI, “initial phase” was renamed “early phase.” Category 6 was rewritten; therefore, surgical excision is recognized as one of several definitive local treatments, and an “uncoupled” principle now separates assessment from management. The auditing section folds Category 3 follow-up into basic auditing and adds a Method of Detection data field. Most supporting data, however, predate v2025, and reader agreement remains lower for newer descriptors such as non-mass enhancement; whether the revisions measurably improve reproducibility is still unproven. Integrating every high-sensitivity tool also brings more false positives, overdiagnosis, and cost; artificial intelligence and radiomics may help close the reproducibility gap, but resource-stratified, equitable implementation will be essential. With v2025, BI-RADS becomes a multimodality framework rather than a reporting lexicon alone.