ACR Releases BI-RADS® v2025 Manual

The American College of Radiology (ACR) has published the BI-RADS® v2025 Manual, an updated, illustrated reference designed to support clearer, more consistent breast imaging reports and performance evaluation in clinical practice.

What’s new at a high level

ACR frames BI-RADS v2025 as an extension of the 5th edition BI-RADS Atlas, with significant expansion in scope and content. The document shifts “edition” naming to a year-based versioning system, aligning BI-RADS with ACR’s broader RADS programs, and changes the name from BI-RADS Atlas to BI-RADS Manual to reflect expanded content.

The manual grows substantially in size and imagery, increasing from 696 pages in the prior edition to 896 pages in v2025 and expanding to 923 clinical images, including additional modality examples such as DBT, synthetic mammography, and ABUS.

Contrast-Enhanced Mammography becomes a core section

One of the most notable structural shifts is that contrast-enhanced mammography (CEM) is now an intrinsic section of the manual rather than a supplement—reflecting the modality’s increasing clinical use and the need for standardized reporting language.

Standardization across modalities and updated assessment language

ACR also harmonizes report organization across modalities and introduces standardized structured exam indication verbiage intended for consistent use across breast imaging. Lexicon terms are reordered “from least to most suspicious” where practical, supporting clarity and consistency in interpretation.

Assessment language is updated as well. For BI-RADS Category 0, the manual now separates incomplete assessments into two distinct statements—one for cases needing additional imaging evaluation and another for cases needing prior exams for comparison—reflecting updated MQSA-related requirements. Management language for Category 6 is revised to acknowledge definitive local therapies that may not always involve surgical excision.

Mammography updates: DBT, terminology refinements, and descriptor changes

Within mammography, BI-RADS v2025 incorporates examples beyond standard digital mammography, including DBT and synthetic mammography. It also updates definitions to reflect DBT capabilities—recognizing that features used to define a mass may be apparent on a single projection when imaged with DBT.

Their “What’s New” guide also details multiple terminology refinements aimed at reducing ambiguity (including adjustments to margin and shape terminology) and streamlining calcification descriptors by focusing on appearance rather than presumed histopathology.

MRI and broader workflow updates

Across sections, BI-RADS v2025 introduces dedicated FAQ sections and adds a general FAQ section addressing cross-modality questions. The guide also describes updated report organization for MRI, expanding structured elements such as acquisition parameters and background parenchymal enhancement (BPE). 

Additional information and resources can be found on the ACR's website.