Current Status and Future of BI-RADS in Multimodality
Imaging, From the AJR Special Series on Radiology
Reporting and Data Systems
Mohammad Eghtedari, MD, PhD1, Alice Chong, MD, MHCI, Rebecca Rakow-Penner, MD, PhD, Haydee Ojeda-Fournier, MD
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Breast Imaging · Review
Keywords
BI-RADS, breast cancer, breast ultrasound,
dynamic contrast-enhanced breast MRI,
mammography
Submitted: Sep 28, 2020
Revision requested: Oct 16, 2020
Revision received: Nov 12, 2020
Accepted: Dec 1, 2020
First published online: Dec 9, 2020
The authors declare that they have no
disclosures relative to the subject matter of
this article.
Based on presentations at the Radiological
Society of North America 2014 annual
meeting, Chicago, IL, and the 2019
European Congress of Radiology annual
meeting, Vienna, Austria.
Eghtedari et al.
BI-RADS in Multimodality Imaging
Breast Imaging
Review
Eghtedari M, Chong A, Rakow-Penner R,
Ojeda-Fournier H
doi.org/10.2214/AJR.20.24894
AJR 2021; 216:860–873
ISSN-L 0361–803X/21/2164–860
© American Roentgen Ray Society
860 | www.ajronline.org
BI-RADS is a communication and data tracking system that has evolved since its
inception as a brief mammography lexicon and reporting guide into a robust struc-
tured reporting platform and comprehensive quality assurance tool for mammog-
raphy, ultrasound, and MRI. Consistent and appropriate use of the BI-RADS lexicon
terminology and assessment categories effectively communicates findings, esti-
mates the risk of malignancy, and provides management recommendations to pa-
tients and referring clinicians. The impact of BI-RADS currently extends internation-
ally through six language translations. A condensed version has been proposed to
facilitate a phased implementation of BI-RADS in resource-constrained regions. The
primary advance of the 5th edition of BI-RADS is harmonization of the lexicon terms
across mammography, ultrasound, and MRI. Harmonization has also been achieved
across these modalities for the reporting structure, assessment categories, manage-
ment recommendations, and data tracking system. Areas for improvement relate to
certain common findings that lack lexicon descriptors and a need for further clarifica-
tion of proper use of category 3. BI-RADS is anticipated to continue to evolve for ap-
plication to a range of emerging breast imaging modalities.
BI-RADS was developed and updated to the current 5th edition by committees compris-
ing breast imaging radiologists and breast-specific subspecialty clinicians [1–5]. It has evolved
from a simple mammography lexicon to a multimodality lexicon for mammography, ultra-
sound (US), and MRI. As a structured reporting platform and comprehensive quality assur-
ance tool, BI-RADS provides assessment categories and management recommendations.
This review describes the origin, current functions, and potential future applications of
BI-RADS. It summarizes breast imaging lexicons’ harmonization across multiple imaging
modalities, resulting in improved reporting and communication.
Past
The first edition of BI-RADS in 1992 introduced the practice of standardized reporting
in mammography whereby a specific lexicon of imaging features was created to provide
specific and consistent management recommendations [1]. Lexicon descriptors predict-
ed probabilities for both benign and malignant disease on the basis of lesion shape and
margin across multiple modalities including mammography, US, and breast MRI (Figs. 1
and 2). Subsequent editions of BI-RADS were released in 1995, 1998, and 2003 [2–4]. The
3rd edition (1998) was the first to contain an atlas of images to illustrate examples of each
descriptor [3]. The 4th edition (2003) revised terminology; subdivided category 4 findings
into a, b, and c; and introduced US and MRI standardized reporting [4].
Present
The BI-RADS 5th edition, copyrighted in 2013 and released in February 2014, is substan-
tially expanded [5]. It contains over 700 illustrations and has an accompanying electronic
version. The digital BI-RADS manual provides hyperlinks to lexicon descriptors, frequently
asked questions (FAQ), and references. Reorganization and consolidation of terms include
simplification of US and MRI lexicon descriptors in the special cases section. The 5th edi-
tion also allows a diagnosis to serve as descriptor; for example, “post-surgical change” may
be used to describe an area of postsurgical change rather than describing shape, margins,
and echogenicity of the finding or findings (Fig. 3). New lesion descriptors include devel-
oping asymmetry for mammography, elasticity assessment for US (Fig. 4), and breast im-
plant descriptors for MRI (Fig. 5).
1
All authors: Department of Radiology, University of California San Diego Health System, 9400 Campus Point Dr,
La Jolla, CA 92037. Address correspondence to H. Ojeda-Fournier (hojeda@health.ucsd.edu).
AJR:216, April 2021
 BI-RADS in Multimodality Imaging
Although assessment categories and recommendations re-
main unchanged in the 5th edition, BI-RADS categories and rec-
ommendations are now decoupled and may stand independent-
ly. For instance, BI-RADS category 2 is assigned to a breast
abscess or a simple cyst that is symptomatic because of size to
indicate benignity. Recommendation for aspiration may be made
for symptomatic relief rather than a recommendation to return to
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annual mammography that was previously coupled to a BI-RADS
category 2 assignment. This change allows flexibility in manage-
ment recommendations while maintaining accurate medical au-
dits based on imaging findings.
Other improvements to the BI-RADS manual include an ex-
panded FAQ section and data tables summarizing published
studies that validate descriptors in the lexicon (e.g., the likelihood
of malignancy associated with the distribution of calcifications).
The BI-RADS website provides publicly available downloadable
reference cards, FAQ documents, a digital breast tomosynthesis
(DBT) supplement, and selected content from the mammogra-
phy, US, and MRI manuals. Open access to website content in-
cludes a summary of clinically relevant audits, guidance on data
to be collected, and derived data to evaluate.
Assessment Categories and Recommendations
Table 1 summarizes the seven assessment categories with as-
sociated standardized recommendations. The Mammography
Quality Standards Act (MQSA) regulations mandate that each
mammography report include the assessment category [6]. Spe-
cifically, the report must include the assessment category word,
rather than the number. For example, a negative screening mam-
mogram needs to state “negative.” Stating solely “category 1” or
“BI-RADS category 1” is insufficient to comply with the federal
law. The final category applies to the overall study. However, fa-
cilities may obtain permission to give a final assessment to each
breast. BI-RADS recommendations are concordant with the man-
dated assessment recommendations. Although not required by
MQSA, the same assessment categories and their accompanying
recommendation should also be used for US and MRI.
The assessment categories predict benign versus malignant
breast disease [7, 8]. Categories 0, 1, and 2 are used at screening
mammography, US, and MRI with the same implication. Catego-
ry 0 indicates an incomplete study, whereas categories 1 and 2 in-
dicate a benign finding. Categories 3, 4, and 5 are assigned after
a complete diagnostic imaging evaluation. Performing diagnos-
tic evaluation of a finding identified at screening mammography,
even if the finding has features characteristic of malignancy, allows
direct conversation with the patient regarding the imaging finding
as well as discussion of next steps, including image-guided biopsy.
BI-RADS category 3 is associated with a less than 2% likelihood
of malignancy and is not intended to be used when a radiologist
is unsure of a finding. A favorable outcome of appropriate use
of BI-RADS category 3 is reducing the number of false-positive
biopsies while maintaining an acceptable cancer detection rate.
A study by Berg et al. [9] of 45,202 women from 471 centers in
the National Mammography Database found a 1.86% cumulative
cancer yield for BI-RADS category 3, validating the appropriate
use of this category. In that study, nearly 58% of the malignancies
were diagnosed at or before the 6-month interval follow-up, un-
derscoring the efficacy of this short-term follow-up recommen-
AJR:216, April 2021
HIGHLIGHTS
 The primary advance of the 5th edition of BI-RADS is
harmonization of lexicon terms across mammography,
US, and MRI.
 The assessment categories 0 through 6 estimate prob-
ability of malignancy and provide management rec-
ommendations; further clarification of proper usage of
category 3 is warranted.
 BI-RADS will likely continue to evolve for application to
emerging breast imaging modalities, including molec-
ular breast imaging, contrast-enhanced mammogra-
phy, and positron emission mammography.
dation. However, BI-RADS category 3 remains confusing and in-
correctly used [10]. Three BI-RADS category 3 findings that have
been validated for use at baseline mammography or in exam-
inations with no available prior imaging include grouped round
(punctate) calcifications, circumscribed solitary mass, or a focal
asymmetry with no US correlate after complete diagnostic eval-
uation [11–13]. Specific US criteria for BI-RADS category 3 include
nonpalpable circumscribed oval masses suggesting fibroadeno-
ma and complicated cysts. Evidence for specific criteria, appro-
priate length of follow-up, or acceptable cancer detection rates
is lower for MRI BI-RADS category 3, possibly relating to the high-
er cancer yield for lesions in that category compared with mam-
mographically detected BI-RADS category 3 lesions [14]. Grimm
et al. [15] reported a 4.3% malignancy rate for MRI BI-RADS cate-
gory 3 lesions, with nonmass enhancement exhibiting over twice
the malignancy rate of foci and masses. Several studies have re-
ported that the short-term follow-up afforded by BI-RADS cate-
gory 3 allowed early-stage breast cancer identification, with no
adverse outcomes attributed to a short delay in diagnosis [14–17].
BI-RADS category 3 should not be used in patients with a new
breast cancer diagnosis, patients awaiting organ transplant, or
patients who are pregnant or planning pregnancy.
BI-RADS category 4, which has a broad range of expected risk
of malignancy (2% to < 95%), has been subdivided into catego-
ries 4A (low suspicion, > 2% to 10% expected risk), 4B (moder-
ate suspicion, > 10% to 50% expected risk), and 4C (high sus-
picion, > 50% to < 95% expected risk) to convey more specific
expected risk of malignancy and to help address radiology-pa-
thology discordance [18]. Category 4A can be used to direct cas-
es that may be safely downgraded, by using possible supple-
mental technologies such as elastography or contrast-enhanced
mammography (CEM) [19–21]. Categories 4C and 5 should not
be considered for downgrade because the risk of malignancy is
too high. In a single-institution study by Strigel et al. [22], subdi-
visions of BI-RADS category 4 on MRI yielded malignancy rates in
the same range as on mammography and US, supporting the use
of BI-RADS category 4 subdivisions for MRI. Otherwise, evidence
for the MRI subdivision of category 4 is limited.
BI-RADS category 5 implies a high likelihood of malignan-
cy (95% or greater) and is applied identically across mammog-
raphy, US, and MRI. Historically, a category 5 designation guides
surgeons toward a one-step surgical plan rather than an incision-
861
 Eghtedari et al.
TABLE 1: BI-RADS 5th Edition: Assessment Categories and Recommendations
Category Description
0 Assessment is incomplete: examination is incomplete until further
evaluation is performed
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0 Assessment is incomplete: comparison films requested
1 Negative: completely negative examination
2 Benign findings: radiologist chooses to describe a benign lesion that
carries no malignant potential
3 Probably benign finding: controversial category to be used when a
finding is almost certainly benign but for which a short interval
follow-up is desired; unlikely to require biopsy and carries a chance
of malignancy up to 2%
4a Suspicious abnormality: finding not classic for malignancy, > 2% to
< 95% chance of malignancy
5 Highly suggestive of malignancy: 95–100% chance of malignancy;
findings are characteristic of malignancy
6 Known biopsy-proven malignancy: proven cancer that has not
completed definitive treatment
Note—ACR = American College of Radiology, SBI = Society of Breast Imaging, US = ultrasound.
a
On mammography and US, category 4 can be subdivided into 4A (low suspicion for malignancy, > 2% to 10%), 4B (moderate suspicion for malignancy, > 10% to 50%),
and 4C (high suspicion for malignancy, > 50% to < 95%). This subdivision does not apply to MRI.
al biopsy that would necessitate a second surgery for oncologic
therapy. If percutaneous biopsy of a category 5 lesion reveals a
benign histopathology, careful radiology-pathology correlation
is required to determine if repeat image-guided biopsy or surgi-
cal biopsy is the optimal next step. Finally, BI-RADS category 6,
introduced in the 4th edition, describes patients with a known
malignancy who require no further imaging or who are undergo-
ing oncologic therapy.
Lexicon
A lexicon is a list of standardized terms used to describe imag-
ing findings concisely and reproducibly. The lexicons for mam-
mography, US, and MRI have been validated in multiple studies
across the different imaging modalities [20, 21, 23–25]. The BI-
RADS 5th edition harmonizes the terminology across imaging
modalities. Tables 2–4 summarize the relevant changes in the
mammography, US, and MRI lexicons.
862
Recommendation
Additional evaluation with mammographic views, US, or less
commonly MRI; counted toward the recall rate; after completion of
workup, new final assessment category is provided; should rarely
be used after US and MRI examinations are complete
Category 0 for comparison should only be used when such
­comparison is required to make a final assessment; not counted
toward the recall rate
Return to screening in 1 year (per ACR and SBI recommendations);
malignancy is not expected
Return to screening in 1 year (per ACR and SBI recommendations);
recommendation is the same as in category 1; because description
of benign findings may lead to patient and referring clinician
anxiety and ordering of unnecessary imaging studies, category 1 is
preferred over category 2 whenever appropriate
Follow-up examinations at short intervals of < 1 year (typically 6
months) for 24–36 months is recommended; stability seen at the
end of follow-up is considered benign, at which point the finding is
reassigned category 2; category to be used after a complete
diagnostic workup of the lesion and is never to be used at the time
of screening mammograms
Some form of intervention is necessary, preferably image-guided
core biopsy to establish a histopathologic diagnosis; follow-up of
biopsy results with radiology-pathology correlation is assigned to
the radiologist performing the biopsy; in clinical practices using the
subdivision categories, the report needs to first state suspicious,
followed by the subcategory (e.g., “suspicious right breast,
moderate suspicion for malignancy”)
Percutaneous core biopsy for tissue sampling to assist with oncologic
management or to plan one-stage definitive surgical intervention,
which may include lymph node sampling; benign result is
considered discordant, and additional intervention is typically
recommended and may include repeat image-guided vs surgical
biopsy
Appropriately used in patients who are undergoing neoadjuvant
therapy or in those who require further staging; clinical manage-
ment of the malignancy is recommended
Since the 5th edition of BI-RADS, several breast imaging mo-
dalities have emerged that lack a defined lexicon within the BI-
RADS standardization, including CEM, molecular breast imaging
(MBI), and positron emission mammography. Studies have at-
tempted to adapt existing descriptors for these modalities. For
example, several studies that evaluated the adoption of MRI BI-
RADS descriptors to CEM suggest that mass lesion features, in-
cluding shape, margin, and internal enhancement, convey the
most consistent results across MRI and CEM [19–21]. Kamal et
al. [19] evaluated nonmass enhancement on CEM and reported
that the MRI descriptors for symmetry, distribution, and internal
enhancement were predictive of benign versus malignant out-
comes and could be applied for CEM. Similarly, the BI-RADS lexi-
con has been adapted for MBI and positron emission mammog-
raphy, incorporating recommendations for lesion location, size,
features, and qualitative and quantitative relevant molecular
agent uptake [23–25].
AJR:216, April 2021
 BI-RADS in Multimodality Imaging

TABLE 2: Masses, Calcifications, and Other Mammographic Findings in BI-RADS 5th Edition
Finding, ­Classification Descriptors Comments
Mass
Shape Oval, round, irregular Defined as a space-occupying 3D object; reordered “oval” and
“round” from 4th edition; removed “lobular” to avoid confusion
with margin
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Margin Circumscribed, obscured, microlobulated, indistinct, Describes the periphery of a mass and should not be confused with
spiculated the shape of a mass
Density High density, equal density, low density, fat-containing Density of a mass should not be confused with the mammographic
density and should not be used to describe asymmetries; replaced
“radiolucent” with “fat-containing”
Calcification
Typically benign Skin, vascular, coarse or “popcornlike,” large rodlike, To simplify descriptors, “eggshell” and “lucent-centered” were
round, rim, dystrophic, milk of calcium, suture combined into “skin calcifications”; “punctate” and “round” were
combined into the preferred term “round”
Suspicious ­morphology Amorphous, coarse, heterogeneous, fine pleomorphic, “Intermediate concern” and “higher probability malignancy”
fine linear or fine-linear branching calcifications were combined into the general category of
“suspicious” calcifications; the term “indistinct” was removed from
the lexicon, and the terms “fine pleomorphic,” “fine linear,” and
“fine-linear branching” were added
Distribution Diffuse, regional, grouped, linear, segmental Used with both benign and suspicious morphology; the terms
“scattered” and “clustered” were removed, with “grouped” added
as the term preferred to the latter
Architectural distortion Term may be a primary descriptor or may be used as an associated
feature
Asymmetry Asymmetry, global asymmetry, focal asymmetry, Added section for asymmetries alone and term “developing
­developing asymmetry asymmetry”
Intramammary lymph Separated findings of intramammary lymph node, skin lesion, and
node solitary dilated duct; removed “asymmetric tubular structure”
Skin lesion
Solitary dilated duct
Associated features Skin retraction, nipple retraction, skin thickening, Removed “skin lesion,” which is now a separate finding;
trabecular thickening, axillary adenopathy, “­calcifications” may be used as a primary descriptor or as an
­architectural distortion, calcifications associated feature

Breast Composition
Mammography
Breast composition is determined by subjective analysis of the
area of attenuating glandular breast tissue on mammography and
is divided into four categories: almost entirely fatty, scattered areas
of fibroglandular density, heterogeneously dense, and extremely
dense. Density on mammography was previously coded as densi-
ty categories 1 through 4, creating confusion with the assessment
categories. In the 5th edition, breast composition is now coded as
density a, b, c, or d for fatty through extremely dense. In addition,
percentiles and quartiles assigned to breast composition on mam-
mography have been removed, and density is now assessed visu-
ally. Also, a breast may be assessed as dense on the basis of focal
areas of dense breast tissue that potentially mask the presence of
cancer, even if the entire breast is nondense. A single-institution
study reported increased use of the dense category assessment
based on these changes, even though not all radiologists adopted
the new BI-RADS density assessment [26].
In 2009, Connecticut passed a law mandating radiologists to
inform women of their breast density, relying on evidence that
higher breast density was associated with increased probabil-
ity that a finding may be hidden by normal dense breast tis-
sue on mammography, the so-called masking effect [27–30]. In
February 2019, the U.S. Congress passed a law that amended
the MQSA, mandating inclusion of lay language about breast
density in all mammography reports and summaries sent to
patients and their providers [31]. The risk associated with mam-
mographic density remains controversial given the unresolved
question of whether dense breast tissue is a risk factor for
breast cancer per se, whether it decreases the sensitivity for
finding cancers that are masked or obscured, or both [32, 33].
Incorporation of texture analysis may help better define the
role of breast density in risk assessment, and this type of anal-
ysis will likely play a larger role in image interpretation in the
future [34].
Ultrasound
The change in the US lexicon of “background echotexture” to
“tissue composition” represents an effort to harmonize “breast
composition” on US with mammographic density and breast fi-

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 Eghtedari et al.

TABLE 3: Ultrasound Features in BI-RADS 5th Edition

Finding, Classification Descriptors Comments
Tissue composition Renamed, used only for whole breast screening ultrasound
Background echotexture
Homogeneous Fat, fibroglandular
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Heterogeneous
Masses
Shape Oval, round, irregular
Orientation Parallel, not parallel
Margin Circumscribed or not circumscribed (indistinct, angular, Removed “lesion boundary” category
microlobulated, spiculated)
Echo pattern Anechoic, hyperechoic, complex cystic and solid, Changed “complex” echo pattern descriptor to “complex cystic
­hypoechoic, isoechoic, heterogeneous and solid,” added “heterogeneous” descriptor for echo
pattern
Posterior features No posterior acoustic features, enhancement, shadowing, Removed “surrounding tissue” category (some descriptors
combined pattern from that category added to “associated features” category)
Calcifications Calcifications in a mass, calcifications outside of a mass, Removed “micro” vs “macro” distinction, added “intraductal
intraductal calcifications calcifications”
Associated features Added “associated features” category (includes descriptors
from previous “lesion boundary” and “vascularity” categories)
Architectural distortion
Duct changes
Skin changes Skin thickening, skin retraction
Edema
Vascularity Absent, internal vascularity, vessels in rim
Elasticity assessment Soft, intermediate, hard Added descriptors for elasticity assessment, “elasticity” may be
used for both strain and shear wave in the assessment of
tissue stiffness
Special cases Simple cyst, clustered microcysts, complicated cyst, mass in Section expanded to simplify reporting by providing a unique
or on skin, foreign body including implants, lymph nodes diagnosis rather than trying to insinuate descriptors into a
(intramammary or axillary), vascular abnormalities (AVMs, diagnosis
pseudoaneurysms, or Mondor disease), postsurgical fluid
collection, fat necrosis
Note—The dedicated vascularity section has been removed in the 5th edition, and this section’s lexicon terms have been incorporated into the associated features
section. AVM = arteriovenous malformation.

broglandular tissue on MRI. Figure 6 shows how breast density on
mammography correlates with tissue composition on US and the
quantity of fibroglandular tissue on MRI.
MRI
Background parenchymal enhancement (BPE) is distinct from
mammographic density or MRI fibroglandular tissue. BPE, in-
dependent of breast density, is more clearly associated with in-
creased breast cancer risk. This association has been shown on
MRI and MBI [33, 35]. Agreement for BPE has been shown be-
tween CEM and MRI, suggesting that CEM enhancement may
also be associated with increased breast cancer risk [36]. Screen-
ing MRI was previously recommended to be scheduled in the
second week of the menstrual cycle to decrease background BPE
[37, 38]. However, timing of the MRI based on menstrual cycle has
been questioned on the basis of a study of over 1200 premeno-
pausal women that indicated that the menstrual cycle phase did
not differentiate outcomes [39].
Harmonization
Harmonization of terminology across mammography, US,
and MRI allows accurate correlation between imaging modali-
ties, communication among radiologists, and uniform reporting
to referring clinicians. The lexicon applies identically to screen-
ing and diagnostic mammography and is nearly uniform across
mammography, US, and breast MRI. The descriptors provide esti-
mated risk of malignancy, and repeat biopsy may be required to
establish a histopathologic diagnosis when radiologic-patholog-
ic correlation is discordant (Fig. 7).
An example of the updates to allow harmonization in the 5th
edition of BI-RADS is the change of the MRI term “smooth mar-
gins” to “circumscribed” to be concordant with mammography

864 AJR:216, April 2021

 BI-RADS in Multimodality Imaging

TABLE 4: MRI Findings in BI-RADS 5th Edition

Finding, Classification
Amount of fibroglandular tissue
BPE
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Descriptors Comments
Almost entirely fat, scattered fibroglandular tissue, heterogeneous New section harmonized with mammogra-
fibroglandular tissue, extreme fibroglandular tissue phy descriptors
New section unique to contrast-enhanced
breast MRI

Level Minimal, mild, moderate, marked

Symmetry Symmetric or asymmetric
Focus Changed definition of “focus”; no longer
based on size criteria
Mass Removed “enhancing internal septations”
and “central enhancement” because those
terms were infrequently used
Shape Oval (includes lobulated), round, irregular
Margin Circumscribed; not circumscribed (irregular, spiculated)
Internal enhancement Homogeneous, heterogeneous, rim enhancement, dark internal
septations
Nonmass enhancement
Distribution Focal, linear, segmental, regional, multiple regions, diffuse Removed “ductal”
Internal enhancement patterns Homogeneous, heterogeneous, clumped, clustered ring Removed “stippled/punctate,” added
“clustered ring”
Intramammary lymph node
Skin lesion
Nonenhancing findings Ductal hyperintensity on unenhanced T1-weighted imaging; cyst;
postoperative collections (hematoma or seroma); posttherapy skin
and trabecular thickening; nonenhancing mass; architectural
distortion; signal void from foreign bodies, clips, and so forth
Associated findings Nipple retraction, nipple invasion, skin retraction, skin thickening, skin Separated “associated findings” into
invasion, direct invasion, inflammatory breast cancer, axillary “nonenhancing findings,” “associated
adenopathy, pectoralis muscle invasion, chest wall invasion, architec- findings,” and “fat-containing lesions”
tural distortion
Fat-containing lesions Lymph nodes (normal or abnormal), fat necrosis, hamartoma,
­postoperative seroma or hematoma with fat
Location of lesion and depth
Kinetic curve assessment (signal
intensity–time curve description)
Initial phase Slow, medium, fast The term “rapid” was changed to “fast” in
the initial phase of enhancement
Delayed phase Persistent, plateau, washout
Implant findings Implant material and lumen type, location, contour, intra- and Unenhanced MRI for implant evaluation is
­extracapsular findings, water droplets, periimplant findings not assigned a BI-RADS category code
Note—BPE = background parenchymal enhancement.

and US. On the other hand, exceptions to harmonization in-
volve descriptors specific to an imaging modality, such as mam-
mographic density, US echogenicity, and MRI signal intensity.
When lexicon descriptors overlap between benign and malig-
nant features or are discordant between imaging modalities, the
most suspicious feature is used to recommend an assessment
category and management (Fig. 8).
The lexicon descriptors that have evolved for specific imag-
ing techniques may not be amenable to harmonization. Spe-
cifically, the MRI technique of dynamic contrast enhancement
allows kinetic assessment of changes in signal intensity over
time. Accordingly, the MRI lexicon contains unique descriptors
for the initial and delayed phases of the contrast kinetics that
do not apply to other imaging techniques (Fig. 9). Lexicon de-
scriptors for contrast kinetics may be applied in the future to
evolving technologies such as CEM. For example, Perry et al.
[40] suggested applying existing descriptors to CEM by lever-
aging mammographic lesion descriptors for low-energy images
and MRI descriptors (BPE and enhancement characteristics) for
recombined images.

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 Eghtedari et al.
Multimodality imaging allows mammography, US, and MRI
to be used in a complementary way to evaluate breast cancer.
The limitations of mammography include limited evaluation of
the upper inner quadrant, lack of assessment of the chest wall,
and decreased sensitivity in dense breasts. US is limited by op-
erator dependence, and posterior shadowing from lesions may
decrease the ability to accurately assess the chest wall. Although
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the amount of fibroglandular breast tissue does not limit MRI,
marked BPE may limit assessment of small masses. However, MRI
is superior in the evaluation of the chest wall (Fig. 10).
In addition to harmonization of lesion descriptors, harmoni-
zation across modalities has also been applied for the reporting
structure, assessment categories, management recommenda-
tions, and data tracking system.
Reporting
The BI-RADS manual provides guidance on the following as-
pects of structured reporting: indication for the study, breast tis-
sue composition, descriptions of essential findings, comparison
with previous studies, assessment, and management. MQSA re-
quires facilities to provide a structured mammography report.
Close to 40 million mammography examinations were per-
formed in the United States last year, most of which were inter-
preted using a structured report [41]. Increasing familiarity with
mammography structured reports will likely lead to increased ef-
ficiency by referring clinicians [42]. Although not part of MQSA,
the same structured reporting should be used across all breast
imaging modalities. Whenever possible, a combined report
should be issued. For example, if a patient presents for diagnos-
tic evaluation and both mammography and US are performed,
then a combined report containing a section for mammography
findings and a separate section for US findings, with a final overall
assessment and recommendation for both modalities, is encour-
aged and ideal for decreasing confusion. Consider a patient who
presents for a palpable finding. Mammography shows no posi-
tive findings, but further US evaluation is required (category 0).
US performed the same day shows a simple cyst (category 2). In
this scenario, two separate reports with two different recommen-
dations (i.e., recommendation for additional imaging, followed
by a recommendation for return to routine screening) could be a
source of confusion to the patient and referring clinician.
Guidance and Audit Parameters
MQSA requires a minimum audit of all mammography facilities
and is subject to annual review during the MQSA inspection. As
noted, each mammography report must be assigned one of the
seven assessment categories. For screening mammography, BI-
RADS categories 0 and 3 are considered positive in the medical
audit, whereas BI-RADS categories 1 and 2 are considered nega-
tive. The use of BI-RADS categories 4 and 5 are discouraged in the
screening setting. During diagnostic imaging workup, BI-RADS
category 3 is considered negative for audit purposes. Appropri-
ate examination coding allows efficient outcome tracking.
Important audit parameters include cancer detection rate per
1000 women, recall rate, PPV, interval cancer rate, sensitivity, and
specificity [8, 43–45]. A section of the 5th edition manual is ded-
icated to follow-up and outcome monitoring and includes a de-
tailed glossary of statistical terms, guidance for data calculation,
866
and multiple charts with established benchmarks. This section
of the BI-RADS manual is a critical quality assurance resource in
guiding feedback to individual radiologists as well as to practic-
es as a whole.
Each imaging modality chapter contains guidance subsections
that have been expanded in the 5th edition. The guidance subsec-
tions provide useful information, advice, clarifications, and FAQ
answers. Examples from the guidance subsections include differ-
entiation of mass versus asymmetry on mammography, use of ra-
diopaque skin markers for clinically palpable lesions, details of the
US findings appropriate for coding a lesion as BI-RADS category
3, and multiple points of clarification in the MRI BI-RADS lexicon.
Global Implications
The BI-RADS manual is used in North America and most of Eu-
rope [46]. The 5th edition has been translated to Spanish, Ger-
man, Portuguese, Chinese, Japanese, and Greek.
In countries that lack the resources to support the full imple-
mentation of BI-RADS, ensuring consistent reporting, tracking pa-
tient management, and improving performance and patient out-
comes may be challenging. The Breast Health Global Initiative has
proposed a phased implementation strategy to implement BI-
RADS in low-resource areas. The use of a condensed version of BI-
RADS, such as one containing limited descriptors from the breast
US lexicon, is recommended before the transition to full BI-RADS
for each phase of implementation [47]. In Uganda, breast US edu-
cation using a condensed BI-RADS resulted in improved interpre-
tative performance and fewer unnecessary biopsies [48].
Current Limitations
Several limitations of varying clinical importance are evident
in the use of BI-RADS. For example, the definition of “regional
distribution” of an abnormal finding varies between mammog-
raphy and MRI. Although a regional distribution of calcifications
on mammography means that the calcifications are more exten-
sive than 2 cm but smaller than a segment, regional distribution
of nonmass enhancement on MRI implies that the area of abnor-
mality is in at least one quadrant and more than a single duct sys-
tem of the breast.
A main goal of BI-RADS is to simplify management. Therefore,
the differential use of BI-RADS categories 1 and 2 is controversial
given that their management is identical. Although some radiol-
ogists comment on benign findings (calcifications, stable masses,
or asymmetries, all of which are category 2), other radiologists
choose not to comment on them. The guidance chapter suggests
that whenever possible, the same category (either 1 or 2) be ap-
plied from year to year to avoid confusing patients and referring
clinicians. The same issue applies to the management of BI-RADS
4 and five lesions, and within BI-RADS category 4, to categories
4A, 4B, and 4C findings. Both categories 4 and 5 predict malig-
nancy and warrant recommendation for biopsy, thus creating op-
portunity for confusion among patients and referring providers.
Common findings that lack lexicon descriptors also present
a limitation. For example, benign postsurgical scar (without an
associated fluid collection), though commonly encountered in
breast imaging practices, is not a descriptor in the mammogra-
phy lexicon. The descriptor “architectural distortion” may be ap-
plied to this finding, but architectural distortion is presumed to
AJR:216, April 2021
 BI-RADS in Multimodality Imaging
be a malignancy until proven otherwise. Additional verbiage is
needed to clarify that the architectural distortion represents a
benign scar, undermining the goal of simplifying the report. Also,
the mammography lexicon definitions of “mass” and “asymme-
try” do not take into account DBT technique. The mammogra-
phy lexicon defines a mass as a finding that is seen on two views.
However, using DBT, a “mass” or space-occupying lesion may be
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seen over multiple planes in a single projection. The definition
of “mass” could be refined to harmonize DBT with US and MRI,
which would be particularly useful for developing computer-aid-
ed detection and diagnosis software for DBT [49]. In addition, US
“nonmass” lesions (focal hypoechoic areas with no associated
shape or margins) currently have no associated lexicon descrip-
tors [50]. These lesions are found in patients with and without
symptoms, and pathology correlation includes both benign and
malignant histology.
The term “interval cancer” is defined as cancer that is found
during the time between a regular screening mammogram that
appears normal and the next screening mammogram. Interval
cancers are recognized in the BI-RADS manual in Europe, but
not in the United States. In the United States, BI-RADS instead
encourages the calculation of a false-negative rate, which is the
rate of cancer detection within 1 year after negative mammogra-
phy. This 1-year time frame was selected because most organiza-
tions recommend that screening mammography be performed
annually. This approach may warrant reevaluation, given that
the most recent American Cancer Society breast cancer screen-
ing guidelines recommend switching to biennial mammography
after 55 years old for a patient with average risk [51]. Future BI-
RADS versions may benefit from a more precise definition for the
false-negative mammography rate or for interval cancer.
Future
Emerging breast imaging modalities will follow suit in the use
of imaging descriptors. For example, MBI and CEM will benefit
from uniform BI-RADS terminology as they become more widely
adopted. The latest edition of the American Joint Committee on
Cancer has already implemented breast cancer’s molecular pro-
file as a parameter for breast cancer staging. Future BI-RADS edi-
tions should include terminology describing the molecular pro-
file of cancer or the quantitative measurements of water diffusion
on DWI [52, 53]. In de-escalation treatment, a malignancy may not
undergo surgical excision after neoadjuvant systemic therapy
that leads to complete pathologic response on core biopsy of the
tumor bed. An assessment category descriptor will need to be
developed for such lesions as they present for follow-up.
Future BI-RADS editions should also clarify category 3 lesions
[10, 14, 54]. Specifically, greater consideration should be given for
what represents “sufficient experience” to justify using category
3 in MRI or for lesions other than calcifications, circumscribed sol-
id mass, or asymmetry. The definition of category 3 could also be
expanded to include new or developing lesions such as develop-
ing fat necrosis; it is currently limited to baseline studies or exam-
inations without comparison studies available.
Studies have shown that training in BI-RADS increases inter-
pretative performance and agreement in feature analysis for
both mammography and US [55, 56]. Continued BI-RADS train-
ing and education of residents, fellows, and practicing radiolo-
AJR:216, April 2021
gists who may not be breast subspecialists is therefore particu-
larly important.
Conclusion
BI-RADS was developed as a communication, reporting, and data
tracking system. Consistent and appropriate use of the BI-RADS lex-
icon terminology and assessment categories effectively communi-
cates findings, articulates the degree of concern, and provides rec-
ommendations to patients and referring clinicians. The most recent
BI-RADS edition harmonized the lexicon across the multiple imag-
ing modalities used to evaluate the breast. BI-RADS will continue to
evolve because changes in technology and research provide new
data points, including new breast imaging modalities.
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(Figures start on next page)
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 BI-RADS in Multimodality Imaging
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A B C
Fig. 1—42-year-old woman with oval mass with circumscribed margins, consistent with fibroadenoma.
A, Right mediolateral oblique mammogram shows oval equal-density mass with circumscribed margins (arrow) in upper outer right breast.
B, Transverse ultrasound shows oval mass with circumscribed margins and hypoechoic echo pattern (arrow) corresponding to mammographic finding.
C, Dynamic axial contrast-enhanced T1-weighted MRI shows oval mass with circumscribed margins and homogeneous internal enhancement (arrow).

A B C
Fig. 2—70-year-old woman with invasive lobular breast cancer.
A, Right mediolateral oblique synthetic view digital breast tomosynthesis screening mammogram shows architectural distortion (circle).
B, Transverse ultrasound shows irregular hypoechoic mass with angular margins and posterior shadowing (arrow) corresponding to mammographic finding.
C, Axial dynamic contrast-enhanced T1-weighted breast MRI shows irregular mass with irregular margins and heterogeneous internal enhancement. Signal void from
biopsy clip is marked by arrow.

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 Eghtedari et al.
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B C
Fig. 3—52-year-old woman who had undergone lumpectomy and radiation therapy and presented with
palpable finding (arrow) at left breast 3-o’clock position.
A, Left mediolateral oblique 2D mammogram shows focal asymmetry correlating with lumpectomy site.
B, Transverse ultrasound shows postsurgical seroma.
C, Axial T2-weighted MRI shows postoperative seroma with nonenhancing T2 hyperintensity. Simplified
ultrasound “special cases” lexicon allows diagnosis using “post-surgical change” descriptor.

Fig. 4—69-year-old woman with intracapsular rupture of silicone gel–filled implant. Axial fat-suppressed and
water-suppressed silicone-specific MRI shows keyhole sign (arrow) and subcapsular line (arrowhead).

870 AJR:216, April 2021

 BI-RADS in Multimodality Imaging

Fig. 5—Adaptation of BI-RADS lexicon to novel

application of elastography. 30-year-old woman
with T2N0M0 invasive ductal carcinoma (estrogen
receptor–positive, progesterone receptor–negative,
HER2 [also known as ERBB2]-negative).
A, Right mediolateral oblique 2D mammogram
shows irregular high density mass with indistinct
margins (arrow).
B, Axial dynamic T1-weighted contrast-enhanced
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MRI shows irregular mass with irregular margins,

rim enhancement, and heterogeneous internal
enhancement (arrow).
C, Radial gray-scale ultrasound shows irregular mass
with angular margins and complex cystic and solid
echo patterns corresponding to mammographic and
MRI findings.
D, Radial shear wave elastography using acoustic
radiation force shows increased stiffness, suggesting
malignancy.

A B

C D

Fig. 6—Effects of breast tissue composition on

image interpretation in 40-year-old woman.
A, Left craniocaudal mammogram shows extremely
dense breast tissue, which lowers sensitivity of
mammography.
B, Left radial ultrasound shows homogeneous
fibroglandular background echotexture, concordant
with mammographic finding. Tissue composition is
only used in facilities that use screening ultrasound.
A B (Fig. 6 continues on next page)

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 Eghtedari et al.
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C D
Fig. 6 (continued)—Effects of breast tissue composition on image interpretation in 40-year-old woman.
C, Axial T1-weighted non–fat-saturated MRI shows extreme fibroglandular tissue correlating with mammographic density, which does not limit MRI sensitivity.
D, Axial dynamic contrast-enhanced T1-weighted MRI shows minimal background parenchymal enhancement (BPE). When marked, BPE may limit sensitivity of MRI.

A B C
Fig. 7—62-year-old woman with abnormal mammogram.
A, Craniocaudal 2D mammogram shows irregular mass with spiculated margins and fine pleomorphic calcifications.
B, Transverse ultrasound shows irregular mass with angular margins and posterior shadowing (arrow) corresponding to mammogram finding. Ultrasound-guided
biopsy revealed stromal fibrosis without atypia or malignancy, which represented radiologic-pathologic discordance. Wire-guided localization and surgical excision
were recommended.
C, Specimen radiograph of excised lesion shows mass, calcifications, and clip marker. Histopathology revealed extensive sclerosing adenosis with no malignancy.

Fig. 8—55-year-old woman with biopsy-proven

triple-negative invasive ductal carcinoma,
noted as round mass. Imaging characteristics on
mammography, ultrasound (US), and MRI provide
complementary information.
A, Mediolateral oblique 2D right digital
mammogram shows high-density round mass with
circumscribed margins. High density is suspicious
finding on mammography.
B, Radial US shows round mass with circumscribed
margins and complex cystic and solid echo pattern
with posterior enhancement. Term “complex cystic
and solid” is suspicious finding, BI-RADS category
4C.
A B (Fig. 8 continues on next page)

872 AJR:216, April 2021

 BI-RADS in Multimodality Imaging

Fig. 8 (continued)—55-year-old woman with

biopsy-proven triple-negative invasive ductal
carcinoma, noted as round mass. Imaging
characteristics on mammography, ultrasound (US),
and MRI provide complementary information.
C, Axial fat-saturated T2-weighted MRI shows
hyperintense fluid within mass.
D, Axial contrast-enhanced fat-saturated T1-
weighted MRI shows round mass with spiculated
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margins and rim enhancement. Spiculations and rim

enhancement are highly suggestive of malignancy,
BI-RADS category 5.

C D

Fig. 9—55-year-old woman with invasive

ductal carcinoma (estrogen receptor–positive,
progesterone receptor–negative, HER2 [also
known as ERBB2]-positive). MRI provides unique
quantitative kinetic information that is based on
signal intensity–time curve and further characterizes
lesions.
A and B, Axial T1-weighted fat-saturated dynamic
contrast-enhanced MR images without (A) and
with (B) kinetic color overlay superimposed over
segmental nonmass enhancement at site of known
malignancy. In this software package, blue indicates
persistent kinetics, yellow indicates plateau, and
red indicates washout. Most suspicious descriptor is
used to increase sensitivity. L1 = lesion 1.

A B

B C

Fig. 10—43-year-old woman with palpable invasive ductal breast cancer (estrogen receptor–positive,
progesterone receptor–positive, HER2 [also known as ERBB2]-negative). Descriptors may be based on information
provided by imaging technique; MRI shows chest wall invasion that is not seen on mammography or ultrasound.
A, Right 2D mediolateral oblique mammogram shows focal asymmetry (arrow) that is only seen in retrospect.
B, Longitudinal ultrasound shows irregular mass with indistinct margins corresponding to mammographic
finding.
C, Axial dynamic T1-weighted contrast-enhanced MRI shows irregular mass invading through chest wall (arrows).
A

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