{"id":19621,"date":"2026-09-28T05:16:55","date_gmt":"2026-09-28T08:16:55","guid":{"rendered":"https:\/\/rtmedical.com.br\/tmp-en-1790583415012\/"},"modified":"2026-09-28T05:17:02","modified_gmt":"2026-09-28T08:17:02","slug":"bi-rads-2025-axillary-nodes-audit","status":"publish","type":"post","link":"https:\/\/rtmedical.com.br\/en\/bi-rads-2025-axillary-nodes-audit\/","title":{"rendered":"BI-RADS v2025: Axillary Nodes and Audits Take Center Stage"},"content":{"rendered":"

BI-RADS v2025<\/strong>, the sixth edition of the American College of Radiology (ACR) reporting system, adds a dedicated section on axillary lymph nodes across modalities, a stand-alone chapter for contrast-enhanced mammography and a module on auditing and outcomes monitoring. In a video interview with Diagnostic Imaging<\/em>, Stamatia Destounis, chair of the ACR Breast Imaging Commission, explained that the node guidance grew directly out of the confusion caused by COVID-19 vaccine adenopathy, and she left a warning: practices that audit their own category 3 may find it running ten times larger than it should.<\/p>\n

\"Technologist
BI-RADS v2025 gives lymph nodes their own reporting section in mammography, ultrasound and MRI. Photo: NCI\/Rhoda Baer (public domain).<\/figcaption><\/figure>\n

What Destounis highlighted in the interview<\/h2>\n

Destounis is managing partner of Elizabeth Wende Breast Care in Rochester, New York, and first author of the expert panel review of the new manual published in August in the American Journal of Roentgenology<\/em>. Speaking with journalist Jeff Hall in a piece posted September 10 and re-featured by the site on September 24, she singled out three fronts: the auditing and outcomes section, the dedicated contrast-enhanced mammography (CEM) section and the expanded guidance for reporting lymph nodes on mammography, ultrasound and MRI.<\/p>\n

On nodes, she was blunt. During the vaccination campaign, she recalled, “everybody had axillary lymphadenopathy” and practices were “chasing our tails” trying to decide how long to wait, whether to recall the patient and whether every case needed a biopsy to rule out lymphoma or an occult breast cancer. The lesson, in her telling, was that radiologists needed a management roadmap for axillary adenopathy, and the new manual tries to provide one.<\/p>\n

The second warning concerned category 3. The criterion has not changed: a likelihood of malignancy of 2% or less<\/strong>. Yet when practices audit how many exams receive that assessment, many discover it accounts for 20% to 30% of reports. “The BI-RADS 3 category should be a very small part of your practice, and you need to audit it,” Destounis said, describing the result as a wake-up call for many colleagues.<\/p>\n

The edition took five years to complete. Because the manual is now electronic, she expects future updates to arrive faster. Topics she would like to see addressed include breast arterial calcifications, increasingly tied to cardiovascular risk, molecular imaging and other contrast-based studies.<\/p>\n

What changes in the report, modality by modality<\/h2>\n

The AJR<\/em> review and the thirteen-point summary published by Diagnostic Imaging<\/em> itself help ground the changes. In mammography, a finding seen on a single tomosynthesis projection may now be called a mass, acknowledging DBT’s depth resolution. The margin descriptor “microlobulated” was dropped, “lobulated” was added as a shape descriptor and “developing asymmetry” no longer stands as its own category. Lymph nodes, previously tucked among “associated features,” get a separate section with systematic description of morphology and laterality. Category 0 was also clarified: the report should state whether the recall is for additional imaging or simply for comparison with prior studies.<\/p>\n

In ultrasound, the node discussion now covers internal mammary and supraclavicular chains alongside intramammary and axillary nodes. New elasticity descriptors arrive, along with the term “non-mass lesion” and the “echogenic rind,” a thick band surrounding a mass that carries a high positive predictive value for malignancy and should be included in lesion measurements. Clustered microcysts are classified as category 2. In MRI, “irregular” becomes “indistinct” for margins, architectural distortion leaves the list of associated features and peritumoral edema joins it, with a note that extensive edema is associated with a higher risk of nodal metastasis.<\/p>\n

From vaccine to guideline: how axillary adenopathy reshaped management<\/h2>\n

The trajectory Destounis sketches in a few sentences is documented in detail in the literature. In January 2021 the Society of Breast Imaging, in a document she co-authored, issued conservative recommendations: schedule screening mammography before vaccination or several weeks after, and for unilateral adenopathy in a recently vaccinated patient, short-interval follow-up at 4 to 12 weeks. The Radiology<\/em> scientific expert panel that year took a similar stance.<\/p>\n

Subsequent data dismantled that caution on two points. First, delay was unwarranted: a series of 407 women published in Radiology<\/em> in 2022 (Wolfson et al.) found no cancers among post-vaccine adenopathies and titled the finding “no reason to delay screening mammogram.” Second, adenopathy lasts longer than assumed: in the longitudinal study by Ha et al., also in Radiology<\/em>, half of the patients re-examined by ultrasound about 12 weeks after the dose still had enlarged nodes. Reviews in RadioGraphics<\/em> (Zhang et al., 2022) and Radiology<\/em> (Wolfson and Kim, 2023) consolidated what radiologists need to know.<\/p>\n

The synthesis came in the 2023 revision of the European Society of Breast Imaging<\/a> recommendations, published in Insights into Imaging<\/em>: breast exams should not be postponed because of vaccination; vaccination date, dose and injection site should be collected and made available to the radiologist; and in a patient with no cancer history and no suspicious breast finding, unilateral adenopathy on the side of a vaccine given within the previous 12 weeks should be classified as BI-RADS 2<\/strong> with no further work-up. If a suspicious ipsilateral breast finding is present, management follows routine practice, including biopsy. The SBI had revised its own guidance in 2022 along the same lines. BI-RADS v2025 folds that logic into the manual itself rather than leaving it in parallel documents.<\/p>\n

How to audit category 3 in practice<\/h2>\n

The 20%-to-30% message deserves an operational translation. A BI-RADS audit starts from metrics that any RIS or PACS with structured reporting can extract: recall rate, cancer detection rate per thousand exams, positive predictive value in its three versions (PPV1 for recall, PPV2 for biopsy recommendation, PPV3 for biopsy performed), sensitivity and specificity. For category 3, the denominator is every exam given that assessment in the period, and the numerator is the cancers diagnosed in those cases during surveillance; the fraction must stay at 2% or below.<\/p>\n

Two habits typically inflate the category. The first is assigning it at screening, before a complete diagnostic work-up, as a way of not deciding. The second is applying it to findings that already meet benign criteria, generating unnecessary six-month follow-ups and anxiety. In both cases the count of “probably benign” reports grows while the malignancy rate sinks well below 2%, a sign that the category has become a refuge rather than a tool. The opposite failure also shows up: a category 3 malignancy rate above 2% points to lesions that should have been biopsied. It was precisely a break in that kind of feedback loop that sat at the center of a $7 million missed breast cancer case that forced process changes.<\/p>\n

What this means outside the United States<\/h2>\n

BI-RADS is the lingua franca of breast reporting far beyond the ACR’s home turf. In Brazil, the Col\u00e9gio Brasileiro de Radiologia publishes the Portuguese translation of the manual, and the public health system’s screening database records every mammogram outcome by BI-RADS category. The new edition therefore lands in ecosystems that already depend on it, from RIS templates to health department production spreadsheets. Adopting the new terminology (non-mass lesion, echogenic rind, revised node descriptors) will require template revisions and team training, something that rarely happens in a coordinated way.<\/p>\n

The node guidance has immediate relevance. Countries such as Brazil administered hundreds of millions of COVID-19 vaccine doses and run annual influenza campaigns plus periodic boosters, yet “when was your last vaccine, and in which arm?” is still not on most mammography intake forms. Adding it costs almost nothing and prevents recalls. Auditing category 3, by contrast, exposes a structural gap: outside large centers, few services close the outcome loop by matching reports against biopsy results and cancer registries. Without that linkage there is no way to know whether category 3 sits at 2% or 30%.<\/p>\n

BI-RADS is also the yardstick against which artificial intelligence triage tools are measured, such as the Vara system that recently won CE marking for autonomous mammography triage<\/a>. A service that does not audit its own radiologists will struggle to audit an algorithm. The same logic applies to the debate over whether screening ultrasound is still needed in the tomosynthesis era<\/a>: the new manual supplies the descriptors, but only an audit shows whether they are being used well. The roundup of breast imaging studies that defined 2026<\/a> helps place these changes in context. The full expert panel review is available in the AJR<\/a>.<\/p>\n

Source:<\/strong> Diagnostic Imaging<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"

The new BI-RADS edition adds axillary node guidance, a CEM chapter and an audit module. Destounis warns category 3 runs 20-30% in many practices.<\/p>\n","protected":false},"author":1,"featured_media":19597,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"om_disable_all_campaigns":false,"_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"ngg_post_thumbnail":0,"_rt_cluster":"","fifu_image_url":"","fifu_image_alt":"","footnotes":""},"categories":[100],"tags":[],"class_list":["post-19621","post","type-post","status-publish","format-standard","has-post-thumbnail","category-radiology"],"aioseo_notices":[],"rt_seo":{"title":"","description":"The new BI-RADS edition adds axillary node guidance, a CEM chapter and an audit module. Destounis warns category 3 runs 20-30% in many practices.","canonical":"","og_image":"","robots":"index,follow","schema_type":"Article","include_in_llms":true,"llms_label":"BI-RADS v2025: axillary nodes, CEM and auditing category 3","llms_summary":"Diagnostic Imaging video interview with Stamatia Destounis (ACR Breast Imaging Commission chair) on BI-RADS v2025: dedicated lymph node section across modalities, prompted by COVID-19 vaccine adenopathy; contrast-enhanced mammography chapter; auditing and outcomes module. Category 3 must carry \u22642% malignancy, yet many practices find 20-30% of reports in it. Covers the SBI 2021 \u2192 EUSOBI 2023 evolution (ipsilateral adenopathy within 12 weeks of vaccination = BI-RADS 2) and how to audit.","faq_items":[],"video":[],"gtin":"","mpn":"","brand":"","aggregate_rating":[]},"_links":{"self":[{"href":"https:\/\/rtmedical.com.br\/en\/wp-json\/wp\/v2\/posts\/19621\/"}],"collection":[{"href":"https:\/\/rtmedical.com.br\/en\/wp-json\/wp\/v2\/posts\/"}],"about":[{"href":"https:\/\/rtmedical.com.br\/en\/wp-json\/wp\/v2\/types\/post\/"}],"author":[{"embeddable":true,"href":"https:\/\/rtmedical.com.br\/en\/wp-json\/wp\/v2\/users\/1\/"}],"replies":[{"embeddable":true,"href":"https:\/\/rtmedical.com.br\/en\/wp-json\/wp\/v2\/comments\/?post=19621"}],"version-history":[{"count":1,"href":"https:\/\/rtmedical.com.br\/en\/wp-json\/wp\/v2\/posts\/19621\/revisions\/"}],"predecessor-version":[{"id":19623,"href":"https:\/\/rtmedical.com.br\/en\/wp-json\/wp\/v2\/posts\/19621\/revisions\/19623\/"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/rtmedical.com.br\/en\/wp-json\/wp\/v2\/media\/19597\/"}],"wp:attachment":[{"href":"https:\/\/rtmedical.com.br\/en\/wp-json\/wp\/v2\/media\/?parent=19621"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/rtmedical.com.br\/en\/wp-json\/wp\/v2\/categories\/?post=19621"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/rtmedical.com.br\/en\/wp-json\/wp\/v2\/tags\/?post=19621"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}