Standardized structured breast CEM report based on BI-RADS v2025: a technical note

M. Joyce Torres-Navarro, Centro de Imagenologia Integral IMAX; Instituto de Estudios Superiores de Tamaulipas, Universidad Anahuac; Tampico, Tamaulipas, Mexico;
Carolina Dias-Rivero, Centro de Imagenologia Integral IMAX; Instituto de Estudios Superiores de Tamaulipas, Universidad Anahuac; Tampico, Tamaulipas, Mexico;
David F. Perez-Montemayor, Centro de Imagenologia Integral IMAX Tampico; Instituto de Estudios Superiores de Tamaulipas, Universidad Anahuac; Tampico, Tamaulipas, México;
Karla G. Garcia-Alvarez, Laboratorio de Patologia, Hospital Beneficiencia Española de Tampico, Tampico, Tamaulipas, Mexico;

The Breast Imaging Reporting and Data System (BI-RADS) lexicon standardizes the interpretation and reporting of breast findings to ensure clear, precise, and consistent communication between radiologists and referring physicians. Until its fifth edition, the BI-RADS system covered only digital mammography (DM), ultrasound (US), and magnetic resonance imaging (MRI). BI-RADS v2025 incorporates a specific lexicon for contrast-enhanced mammography (CEM), a technique that combines mammography with intravenous iodinated contrast media to evaluate lesion vascularity. Greater contrast enhancement improves the detection and characterization of suspicious lesions – especially in dense breasts – offering a faster, more accessible alternative to MRI in certain clinical scenarios. Although BI-RADS provides descriptors, categories, and standardized language for interpreting breast imaging findings, it lacks a structured reporting template for complete report writing. Therefore, the implementation of proprietary or institutional formats is necessary to ensure document uniformity and quality. In radiology, the use of structured templates significantly impacts the quality, efficiency, and safety of reports. They standardize language and report structure, reduce variability among radiologists, and decrease the possibility of omitting relevant findings. By following a predefined format, reports become more comprehensive and consistent, especially in frequent studies or those requiring systematic evaluation of multiple structures. This technical note provides a template for creating a structured and standardized report based on the BI-RADS v2025 lexicon to optimize diagnostic clarity, reproducibility of findings, and appropriate decision-making. It consists of eighteen sections, that includes general information, clinical history, most relevant previous studies, specific descriptors for abnormal findings, and the corresponding category and recommendations.

Keywords: Mammography. Contrast media. Diagnostic imaging. Computerized medical records systems. Breast Imaging. Reporting and Data System.