Contrast-Enhanced Mammography BI-RADS 2025: Updates & Reporting Standards Explained

Key Takeaways

• BI-RADS 2025 makes contrast-enhanced mammography a core section of the ACR manual, replacing the 2022 supplement and standardizing CEM reporting across sites nationwide.
• CEM reports separate low-energy images, read with the mammography lexicon, from recombined images, which use modified MRI-derived terms to describe contrast uptake.
• Lesion conspicuity, graded low, moderate, or high against background parenchymal enhancement, is a defining CEM descriptor, while the older MRI term focus has been removed.
• The manual reorders lexicon terms from least to most suspicious and revises Category 0 and Category 6 assessment language for clearer management.
• Every CEM exam uses intravenous iodinated contrast, so at ContrastConnect we provide CMS-compliant virtual supervision for facilities running these exams.

What BI-RADS 2025 Means for CEM Reporting

The ACR BI-RADS 2025 Manual is the first major revision since the 2013 fifth-edition Atlas, and its biggest structural change for breast imaging is making CEM a permanent, integrated section rather than a separate supplement. That upgrade reflects how quickly clinical adoption has grown: CEM sensitivity and specificity for cancer detection now approach those of breast MRI, at lower cost and with wider accessibility.

The updated manual standardizes how sites describe findings, grade enhancement, and assign assessment categories across both the low-energy and recombined image sets that every CEM exam produces. Consistent terminology means second opinions, audits, and multi-site data pooling all become more straightforward.

Because each CEM exam requires intravenous iodinated contrast, a supervising physician must be available for every injection. ContrastConnect provides that coverage virtually for outpatient and multi-site imaging networks.

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Key BI-RADS 2025 Updates for Contrast-Enhanced Mammography

CEM Moves From Supplement to Core Section

CEM is now an intrinsic section of the manual. The ACR attributes the change to increased clinical use and the need for shared reporting language across sites. Integration gives CEM the same reference status as mammography, ultrasound, and MRI within a single document. The manual expanded from 696 to 896 pages and 923 clinical images, adding examples in tomosynthesis, synthetic mammography, and automated breast ultrasound.

It was renamed from Atlas to Manual and moved to year-based versioning consistent with other ACR RADS systems. Each modality section now includes a dedicated FAQ, and a general FAQ covers cross-modality questions.

Standardized terminology also supports comparability. When sites report CEM with the same terms and structure, second opinions, audits, and multi-site data pooling become more straightforward. CEM adoption has grown partly because it is more accessible and less expensive than breast MRI.

Standardized Reporting & Assessment Language

BI-RADS 2025 aligns report organization across modalities and introduces standardized structured exam-indication wording for all breast studies. The structured wording is intended to make the reason for each study explicit and uniform, which supports data collection and quality auditing.

Lexicon terms are ordered from least to most suspicious where a graded sequence is meaningful, such as margin and enhancement descriptors. Assessment language was revised in two places. Category 0 separates incomplete assessments into two statements, one for cases requiring additional imaging and one for cases requiring prior exams for comparison, reflecting updated MQSA requirements.

Category 6, used for known cancer, now recognizes definitive local treatments that do not always involve surgical excision. CEM reports follow the same organization applied to mammography, ultrasound, and MRI.

CEM Reporting Standards Explained

CEM is ordered for specific clinical questions, and the report reflects both the indication and the exam technique. The exam is used most often for problem-solving after an inconclusive recall, for evaluating dense breasts, and for staging known cancer, and each indication is entered using the standardized exam-indication wording introduced in 2025. The CEM reporting lexicon then structures the findings from the low-energy and recombined images.

Low-Energy & Recombined Images

The lexicon defines three finding types: low-energy only, low-energy plus recombined, and recombined only. For example, suspicious calcifications without enhancement are a low-energy-only finding, an enhancing mass visible on both image sets is a low-energy plus recombined finding, and enhancement with no mammographic correlate is a recombined-only finding.

Low-energy findings use the standard mammography lexicon for masses, calcifications, and architectural distortion. Low-energy images are considered comparable to a standard digital mammogram, so a separate 2D mammogram is generally not required for the same visit. When a low-energy finding also enhances, the report adds the internal enhancement pattern, the extent of enhancement relative to the low-energy abnormality, and the degree of enhancement compared with background parenchymal enhancement (BPE).

Recombined-only findings, which have no low-energy correlate, are described with breast MRI terms adjusted for two-dimensional mammography. BPE is graded from minimal to marked, as on MRI, because high background enhancement can obscure or mimic lesions. As with MRI, BPE on CEM varies with hormonal status, so imaging premenopausal patients in the second week of the menstrual cycle can reduce background enhancement.

Lexicon Terms & Enhancement Descriptors

CEM findings are classified as masses or non-mass enhancement (NME), consistent with MRI. Masses are described by shape, margin, and internal enhancement, such as homogeneous, heterogeneous, or rim enhancement. NME is described by distribution, such as focal, linear, or segmental, and by internal pattern, such as clumped or heterogeneous.

Rim enhancement and heterogeneous internal enhancement are more often associated with malignancy, while homogeneous enhancement is less specific. The extent of enhancement in a known lesion is recorded as complete, partial, or absent.

Two lexicon changes apply specifically to CEM. The term enhancing asymmetry denotes enhancement seen on a single view. The MRI term focus was removed because it does not apply to CEM. Lesion conspicuity grades a lesion's enhancement relative to BPE as low, moderate, or high.

Conspicuity reflects both the lesion's own enhancement and the surrounding background, so a strongly enhancing lesion in a high-BPE breast can still receive a lower grade. Unlike MRI, CEM does not produce kinetic enhancement curves, so enhancement is assessed qualitatively from the recombined images rather than by wash-in and washout patterns.

Assessment Categories & Documentation

CEM uses the 0 to 6 assessment scale, and the final category determines management. Category 3 indicates a low probability of malignancy suitable for short-interval follow-up, while Categories 4 and 5 indicate findings that warrant tissue sampling. Category 4 can be subdivided into 4A, 4B, and 4C to indicate low, moderate, and higher suspicion. 

A complete CEM report documents the exam indication, BPE level, LE and RC findings, enhancement descriptors, and final assessment. BI-RADS 2025 sets a consistent report order across modalities, so a CEM report reads in the same sequence as a mammography or MRI report, which supports faster review by referring clinicians and auditors.

Supporting CEM Growth With ContrastConnect

BI-RADS 2025 positions CEM as a routine breast imaging exam, and adoption continues to rise across outpatient networks. Each CEM exam requires a supervising physician for the contrast injection, which adds a staffing and compliance requirement alongside accurate reporting.

At ContrastConnect, we address that requirement with virtual contrast supervision for multi-site imaging groups, which removes the need for an onsite radiologist at every location. Facilities planning to expand CEM volume can request a coverage assessment from our team to confirm compliant supervision before they scale.

Frequently Asked Questions (FAQs)

Is contrast-enhanced mammography the same as CESM?

Yes. Contrast-enhanced mammography (CEM) is also called contrast-enhanced spectral mammography (CESM) or contrast-enhanced digital mammography. All describe the same technique: intravenous iodinated contrast is administered, then paired low-energy and high-energy images are captured and recombined to show where contrast collects in the breast, which improves cancer detection compared with standard mammography alone.

Can CEM be used for routine breast cancer screening?

Not routinely. For average-risk women, standard mammography remains the screening exam, and CEM is generally reserved for diagnostic questions or higher-risk patients. Screening use of CEM is still under study, and availability depends on local protocols and access to iodinated contrast, so it is not yet a standard population-screening tool.

Who should avoid contrast-enhanced mammography?

CEM uses intravenous iodinated contrast, so it is generally avoided in patients with a history of severe reaction to iodinated contrast agents. Impaired kidney function and pregnancy also call for caution and physician review. Patients should share allergy history, medications, and kidney status before the exam so staff can assess suitability.

Does CEM require physician supervision for the contrast injection?

Yes. Because CEM uses intravenous iodinated contrast, a supervising physician must be available to manage any contrast reaction under CMS rules. Many outpatient sites meet this requirement through virtual supervision where permitted, which keeps CEM available without a radiologist physically on site for every exam or extended hour. State rules on remote supervision vary, so eligibility should be confirmed locally.

Who can supervise contrast for a multi-site CEM program?

At ContrastConnect, our radiologist-owned team delivers CMS-compliant virtual contrast supervision across outpatient networks through a secure, HIPAA-compliant platform. We treat 130+ contrast reactions monthly, respond in seconds, and provide audit-ready documentation, which helps imaging centers reduce cancellations, extend hours, and scale without adding onsite radiologists at every location.

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Note: Information provided is for general guidance only and does not constitute medical, legal, or financial advice. Pricing estimates and regulatory requirements are current at the time of writing and subject to change. For personalized consultation on imaging center operations and virtual contrast supervision, contact ContrastConnect.