MRI Report Organization

The breast MRI report should be concise and follow a standardized structure.

Eight Required Report Components

  1. Indication for examination — structured category (new in v2025)
  2. Comparison to previous examination(s) with dates
  3. Acquisition parameters — field strength, sequences, contrast details, artifacts
  4. Amount of fibroglandular tissue (FGT) — A, B, C, or D
  5. Level of BPE — minimal, mild, moderate, or marked
  6. Clear description of important findings — using lexicon terminology without embellishment
  7. Assessment — BI-RADS category number and wording
  8. Management recommendations — concordant with assessment

v2025: Structured Exam Indications (New)

Three major indication categories:

Major IndicationExamples
Asymptomatic ScreeningElevated risk, gene mutation, dense breasts, prior breast cancer
Diagnostic: Work-UpClinical findings, imaging findings, follow-up category 3, implant assessment
Diagnostic: Current Breast CancerExtent of disease, response during/after NAC

Board Pearl

“Asymptomatic Screening” should only be used for patients with no current clinical/imaging findings and no current breast cancer. This structured indication system facilitates outcome auditing by separating screening from diagnostic exams.

Report Wording

  • Use lexicon terms without embellishment or definitions in narrative
  • Assessment category number AND wording in impression: e.g., “Assessment category 4B, Suspicious. Intermediate Suspicion for Malignancy”
  • Document any discussions between interpreting physician and referring clinician