BI-RADS v2025 for breast ultrasound: key updates and Asian perspectives

Clinical Background and Rationale

Women with dense breasts constitute a large proportion of the screening population, particularly in East Asia, yet breast density alone does not necessarily indicate tissue at increased risk for cancer development [10–12]. In women with dense breasts, supplemental screening modalities such as ultrasound or magnetic resonance imaging (MRI) are often recommended to improve cancer detection [13]. However, these additional examinations are well known to substantially increase false-positive findings, leading to unnecessary recalls and biopsies, increased patient anxiety, and higher healthcare costs. Accordingly, there is growing interest in more refined risk-stratification strategies that go beyond mammographic density and enable more personalized screening approaches with a better balance between benefit and harm [14,15].

Ultrasound offers unique advantages for tissue characterization that mammography cannot provide. In particular, ultrasound can differentiate glandular tissue from fibrous stroma within fibroglandular tissue, whereas both components appear uniformly dense on mammography. Accumulating evidence suggests that the relative proportion of glandular tissue within dense breasts varies considerably among individuals and may carry biologically and clinically meaningful information [16]. This concept has led to increasing interest in ultrasound-based assessment of tissue composition as a potential imaging biomarker for breast cancer risk stratification, especially in populations in which ultrasound is widely used for screening [17].

In this context, BI-RADS v2025 introduces GTC as a new element of breast tissue composition assessment on ultrasound. By explicitly separating tissue pattern from the proportion of glandular tissue, GTC is intended to better capture interindividual heterogeneity across the full spectrum of breast tissue composition rather than density alone. It also provides a framework for incorporating sonographic tissue characteristics into risk assessment, screening strategy optimization, and diagnostic interpretation.

Definition and Classification of GTC

In BI-RADS v2025, ultrasound tissue composition is reorganized into two complementary elements: tissue pattern and GTC. These features can be assessed on either handheld or automated breast ultrasound (ABUS). The previously defined background echotexture categories are subsumed under tissue pattern, whereas GTC is newly introduced to qualitatively assess the proportion of glandular tissue within fibroglandular tissue. On ultrasound, glandular tissue typically appears iso- or hypoechoic relative to surrounding fat, whereas fibrous stroma appears hyperechoic, allowing visual differentiation that is not possible on mammography. GTC is classified into four categories—minimal (<25%), mild (25%–49%), moderate (50%–74%), and marked (≥75%)—according to the relative proportion of glandular tissue (Figs. 1, 2). The concept and classification of GTC were initially proposed by a research group at Seoul National University Hospital in Korea [14].

Fig. 1.

Mammographic and ultrasound appearance of normal breast tissue with schematic diagram.

A. Craniocaudal mammogram in a 48-year-old woman shows dense fibroglandular tissue (FGT) with overlapping densities, in which the glandular and fibrous components are indistinguishable. B. Ultrasound image shows relatively hypoechoic glandular tissue (arrows) and hyperechoic stromal tissue within the FGT, allowing clear differentiation between the two components. C. Corresponding schematic ultrasound diagram illustrates glandular tissue (arrows) within the FGT in gray and fibrous tissue in white.

Fig. 2.

Classification of glandular tissue component (GTC) on automated breast ultrasound.

The proportion of GTC within the overall fibroglandular tissue (FGT, outlined by the dashed line) is qualitatively classified into four categories: minimal (<25%) (A), mild (25%–49%) (B), moderate (50%–74%) (C), and marked (≥75%) (D).

In a prospective study involving 11 radiologists, interobserver agreement for GTC assessment was moderate, with κ values of 0.41 for the four-category classification and 0.52 for binary classification, which are comparable to or higher than those reported for background parenchymal enhancement on breast MRI [14].

Association of GTC with Breast Cancer Risk and Interpretation

Accumulating evidence indicates that sonographic GTC is associated with future breast cancer risk, a finding that is particularly relevant in regions where ultrasound is frequently used as a primary or integral screening modality. In a large longitudinal study of 14,767 screening ultrasound examinations, women with higher GTC had a significantly greater risk of subsequent breast cancer than those with low GTC (hazard ratio, 1.5; P=0.03). In a subset of 233 women with histological correlation, GTC was inversely associated with lobular involution [14]. These findings formed the basis for the BI-RADS v2025 recommendation to report GTC together with tissue pattern in both screening and diagnostic ultrasound examinations. A prospective multinational cohort study is also ongoing to further validate the association between sonographic GTC and breast cancer risk (ClinicalTrials.gov identifier: NCT05460975).

Beyond risk prediction, GTC may also have important implications for image interpretation and clinical decision-making. Women with high GTC have been shown to have higher rates of abnormal interpretation on supplemental screening ultrasound than those with low GTC, underscoring the importance of distinguishing normal variation in the amount of glandular tissue from true pathological findings [18]. In benign or physiological conditions, ductal and lobular architecture remains structurally continuous despite increased glandular volume, and internal vascularity is typically absent on Doppler imaging. GTC may also contribute to malignancy risk stratification in equivocal lesions. In a retrospective study of BI-RADS category 4A masses, malignancy rates were significantly higher in the high-GTC group than in the low-GTC group after propensity score matching, and GTC was identified as an independent predictor of malignancy [19]. In addition, preoperative assessment of GTC on ultrasound was independently associated with survival outcomes in patients with invasive breast cancer, suggesting a potential prognostic role that warrants further investigation [20,21].

Future Directions

As a qualitative assessment, the clinical utility of GTC depends on acceptable interobserver reproducibility. Although previous studies suggest that GTC can be incorporated into routine clinical practice with appropriate education and structured training, interobserver variability remains a challenge, particularly among readers with different levels of breast imaging experience. To improve consistency and facilitate broader adoption, quantitative software tools and deep learning-based artificial intelligence (AI) models are being actively explored. Early studies suggest that these approaches may improve both diagnostic performance and reproducibility of GTC assessment, with the greatest benefit observed among radiologists without dedicated breast imaging training [22]. As a relatively new conceptual framework in sonographic tissue assessment, GTC requires continued validation to clarify its association with breast cancer risk and its effects on screening performance and diagnostic accuracy across diverse clinical settings.

Concept and Background of NMLs

With advances in breast ultrasound technology and improved understanding of breast pathology on ultrasound, NMLs have increasingly been recognized as a distinct category of abnormal findings that do not meet the conventional definition of a mass. These lesions are identifiable as discrete abnormalities in three dimensions but lack convex outer margins, a definable shape, or clear demarcation from the surrounding tissue [23,24]. Rather than forming discrete space-occupying masses, NMLs are characterized by abnormal ductal and lobular patterns within the breast parenchyma. This concept was systematically summarized by Uematsu in 2012 [23], who classified these ultrasound findings as ductal or nonductal hypoechoic areas based on their anatomic distribution and structural patterns. This framework, which was developed largely from clinical experience in Asian practice, where ultrasound plays a central role, was subsequently adopted by the BI-RADS committee and led to the introduction of “non-mass lesions” as a new category in the Findings section of the updated BI-RADS ultrasound lexicon. Ductal abnormalities, particularly dilated ducts with intraductal lesions, are common ultrasound findings that often prompt biopsy and are now included within the NML category [25]. In contrast, ductal changes without a discrete intraductal lesion—such as unilateral or bilateral ductal dilatation—are not classified as NMLs but are instead described as associated features because they are not regarded as suspicious lesions.

The primary rationale for incorporating NMLs into the Findings section of the BI-RADS ultrasound lexicon is that NMLs on ultrasound are conceptually analogous to non-mass enhancement on breast MRI [23,24]. Although contrast-enhanced breast MRI is highly sensitive for breast cancer detection, its specificity remains limited. Suspicious lesions that present as non-mass enhancement on MRI are frequently not detected on second-look ultrasound, and only approximately half appear as NMLs [26]. Integrating the ultrasound and MRI lexicons is therefore logical and may help streamline clinical management. In this context, NMLs on ultrasound represent a key concept that links non-mass enhancement detected on MRI, contrast-enhanced mammography, and computed tomography, thereby facilitating harmonized interpretation and management across imaging modalities [23,24]. Recognition of NMLs therefore represents an important conceptual shift in breast ultrasound interpretation.

Anatomical Basis of NMLs on Ultrasound

On ultrasound, normal breast tissue is characterized by dendritic hypoechoic ductal and lobular structures surrounded by fibrous stroma, whereas edematous or fat-containing stroma appears hyperechoic [24]. NMLs represent focal or regional disruption of normal ductal and lobular architecture within these dendritic structures and appear as hypoechoic or heterogeneous areas without forming a discrete mass. Their identification therefore relies primarily on qualitative assessment of architectural deviation rather than simple echogenic contrast within ductal and lobular structures [23,24]. A defining feature of NMLs is the presence of abnormal ductal or lobular patterns, such as loss of normal ductal tapering, discontinuity or irregularity of ductal courses, or focal breakdown of lobular architecture. Ductal carcinoma in situ and invasive lobular carcinoma frequently present with these architectural abnormalities without forming discrete masses, highlighting the critical importance of structural pattern recognition in the evaluation of NMLs [23,24]. Accordingly, a structured, anatomy-based approach to ultrasound interpretation has been advocated to better characterize such deviations from normal architecture. In this context, Izumori and colleagues from Japan proposed a three-dimensional, dynamic interpretation method termed “anatomical scanning,” which has also been described as a breast ultrasound technique based on histopathological and anatomical knowledge. This method improves understanding of individual variation in normal mammary gland architecture and enables evaluation of NMLs as deviations from normal structural patterns [27].

BI-RADS Descriptors and Reproducibility for NMLs

For NMLs, conventional mass descriptors such as shape and margin are generally not applicable. Instead, NMLs are primarily characterized by three descriptors: distribution, echo pattern, and posterior features. Distribution, which is unique to NMLs, is classified as regional, focal, linear, or segmental. Regional distribution refers to involvement of a relatively large area of the breast that does not conform to a linear or segmental pattern. Focal distribution indicates a small, confined area of abnormality without discrete mass-like margins. Linear distribution describes a longitudinal arrangement that may follow the course of a duct, whereas segmental distribution refers to a triangular area with the base toward the pectoralis muscle and the apex toward the nipple, corresponding to a ductal segment. Echo pattern is described as hyperechoic, heterogeneous, or hypoechoic, and posterior features are categorized as none, enhancement, or shadowing, using definitions consistent with those applied to masses. Together, these descriptors provide a standardized framework for characterizing NMLs, even though they do not form discrete masses. Associated findings, including calcifications, architectural distortion, abnormal ductal changes, and hypervascularity, may further aid lesion assessment.

Despite concerns regarding reader dependence, accumulating evidence suggests acceptable reproducibility in distinguishing NMLs from masses with indistinct margins. Interreader agreement for classifying lesions as either masses or NMLs on breast ultrasound has been reported to be moderate to substantial (κ=0.53–0.64) [28]. Furthermore, a study from Korea demonstrated good-to-excellent interreader agreement for individual sonographic features of NMLs (κ=0.63–0.81) [29].

Ultrasound Features of Benign and Malignant NMLs

Published studies have reported that approximately 10%–54% of NMLs detected on ultrasound are malignant [30]. Among malignant tumors presenting as NMLs, ductal carcinoma in situ and invasive lobular carcinoma are relatively more common than invasive ductal carcinoma (Figs. 3, 4). Benign NMLs encompass a wide spectrum of entities, most commonly fibrocystic changes, stromal fibrosis, fibroadenomatoid hyperplasia, sclerosing adenosis, radial scar or complex sclerosing lesion, intraductal papilloma, atypical ductal hyperplasia, duct ectasia, chronic mastitis, granulomatous mastitis, abscess, and diabetic mastopathy.

Fig. 3.

High-grade ductal carcinoma in situ.

Ultrasound image in a 45-year-old woman shows a segmental hypoechoic non-mass lesion (arrows) with ductal extension and echogenic foci (arrowheads), suggestive of calcifications.

Fig. 4.

Invasive lobular carcinoma.

A. Axial contrast-enhanced magnetic resonance image in a 63-year-old woman shows linear non-mass enhancement (arrow) in the lower inner quadrant of the left breast. B. Second-look ultrasound demonstrates a corresponding 10-mm linear non-mass lesion (dashed lines).

Several ultrasound features have been associated with malignancy in NMLs, including segmental distribution, abnormal ductal changes, calcifications, posterior shadowing, architectural distortion, and the absence of multiple small cysts [31,32]. In contrast, the presence of multiple small cysts within an NML has been associated with benign outcomes, as shown in a study of 715 patients [33]. Reported malignancy rates vary according to clinical indication, patient symptoms, and the presence of abnormalities on other imaging modalities [29,34,35]. In a retrospective study of 1,152 women with NMLs, malignancy rates were 10.4% (26 of 251) in screening examinations, 43.4% (295 of 679) in diagnostic workup cases, and 40.1% (89 of 222) in patients with current breast cancer [34]. Clinical symptoms further increase the likelihood of malignancy in NMLs. In addition, the presence of corresponding findings on other imaging modalities—such as architectural distortion, focal asymmetry, or calcifications on mammography, or abnormal enhancement on contrast-enhanced mammography or MRI—significantly increases the probability of malignancy. Therefore, correlation with clinical presentation and multimodality imaging is essential for comprehensive evaluation of ultrasound-detected NMLs. An interpretation algorithm for NMLs on ultrasound, developed through expert consensus in Korea, China, and Japan, is presented in Fig. 5 [35,36].

Fig. 5.

Diagnostic approach to non-mass lesions on breast ultrasound (US).

This flowchart illustrates a practical diagnostic approach that integrates clinical correlation, distribution patterns, and associated imaging features. Lesions with clinical abnormalities, suspicious findings on other imaging modalities, segmental distribution, or associated calcifications are recommended for biopsy. In the absence of these features, short-term or routine follow-up may be considered. ^a)Non-mass lesions corresponding to non-mass enhancement on contrast-enhanced magnetic resonance imaging should be regarded as highly suspicious, and biopsy is recommended. ^b)If detected on screening US without associated calcifications, short-term follow-up may be considered. Adapted from Kim et al., Korean J Radiol 2025;26:1133-1148 [36], according to Creative Commons license.

Clinical Implications of NMLs in BI-RADS v2025

The inclusion and refinement of NMLs in BI-RADS v2025 represent a pivotal update in breast ultrasound interpretation. By formally integrating concepts that have been actively developed in Asian practice, where ultrasound is frequently used as a primary imaging modality, this revision acknowledges the clinical importance of tissue-based abnormalities, including ductal and lobular changes that occur without discrete mass formation. In this context, ultrasound-detected NMLs provide a critical link between non-mass enhancement identified on MRI and corresponding findings across other imaging modalities, reinforcing the role of ultrasound in lesion correlation, targeted biopsy, and follow-up, particularly in women with dense breasts. Because assessment of NMLs is inherently operator- and reader-dependent, standardized terminology, structured training, and quality-control systems are essential to ensure consistent interpretation while minimizing false-positive findings and preserving diagnostic sensitivity [3,24,37,38].

Clinical Background and Rationale

In BI-RADS v2025, lymph nodes are presented as a distinct category in the ultrasound lexicon, reflecting their central role in breast cancer staging, prognosis, and treatment planning. This update includes expanded discussion of lymph node assessment as an imaging finding, with emphasis on standardized morphological evaluation and staging. The change is consistent with the growing emphasis on standardized nodal assessment as breast cancer management increasingly shifts toward less invasive surgical strategies and more selective axillary intervention [8].

Ultrasound plays a pivotal role in regional lymph node evaluation because of its wide availability, real-time imaging capability, and utility for image-guided biopsy. High-frequency linear transducers enable comprehensive assessment of regional nodal basins, and reported sensitivities for detecting axillary nodal metastasis range from 53% to 70% [39,40], increasing to approximately 80% when ultrasound-guided biopsy is added [41,42]. When adequate sampling is achieved, as indicated by the presence of lymphocytes, core needle biopsy and fine-needle aspiration biopsy demonstrate similarly high specificity (98%–100%) [43]. Accordingly, BI-RADS v2025 clearly defines regional nodal stations and provides systematic criteria for differentiating normal from abnormal nodal morphology.

Beyond diagnosis, axillary ultrasound is increasingly being explored as a triage tool for de-escalation of axillary surgery. Following the paradigm shift initiated by the ACOSOG Z0011 trial, several prospective trials—including SOUND, INSEMA, BOOG 2013-08, and NAUTILUS—have investigated the safety of omitting sentinel lymph node (SLN) biopsy in clinically node-negative patients undergoing breast-conserving therapy [44-47]. Among these studies, the NAUTILUS trial, conducted by a Korean multicenter research group, established standardized axillary ultrasound criteria and imaging-based exclusion rules to support safe omission of SLN biopsy in selected patients [47]. Building on this work, the ongoing NeoNAUTILUS trial extends this concept to the neoadjuvant setting by evaluating imaging-based prediction of nodal response [48]. Collectively, these developments underscore the expanding role of high-quality, standardized axillary ultrasound and provide a strong rationale for recognizing lymph nodes as a standalone category in the BI-RADS ultrasound lexicon.

Morphological Evaluation of Lymph Nodes

On ultrasound, lymph nodes consist of a hypoechoic cortex and a central hyperechoic fatty hilum. The presence of Doppler flow within afferent and efferent hilar vessels helps confirm nodal identity. For differentiating benign from malignant lymph nodes, morphological and structural features are generally more informative than size alone [49]. Normal or benign axillary lymph nodes are typically oval or reniform, with smooth margins, a homogeneous hypoechoic cortex measuring less than 3 mm in thickness, and a preserved fatty hilum. In contrast, abnormal or suspicious lymph nodes may appear round, with a long-axis/short-axis ratio of less than 2, cortical thickening greater than 3 mm, eccentric cortical hypertrophy, irregular margins, compression or displacement of the hilum, complete hilar effacement, or peripheral (nonhilar) vascularity [50]. These morphological features largely reflect changes in the relationship between the cortex and fatty hilum that can be appreciated on ultrasound (Fig. 6) [43,49,51]. Extranodal extension, defined as tumor cells extending beyond the nodal capsule, is associated with poor prognosis and suggests the presence of nonsentinel nodal metastases (Fig. 7) [43,52].

Fig. 6.

Morphological evaluation of lymph nodes.

A. Ultrasound image in a 44-year-old asymptomatic woman without breast cancer shows an axillary lymph node with a predominant echogenic hilum (asterisk) and a nearly imperceptible hypoechoic cortical rim (arrow), consistent with a normal lymph node. B. Ultrasound image in a 59-year-old woman with newly diagnosed invasive breast carcinoma shows an ipsilateral axillary lymph node with central hilar fat (asterisk) surrounded by a 2-mm hypoechoic cortex (arrow), consistent with a normal lymph node. Pathology confirmed the absence of nodal metastasis. C. Ultrasound image in a 37-year-old woman with invasive ductal carcinoma shows an ipsilateral lymph node with diffuse cortical thickening and a compressed, displaced echogenic hilum (asterisk), consistent with an abnormal lymph node. Pathology confirmed metastatic involvement. D. Ultrasound image in a 55-year-old woman with left breast cancer shows a rounded ipsilateral lymph node (arrow) with an effaced hilum, consistent with an abnormal lymph node. Pathology confirmed metastasis.

Fig. 7.

Extranodal extension.

Ultrasound image in a 58-year-old woman with invasive ductal carcinoma of the left breast shows an irregular ipsilateral axillary lymph node (arrow) with an indistinct margin and an associated echogenic rind (asterisk). Surgical pathology revealed metastatic tumor breaching the nodal capsule and infiltrating adjacent tissues.

Importantly, there is no strict upper size limit for morphologically normal axillary lymph nodes. Larger nodes may still be benign if the cortex remains thin relative to overall nodal size and the fatty hilum is preserved. Conversely, even nonenlarged lymph nodes may be considered abnormal if they show marked cortical hypoechogenicity, abnormal cortical configuration, or loss of the hilum [8,43]. No single ultrasound feature reliably distinguishes metastatic involvement from reactive hyperplasia; therefore, comprehensive interpretation that incorporates clinical history, such as recent vaccination, and other imaging findings remains essential.

To improve the diagnostic performance of ultrasound, adjunctive techniques such as color Doppler ultrasound, elastography, and contrast-enhanced ultrasound (CEUS) have been investigated in multiple studies from East Asia [53]. The pooled sensitivity and specificity of CEUS for diagnosing SLN metastasis were 0.91 and 0.86, respectively, and percutaneous CEUS was more sensitive than intravenous CEUS for detecting SLN metastases (0.92 vs. 0.82, P<0.05). This indicates that CEUS, particularly percutaneous CEUS, is a reliable imaging technique that provides important information for clinical staging and management of breast cancer [54]. Percutaneous CEUS involves periareolar subcutaneous injection of contrast agents (e.g., SonoVue), which allows real-time visualization of lymphatic channels and SLNs. Several institutions in China are currently investigating percutaneous CEUS as a potential alternative to radioisotope-based techniques for SLN mapping.

Advances in AI have also demonstrated promising potential for radiomics and deep learning applied to breast ultrasound, enabling noninvasive preoperative assessment of axillary lymph nodes to assist clinical decision-making and potentially improve patient prognosis [55]. In one pooled analysis, sensitivity was 0.88, specificity was 0.75, and the area under the receiver operating characteristic curve was 0.89 for prediction of lymph node metastasis in patients with breast cancer [56].

Anatomical Location of Regional Lymph Nodes

Breast lymphatic drainage primarily involves the intramammary, axillary, internal mammary, and supraclavicular lymph nodes. Ipsilateral axillary, internal mammary, and supraclavicular nodes are collectively defined as regional lymph nodes and are integral to clinical and pathological N staging in breast cancer (Fig. 8) [43]. Ultrasound evaluation of these nodal basins contributes to accurate staging, surgical planning, and treatment selection. Metastasis to contralateral regional lymph nodes is classified as distant metastatic disease (stage IV) [57].

Fig. 8.

Regional lymph node anatomy.

The margins of the pectoralis minor muscle define the axillary lymph node levels. Level I (blue nodes) lies inferior and lateral to the lateral border of the pectoralis minor muscle; Level II (purple nodes) lies posterior to the muscle and includes the interpectoral (Rotter’s) nodes; and Level III (infraclavicular, orange nodes) lies superior and medial to the medial border of the muscle. Supraclavicular nodes (yellow nodes) are located superior to the clavicle, and internal mammary nodes (dark pink nodes) are distributed along the parasternal intercostal spaces. These nodal groups correspond to the regional lymph node categories used in the American Joint Committee on Cancer clinical and pathological nodal staging system for breast cancer [57].

Intramammary lymph nodes may occur throughout the breast but are most commonly located in the upper outer quadrant and posterior third of the breast, particularly along the axillary tail. Although they are typically small (0.3–1.0 cm), the fatty hilum may be inconspicuous; in such cases, Doppler imaging may facilitate identification by demonstrating hilar vascular flow. In TNM staging, intramammary nodal metastasis is considered equivalent to level I axillary nodal involvement [8].

Axillary lymph nodes are classified into three levels according to their relationship to the pectoralis minor muscle (Fig. 9). Level I nodes lie lateral to the lateral margin of the pectoralis minor muscle. Level II nodes are located posterior to the muscle or between the pectoralis major and minor muscles, including interpectoral (Rotter’s) nodes. Level III nodes are situated medial to the medial margin of the pectoralis minor muscle. Accurate localization and reporting of abnormal nodes, particularly interpectoral nodes, are important for surgical planning [8].

Fig. 9.

Levels of axillary lymph nodes.

Ultrasound image in a 34-year-old woman shows the levels of axillary lymph nodes in the left axilla. Level I nodes are located lateral to the pectoralis minor muscle. Level II nodes are located posterior to the pectoralis minor muscle (asterisk), including interpectoral (Rotter’s) nodes. Level III nodes are located medial to the pectoralis minor muscle.

Internal mammary lymph nodes are located in the parasternal intercostal spaces, typically from the first to the fourth intercostal spaces, and lie adjacent to the internal mammary artery and veins [58–60]. Suspicious internal mammary nodes in patients with breast cancer warrant consideration of metastasis and may be sampled by ultrasound-guided biopsy when feasible (Fig. 10) [61].

Fig. 10.

Axillary and internal mammary lymph node metastases.

Ultrasound images in a 59-year-old woman with newly diagnosed invasive breast carcinoma show ipsilateral axillary lymph node metastasis (A) and internal mammary lymph node metastases (B) (arrows), with cortical thickening and hilar compression (asterisks).

Supraclavicular lymph node involvement represents the highest regional nodal stage (N3c) and has important implications for staging and treatment. Ultrasound examination of the supraclavicular fossa is warranted when lower-level lymph nodes demonstrate imaging findings suspicious for metastasis.

Clinical Implications and Future Directions of Lymph Node Assessment

In summary, classification of lymph nodes as a separate category in the updated BI-RADS ultrasound lexicon underscores their distinct diagnostic and prognostic roles in breast cancer evaluation. Clear, standardized assessment of nodal morphology—including cortical thickness, hilar status, and vascular features—supports more consistent interpretation and facilitates appropriate risk stratification in clinical practice. Importantly, distinguishing lymph node findings from parenchymal or lesion-based abnormalities reduces ambiguity in reporting and enhances multidisciplinary communication, particularly in the era of surgical de-escalation and personalized treatment planning. As the role of axillary ultrasound continues to evolve, incorporation of structured assessment frameworks and emerging quantitative or AI-assisted tools may further improve reproducibility and clinical utility in breast imaging practice.