NI-RADS in posttreatment head and neck cancer surveillance: a framework for standardized imaging with clinical impact

The Neck Imaging Reporting and Data System (NI-RADS), developed through the American College of Radiology (ACR), provides a standardized framework for interpreting and managing posttreatment imaging in head and neck cancer. Building upon the success of NI-RADS PET/CT, the recently released NI-RADS MRI version 2025 represents a major advancement, introducing modality-specific descriptors and management recommendations tailored to MRI. This review summarizes the history and development of NI-RADS, highlighting both the validated PET/CT framework and the subsequent MRI update. At its core, NI-RADS offers a standardized lexicon for post-treatment findings, a structured reporting format that stratifies risk of disease recurrence, and linked management recommendations. Surveillance imaging is an essential component of post-treatment head and neck cancer care. Evidence strongly supports early imaging surveillance within six months of definitive therapy, whereas the benefits of long-term imaging surveillance remain under-investigated. With the goal of improving patient outcomes, NI-RADS provides a consistent, risk-adaptable framework that supports both clinical decision-making and standardized data collection for future outcomes research. NI-RADS will continue to evolve with advances in oncologic management and imaging technology. Future updates may incorporate ultrasound, advanced imaging techniques, and circulating tumor biomarkers. As surveillance strategies in head and neck cancer advance, NI-RADS is well positioned to serve as the foundation for personalized, risk-based imaging surveillance.