Most existing artificial intelligence systems for breast ultrasound rely primarily on image-driven prediction, with limited incorporation of the knowledge from the Breast Imaging Reporting and Data System (BI-RADS) and the intermediate assessment processes underlying radiologists' workflow, thereby constraining their interpretability and alignment with clinical practice. We curated, to our knowledge, the largest multicenter collection of breast ultrasound images paired with structured BI-RADS descriptors, comprising 9,941 patients across 20 independent datasets. Across 14 testing datasets, IBUS demonstrated consistent generalization performance across different clinical centers and imaging conditions. Incorporating BI-RADS descriptors enabled fine-grained risk stratification, while cross-checking predicted BI-RADS grades against malignancy probabilities identified internally discordant predictions that may warrant additional clinical review. In a reader study involving eight radiologists, IBUS assistance increased diagnostic sensitivity among both junior and senior readers, with the potential of guiding radiologists to make targeted revision in risk stratification. Overall, IBUS exhibits its potential as a second-stage decision-support system that complements radiologists by providing additional risk estimates and interpretable evidence for diagnostically challenging cases. The demo video of IBUS platform is publicly available at https://github.com/zsz1997/IBUS.

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