Laudário Report templates Breast

Breast ultrasound report template (BI-RADS)

The breast report follows the BI-RADS lexicon: each lesion with shape, orientation, margins, echo pattern, clock-face location and distance from the nipple, and a final category with management.

Normal template

BREAST AND AXILLARY ULTRASOUND

FINDINGS:

Tissue composition: [homogeneous-fat/homogeneous-fibroglandular/heterogeneous].

No nodules, cysts or architectural distortion in either breast.

Skin, nipple-areolar complex and muscle planes normal in appearance.

Axillary lymph nodes normal in appearance, with thin cortex and preserved hilum.

IMPRESSION:

Normal breast ultrasound.

BI-RADS 1.

Example: probably benign nodule

FINDINGS:

N1: oval nodule, parallel to the skin, with circumscribed margins, hypoechoic, with no posterior acoustic features, in the right breast at 10 o'clock, 4 cm from the nipple, measuring 1,1 x 0,6 x 0,8 cm.

IMPRESSION:

Nodule in the right breast with probably benign features.

BI-RADS 3.

RECOMMENDATIONS:

Follow-up ultrasound in 6 months.

Fields in brackets are filled in from the exam. The template is a starting point: the report must reflect what was seen and your practice's guidelines.

Frequently asked questions

What is the management for BI-RADS 3?

Short-interval follow-up, usually with ultrasound at 6 months, then at 12 and 24 months.

Does ultrasound replace mammography?

Not in population screening. It complements mammography, especially in dense breasts.

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