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Patient information:
Patient Name: [Patient’s Name]
Age/Sex: [Age] / Female
Referring Physician: [Doctor’s Name]
Date of Examination: [DD/MM/YYYY]
Indication: [Screening / Palpable Lump / Follow-up of Mammographic Finding]
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3D Contrast-Enhanced Ultrasound (CEUS) of Right Breast
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Examination Performed
- Modality: 3D Contrast-Enhanced Ultrasound (CEUS)
- Contrast Agent: [Contrast name, e.g., Sonovue (sulfur hexafluoride microbubbles)]
- Injection Dose: [Dose in mL]
- Mode of Imaging: Real-time grayscale, Doppler, contrast-enhanced with 3D volumetric reconstruction
Findings
Lesion Characteristics
- Location: [Clock-face position, depth, quadrant, distance from nipple]
- Size: [Length × Width × Height in mm]
- Shape: [Oval, round, irregular]
- Margins: [Circumscribed, indistinct, microlobulated, spiculated]
- Echogenicity: [Hypoechoic, isoechoic, hyperechoic, complex]
- Posterior Features: [Enhancement, shadowing, none]
- Vascularity (CEUS): [Peripheral, central, absent, diffuse]
- Enhancement Pattern: [Rapid wash-in/wash-out, persistent, plateau]
- Kinetics: [Early arterial phase enhancement, delayed wash-out, non-enhancing]
- 3D Volume Analysis: [Lesion morphology, enhancement distribution]
Axillary Lymph Nodes
- Enlargement: [Present/Absent]
- Cortical Thickening: [Yes/No]
- Hilum: [Preserved/Absent]
- CEUS Enhancement: [Increased/decreased/no abnormal enhancement]
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Impression
- [Benign, probably benign, suspicious, highly suspicious, or malignant features]
- [Recommendation for follow-up, biopsy, MRI, or surgical consultation]
- BI-RADS Category: [0-6]
Recommendation: Short-term follow-up biopsy, MRI, or surgical consultation.
