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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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Qualitative Contrast-Enhanced Ultrasound (CEUS) right breast
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Findings:
Baseline B-mode Ultrasound:
- A hypoechoic lesion measuring [Size] cm was identified in the [Right/Left] breast at [Clock Position].
- The lesion appears [well-defined/ill-defined, oval/irregular, homogeneous/heterogeneous].
- No significant posterior acoustic features ([enhancement/shadowing]) were noted.
- Axillary lymph nodes appear [normal/enlarged/reactive].
Color Doppler Assessment:
- [Increased/Minimal] vascularity within the lesion.
- [Peripheral/Central/Mixed] vascular distribution observed.
Contrast-Enhanced Ultrasound (CEUS) Findings:
- Following the administration of [contrast agent name & dose], real-time contrast enhancement was observed.
- Wash-in phase: Rapid/moderate/delayed enhancement.
- Peak enhancement: Homogeneous/heterogeneous.
- Wash-out phase: [Rapid/gradual/persistent] washout pattern.
- Vascular distribution:
- Benign features: Centripetal enhancement, homogenous enhancement, smooth margins.
- Suspicious features: Irregular rim enhancement, heterogeneous enhancement, penetrating vessels.
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Impression:
- Findings are [suggestive of a benign lesion/malignant features observed].
- BI-RADS Category: [BI-RADS 2/3/4/5] based on imaging features.
- The CEUS findings correlate with [benign/malignant] features.
- [No suspicious enhancement/malignant enhancement pattern] noted.
- Clinical correlation and follow-up as necessary.
Recommendation: Further evaluation with [biopsy/MRI/follow-up ultrasound] is recommended.
