Reporting and final assessment categories – Standard reporting of breast imaging
- Describe the clinical profile (patient’s history and clinical examination findings), indication for the study (screening, diagnostic, or follow-up), including details of any earlier surgical interventions and risk status.
- Mammography and ultrasound findings are listed in the same report. The final BI-RADS is then stated.
- Describe the breast composition: ACR categories a–d.
- Describe mammography findings using the standardized terminology of the mammography lexicon: mass, calcifications, architectural distortion, asymmetry, and associated features, e.g. “Mass with calcifications, skin thickening, and nipple retraction”.
- Localize the finding by laterality, quadrant, distance from nipple, and depth from skin.
- Correlate mammography and breast ultrasound findings with clinical information.
- Describe ultrasound findings using the standardized terminology of the ultrasound lexicon.
- Compare images with those obtained during earlier examinations and note any interval changes.
- Conclude with the final assessment category – BI-RADS categories 0–6 – and the associated phrase.
- Suggest further assessment recommendations.
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