How should a breast ultrasound case report be structured and what details should be included?

Breast Ultrasound Case Report Structure

A breast ultrasound case report should follow the SCARE 2018 guidelines for surgical case reports, incorporating specific breast imaging elements from BI-RADS classification and standardized ultrasound reporting principles. 1, 2

Essential Components

Title and Keywords

• Include "case report" and the specific focus area (e.g., "breast ultrasound diagnosis," "palpable mass evaluation") in the title 2
• Provide 3-6 keywords including "case report" and relevant imaging/clinical terms 2

Abstract Structure (4 key elements)

• Introduction: What makes this case unique or educational for breast imaging practice 2
• Clinical presentation: Patient's main concerns and key clinical findings 2
• Diagnosis and interventions: Include imaging findings, BI-RADS category, and management 2
• Conclusion: Main take-away lessons for clinical practice 2

Patient Information Section

Demographic details (de-identified): age, sex, ethnicity, relevant factors like BMI 2

Presentation details:

• Specific symptoms (palpable lump, nipple discharge, pain, skin changes) 3
• Mode of presentation (self-detected, screening-detected, physician referral) 2
• Past medical/surgical history including prior breast procedures 2
• Medication history, family history (especially breast cancer), smoking status 2

Clinical Findings

Document the physical examination findings systematically 4:

• Breast inspection findings (skin changes, asymmetry, nipple abnormalities)
• Palpation findings with specific location (clock position and distance from nipple)
• Lymph node examination (axillary, supraclavicular) 5
• Include clinical photographs if consent obtained 2

Diagnostic Assessment

Ultrasound technical details 6, 7:

• Equipment used (manufacturer, model, transducer frequency)
• Patient position during examination
• Scanning technique employed

Imaging findings using standardized terminology 3, 5:

For masses, describe:

• Location (quadrant, clock position, distance from nipple)
• Size (three dimensions in mm)
• Shape (oval, round, irregular)
• Orientation (parallel vs. not parallel to skin)
• Margin characteristics (circumscribed, indistinct, angular, microlobulated, spiculated)
• Echo pattern (anechoic, hyperechoic, complex, hypoechoic, isoechoic, heterogeneous)
• Posterior acoustic features (none, enhancement, shadowing, combined)
• Presence of calcifications
• Vascularity pattern if Doppler used

For cysts, specify:

• Simple vs. complicated vs. complex cystic and solid 3
• Internal echoes and mobility of components 3

BI-RADS classification 5:

• Category 0: Need additional imaging
• Category 1: Negative
• Category 2: Benign findings (simple cysts, intramammary lymph nodes, stable fibroadenomas)
• Category 3: Probably benign (<2% malignancy risk) - requires short-interval follow-up
• Category 4: Suspicious (3-94% malignancy risk) - biopsy recommended
• Category 5: Highly suggestive of malignancy (≥95% risk)
• Category 6: Known biopsy-proven malignancy

Correlation with Other Imaging

Document correlation with mammography findings when available 8:

• For women ≥40 years: mammography is typically the initial examination 8
• For women <30 years: ultrasound may be the primary modality 8
• Note concordance or discordance between imaging modalities 3

Diagnostic Reasoning

• Differential diagnoses considered 2
• Why certain diagnoses were favored or excluded 2
• Diagnostic challenges encountered (technical, patient-related) 2

Therapeutic Intervention

Biopsy details if performed 3:

• Type (core needle biopsy preferred over fine needle aspiration)
• Guidance method (ultrasound-guided)
• Number of cores obtained
• Immediate complications

Management pathway based on BI-RADS category 3:

• Category 3: Short-interval follow-up at 6-12 months 3
• Category 4-5: Core needle biopsy 3
• Post-biopsy concordance assessment (benign and concordant vs. discordant) 3

Follow-up and Outcomes

• Timeline of events from presentation to final diagnosis 2
• Histopathological results with concordance to imaging 3
• Subsequent management decisions 2
• Patient outcome and current status 2

Images and Figures

Include standardized ultrasound images 9:

• Remove all patient identifiers
• Provide clear anatomical orientation
• Use arrows or annotations to highlight key findings
• Include both transverse and longitudinal views
• Add legends explaining what is shown
• Consider including drawings for complex findings 9

Common Pitfalls to Avoid

Terminology inconsistency: Use standardized BI-RADS lexicon throughout 5

Incomplete mass characterization: All descriptors (shape, margin, orientation, echo pattern, posterior features) must be documented 6, 7

Missing correlation: Always attempt to correlate ultrasound findings with clinical examination and mammography when available 5

Inadequate follow-up documentation: For Category 3 lesions, document the complete follow-up timeline and stability assessment 3

Biopsy-imaging discordance: When histology doesn't match imaging suspicion, this must be explicitly stated and surgical excision considered 3

Additional Considerations

Informed consent: Document that patient consent was obtained for publication 2

Conflicts of interest and funding sources: Declare any relevant conflicts 2

Patient perspective: When appropriate, include the patient's experience with the diagnostic process 1

This structured approach ensures comprehensive documentation while maintaining clarity for both radiologists and referring clinicians, ultimately improving patient care through standardized communication 6, 7, 10.