What is the proper procedure for performing a breast ultrasound?

How to Perform a Breast Ultrasound

Patient Positioning and Preparation

Position the patient supine with the ipsilateral arm raised overhead to flatten breast tissue against the chest wall, which optimizes visualization of breast structures. 1, 2

• Have the patient lie flat on the examination table with the arm on the side being examined placed behind their head 2
• This positioning spreads breast tissue evenly over the chest wall, reducing tissue thickness and improving image quality 1
• For automated breast ultrasound systems, prone positioning may be used as an alternative, though this requires specialized equipment 3, 4

Infection Control and Equipment Setup

Cover the ultrasound probe with a disposable probe cover or glove before each examination, and sanitize all equipment that contacts the patient between examinations. 5

• Use a probe cover or glove on the transducer for every patient 5
• Sanitize the ultrasound probe, keyboard, and machine surfaces with disinfectant before each patient 5
• Healthcare workers performing the examination should wear surgical masks, and patients should wear surgical masks during the procedure 5
• For standard examinations, providers should wear surgical mask, visor or goggle protection, disposable gown, disposable cap, and disposable gloves 5

Systematic Scanning Technique

Use a high-frequency linear transducer (typically 5-14 MHz) and scan the entire breast tissue pentagon systematically using overlapping passes in a vertical strip pattern or radial pattern. 3, 6, 7

• Cover the entire pentagon-shaped area of breast tissue, which extends from the clavicle superiorly to the inframammary fold inferiorly, from the sternal edge medially to the mid-axillary line laterally 2
• Apply gentle, consistent pressure with the transducer to ensure adequate tissue contact without excessive compression 6
• Use overlapping scanning motions to ensure complete coverage of all breast tissue 2
• Pay particular attention to the upper outer quadrant and the area under the areola/nipple, as these are the most common sites for cancer 2

Specific Areas to Examine

Systematically evaluate both breasts in their entirety, including bilateral axillary regions, to identify any masses, architectural distortions, or lymphadenopathy. 1, 7

• Scan the entire breast tissue of both breasts, not just the area of clinical concern 1
• Evaluate bilateral axillae for lymph node abnormalities 1
• Assess for solid versus cystic lesions, characterize any masses identified, and look for architectural distortions 1
• Document the location of any findings using clock-face position and distance from the nipple 5

Image Acquisition and Documentation

Obtain images in both transverse and longitudinal planes for any identified abnormalities, and document findings using BI-RADS classification. 5, 7

• Capture representative images of normal tissue and any abnormalities in orthogonal planes 6
• Measure lesions in three dimensions when abnormalities are identified 6
• Use color Doppler or elastography as adjunctive techniques when available to further characterize suspicious lesions 6, 7
• Classify findings according to BI-RADS categories (1-6) to guide management recommendations 5, 7

Clinical Context Integration

Correlate ultrasound findings with clinical examination findings and mammographic results when available to ensure concordance and guide biopsy decisions. 5, 1, 8

• For women ≥30 years, ultrasound typically follows diagnostic mammography to characterize findings 1, 8
• For women <30 years, ultrasound serves as the primary imaging modality 1, 8
• When ultrasound identifies a suspicious lesion (BI-RADS 4-5), proceed directly to ultrasound-guided core needle biopsy, which provides real-time needle visualization and requires no radiation exposure 1
• If clinical examination reveals a palpable abnormality but ultrasound is negative (BI-RADS 1), tissue biopsy or close observation at 3-6 month intervals should still be considered 5

Common Pitfalls to Avoid

• Failing to examine the entire breast tissue pentagon, which can miss lesions outside the area of clinical concern 2
• Using inadequate transducer pressure, which may miss deeper lesions or fail to compress cysts adequately 2
• Not evaluating the axillae bilaterally, which can miss nodal metastases 1
• Relying solely on ultrasound without mammographic correlation in women ≥30 years, as ultrasound cannot reliably detect microcalcifications or architectural distortions visible only on mammography 5, 8
• Rushing the examination—a thorough breast ultrasound of average-sized breasts takes several minutes per breast to ensure complete coverage 2