Breast Ultrasound Report Template: Normal and Lesion Examples

A breast ultrasound report should state whether the examination is targeted or a survey, describe lesions with BI-RADS ultrasound descriptors, correlate with the clinical or other imaging finding, and provide a final assessment. A negative targeted examination does not establish that the whole breast or a mammographic/MRI finding is normal. The examples below address adult breast imaging; adult BI-RADS risk categories should not be applied automatically to children or adolescents.

Editable complete report framework

Examination: [Right/left/bilateral breast ultrasound; targeted / whole-breast survey].
Indication: [Palpable finding, pain, mammographic/MRI finding, screening, or follow-up].
Comparison: [Studies and dates / none].
Technique: [High-frequency linear transducer; side/region examined; state whether axilla was included]. [Scope and technical limitations.]

Findings:
Breast tissue: [Background echotexture; area covered if survey].
Target lesion 1: [Side, clock-face location, distance from nipple, three dimensions; shape, orientation, margin, echo pattern, posterior features, calcifications, vascularity, and associated features].
[Separate block for each additional lesion.]
Axilla: [If examined, nodal appearance].
Clinical/mammographic/MRI correlation: [Concordant / discordant / no comparison].

Impression:
1. [Finding and side].
2. [One overall BI-RADS final assessment for the complete examination].
3. [Additional imaging, follow-up, or tissue sampling consistent with the category and local protocol].

Define scope and lesion location

State the indication and examination scope: targeted ultrasound of one finding, correlation with a mammographic/MRI target, or a whole-breast survey. Use consistent side, clock-face position, and distance from the nipple. For three-dimensional measurements, use a stable institutional order for the two orthogonal planes and third axis.

Describe a mass using BI-RADS ultrasound lexicon terms for shape, orientation (parallel or not parallel to the skin), margin, echo pattern, and posterior acoustic features. Add calcifications, duct changes, associated tissue findings, and Doppler vascularity when relevant. The v2025 lexicon includes elastography descriptors; use them only when the technique is performed and your practice has adopted them. No single descriptor determines the diagnosis or final category.

State whether the ultrasound finding matches the clinical finding or mammographic/MRI target. A negative targeted ultrasound alone does not exclude a clinically suspicious palpable finding or a finding on another modality; explain the examination's scope and any needed next assessment when there is discordance.

Fictional complete report examples

The cases and measurements below are fictional.

No correlate on targeted examination

Examination: Targeted right breast ultrasound.
Indication: Pain at 9 o'clock; no palpable mass.
Comparison: Diagnostic mammogram dated 2026-09-18.

Technique: High-frequency linear transducer used to examine the right breast from 8 to 10 o'clock, the nipple, and axilla. Diagnostic image quality.

Findings: No solid or cystic lesion is identified at the marked area of pain. No ductal dilatation or posterior shadowing is present in the examined region. Axillary nodes have benign morphology.

Impression: No sonographic correlate to the area of pain on targeted right breast ultrasound (BI-RADS 1). If a new or progressive clinical finding is present, appropriate clinical and imaging correlation is needed beyond the scope of this negative targeted examination.

Simple cyst

Examination: Targeted left breast ultrasound.
Indication: Correlation for a left breast mass on mammography.
Comparison: Mammogram dated 2026-10-05.

Technique: High-frequency linear transducer used to examine the left breast at 2 o'clock and the axilla.

Findings: At left 2 o'clock, 3 cm from the nipple, there is an 8 × 6 × 5 mm oval, circumscribed, anechoic lesion with posterior acoustic enhancement. No solid component or internal vascularity. The axilla is unremarkable. The finding corresponds to the mammographic focus.

Impression: Simple cyst corresponding to the mammographic focus (BI-RADS 2).

Irregular mass with suspicious features

Examination: Targeted left breast ultrasound.
Indication: Assessment of a left breast mass detected on mammography.
Comparison: Diagnostic mammogram dated 2026-10-12.
Technique: High-frequency linear transducer used to examine the left breast at 10 o'clock and the axilla.

Findings: At left 10 o'clock, 6 cm from the nipple, there is a 12 × 10 × 8 mm irregular hypoechoic solid mass that is not parallel to the skin and has irregular/angular margins. Posterior acoustic shadowing and internal vascularity are present. The finding corresponds to the mammographic target. No suspicious axillary node is identified.

Impression: Suspicious left breast mass (BI-RADS 4). Image-guided biopsy should be considered after correlation with all imaging and clinical findings.

Incomplete workup and final assessment

Do not describe a target as negative if it was not visualized or the workup is incomplete. When BI-RADS 0 is appropriate, state why a final assessment cannot yet be made and what additional imaging is needed. BI-RADS 3 is for a probably benign finding with short-interval follow-up suggested; BI-RADS 4 means biopsy should be considered, and BI-RADS 5 requires appropriate action. Keep the recommendation consistent with the final category, other imaging, and clinical context. BI-RADS 6 may be used for known biopsy-proven malignancy in the appropriate clinical pathway.

Final checklist and common pitfalls

• Targeted/survey scope, side, indication, and comparisons are stated.
• Lesion location includes clock-face position and distance from nipple; size uses three dimensions.
• Shape, orientation, margin, echo pattern, and posterior features are described.
• Clinical and mammographic/MRI correlation is documented, including discordance.
• Final BI-RADS assessment and recommendation reflect the whole examination.
• “No lesion in the targeted area” is not expanded into “the whole breast is normal.”

For BI-RADS v2025 terminology and report organization, see the update guide.

References

• American College of Radiology. ACR BI-RADS v2025 Manual, particularly the Ultrasound section. ACR BI-RADS (opens in a new tab)
• American College of Radiology. Reporting: Breast Ultrasound, revised January 2, 2026. Report content and structure (opens in a new tab)
• American College of Radiology. ACR Practice Parameter for the Performance of a Diagnostic Breast Ultrasound Examination. Practice parameter (PDF) (opens in a new tab)

Clinical note: This educational framework does not replace the BI-RADS manual, independent image review, or clinical judgment. The cases are fictional.