乳房X光摄影影像判读的标准化报告系统.PDF

2.1 乳房 X 光攝影影像判讀的標準化報告系統 目的：為了避免錯誤解讀乳房攝影的檢查結果，使用標準化的報告格式、詞彙、 分類與建議處置，可讓臨床醫師充分瞭解報告內容與含意，做出適當的決策。此 外影像檢查不具專一性，良性與惡性腫瘤可出現相似的表徵，為了提高診斷率並 減少偽陽性對篩檢婦女的傷害，標準化報告系統可作為判讀醫師執行醫學評量的 基礎。 方法： 一、乳房 X 光攝影標準化報告格式。 1. 基本資料: 姓名、病歷號、年齡或出生年月日、檢查日期 2. 檢查名稱 : 兩側或單側檢查、篩檢或診斷式乳房X 光攝影 3. 報告內容 :是否比較舊片，乳腺緻密度分類詳見二( .) ，異常發現(有 )(無) ， 建議使用統一的詞彙 詳見三( .) 4. 分類與建議處置: (詳見四 .) 5. 判讀醫師: 姓名、專科醫師證書字號 二、乳腺緻密度(BREAST COMPOSITION) 1. The breast is almost entirely fat (25% glandular). 2. There are scattered fibroglandular densities (approximately 25%-50% glandular). 3. The breast tissue is heterogeneously dense, which could obscure detection of small masses (approximately 51%-75% glandular). 4. The breast tissue is extremely dense. This may lower the sensitivity of mammography (75% glandular). 三、報告內容所使用的統一詞彙。 A. MASSES A “MASS”is a space-occupying lesion seen in two different projections. If a potential mass is seen in only a single projection it should be called an 1 “ASYMMETRY”until its three-dimensionality is confirmed. 1. SHAPE a. Round A mass that is spherical, ball-shaped, circular or globular in shape. b. Oval A mass that is elliptical or egg-shaped. c. Lobular A mass that has an undulating contour. d. Irregular The lesion’s shape cannot be characterized by any of the above. 2. MARGIN ( Modifies the shape of the mass ) a. Circumscribed (Well-Defined or Sharply-Defined) Margin The margin is sharply demarcated (at least 75% of the margin must be well defined, with the remainder no worse than obscured by overlying tissue, for a mass to qualify as “circumscribed“) with an abrupt transition between the lesion and the surrounding tissue. Without addition