Audit on Structured Reporting of Superficial Soft Tissue Masses on Ultrasonography in Relation to Guiding Clinical Management

Audit on structured reporting of superficial soft tissue masses on ultrasonography focusing on the adequacy of lesion and management documentation to facilitate subsequent clinical management

Ultrasound is the appropriate first-line modality for imaging superficial or palpable soft tissue mass by the American College of Radiology Appropriateness criteria¹. It allows real-time, radiation-free, and cost-effective assessment of superficial soft tissue lesions^1,2,3,4. 

Ultrasound is considered the most appropriate initial triage modality for accessible tumors into benign, equivocal, or suspicious categories ^2,3,4. Its reproducibility and reliability depend on appropriate documentation. A clearly written examination report is part of the mandatory technical standards ^2,3,4.

To maintain the reporting standard to guide clinical management, the Society of Radiologists in Ultrasound consisting of musculoskeletal radiologists, oncologic orthopedic surgeons, and pathologists published a Consensus Conference Statement (2022) on the standards for reporting superficial soft tissue mass on ultrasonography. It is in accordance with those published in the British Medical Ultrasound Society (2021) and the European Society of Skeletal Radiology (ESSR) (2015). 

When the ultrasound appearance is typical and there are no worrisome clinical features, no further evaluation or follow-up other than periodic self-monitoring is necessary ^2,3,4. On the contrary, when there are equivocal or suspicious imaging findings, further imaging or referral is necessary ^2,3.

The standard: 

1. The anatomical location in the body is reported^2,3,4.

2. The location in tissue (e.g. epidermal/ dermal/ subcutaneous/ intramuscular) is reported^2,3,4.

3. The composition (e.g. solid or cystic) of the lesion is reported^2,3,4. 

4. The size in three dimensions is reported^2,3,4. 

5. Any important anatomical structure being involved is reported^2,4.

6. The echogenicity of the lesion is being reported^2,3,4.

7. The margin of the lesion is being reported^2,3,4. 

8. The sound attenuation of the lesion is being reported⁴.

9. The vascularity of the lesion is being reported^2,3,4.

10. The report should also contain a defined recommendation for further care for equivocal or suspicious cases^2,3,4. If the examination is performed by sonographers or other non-medical professionals, a radiologist's opinion should be sought and documented to ensure that advice is appropriate and a named radiologist is identified for further discussion.

Target: 

Ultrasound reports for superficial soft tissue mass should be collected and reviewed. All cases performed during the preceding six months, or the most recent 100 consecutive cases (whichever number is greater). Cases with no identifiable lesion should be excluded.

Indicators: 

The percentage of ultrasound reports which adhere to each of the standards.

Data items to be collected: 

1. Is the anatomical location in the body reported?

2. Is the location in tissue (e.g. epidermal/ dermal/ subcutaneous/ intramuscular) reported? 

3. Is the composition (e.g. solid or cystic) of the lesion reported? 

4. Is the size in three-dimension reported?

5. Is involved important anatomical structure being reported?

6. Is echogenicity of the lesion is being reported? 

7. Is the margin of the lesion is being reported? 

8. Is the sound attenuation of the lesion is being reported?

9. Is the vascularity of the lesion is being reported? 

10. Does the report contain a defined recommendation for further care for equivocal or suspicious cases?

Suggested number: 

Ultrasound reports for superficial soft tissue mass should be collected and reviewed. All cases performed during the preceding six months, or the most recent 100 consecutive cases (whichever number is greater). Cases with no identifiable lesion should be excluded.

1. Publicise the standards for ultrasound superficial soft tissue mass reporting, through in-person departmental radiology meetings and dissemination of written material to radiologists and sonographers. 

2. Create a structured report template for use during electronic report transcription, in order to improve standardization of reporting items.

3. Re-audit six months after the intervention, to assess for improvement in practice. Continue the audit spiral, to ensure sustained compliance with the standards.

1. Radiology information system (RIS) to review administrative details and reports.

2. Picture archiving computer system (PACS) to review saved ultrasound images.

3. Statistical computer software, such as Microsoft Excel, for recording and analysing data.

1. Expert Panel on Musculoskeletal Imaging:, Kransdorf MJ, Murphey MD, Wessell DE, Cassidy RC, Czuczman GJ, Demertzis JL, Lenchik L, Motamedi K, Pierce JL, Sharma A, Walker EA, Ying-Kou Yung E, Beaman FD. ACR Appropriateness Criteria® Soft-Tissue Masses. J Am Coll Radiol. 2018 May;15(5S):S189-S197. doi: 10.1016/j.jacr.2018.03.012. PMID: 29724421.

2. Noebauer-Huhmann IM, Weber MA, Lalam RK, Trattnig S, Bohndorf K, Vanhoenacker F, Tagliafico A, van Rijswijk C, Vilanova JC, Afonso PD, Breitenseher M, Beggs I, Robinson P, de Jonge MC, Krestan C, Bloem JL. Soft Tissue Tumors in Adults: ESSR-Approved Guidelines for Diagnostic Imaging. Semin Musculoskelet Radiol. 2015 Dec;19(5):475-82. doi: 10.1055/s-0035-1569251. Epub 2015 Dec 22. Erratum in: Semin Musculoskelet Radiol. 2015 Dec;19(5):e1. PMID: 26696086.

3. Society and College of Radiographers and British Medical Ultrasound Society: Guidelines for Professional Ultrasound Practice - revised December 2021.

4. Jacobson JA, Middleton WD, Allison SJ, Dahiya N, Lee KS, Levine BD, Lucas DR, Murphey MD, Nazarian LN, Siegel GW, Wagner JM. Ultrasonography of Superficial Soft-Tissue Masses: Society of Radiologists in Ultrasound Consensus Conference Statement. Radiology. 2022 Jul;304(1):18-30. doi: 10.1148/radiol.211101. Epub 2022 Apr 12. PMID: 35412355.

Dr KY Li

Co-authors

Dr HM Kwok

Dr NY Pan