0:00

So we'll look at several cases one at a time.

0:04

Our first case is a 47 year old woman with a

0:07

palpable lump in the right lateral breast and this

0:10

was felt on recent physical exam by her provider.

0:13

The patient doesn't feel a lump.

0:16

So, here is the first patient,

0:18

the 47 year old woman.

0:20

We have bilateral CC views at the

0:23

top of the screen and bilateral MLO (mediolateral oblique)

0:26

views at the bottom of the screen.

0:28

You can see that there's a triangular skin

0:30

marker placed over the area of palpable

0:32

concern in the right lateral breast

0:35

with no underlying abnormality seen.

0:37

The patient's breast tissue is extremely dense.

0:42

So we'll go ahead and look

0:43

at our tomosynthesis views.

0:46

So for each view, I'm just going to scroll

0:50

through the tomosynthesis images, and you

0:55

can see our triangular skin marker here,

1:00

and as we scroll through, there's really nothing

1:02

other than normal looking tissue there.

1:05

We'll pull in our right MLO view, again,

1:10

here's our triangular skin marker, and just

1:14

normal looking And of course, we're looking at

1:19

both breasts, so we'll go through both sides.

1:23

This is the left CC view tissue,

1:26

really looking pretty similar to the right side.

1:30

And then our left MLO view,

1:36

pretty similar there.

1:37

Okay.

1:38

So the mammogram really hasn't given

1:41

us the reason for the palpable lump.

1:44

So we'll go ahead and use ultrasound next.

1:49

Bring in the ultrasound.

1:51

And here's the ultrasound on this patient.

1:52

Because the patient's tissue was so dense,

1:55

we decided to do a bilateral whole breast ultrasound

2:00

and then focus in on the area of the breast.

2:03

of interest as well.

2:04

So these are images of the right breast.

2:08

And then when we get to the palpable

2:09

area, the breast tissue is heterogeneous,

2:12

but very similar to the rest of the

2:16

tissue, nothing standing out there.

2:20

And then we went through the left

2:22

breast, which is, has a similar

2:24

appearance, heterogeneous tissue.

2:26

But no focal abnormality and just coming back

2:31

to that palpable area, which looked normal.

2:35

So in this case, we went in to speak

2:38

to the patient, did a limited physical

2:41

examination of that right lateral breast.

2:43

And the patient indicated an area at the

2:46

10 o'clock position where she thought

2:48

her doctor was feeling something.

2:50

So we scanned that area in real time and

2:53

also just saw heterogeneous breast tissue.

2:57

So, I wanted to spend a few minutes

2:59

talking about reporting tips, um,

3:01

for a diagnostic breast imaging exam.

3:05

So, for somebody with a breast symptom,

3:07

the location of the problem and the type

3:10

of symptom should be noted in the history

3:12

or indication section of the report,

3:14

and then also in the body of the report,

3:16

the impression, and the recommendation.

3:19

The exam and the report really

3:20

should answer the clinical question.

3:23

You want to use the BI RADS lexicon

3:25

to describe the findings and assign an

3:27

appropriate BI RADS assessment category

3:30

and corresponding recommendation.

3:33

And I just pulled in the report for

3:35

the patient that we just looked at.

3:37

So in our history section, we say that the

3:39

patient is a 47 year old woman that she's

3:42

seen for evaluation of a palpable finding

3:44

in the right lateral breast, felt on recent

3:47

physical examination with a new provider.

3:49

So we're indicating that this was a

3:51

provider examination finding and that the

3:54

patient doesn't feel a change in this area.

3:57

And we go through our standard reporting.

3:59

We say that the breast tissue is extremely dense.

4:03

I always mentioned that a triangular

4:05

skin marker was placed over the area of

4:07

palpable concern and where it was placed

4:10

and what underlies that tissue, whether we

4:12

see a mass or it was just normal tissue.

4:15

And in this case, it corresponded to

4:17

normal appearing dense breast tissue.

4:20

Then, um, ultrasound, you know,

4:22

what type of ultrasound we did.

4:23

In this case, it was bilateral whole breast

4:25

because of the patient's tissue density.

4:27

And then in the right breast at the 10

4:29

o'clock position, 10 centimeters from

4:31

the nipple, you know, where the patient

4:33

indicated the area of palpable concern.

4:35

And That there was normal tissue in that

4:37

location, so I'm sort of following through with

4:39

that palpable lump theme throughout this report.

4:43

And then in the impression, I'm saying

4:45

there's no evidence of malignancy and

4:47

the palpable area of concern corresponds

4:49

to normal heterogeneous breast tissue.

4:51

And in my recommendation section.

4:54

I'm recommending that the patient follow

4:56

up with her referring provider for that

4:58

area of concern in the right breast,

5:00

and then also that she should have an annual

5:02

screening mammogram for both breasts.

5:05

And, um, we also mentioned how the

5:08

results were communicated to the patient.

5:10

Was it just in writing?

5:11

Was it verbally and in writing?

5:13

So we'll indicate that as well.

5:15

And this tells me if I look at this report

5:17

later, I know that I spoke with the patient

5:19

because I said I did in this part of the report.

5:22

So I think all of these things are

5:23

important when you're reporting,

5:24

especially a symptomatic patient.

5:26

I do see a lot of reports, uh, from outside

5:29

institutions where a palpable lump is mentioned

5:32

in the history, but then never mentioned again.

5:35

So it's very hard to know whether it was

5:37

actually assessed or what the radiologist

5:39

thought the palpable lump corresponded to.

5:42

So you want to make sure that you're carrying

5:44

that through the whole report and answering

5:47

the clinical question by the end of the report.

5:51

The same is true for patients with

5:53

pain or nipple discharge, or they

5:55

were following up a specific finding.

5:58

You want to mention that in your report.