HISTORY: 56-year-old woman with a history of recently diagnosed right breast cancer. Evaluation of extent of disease.
Summary of prior imaging:
Mammography: Patient presented after recent abdominal CT demonstrated an enhancing mass in the lateral aspect of the right breast. Diagnostic mammogram demonstrated scattered fibroglandular densities with an irregular obscured mass in the right breast at 8:00 anterior depth.
Ultrasound: Subsequent ultrasound demonstrated a correlating 31 x 30 x 19 mm irregular hypoechoic mass with posterior acoustic shadowing at 8:00 5 cm from the nipple. There was no axillary adenopathy identified.
Breast MRI: NA
FINDINGS
Quality control issues: ☒None ☐Poor/lack contrast bolus ☐Poor fat suppression
☐ Susceptibility ☐Movement ☐Other: Click or tap here to enter text.
Background Parenchymal Enhancement: Minimal
Amount of Fibroglandular Tissue: Scattered fibroglandular tissue
LEFT BREAST
Narrative: Negative. No suspicious enhancement or lymphadenopathy.
Associated findings LEFT breast: ☐Nipple retraction, ☐Nipple involvement, ☐Skin retraction, ☐Skin thickening, ☐Skin invasion-direct, ☐Skin invasion-inflammatory,
☐ Pectoral muscle invasion, ☐Chest wall invasion, ☐ Architectural distortion
Non-enhancing findings LEFT breast: ☐High ductal signal pre contrast T1, ☐Cyst(s),
☐ Hematoma/seroma, ☐Post therapy skin/trabecular thickening, ☐Non-enhancing mass,
☐ Architectural distortion, ☐Signal void from clips
Fat containing lesions LEFT: ☐Fat necrosis, ☐Hamartoma, ☐Post-operative seroma/hematoma with fat
Lymph nodes LEFT: ☒Normal axillary, ☐Abnormal axillary: description, ☐ Abnormal internal mammary: description
RIGHT BREAST
Narrative: At 8:00, 5 cm from the nipple there is a 2.6 cm (AP) irregular mass with irregular margins and rim enhancement. There is focal susceptibility artifact at the inferior margin of the mass compatible with a biopsy clip. There is no suspicious lymphadenopathy.
Associated findings RIGHT breast: ☐Nipple retraction, ☐Nipple involvement, ☐Skin retraction, ☐Skin thickening, ☐Skin invasion-direct, ☐Skin invasion-inflammatory,
☐ Pectoral muscle invasion, ☐Chest wall invasion, ☐ Architectural distortion
Non-enhancing findings RIGHT breast: ☐High ductal signal pre contrast T1, ☐Cyst(s),
☐ Hematoma/seroma, ☐Post therapy skin/trabecular thickening, ☐Non-enhancing mass,
☐ Architectural distortion, ☐Signal void from clips
Fat containing lesions RIGHT: ☐Fat necrosis, ☐Hamartoma, ☐Post-operative seroma/hematoma with fat
Lymph nodes RIGHT: ☒Normal axillary, ☐Abnormal axillary: description, ☐ Abnormal internal mammary: description
Extramammary findings: None
SUMMARY:
1) Known biopsy-proven malignancy at 8:00 anterior depth in the right breast, measuring up to 2.6 cm on MRI.
2) No axillary adenopathy
RECOMMENDATIONS: BI-RADS Category 6. Surgical excision when clinically appropriate (follow up with the surgeon or oncologist).
INTERPRETER: Click or tap here to enter text.
