HISTORY:
44-year-old woman presenting with a palpable right breast mass. US guided biopsy of mass showed invasive ductal carcinoma ER+ PR+ Heu2+. Right axillary node biopsy was negative.
Summary of prior imaging:
Mammography: Extremely dense breasts with ill-defined 4cm mass RUOQ Ultrasound: 3.5 cm lobulated vascular hypoechoic mass 11:30 4cm FN. 2 cm right axillary node with thickened cortex.
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: Extreme fibroglandular tissue
LEFT BREAST
Narrative: Multiple cysts, no enhancing lesions
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: Lack of intravenous contrast negates evaluation of this study. Known IDC is seen as 3.5 cm “non enhancing” mass with peripheral clip artifact. Multiple cysts
Right breast lesion 1
Lesion type: Mass
3.5 cm. Upper outer Quadrant. 11:00 Radian. 4 cm from the nipple
Mass/post-surgical change: Shape:Oval/lobulated. Margins:Circumscribed , Enhancement
cannot be evaluated.
BI-RADS:6: Known biopsy-proven malignancy – Appropriate action should be taken
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: At least 2 mildly abnormal nodes, largest 16 mm with a clip artifact, ☐ Abnormal internal mammary: description
Extramammary findings: None
SUMMARY: Failed contrast bolus. Known 3.5 cm Right IDC does not therefore enhance
RECOMMENDATIONS: Repeat study as soon as possible
