HISTORY: 80 year old woman status post bilateral mastectomies presented for implant assessment
Summary of prior imaging:
Mammography: None post op
Ultrasound: None post op
Breast MRI: None
FINDINGS
Quality control issues: ☒None ☐Poor/lack contrast bolus ☐Poor fat suppression
☐Susceptibility ☐Movement ☐Other
Background Parenchymal Enhancement: Not applicable
Amount of Fibroglandular Tissue: Not applicable
LEFT BREAST
Narrative
Status post left mastectomy with retropectoral silicone implant reconstruction. No suspicious enhancing masses or areas of nonmass enhancement. No axillary or internal mammary adenopathy is seen. No abnormal skin or pectoralis muscle enhancement. The left breast implant is intact.
Left breast lesion 1
Lesion type: Choose an item.
Longest measurement cm. Choose an item Quadrant. Choose an item. Radian. dist from nipple cm from the nipple
BI-RADS: 1: Negative: Routine breast MRI screening if cumulative lifetime risk =>20%
Associated findings LEFT: ☒NONE, ☐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: ☒NONE, ☐High ductal signal pre contrast T1, ☐Cyst(s), ☐Hematoma/seroma, ☐Post therapy skin/trabecular thickening, ☐Non-enhancing mass, ☐Architectural distortion, ☒Signal void in the skin
Fat containing lesions LEFT: ☒NONE, ☐Fat necrosis, ☐Hamartoma, ☐Post-operative seroma/hematoma with fat
Lymph nodes LEFT: ☒Normal axillary, ☐Signal void from clips, ☐Abnormal axillary, ☐ Abnormal internal mammary
RIGHT BREAST
Narrative
Status post right mastectomy with TRAM flap reconstruction. No suspicious enhancing masses or areas of nonmass enhancement. No axillary or internal mammary adenopathy is seen. No abnormal skin or pectoralis muscle enhancement.
Right breast lesion 1
Lesion type: Choose an item.
Longest measurement cm. Choose an item Quadrant. Choose an item. Radian. dist from nipple cm from the nipple
BI-RADS: 1: Negative: Routine breast MRI screening if cumulative lifetime risk =>20%
Associated findings RIGHT: ☒NONE, ☐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: ☒NONE, ☐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: ☒NONE, ☐Fat necrosis, ☐Hamartoma, ☐Post-operative seroma/hematoma with fat
Lymph nodes RIGHT: ☒Normal axillary, ☐Abnormal axillary, ☐ Abnormal internal mammary
Extramammary findings: None
LEFT BI-RADS: 2: Negative
RIGHT BI-RADS: 2: Negative
RECOMMENDATIONS: Clinical follow up
SUMMARY: Negative postoperative study
