HISTORY: 74-year-old woman with recently diagnosed Right breast DCIS presenting for staging.
Summary of prior imaging:
Mammography: New focal asymmetry RUOQ identified on routine screening. Left breast normal.
Ultrasound: 9mm lobulated hypoechoic mass 10:00 Right breast
Breast MRI: N/A
FINDINGS
Quality control issues: ☐None ☐Poor/lack contrast bolus ☐Poor fat suppression
☐Susceptibility ☒Movement ☐Other
Background Parenchymal Enhancement: Minimal
Amount of Fibroglandular Tissue: Scattered fibroglandular tissue
LEFT BREAST
Narrative: There is 2.5 cm of clumped linear non mass enhancement in the upper LEFT breast
Left breast lesion 1
Lesion type: Non-mass enhancement
2.5 cm. Upper outer Quadrant. 12:00 Radian. 5 cm from the nipple
Non mass enhancement: Distribution: Linear, Internal enhancement: Clumped, Kinetics: delayed- Subthreshold
BI-RADS:4: Suspicious abnormality: Tissue diagnosis
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 from clips
Fat containing lesions LEFT: ☒NONE, ☐Fat necrosis, ☐Hamartoma, ☐Post-operative seroma/hematoma with fat
Lymph nodes LEFT: ☒Normal axillary, ☐Abnormal axillary, ☐ Abnormal internal mammary
RIGHT BREAST
Narrative: 1.0 irregular mass with a clip at the site of known DCIS. No additional lesions
Right breast lesion 1
Lesion type: Mass
1 cm. Upper outer Quadrant. 10:00 Radian. 4 cm from the nipple
[delete if not needed] Mass/post-surgical change: Shape:Irregular. Margins:Not
circumscribed-irregular . Enhancement: Homogenous. Kinetics: delayed-Plateau
BI-RADS:6: Known biopsy-proven malignancy: Surgical exicision when clinically appropriate
Associated findings RIGHT breast: ☒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 breast: ☒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
SUMMARY: Solitary known 1 cm malignancy in the RUOQ with 2.5 cm area 12:00 suspicious for DCIS
LEFT BI-RADS:4: Suspicious abnormality: Tissue diagnosis
RIGHT BI-RADS:6: Known biopsy-proven malignancy – Appropriate action should be taken
RECOMMENDATIONS: MRI guided biopsy of left breast.
