Ms. Stange is a 56 year old female with a personal history of bilateral mastectomies in 2016 for right breast DCIS. She had expanders placed which were complicated by infection and subsequently removed. She now presents with left breast wound dehiscence and fluid collection. The patient is status post bilateral mastectomies. On the right side, there is a simple fluid collection identified that is partially retro-pectoral and partially pre-pectoral. The collection measures 2.5 x 4.8 x 5.3 cm (AP x ML x SI). The antero-lateral portion of this fluid collection appears to extend towards the skin surface and may represent local wound dehiscence. On the left side, there is an encapsulated complex fluid collection identified that is partially retro-pectoral and partially pre-pectoral. The collection measures 2.7 x 8.6 x 6.1 cm (AP x ML x SI) and has multiple fluid-fluid layers. The capsule surrounding this collection demonstrates mild peripheral rim enhancement, which may be an indication of superimposed infection. No abnormal lymph nodes are identified in either axillary or internal mammary region.
Patient is status post bilateral mastectomies with bilateral complex fluid collections. Please see above for full details. BIRADS: 2 - Benign finding.RECOMMENDATION: C - Clinical Correlation Needed.