A patient submitted outside study for review. Submitted for review are digital mammographic images (9/22/2016), ultrasound images of left breast (9/22/2016), images from ultrasound guided biopsy of left breast (9/28/2016), images from stereotactic biopsy of left breast with specimen radiograph and postprocedural left mammographic images (9/28/2016), breast MRI (10/3/2016), MR-directed ultrasound for left breast (10/13/2016), images from MRI-guided biopsy of left breast and postprocedural left mammographic images (10/13/2016) performed at outside institution. For comparison, digital mammographic images (10/9/2015) are available. DIGITAL MAMMOGRAPHIC IMAGES (9/22/2016):The breast parenchyma is heterogeneously dense (BiRADS Density Category C), unchanged in pattern and distribution. There is a stable circumscribed mass at 12:30 position in the left breast.There are new clusters of calcifications at upper outer quadrant in the left breast. Each cluster measures less than 1 cm, and total measurement of these clusters is 48 x 19 mm on CC view (LR x AP)No dominant mass, suspicious microcalcifications or areas of architectural distortion are noted in right breast. ULTRASOUND IMAGES OF LEFT BREAST (9/22/2016):Clustered simple cysts are present at 12:30 position in the left breast measuring 26 x 6 mm, corresponding to the circumscribed mass seen on the mammogram.At 3:00 position, there is an ill-defined hypoechoic mass measuring 13 x 5 mm with surrounding hazy hypoechoic area. This lesion is associated with a few small hypoechoic masses.IMAGES FROM ULTRASOUND GUIDED BIOPSY OF LEFT BREAST (9/28/2016):A needle biopsy was performed for the ill-defined hypoechoic mass at 3:00 position with an appropriate needle placement. A Bard Venus clip was placed to the target lesion. Per outside radiology report, the result was malignant; invasive lobular carcinoma grade 1, with lobular carcinoma in situ, classic and pleomorphic type.IMAGES FROM STEREOTACTIC BIOPSY OF LEFT BREAST WITH SPECIMEN RADIOGRAPH AND POSTPROCEDURAL LEFT MAMMOGRAPHIC IMAGES (9/28/2016):A stereotactic biopsy was performed for one of the clusters of calcifications at upper outer quadrant in the left breast. Specimen radiograph demonstrates target calcifications within sampled cores. X shaped clip was placed to the biopsy site.Postprocedural left mammographic images demonstrate X shaped clip from stereotactic biopsy and Venus clip from ultrasound-guided biopsy at 3:00 position in the left breast. Distance between the 2 clips is about 15 mm.Per outside radiology report, a result of the stereotactic biopsy was malignant; prominent lobular carcinoma in situ, classic and pleomorphic type with pagetoid spread into ducts, with focal microinvasion. BREAST MRI (10/3/2016):The study was performed with a protocol outlined in the outside radiology report. There is a segmental non-mass enhancement at lateral aspect of left breast near 3:00 position measuring 71 x 48 x 47 mm (AP x LR x CC). Marker clip from ultrasound-guided biopsy is identified at posterior aspect of this non-mass enhancement, and 16 mm hematoma from stereotactic biopsy at lateral posterior aspect within the non-mass enhancement. The non-mass enhancement extends anteriorly, close to the nipple.There is no abnormal enhancement in the right breast.No suspicious lymph nodes are seen in either axilla.MR-DIRECTED ULTRASOUND FOR LEFT BREAST (10/13/2016):MR directed ultrasound was performed for left retroareolar region. On the MRI, non-mass enhancement extended toward the nipple. No sonographic correlation was obtained.IMAGES FROM MRI-GUIDED BIOPSY OF LEFT BREAST AND POSTPROCEDURAL LEFT MAMMOGRAPHIC IMAGES (10/13/2016):MR guided biopsy for the left breast at anterior central breast was performed. Postprocedural left mammographic images show a marker clip at anterior central aspect of the left breast. Per outside radiology report, the pathology was malignant, LCIS, pleomorphic and classic type. Distance between stereotactic biopsy clip and MR guided biopsy clip is approximately 45 mm.
1. Biopsy proven left breast cancer at three sites. MRI demonstrates extensive lesion in the left breast.2. No mammographic or MRI evidence of malignancy in the right breast3. No suspicious lymph nodes in either axilla on MRIBIRADS: 6 - Known cancer.RECOMMENDATION: X - No Letter.