Ms. Ottenweller is a 61-year-old female with history of recurrent right breast IDC status post mastectomy and sentinel lymph node biopsy in December 2014. Patient also has personal history of benign MRI-guided biopsy of the left breast in 02/2009 for periductal chronic inflammation. No family history of breast cancer. No current breast complaints. Three standard views of the left breast were performed digitally and reviewed with the aid of R2 CAD, 9.3. The breast parenchyma is composed of scattered fibroglandular elements (BiRADS Density Category B), unchanged in pattern and distribution. Surgical clips are reidentified along the inferomedial aspect of the left breast, along with postsurgical architectural distortion from prior breast reduction surgery. Biopsy marker clip is reidentified in the left breast from prior benign MRI-guided biopsy. No dominant mass, suspicious microcalcifications or areas of architectural distortion are noted in the left breast.
Stable postsurgical changes of the left breast. No mammographic evidence of malignancy. As long as the patient's physical examination remains unremarkable, left unilateral diagnostic mammogram is recommended annually. Results and recommendations were discussed with the patient.BIRADS: 2 - Benign finding.RECOMMENDATION: ND - Diagnostic Mammogram.