58-year-old female status post right lumpectomy 2006 for multifocal tubular cancer followed by radiation and tamoxifen presents with a palpable lump in the left breast for 4 months. History of sarcoidosis. Mammogram: Three standard views of both breasts and spot compression views of left breast were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is heterogeneously dense, which may obscure small masses, unchanged in pattern and distribution. Radiopaque linear markers were placed on scars overlying the right breast and axilla. Stable architectural distortion and scarring are again noted in the right upper outer quadrant. Benign scattered calcifications in both breasts are stable. Several stable benign masses are again seen in the left breast. Triangular marker denoting palpable abnormality is identified in the left breast 4 o'clock position. A spot compression views a benign oval, partially circumscribed 11-mm mass is noted, mostly unchanged from prior mammograms.No new dominant mass, suspicious microcalcifications or areas of architectural distortion in either breast. Multiple surgical clips are projected over the right axilla. Ultrasound: Targeted left breast 4 o'clock position ultrasound corresponding to mammographic abnormality performed. There is an oval parallel oriented mass measuring 1.1 x 0.5 x 0.8 cm with a blood vessel traversing superior anterior to it. This most like represents a benign fibroadenoma and also most likely corresponds to the benign morphology mass seen on mammograms and MRI dating back to 2006.
Palpable abnormality left breast 4 o'clock position most likely corresponds to benign fibroadenoma, with a mammographic and MRI correlate which is stable dating back to 2006. Annual diagnostic mammogram with left breast ultrasound is recommended. Findings and recommendations were discussed with the patient in detail.BIRADS: 2 - Benign finding.RECOMMENDATION: ND - Diagnostic Mammogram.