History of locally advanced multicentric left breast cancer status post chemotherapy with good response, patient presents for left breast mammogram and ultrasound to look for residual tumor. Ultrasound of the left axilla to be performed to locate the clip within the biopsied lymph node for future localization. Mammogram: Three standard views of the 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(BiRads Density Category C), unchanged in pattern and distribution. Hydro mark Clip identified in the left lower axillary region with irregular density around it. No definite lymph node morphology is noted surrounding the clip which could be due to post biopsy change.2 oval focal asymmetries identified in the posterior superior left breast best seen on MLO view inferior to the clip which most likely represent cysts on subsequent ultrasound and MRI performed today.Hydro mark clip identified in the left breast 6:00 position. Large area of focal asymmetry with suspicious calcifications extending from approximately 4-8 o'clock position still spans most of the central left breast approximately measuring 12 cm predominantly in the inferior breast on the MLO view.Approximately 2 cm area of focal asymmetry is identified in the left retroareolar region which corresponds to the findings on MRI.Ultrasound: Irregular mixed echogenic mass is identified in the retroareolar region measuring 2 x 0.7 x 2.2 cm. Multiple similar morphology masses discontinuous in nature are identified in the left breast from 6 to 9:00 position. Largest mass at 6:00 position approximately measures 2.8 x 1.2 x 3.2 cm, previously measured 2.4 x 1.3 x 1.6 cm, almost stable to minimally increased given difference in technique.2 Simple cysts are identified at 2:00 position 8 cm from the nipple and 10 cm from the nipple most likely corresponding to the MRI findings and the 2 focal asymmetries seen on the MLO view. In the same plane at 2:00 position 12 cm from the nipple there is an irregular hypodense area measuring 6 x 4 x 7 mm with a possible clip artifact. This corresponds most likely to the clip within the low-lying left axillary lymph node.2 lymph nodes identified in the left axillary region, the smaller of the 2 lymph nodes was previously visualized on ultrasound, measures 5 x 7 mm and does not demonstrate a definite central fatty hilum.
1. Multicentric disease in the left breast on mammogram and ultrasound.2. Possible clip with adjacent irregular density/post biopsy change after lymph node biopsy is identified on ultrasound. If localization of this clip is needed, an attempt can be made under mammographic guidance; if not then under ultrasound.3. Two left axillary lymph nodes identified, smaller of the 2 appears abnormal.BIRADS: 6 - Known cancer.RECOMMENDATION: T - Take Appropriate Action - No Letter.