Ms.Gloria Jackson, 71 years old, submitted outside study for review. She initially presented to outside hospital for evaluation of a palpable lump in the right upper outer breast on 5/20/2016. Diagnostic ultrasound of the right breast demonstrated a 1.6 x 1.4 cm mass corresponding to the palpable abnormality. Additional 1.1 x 0.8 cm hypoechoic lesion was also identified slightly medial and superior to the palpable lump. Ultrasound-guided biopsy of the 10:00 position, posterior palpable mass revealed invasive ductal carcinoma on 5/25/2016. MRI breast on 6/2/2016 demonstrated 2 enhancing masses and 1 additional nonmass enhancement in the right upper outer breast as well as a 1.5 cm right axillary lymph node with irregular cortical thickening.Images performed at Ingalls Memorial Hospital (Harvey, IL) submitted for review: Mammogram 2/11/2016Ultrasound 5/20/2016Ultrasound-guided biopsy 5/25/2016Postprocedure mammogram 5/25/2016MRI breast the 6/2/2016Images submitted for comparison:Mammogram 1/5/2015 and 12/23/2013 MAMMOGRAM 2/11/2016: 2 standard views of both breasts with repeat MLO view were obtained. The breast parenchyma is asymmetric, heterogeneously on the right and scattered on the left, grossly unchanged from the prior. A biopsy clip is identified in the upper outer right breast. Stable benign calcifications are present in both breasts. Linear metastatic marker overlies the scar over the left anterior breast. No new dominant mass, suspicious microcalcifications or areas of architectural distortion are noted in either breast. RIGHT BREAST ULTRASOUND 5/20/2016 : Static ultrasound images are submitted for interpretation.In the right breast, 10:00 position, 4 cm from the nipple, labeled as the palpable lump, there is an irregular, hypoechoic mass measuring 1.6 x 1.4 cm.In addition, along the same radian in the right breast, approximately 2 cm apart from the above palpable mass, there is a another smaller hypoechoic lesion measuring 1.1 x 0.8 cm. Both are suspicious for malignancy.ULTRASOUND-GUIDED BIOPSY 5/25/2016 : The right breast mass at 10:00 was targeted accurately and a clip was placed. POST PROCEDURE MAMMOGRAM 5/25/2016: A lock shaped clip is placed in the right breast 9:00 position, close to the previous biopsy clip.MRI BREAST 6/2/2016:Multisequence MRI breast imaging with and without intravenous contrast was performed as per outside MRI breast protocol. The breasts are composed of asymmetric fibroglandular tissue, heterogeneous on the right and scattered on the left. There is mild background parenchymal enhancement bilaterally. Kinetic analysis of these images was not possible. RIGHT BREAST:There is susceptibility artifact from the biopsy clip in the the right breast, 10:00 position, 3.5 cm from the nipple. There is an enhancing mass surrounding the biopsy clip measuring 1.9 x 2.2 x 2 cm (LR X AP x SI), which is consistent with the biopsy proven malignancy.In addition, in the right breast, 10:00 position, approximately 1.5 cm anterior to the index mass, is another enhancing mass with irregular margins, which measures 1.2 x 0.9 x 1.1 cm (LR X AP x SI) and correlates with the satellite lesion found on the ultrasound.There is a linear enhancement extending from the index mass anteriorly to the skin and close to the satellite mass, which could represent the biopsy track or possibly additional malignant enhancement.LEFT BREAST: There is an enhancing area with high T2 signal intensity in the slightly inferior aspect of the left central breast, posterior depth, which measures 0.7 x 1.1 x 1.2 cm (LR X AP x SI). There is no suspicious kinetic behavior associated with this non mass enhancement.AXILLAE:A nonspecific lymph node is identified in the right axilla. No suspicious lymph nodes in the left axilla.PER OUTSIDE PATHOLOGY:A. right upper outer breast breast, 10:00, posterior lesion; ultrasound guided core needle biopsy:- Invasive ductal carcinoma, grade 2- This result is concordant with the imaging findings.
RIGHT BREAST: 1. 2.2 cm biopsy-proven malignancy in the right posterior breast 10:00 position.2. 1.2 cm suspicious satellite mass in the right breast 1.5 cm anterior to the index cancer. Ultrasound-guided biopsy is recommended.3. Linear enhancement extending from the index mass to the skin may represent post biopsy enhancement, though if the skin entry site from biopsy is not located towards the nipple compared to the target, malignancy would be more likely. Suggest correlation with physical exam. 4. Nonspecific right axillary lymph node for which ultrasound can be considered if clinically indicated.LEFT BREAST:1. 1.2 cm enhancing area in the posterior left breast, likely a benign process, for which 6 month MRI follow-up is recommended.BIRADS: 6 - Known cancer.RECOMMENDATION: T - Take Appropriate Action - No Letter.