Ms. Pharris submitted outside studies for review.Submitted for review are:-Bilateral mammogram dated 9/22/2016 performed at Northwestern Memorial Healthcare-Images from ultrasound-guided biopsy of the left breast including postprocedure mammogram dated 9/23/2016 performed at Northwestern Memorial Healthcare-Bilateral breast MRI dated 9/29/2016 performed at Northwestern Memorial HealthcareFor comparison,screening mammogram dated 4/3/2014 and bilateral breast ultrasound dated 4/17/2014 are available. BILATERAL MAMMOGRAM:Bilateral CC and MLO views; LM, 1 spot compression, and 2 spot magnification views of the left breast were submitted for review.The breast parenchyma is extremely dense, which limits the sensitivity of mammography. There is a BB marker overlying the upper outer quadrant of the left breast, indicating the site of a palpable abnormality. There are no specific mammographic findings in the area of the BB marker. There are linear and linear branching calcifications in the lower slightly outer left breast at mid-posterior depth, spanning approximately 2.9 cm in greatest AP dimension. Outside paperwork notes that the patient identified a different site of concern than indicated by the BB during a subsequent ultrasound (those images are not available--reported size on ultrasound was up to 2.9 cm). No dominant mass, suspicious microcalcifications or areas of architectural distortion are noted in the right breast. Benign appearing lymph nodes are projected over both axillae.ULTRASOUND GUIDED BIOPSY, LEFT BREAST:Static images from ultrasound-guided biopsy of the left breast were submitted with postprocedure CC and LM views of the left breast.A hypoechoic mass in the left breast, 4:00 position, 2 cm from the nipple was targeted for biopsy. Targeting appears appropriate. Postprocedure mammograms demonstrate a Twirl clip in the lower slightly outer left breast at posterior depth. There are residual calcifications around the clip.BILATERAL BREAST MRI:Multiple enhanced MR sequences are submitted per outside institution's protocol.There is extreme fibroglandular tissue. There is moderate background parenchymal enhancement.There is a vitamin E capsule overlying the lower outer left breast, denoting the site of biopsy. In the lower slightly outer left breast at posterior depth, there is a 2.3 x 3.3 x 3.1 cm irregular necrotic mass with thick rim enhancement, corresponding to biopsied malignancy. Biopsy clip is seen within the mass. This mass demonstrates areas of rapid initial enhancement and delayed phase washout. The mass directly abuts the pectoralis muscle with mild retraction of the muscle. No definite enhancement is seen within the pectoralis muscle. No other areas of abnormal enhancement in the left breast. Enhancement lateral to the mass probably relates to the recent biopsy. Increased T2 signal on STIR images suggests edema in the breast. No suspicious left axillary or internal mammary lymph nodes.In the central outer right breast, there is a 1.2 x 0.7 x 0.5 cm focal area of clumped nonmass enhancement that demonstrates medium initial enhancement and persistent delayed phase enhancement. This focal area of nonmass enhancement is adjacent to a cyst. No suspicious right axillary or internal mammary lymph nodes.OUTSIDE PATHOLOGY (per report):Left breast, 2.9 cm mass at 4:00 and 2 cm from the nipple, ultrasound core needle biopsy: Invasive ductal carcinoma, grade 3 of 3, with apocrine features and focal necrosis.
1. A 2.3 x 3.3 x 3.1 cm centrally necrotic mass in the lower outer left breast, corresponding to biopsy-proven malignancy. The mass abuts the pectoralis muscle with no definite evidence of invasion. Continued surgical management is recommended.2. Suspicious 1.2 x 0.7 x 0.5 cm focal area of clumped nonmass enhancement in the central outer right breast adjacent to a cyst. MR guided ultrasound is recommended. If a suspicious hypoechoic vascular area can be identified on ultrasound, then US guided biopsy could be performed. If this area is not seen on ultrasound, MR guided biopsy is recommended.BIRADS: 6 - Known cancer.RECOMMENDATION: T - Take Appropriate Action - No Letter.