Ms. Johnson is a 46 year old female presenting for a short-term 6 month follow-up of a left nipple mass, suspected to be a papilloma. She denies skin changes or bloody nipple discharge. Upon physical exam, no discrete mass is appreciated in the left nipple.A targeted left ultrasound was performed at the nipple. There is reidentification of a circumscribed isoechoic mass in the left nipple, now measuring 7 x 3 x 4 mm (previously 6 x 3 x 4 mm), grossly unchanged in size allowing for technical differences. This corresponds to the enhancing area seen in the left nipple on breast MRI 8/6/2014 and likely represents a papilloma.
High probability benign mass in the left nipple, likely representing a papilloma. The patient is due for her annual bilateral diagnostic mammogram in July 2016. This area can be evaluated mammographically at that time. Additional imaging, including ultrasound examination, can be performed as clinically warranted. All results and recommendations were discussed with the patient.BIRADS: 3 - Probably benign finding.RECOMMENDATION: 3B - Followup at Short Interval (1-11 Months). 