Ms. Clark is a 40 year old female with a personal history of benign left breast biopsy in April 2016, with pathology revealing UDH. She also has a personal history of prior benign right and left breast biopsy. She has a family history of breast cancer in her mother, breast cancer in aunt and ovarian cancer in an aunt. Three standard views of both breasts 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. An X shaped clip in the upper outer quadrant of the left breast indicates the site of stereotactic biopsy performed on 4/12/2016. A second X shaped clip within the middle outer quadrant of the left breast is unchanged in position. A circumscribed oval mass at the right 6:00 position containing a wing-shaped biopsy marker clip is stable. Multiple small masses are present in both breasts, and appear unchanged when compared to prior mammograms, but were better evaluated by MRI. There are no new masses, suspicious microcalcifications or areas of architectural distortion identified in either breast.
No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral diagnostic mammogram is recommended annually. Results and recommendation were discussed with the patient. If the patient has greater than 20% lifetime risk, annual MRI should be performed. BIRADS: 2 - Benign finding.RECOMMENDATION: ND - Diagnostic Mammogram.