EXAM: MAMMO DIGITAL DIAGNOSTIC TOMO BILATERAL, US BREAST LIMITED RIGHT
DATE: 11/8/2023 10:26 AM
ACCESSION: 20232322998CH, 20232323019CH
DICTATED: 11/8/2023 10:34 AM
INTERPRETATION LOCATION: Chatham Campus

CLINICAL INDICATION: 56 years old Female with LUMP OR MASS IN BREAST  - N63.10 - Mass of right breast, unspecified quadrant. Area of clinical concern in the right breast. Patient has noted dimpling of her skin as well as area of clinical concern

COMPARISON: Prior exam(s) were available and reviewed for comparison. The patient's most recent study is 2012

TECHNIQUE: Full-field and spot digital diagnostic mammography with tomosynthesis was performed. Tomosynthesis imaging was used to improve the sensitivity and specificity of the detection of breast cancer. Targeted

BREAST DENSITY: b - There are scattered areas of fibroglandular density.

FINDINGS: In the area of clinical concern as identified by the patient demarcated with a BB on the skin in the upper outer posterior right breast, there are 2 areas of architectural distortion and associated irregular masses. There is associated skin dimpling. A possible lymph node is noted as well. Mammographically, the 2 suspicious areas are approximately 2.3 cm apart in the superior to inferior projection. No mammographic evidence of malignancy is noted on the left

Targeted ultrasound was performed of the upper outer right breast. At approximately 9:00, 7 cm from the nipple in the area of clinical concern is an irregular hypoechoic mass  that measures approximately 0.8 x 1.2 x 1.7 cm. Superior to that area at approximately 11:00, 6 cm from the nipple is a second irregular hypoechoic mass with echogenic rim measuring approximately 2.0 x 2.0 x 2.8 cm. There is minimal associated vascularity.

Targeted ultrasound was performed of the right axilla. No suspicious axillary lymphadenopathy was noted.

FOCUSED PHYSICAL EXAM:
Skin Changes: Retraction.                  
Palpation: Palpable correlate size is concordant with imaging findings.

IMPRESSION:
2 suspicious irregular masses approximately 2.3 cm apart in the upper outer right breast for which ultrasound-guided biopsy and clip placement is recommended for both lesions.

ASSESSMENT:
BI-RADS Category: 4C-Biopsy : Suspicious.  High suspicion for malignancy.  Biopsy should be performed in the absence of clinical contraindication.

Recommendation Laterality: Right 


Ultrasound guided core needle biopsy and clip placement x 2 is recommended.

Findings and recommendations were discussed with the patient. A result letter and a biopsy information sheet were given to the patient. The patient was instructed a staff member will call  to schedule the appointment for the biopsy. Contact information for UNC breast imaging was also given to the patient to ensure scheduling of this appointment.