Breast mass lesion with "normal" ultrasound

Case contributed by Garth Kruger

Presentation

Developing asymmetry in the right breast

Patient Data

Age: 60 years
Gender: Female

A series of images to illustrate the development of an asymmetry right breast and how to manage the asymmetry.

The reader identifies an asymmetry with the ubiquitous digital arrow.

The patient is recalled for workup and ultrasound.

It is possibly difficult to decide which area is actually the "mass" on the MLO view. Look at the annotated image.

The ultrasound is read as "normal ".

Question: do you stop now? Are you happy that the lesion is adequately worked up? 

After two years

mammography

The MLO view was read as stable and reasonably enough follow up is suggested in one year.

After one year later

mammography

Large mass lesion is now seen two year later. The lesion has indeterminate microcalcifications.

Solid lesion highly suspicious for malignancy.

Birads V lesion which is confirmed as an IDC on ultrasound-guided core biopsy.

After one year

mammography

The MLO view shows the parenchymal distortion related to previous surgery. It's high up in the breast and on cc view, this is always a difficult area to include on the conventional cc image.

The second image is an extended cc view (xcc). It is a very handy tool to illustrate specifically a lesion high up in the breast as the one illustrated. It shows the whole area. You need to see the whole area of scarring in order to say it is not suspicious. Do not be tempted to accept an image where the scar is suboptimally imaged.

Case Discussion

The teaching point is that the initial mammogram was very compelling on the very first image. It's a daily dilemma when you are confronted with a normal ultrasound but your index of suspicion is high on the mammogram. The solution is to get up and ultrasound the patient in real-time and convince yourself that the study is in fact "normal" Do not simply accept "normal" static images if you are convinced a lesion is present.

Second point: just because a lesion does not change with time, is no guarantee it is not malignant.

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