Mass lesion right breast with "normal" ultrasound

Case contributed by Dr Garth Kruger

Presentation

Developing asymmetry in the right breast

Patient Data

Age: 60
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.

Its possibly difficult to decide which area is actually the "mass" on the ML 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? 

The MLO view in 2011 id read as stable and reasonably enough follow up is suggested in one year.

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.

The MLO view in 2013 shows the parenchymal distortion related to previous surgery. Its 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). Its a very handy tool to illustrate specifically a lesion  high up in the breast like the one illustrated. It  shows the whole area. You need to see the whole area of scarring in order to say its 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. Its a daily dilemma when you are confronted with a normal ultrasound but your index of suspicion is high on the mammogram. The solution is too 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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Case information

rID: 21919
Case created: 26th Feb 2013
Last edited: 7th Nov 2017
System: Breast
Inclusion in quiz mode: Included

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