Presentation
A routine screening mammogram of left breast
Patient Data
Another set of images in the series of management cases for breast findings.
The reader notes a new finding compared with previous studies. A small density is seen centrally slightly medially in the left breast. The reader feels the lesion is " spiculated ". The patient is recalled for workup of the left breast.
What workup would you do ?
Answer: additional mammographic views and ultrasound.
The mag views are read as normal and the ultrasound study is unremarkable.
Are you happy? Are you finished?
Is it a Birads I or II or zero ?
Answer: I am not happy. That little lesion is clearly real on the original images. Its none of the Birads, I am not finished yet.
If you look at the mag views, they are too anterior in the breast. I think the lesion is deeper in the breast. What would you do now?
Answer: Just do a CC view of the left breast
The CC view done after the magnified views
The intramammary lymph node is seen again.
Case Discussion
When working up microcalcifications by all means jump right in with mag views.
When you work up a mass or symmetry, pause and consider what it is you wish to see, exactly.
In this case a very small lesion quite deep and the tech is likely going to have a tough time locating the precise spot in quite a generous breast. If the tech is lucky, she will image it first time. If not, repeat views and a struggle may ensue and the patient becomes progressively more concerned by the process.
In cases like this its often the quickest and simplest strategy to just repeat the CC (or do an ML) view. Even a very subtle degree of rotation or obliquity, a couple of degrees, gives you separation of the tissue and definition of the lesion.
As a general rule (not always true) when you want to evaluate an asymmetry do rolled CC and ML views. It gives you so much extra information and an almost 3D picture of gland on fat. Small lesions like this one can be tough to find. Do the CC view first and if you are still puzzled you can add the mag views. The tech will them also know where the lesion is.
In this case, the extra CC view would have given me the answer right off the bat. BIRADS II follow up in one year.
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