28-year-old woman presents for further evaluation of a palpable mobile mass in the left upper-outer quadrant. Patient states there is a possibility she may be pregnant. On physical exam, there is a mobile palpable lump in the upper outer quadrant of the right breast, correlating to the patient's area of concern.A targeted grayscale and color Doppler left ultrasound was performed for the palpable area of concern. In the 2:00 position 3 cm from the nipple, there is a area of dense fibroglandular tissue with associated cystic change. The largest cluster of cysts within this area measures 10 x 6 mm. Another dominant cyst measures 5 x 3 mm. Milk of calcium is noted within all the cysts. There is no solid component or internal vascularity associated with the cysts. No suspicious solid masses are identified in the area.
Benign fibrocystic changes involving the left upper outer quadrant, correlating with the area of palpable concern. No sonographic evidence for malignancy. As long as the physical exam is unchanged, screening mammogram is recommended per risk level. The findings and recommendations were discussed with the patient at time of the exam.BIRADS: 2 - Benign finding.RECOMMENDATION: C - Clinical Follow-up.