Ms. Nuilachae is a 26-year-old with known bilateral breast cysts and masses likely representing fibroadenomas presents for follow-up. RIGHT BREAST ULTRASOUND:On physical exam, there is a palpable mass in the upper outer quadrant of the right breast.A whole breast ultrasound was performed for the palpable and clinical areas of concern. -In the right breast 10:00 position 4 cm from nipple, there is an 8 x 3 x 9 mm circumscribed mass, with sonographic features favoring a benign fibroadenoma. This mass previously measured 9 x 3 x 9 mm and has not significantly changed in size. -In the right breast 12:00 position, 3 cm from nipple there is a 9 x 7 x 11 mm circumscribed anechoic lesion with posterior acoustic enhancement consistent with a simple cyst. -In the right breast 8:00 position 3 cm from nipple, there is an anechoic circumscribed parallel lesion with posterior acoustic enhancement measuring 11 x 5 x 11 mm, consistent with a simple cyst.LEFT BREAST ULTRASOUND: On physical exam there is a palpable mass in the inferior left breast.A whole breast ultrasound was performed for the palpable and clinical areas of concern. -In the left breast 11:00 position 6 cm from nipple, posterior depth there is a parallel circumscribed mass measuring 10 x 5 x 10 mm, suggestive of benign fibroadenoma. This mass previously measured 9 x 3 x 13 mm and has not significantly changed in size. -In inferior left breast near the 6:00 position there is an area of focal fibrocystic change containing innumerable number of cysts measuring up to 6 mm, corresponding to the palpable abnormality.-In the left breast 12:00 position 1 cm from the nipple, there is a cluster of cysts measuring 8 x 6 x 8 mm.
Stable high probability benign bilateral fibroadenomas. Extensive fibrocystic change in the inferior left breast. Bilateral simple cysts. As long as the patient's physical examination remains normal, bilateral ultrasound can be performed in one year to document stability of these findings. At that time, assuming all findings are stable, the patient will have had 2 years of stability and can discontinue annual imaging follow-up as clinically warranted. Results and recommendation were discussed with the patient. BIRADS: 3 - Probably benign finding.RECOMMENDATION: 3B - Followup at Short Interval (1-11 Months).