Ms. Gayton is a 91-year-old female presenting with a palpable right breast mass, identified one month previous. History of benign left breast cyst. Three standard views of both breasts and two additional spot compression views were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibroglandular density. A trying a marker is placed at the site of palpable abnormality in the right upper inner breast. Underlying this marker, is a dense, spiculated, poorly circumscribed mass. Multiple additional benign calcifications, including arterial calcifications, are present bilaterally. ULTRASOUND
(1) 2.5 cm suspicious mass in the right upper inner breast, corresponding to the patient's palpable area of concern. An ultrasound-guided biopsy with placement is recommended for further evaluation. (2) Abnormal right axillary lymph node. An ultrasound-guided biopsy with clip placement is recommended for further evaluation.The patient does take Xarelto and has been asked to hold this medication for 5 days prior to the biopsy. All results and recommendations were discussed with the patient and her caretaker at time of dictation. BIRADS: 5 - Highly suggestive of malignancy.RECOMMENDATION: H - Percutaneous Biopsy/Aspiration.I personally reviewed the Images and/or procedure with the Resident/Fellow and agree with this report.