49-year-old female with history of left breast cyst aspiration x 4. Patient has a new palpable left breast mass for 2 weeks. Denies associated pain. DIAGNOSTIC MAMMOGRAM: Three standard views of both breasts and two spot compression views of the left breast were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibroglandular density, unchanged in pattern and distribution. A triangular marker was placed over the patient's palpable site in the left breast located slightly superior and lateral to the nipple. This corresponded to a central, mid-depth 3 cm circumscribed round mass for which ultrasound will be done for further evaluation. Additional asymmetries are present in both breasts that appear stable compared to prior studies, which may represent underlying cysts. Bilateral benign calcifications are present, unchanged.LEFT BREAST ULTRASOUND: Targeted ultrasound of the patient's palpable site in the left breast demonstrated a 3 x 2.5 cm cyst. No suspicious mass is identified.
Patient's palpable site in the left breast corresponds to a 3 x 2.5 cm cyst. As no pain is associated with this cyst, aspiration is not indicated at this time. No mammographic or sonographic evidence of malignancy. As long as the patient's physical examination remains stable, bilateral screening mammogram is recommended annually. Results and recommendation were discussed with the patient.BIRADS: 2 - Benign finding.RECOMMENDATION: NS - Screening Mammogram.