Ms. Leftwich is a 42-year-old woman with a personal history of right breast DCIS and left breast IDC status post bilateral mastectomy and breast reconstruction in 2009. She presents today from surgery clinic with new palpable abnormality (fullness) in left axilla. Upon physical exam, the clinical area of concern is marked in the left axillary region. There is an area of nodularity identified, however, no discrete mass is palpated.A targeted left axillary ultrasound was performed for the palpable area of concern. Sonographic images identified prominent scar tissue. No suspicious cystic or solid mass is identified.
Prominent left axillary scar tissue. No sonographic evidence for malignancy. The patient should follow up with her primary care team as clinically warranted for the palpable area of abnormality, presuming these results are concordant with the physical exam findings. All results and recommendations were discussed with the patient.BIRADS: 2 - Benign finding.RECOMMENDATION: C - Clinical Correlation Needed.