Ms. Ann Balling is a 61 year old female with personal history of left breast cancer, status post chemotherapy. She presents today for imaging evaluation of treatment response. A targeted left ultrasound was performed for the patient’s area of concern, site of a known cancer. In the left breast, 2:00 position, 5 cm from the nipple, there is a subtle hypoechoic area measuring 10 x 12 mm, which could represent the residua of the known cancer and/or treated tissue. This mass previously measured 37 x 18 x 28 mm. A few lymph nodes are noted in the left axilla. The index lymph node now measures 11 x 9 mm versus 16 x 7 mm on the prior ultrasound.
Interval decrease in size of the left breast cancer and left axillary index lymph node as described above. Also refer to today's separately dictated MRI. Surgical consultation is recommended. Results and recommendations were discussed with the patient. BIRADS: 6 - Known cancer.RECOMMENDATION: B - Surgical Consultation.