A round mass is present in the central, slightly inner right breast at middle depth, but did you notice the irregular mass in the upper outer left breast?
A mass is present in the upper inner left breast, better seen on the MLO view. The diagnostic work-up shows:
What is your assessment?
BI-RADS 1 - Normal BI-RADS 2 - Benign BI-RADS 3 - Probably Benign BI-RADS 4 - Suspicious mass BI-RADS 5 - Highly suggestive of malignancy
BI-RADS 5, Highly suggestive of malignancy
You perform a needle biopsy under ultrasound guidance, and the pathologist reports “Dense fibrosis
What is your recommendation?
Benign and concordant. Recommend mammography in 12 months. Benign and concordant. Recommend mammography in 6 months. Benign but discordant. Recommend mammography in 6 months. Benign but discordant. Recommend surgical excision.
Benign, but discordant. Recommend surgical excision
This is a high density irregular spiculated mass. You will not end up eating your hat on this one. Some cancers induce such a prominent fibrotic response that this is all that can been seen on a needle biopsy core. The purpose of a needle biopsy in lesions like this is purely to help guide surgical planning. A benign core should not stop you from recommending that it be excised.
So, what about the mass in the right central breast?
The diagnostic work-up of the right breast mass:
Given that we have already found a cancer on the left, what is your assessment of the right breast?
Benign and concordant. Recommend mammography in 12 months. Benign and concordant. Recommend mammography in 6 months. Benign but discordant. Recommend mammography in 6 months. Benign but discordant. Recommend surgical excision.
BI-RADS 2, Benign. Simple cyst
This mass is entirely anechoic, has imperceptibly thin walls, and has increased through transmission, and thus is a classic simple cyst.
If we could not definitively show this, and the margins look somewhat lobulated or indistinct, then it would be suspicious, and should be aspirated. If the margins were circumscribed, then it would fall into a probably benign category (IF there were no comparisons!) BUT– when a cancer has already been demonstrated elsewhere in the breast tissue, then biopsy of Probably Benign lesions makes sense for surgical and oncologic planning.
Special Oral Boards Note: BEWARE of the case with more than one finding!
A good practice is to identify the obvious finding… “I see a 2cm round mass in the central breast”
and diligently search the rest of the breast tissue… “I am looking for any other finding.”
IF you don’t see anything else then… “I don’t see anything else, so we have a round mass with smooth margins in the…”
IF you see a second finding… “I also see a second finding which looks more suspicious. I’ll first describe the more suspicious area: a 1.5cm spiculated mass is present in the…”
