Sample Type / Medical Specialty: Obstetrics / Gynecology
Sample Name: MRI Breast - 1

Description: Bilateral breast MRI with & without IV contrast.
(Medical Transcription Sample Report)


Recent diagnosis of left breast cancer. Evaluate malignancy. Bilateral breast MRI with & without IV contrast comparison study performed on 8/24/07 and 8/29/07.

FINDINGS:
There are post biopsy changes seen in the retroareolar region, middle third aspect of the left breast at the post biopsy site.

There is abnormal enhancement seen in this location compatible with patient’s history of malignancy.

There is increased enhancement seen in the inferior aspect of the left breast at the 6:00 o’clock, N+5.5 cm position measuring 1.2 cm. Further work-up with ultrasound is indicated.

There are other multiple benign appearing enhancing masses seen in both the right and left breasts.

None of the remaining masses appear worrisome for malignancy based upon MRI criteria.

IMPRESSION: BIRADS CATEGORY M/5

There is a malignant appearing area of enhancement in the left breast which does correspond to the patient’s history of recent diagnosis of malignancy.

She has been scheduled to see a surgeon, as well as Medical Oncologist.

Dedicated ultrasonography of the inferior aspect of the left breast should be performed at the 6:00 o’clock, N+5.5 cm position for further evaluation of the mass. At that same time, ultrasonography of the remaining masses should also be performed.

Please note, however that the remaining masses have primarily benign features based upon MRI criteria. However, further evaluation with ultrasound should be performed.

Keywords: obstetrics / gynecology, breast cancer, bilateral breast mri, bilateral breast, iv contrast, contrast, ultrasound, ultrasonography, malignancy, mri, benign, masses, breast,