SCRIPT MR KAMIS 21/03/2019 There is no skin thickening nor nipple retraction of

right and left breast

Good morning dr Ira
Good morning dr Lies
Good morning dr Ndari
Good morning dr Fierly
And good morning to all resident
Reporting female patient, 49 years old, referred from
oncology department, with clinical information left
breast tumor suspected malignant asked for right and
left mammography cc/mlo projection :
From History Taking :
Patient felt hard lump in her left breast since one
month ago. Patient also complaint pain in the lump
region. The lump size initially was as big as ping pong
ball and getting bigger. There is no wound nor nipple
discharge at left breast. There is no history of
chemoteraphy and radiotherapy. There is no complain
in right breast. There is no complain in neck nor axilla
region. There is no history of prior examination
Children : 2 (died)
Breastfeeding : (+) both children, until 5 month old
Contraception : -
Menarche : 13 years old
First day of Last Menstruation : 13/02/2019
Family History : son, lymph nodes cancer
From physical examination :
- There is solid palpable lump, fixed, with size
about 7 x 5 cm, tenderness (-), nipple
discharge (-) in lef breast
- There is no palpable lump nor nipple
discharge in right breast
- There is no palpable lump in neck nor axilla
region
There is multiple lymph nodes, oval shaped, equal
density, central hillar luscency (+), with the biggest
short axis about 1 cm at right axilla and about 1,39 cm
at left axilla
From US Confirmatory of Right and Left Breast:
- There is heteroechoic mass, well defined
border, lobulated margin, size about 5,5 x 7,3
cm at retronipple to 3 o clock direction of the
left breast, accompanied with nipple
retraction, which in color doppler ultrasound,
there is perilesion vascularisation
- There is multiple cystic lesion, anechoic, with
biggest size about 1,6x0,8 cm at 9 o clock
direction perinipple of left breast
- There is multiple cystic lesion, anechoic, oval
shaped, well defined border at right breast :
1. At 9 o clock direction, size about 0,9x0,7
cm
2. At 3 o clock direction, size about 1,3x0,68
cm
Our conclusion are :
- Highly suggestive for malignant mass of left
breast (BI-RADS C5)
- Benign calcification and multiple simple cyst
of right breast (BI-RADS C2)
- Non spesific lymphadenopathy at right and
left axilla
-
Thank you

We performed right and left mammography cc/mlo

projection although the request is right
mammography because this is the first examination

From right and left mammography cc/mlo projection

we got :

Right and Left breast parenchym are heterogenously

dense
There is hyperdense mass, irregular shaped, partially
circumscribed margin, size about 10,48x6,77x5,54
with rim calcification inside it in central quadrant of
left breast
There is no mass of right breast
There is multiple round calcification at upper inner
quadrant of right breast, there is single round
calcification at upper outer quadrant of left breast
There is no parenchymal distorsion in right breast