Case 7 Answer 3
BI-RADS 3, Probably Benign. With a negative diagnostic work-up, this finding most likely represents normal breast tissue. However, there is a small chance that this is an infiltrating carcinoma that is not seen on ultrasound.
It is important to note-- having old films would have cleared this up: if the finding were stable, it would be considered BI-RADS 2, Benign. If it were new, larger or denser, it would be considered BI-RADS 4, suspicious.
Thus, because there are no comparisons, and the stability of the finding is unknown, the finding is Probably Benign. A six month follow-up is recommended to ensure stability.
If you answered e. BI-RASDS 0, incomplete, then you are truly an optimist. If hypnosis or other methods succeed in jogging the patient's memory of her prior mammogram, then you may eventually resolve this recommendation. Documenting 10 years' stability would be ideal if possible. It is wise to call the finding Probably Benign, and issue an addendum if/when the old films arrive.