Interpreting Your Report
Comments
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"Overgrowth" is the lay word for "hyperplasia" and there are benign types of hyperplasia.
See this page: https://breast-cancer.ca/epithast/
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thanks. Glad to know isn’t a ‘known’ scary. Reading some reports on here it seems some radiologists are very specific. My report was brief - and they scheduled the biopsy. I’ll post back once I know more.
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Hi DJMammo,
I have two questions for you if you'd be so kind…
- 1) I had my MRI's reread at MD Anderson. My local hospital called my right side linear non-mass enhancement as measuring 0.8 cm, but in looking at the very same MRI slides MD called it 1.2 cm. I can understand a slight difference in opinion but looking at the very same MRI and MD calling it 50% bigger seems dramatic. Can you shed some light on that for me?
- 2) Again, still looking at my first MRI from my local hospital, MD also wrote that, while my nipple discharged continued, no papilloma is identified on MRI (or Mammo or US) but noted that a small one couldn't be entirely ruled out. To remind you, I have a linear non-mass enhancement in my right breast located about 2 cm from the nipple (the one with a single duct serous discharge) sized somewhere between 0.8 cm to 1.2 cm (depending on whom you ask) and a rim enhancing 0.4 cm round mass in my left breast. More than one doctor at MD indicated they do not know if the discharge and the suspicious areas on MRI are related in any way. An MD radiologist mentioned the concern regarding the right breast had to do with its "morphology". I know that means it's shape. My question is this…. Does the fact that I have a pathological nipple discharge on the right increase the likelihood of finding malignancy or increase the likelihood of finding the area on the right to be benign? In other words—statistically does the nipple discharge lean me one way or the other? There must be some data on this.
Thanks in advance and you are wonderful to answer all our questions here!
Deep Waters
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1) MD Anderson is a highly respected institution and I would certainly take their conclusions into consideration over a local hospital that may not have the experience as a cancer center that MDA has.
2) Nipple discharge comes in many colors, we worry about the bloody and the clear ones and there are benign and malignant causes for each. Statistically most are papillomas. Green and blue discharge usually related to benign fibrocystic changes.
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I agree with djmammo. I would go with MD Anderson over a local hospital. Good luck and keep us posted.
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Thanks DJMammo! You are providing clarity for many at a confusing time. You are very kind to give of your time in this way!!
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I was told today that I have fine pleomorphic calcifications in a grouping. My sister was diagnosed at age 45 with high grade DCIS. I am 41. I am having another mammogram in that area Wednesday but magnified. Thoughts?
Also I looked at my images and don’t see all of the white dots in the area they said they are at. When I look online I see pictures that are so obvious where the calcifications are. Thoughts?
Feeing quite anxious so any response is appreciated! Good or bad! My sister is fine so I know I would be too :-)
Michele
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I had IDC eight years ago and my last routine mammogram showed an area of concern 11 by 9 mm. I did the follow up mammogram and ultrasound. The area of concern near the original site is irregularly marginated and hypoechoic. The other breast shows on mammogram a stable involutating fibroadenoma that was biopsied many years ago, with no suspicious micro calcification. Birads 4
I went for the ultrasound guided biopsy 6 weeks ago and they hit an artery with the freezing needle and were unable to proceed. It took over 45 minutes to stop the bleeding. We have since tried three more times but the hematoma blocks the view of the area. I had a MRI and they can see the area of concern and now there is also concern about the area where the fibroadenoma was. I now need two biopsies one in each breast and MRI guided biopsy has been recommended. I know there are false positives with the MRI, but could this former fibroadenoma be worrisome. Can they do both biopsies with the MRI guidance at the same time? Or will I need to do one with ultrasound and one with MRI
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Hello!
Hello!
I was presented with a subaerolar bulge, redness and left breast pain. the ultrasound only showed a defined mass of irregular birdes compatible with the abscess formation. there was nothing else, no nodules, no cysts, no swollen nodes. They gave me antibiotics and the pain disappeared, the swelling also and the redness is almost gone. only the subaerolar bulge remains. I did the biopsy and cytology. the biopsia results say: proliferation of epithelial cells without atypia associated with chronic inflammatory process by foreign body.
what does it mean? I suspect ibc and I do not know if they should have also biopsied the skin not only the lump.
I'm still worried
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Were you on any blood thinners at the time of that biopsy? Taking any NSAIDS at the time?
It should be relatively easy to tell whether or not that finding in the other breast is the fibroadenoma or just near that fibroadenoma. If they are calling it an involuting FA, I assume it has a large benign calcification in it as that is the feature that tells you its an aging FA which would further make its location obvious.
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That path result says there is no cancer where the biopsy was taken. Did you have a piercing of any sort either recently or in the past? An penetrating injury in that area in the past? Pathologists can tell if there was a foreign body present inciting the abscess by the type of inflammatory cells that are present in the tissues.
The imaging and path findings explain your presenting symptoms. It would be odd to have a second abnormality with an identical presentation occurring at the exact same time as the abscess but I suppose its not impossible.
If it were IBC the area you are concerned about should have been getting worse every day since it all started. How long ago did you first have the subareolar bulge? Also do you mean subareolar or infra-areolar?
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thanks djmammo!
I was taking baby aspirin but had stopped 48 hours previously. I was taking fish oil and garlic so have also stopped that as well.
I don't have a copy of the MRI report, but the recommendation is that they biopsy that area as well. The term involvuting was on the mammogram report.
Will they be able to do both at the same time with the guided MRI biopsy?
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Not sure about same day bilateral biopsies. It may require 2 doses of contrast, one for each side and whether they do that would depend on your kidney function. They may want to separate them by a day or two for that reason, also would depend on their scheduling, how many biopsy slots available per today and are they one right after the other etc. You need to call and ask the imaging center that question.
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Djmammo, thank you SO much. Your help is greatly appreciated. It looks like we will do an Ultrasound guided biopsy for left, and the MRI guided for right side.
I got the copy of my MRI report:
1. Demonstrated along the medial margin of the patient's bilobed right sided hematoma is a focus of enhancing tissue which remains concerning for malignancy. Focused ultrasound re-evaluation and biopsy are advised.
2. Demonstrated within the far posterior aspect of the left breast at roughly 2 o'clock radian is a focus of irregularly marginated tissue characterized by worrisome enhancement kinetics. This is concerning for contralateral malignancy. Focused ultrasound assessment and biopsy are advised.
Sorry for the length, since the MRI they tried again to biopsy the right but the hematoma still makes it unclear, hence the MRI guided. But the left is a surprise as on the mammogram it showed as fibroadenoma.
I just want to get on with treatment if this is what is suspected. Any thoughtswould be helpful.
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thanks for your answer. I have suffered subaerolar abscesses for 5 years. in the same breast. I have never smoked or had any piercing. the abscesses have appeared and disappearedand left without medication, I only knew that they were there because of the bulge that I felt and I knew it was because from the first time I passed and they performed the biopsy the mastologist told me that they could reappear. What worries me this time is that in addition to the lump, my breast reddened, the aerola darkened and the pain was very intense. that's why I immediately thought it was ibc.the symptoms have had much improvement, the lump of the abscess is breaking, the redness has not gone away completely, but it has improved quite the same with the color of my aerola. but I have almost 2 months and I do not understand why it lasts so long in returning to its normal state. I was taking clindamycin for 10 days and it still has not improved at all.
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Hi DJMammo! I have a quick question for you regarding MRI results. I've read that false positives on breast MRI are more likely to occur with a first-time MRI and that having a previous MRI (or even multiple MRIs) for comparison diminishes false positives. This certainly makes a lot of sense as anything "changing" is more likely to be malignant than something that's been stable for a year or more.
So, do you have any information on false positive rates on first MRIs versus subsequent MRIs? Are there any studies or statistics on that? To bring it to a more personal level, do my five years of negative MRIs followed by findings this year mean my biopsies next week are less likely to result in false positives? Thanks in advance.
(Funny thing is, I'm doing all this reading to seek information for myself. However, there's a part of me is is fascinated from a purely scientific standpoint. That weird stoic thing kicking in I guess!)
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If your MRI has been stable for years read by the same people, scanned on the same machine and you were scanned at the same time in your cycle each time and suddenly there is something new seen, it more likely real but it doesn't mean its malignant. It can be something new and benign. If the biopsy comes back "normal tissue" to me that a false positive. If the bx comes back fibroadenoma it is still counted against the radiologist as a false positive since its not a cancer even though it was a good call as regards "new finding since last exam".
Here is an article that may come close to what you are asking: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4340856/
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Thanks DJMammo. Interesting....I never thought about anything being "counted against the radiologist". That sounds positively punitive. I've always thought of the radiologist describing what they see and making a recommendation based on education and experience for how to best address what they observe. Personally, I was using the term "false positive" to mean cancer was suspected but ruled out by biopsy (and not that there was nothing there but normal breast tissue). There is certainly "something there" as it's been seen on two somewhat back to back MRIs. As a patient, I would never be upset that a radiologist recommended biopsy and it came back benign. Is there really a system by which radiologists are tracked with regard to not having "enough" recommended biopsies come back malignant?
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"Is there really a system by which radiologists are tracked with regard to not having "enough" recommended biopsies come back malignant?"
Somewhat. They want to know if we are catching all the cancers that come through the department.
The MQSA or Mammography Quality Standards Act governs all aspects of breast imaging from the facility to the radiologist.
Each year, all radiologists reading mammograms receive a quality review report required by the MQSA and generated by the non-physician director of the radiology department or the head technologist. This report includes how many of each type of exam you read, i.e. # of screening mammograms, diagnostic mammograms, breast ultrasounds, how many biopsies you recommended, how many studies in each BIRADS group B1-B5, of the mammograms and biopsies the number of true positive, false positive, true negative and false negative studies. The problematic one is the false negative. This is where a cancer may have been missed. This more often than not is a screening exam called normal and in less than one year the pt comes back because they felt a lump. This counts agains the radiologist's overall score for reliable interpretations which is some ratio of all the true and falsie, pos and neg etc. categories, developed by the MQSA. The last mammogram before the cancer was identified is studied by several other radiologists in your department to determine if it was visible or not visible. (BTW these scores are best among those radiologists who read nothing but breast imaging).
To my knowledge there is as yet no similar requirements for any other modality or organ system in radiology, just breast imaging.
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Here is the actual set of performance measurements required to be reported for every radiologist reading breast imaging in the US
Table 1
Performance Measures and Definitions Included in the Basic Clinical Relevant Mammography Audit of the American College of Radiology
Performance Measure Definition Recall rate Percentage of screening examinations recommended for additional imaging (BI-RADS category 0) Abnormal interpretation rate Percentage of screening examinations interpreted as positive (BI-RADS categories 0, 4, and 5) Recommendation for biopsy or surgical consultation Number of recommendations for biopsy or surgical consultation (BI-RADS categories 4 and 5) Known false-negatives Diagnosis of cancer within 1 year of a negative mammogram (BI-RADS categories 1 or 2 for screening examination; BI-RADS categories 1, 2, or 3 for diagnostic examination) Sensitivity Probability of detecting a cancer when a cancer exists (true-positive examinations / all examinations with cancer detected within 1 year) Specificity Probability of interpreting an examination as negative when a cancer does not exist (true-negative examinations / all examinations without cancer detected in 1 year) PPV1 Percentage of all positive screening examinations that result in a cancer diagnosis within 1 year PPV2 Percentage of all screening or diagnostic examinations recommended for biopsy or surgical consultation that result in a cancer diagnosis within 1 year PPV3 Percentage of all biopsies done after a positive screening or diagnostic examination that result in a cancer diagnosis within 1 year Cancer detection rate Number of cancers correctly detected per 1,000 screening mammograms Minimal cancers Percentage of all cancers that are invasive and ≤ 1 cm, or ductal carcinoma in situ Node-negative cancers Percentage of all invasive cancers that are node negative
Note—PPV = positive predictive value.0 -
Here is the actual set of values calculated every year for every radiologist in the country reading mammograms as required by the MQSA.
Here is the link in case this table shows up too small: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2714544/table/T1/?report=objectonly
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hi DJmammo, wondering if you had any thoughts on the MRI report I posted yesterday regarding the new area of concern in the left breast. In the mammogram it was mentioned as a fibroadenoma but I don't know if this is different. I am hopeful,but worried. Thanks so much!
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DJmammo, thanks for your response. Since then I received the actual MRI report and posted it 7:59 pm may 16. I was hoping that you might shed light on it after seeing the actual MRI report. Any thoughts would br greatly appreciated! Many thanks!
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Its a little confusing.
Right: The report says previous lumpectomy. Did you have a lumpectomy for cancer on the right or is that hematoma from the attempted biopsy that hit an artery? If its just from the attempted biopsy this needs to be corrected as it would be read with a different degree of suspicion by the radiologist if he things cancer has already been diagnosed on this side as an enhancing rim at a lumpectomy site could indicate residual cancer (but in an injury could just represent the healing process).
Left: The description of the finding on the left is not how a firbroadenoma typically presents on an MRI but there is no mention of a separate finding described as a fibroadenoma. If it was previously biopsied and is showing involutional changes on mammogram this may affect how it looks on MRI. They will evaluate it with US before the biopsy and that should explain more.
In both cases they use the term 'washout kinetics' which is the one associated with malignancy. 'Plateau kinetics' can go either way. They never mention the third type of enhancement 'persistent kinetics' which is associated with benign masses and is what is usually seen with fibroadenomas.
Let us know what you next imaging study shows in these areas.
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Hi DJMammo-
Would like your insight on my Mammograms please. I've had a pretty crazy month...I had emergency surgery 4/11 for a first-sized ovarian torsion tumor (benign thank goodness) so while I was off work recovering I went for my (overdue-last one was 2015) had mammogram on 5/10, called back for enhanced mammogram on 5/14 and then stereotactic core biopsy yesterday 5/18, anxiously waiting on pathology report. Figure I'm either on the benign train for my lady parts or I've hit the end of the line on my luck!?!?
Reports:
5/10/18: Mammo Screen BIL w/ 3D
Indication: Screening
Technique: Digital breast tomography obtained with synthesized to the reviews. This examination was reviewed with the aid of CAD system
Comparison: Compared to: 3/11/15 mammo addl diag workup uni, 3/9/15 mammo screen BIL and 11/11/13 mammo screen BIL
Breast composition: BC 4: Extremely dense, which lower the sensitivity of mammography
Findings: amass is seen in the inferior left breast with an adjacent biopsy marker this has been previously sampled and is known to be a Fibroadenoma. A second smaller masses again scene in the left breast, laterally, which also appears unchanged. Scattered benign appearing calcifications are seen in the left breast. In the right breast, there are new linear, branching, segmental calcifications situated in the inferior medial breast. Magnification views recommended for further assessment.
Impression:
1. Left breast mass, with adjacent biopsy marker. This has been previously biopsied and is known to be a fibroadenoma. A second mass is unchanged in the left breast.
2. New extensive branching microcalcifications in right breast. Magnification views recommended for further assessment.
Recommendation: RT: Right RC2: Diagnostic Mammograms
BI-RADS: 0: incomplete-Need additional imaging evaluation and/or prior mammograms for comparison
5/14/18: Mammo Diag Unil Rt
Indication: Microcalcification of rt Breast on mammogram
Technique: Digital Mammography performed for the right breast this examination was reviewed with the aid of CAD system
Breast composition: BC 4: Extremely dense, which lower the sensitivity of mammography
Findings: The right breast microcalcifications are plemomorphic or fine heterogeneous. They are seen throughout the central and inferior aspect of the right breast, involving an area at least 7 x 9 cm. They extend from the subareolar space to the pre-pectoral fascia/retroglandular space.
Impression: suspicious microcalcifications. Recommend stereotactic core biopsy.
Recommendation: RT: Right RC 5: stereotactic biopsy
BI-RADS 4: Suspiciois
My reports seem a bit abbreviated compared to others...new health system for me, should I be concerned? hanks for your time and expertise, look forward to your thoughts based on your experience
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djmammo, Thank you so much!
To clarify, I had a lumpectomy followed by radiation 8 years ago on the right side for IDC. This years mammogram showed a new area of concern which was also seen in the ultrasound and they attempted the biopsy which resulted in the hematoma over 6 weeks ago. So that's why the mri, As now they can't see it clearly by ultrasound.
The left side was biopsied probably over twenty years ago and was fibroadenoma, so fingers crossed.
Just waiting to be scheduled for the two biopsies, will keep you posted. I greatly appreciate your information.
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DJMammo,
Thanks for the information on MQSA reports. It is really interesting! I had no idea. On one hand I think it's important that people (especially those with lives in their hands) be accountable. On the other hand it seems like a lot of pressure and as I said, somewhat punitive to track them this way. It's like when teachers have to "teach to the test" instead of focusing on learning. You know what I mean? And how is it fair to individual radiologists who are not provided good clear "films" or who are overworked with regard to time allowed to really study a film?
I have a question about the reports....Are these reports that are required by the MQSA made public on specific radiologists? That would seem over the top! Or is the information gathered and reports generated on facilities but not individual radiologists? It seems like it would be back in my college days (before the internet and logging on to get grades) when professors would post grades on a public bulletin board using full names of the students. While I generally did well, I felt badly for students who were basically shamed. Not exactly the best method to inspire improvement in my opinion!! LOL
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The reports are generated in house for each radiologist who has read mammograms in the past year, and kept confidential. They are not sent in to the MQSA and not made public. They do have to be signed off on by the medical director of the breast imaging department so I did get to see everyone's in my section. If there was a problem with any one area for any one rad then I would speak to them.
These days only a few docs in groups of all sizes will read mammos as they are a big source of lawsuits compared to other areas of radiology specifically in the realm of "failure to diagnose" and the ever popular "delay in diagnosis". Many rads avoid reading them, on the other hand there is a small subgroup of rads such as myself who go "all in" on breast imaging and do nothing else. I believe this is necessary to read them properly and there should be a sub-specialty certification for breast imaging but so far the ACR does not agree with me.
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Although the path report will be the final word, the description of the calcifications very much suggests DCIS. Since they do not mention a mass so that lowers the chance of this being an invasive cancer. If it does come back DCIS, you will likely have an MRI to see its full extent, and to see if any masses are lurking in the dense tissue and if the lymph nodes look normal. They will check the other breast for the same at this time. At some point after the MRI your surgeon will remove the abnormal area(s) and the pathologist will examine the entire lumpectomy specimen to determine if there are any foci of invasive disease present and that will help determine your treatment. Let us know the results of the biopsy.
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