Interpreting Your Report
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hi Djmammo
I have a question and was hoping you could answer it for me. I had ultrasounds done in February and end of May and both were normal with a cyst in the left breast. Little over a month ago I palpated a rice like hard lump in my right breast and two days ago I had mammogram and ultrasound and these were the findings;
No suspicious masses, calcification or architectural distortions are seen on a mammographically. Breast parenchyma heterogenously dense.
Targeted bilateral ultrasound showed 6 x 3 mm hypoechoic oval nodule demonstrating vascularity in the right 8o’clock position. BIRADS 4. Ultrasound guided core needle biopsy and tissue diagnosis is recommended.
Obviously I am highly concerned this may be something malignant due to being vascular.
What is your opinion on this?
Thank you
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I am super confused on my pathology report. If I sent you a copy of mine can you give me your opinion?
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Can anyone tell me if density of a mass, not having dense breasts, matters in determining the wording of a report? My report reads equal density mass and I've looked around on the message board without finding anything and I don't want to google.
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HI DJ--
Of you have a moment, would like your opinion?
BiRads 4 - hypoechoic mass, with angular margins, and associated shadowing measuring up to 0.4
x 0.5 x 0.4 cm. There is an adjacent linear tract.thoughts? Thank you for your kind work with us.
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The US features of visualized masses depends upon their surface and contents, and relates to the physics of sound waves.
For example a benign simple cyst has a very thin wall with a smooth surface and is filled with relatively homogeneous clear fluid. There is therefore an abrupt change between the solid nature of the breast tissue and the homogeneous liquid in the cyst. The image of a cyst will show a well defined separation between breast tissue and the cyst wall as the sound moves through the cyst. A cyst therefore has a "well defined back wall". There will also be complete transmission of the sound through the cyst, and in fact, faster through the cyst than through the surrounding tissue which results in the image being brighter on the far side of the cyst referred to "through transmission"
Cancers more often than not have an irregular surface and an inhomogeneous solid interior. Sound is scattered by irregular surfaces and slowed within the inhomogeneous solid interior. This causes the margins of the mass to appear irregular and "ill defined" including the "back wall", and will cause "posterior shadowing" on the far side of the mass (which is the opposite of "through transmission") which can also obscure the back wall.
The smaller image shows a cyst with smooth margins, a well defined back wall and good through transmission
The larger image shows a mass with irregular margins, posterior shadowing and poorly defined back wall.
Let us know how the biopsy goes.
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hi! Baseline mammo done last week, diagnostic mammo and US tomorrow. Curious to see if you could break down my report or think of any specific questions when I go in...
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It all sounds quite routine, nothing to worry about yet. On a baseline it is more than reasonable to bring you back to better define the asymmetry and the calcifications. Its a good sign they did not use the word "mass" nor the terms "grouped or branching" for the calcs. These findings could be new or they could be years old, no way to know on a baseline exam.
They will take compression / magnification views of the area in question likely followed by an ultrasound. Many practices will bring you back in 6 months for a check up if this followup is "normal" so don't let that worry you, its a common protocol and for everyones protection.
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thanks for your insight!
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Not actually worried but wanting to understand this line.
Numerous widely scattered microcalcifications throughout left breast many of which represent milk of calcium within microcysts suspicious demonstrate on the ML view (crescent signs)
I think my confusion is the word 'suspicious'
Maybe he's saying there is a cluster that was suspicious but they are showing crescent sign and not a concern?
I am routinely recalled for diagnostic mammograms every 4-6 months. I've never had a screening mammogram once in 7 years without a recall. So this is not my first rodeo.
It's always about different clusters of microcalcifications within my left breast. And I know enough now to understand teacup/crescent is milk of calcium. I have 'type D' dense breasts so I'm forever told it's like looking for a snowflake in a blizzard with me. (Great, makes a girl feel SUPER confident on how helpful all these tests are!) This report also had something new for me:
8 mm cyst with 1 mm adherent instracystic calcification or polyp.
I am 100% sure there were two of those because he turned screen and showed them to me. Said he was sure they were calcifications and then proceeded to shake the transducer (might have term wrong) a few times before saying to tech: "Well, no, neither of them moved. Probably polyps." Not a big deal but when he points out two to me and then only mentions one in report.... but hey, everyone makes mistakes. And that seems simple enough?
I was surprised to have be told I had another dx this time. My usual routine is screening: then dx a few days later, then dx 4 months later, then another dx 8 months. Then a : okay you are good, see you in a year. Maybe the 6 months again is also due to wanting to watch those itty bitty cysts with possible polyps as well? (SIL has intraductal papilloma so I'm aware of that and that benign but still usually is checked? Her's were removed and when more came back actually did have some issues.) Also noting: I have lots of cysts. Lots or little to medium sized cysts. Wee.
I know all these issues are not a big deal or anything to worry about. Just the term 'suspicious' threw me. I'm sticking with a recall of 6 months and a BIRADS 3 means no big at all.
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"Numerous widely scattered microcalcifications throughout left breast many of which represent milk of calcium within microcysts suspicious demonstrate on the ML view (crescent signs)"
Is this the EXACT wording? Seems off grammatically. If it is it there may have been a voice recognition error while dictating. The ML (mediolateral 90 degree view) is the one that demonstrates the tea-cupping and confirms that milk of calcium is present. Perhaps they meant "suspicious for milk of calcium"? Either way did the report say it was new or old?
"8 mm cyst with 1 mm adherent intracystic calcification or polyp." Is this new from last time? This will need to be addressed at some point. I dont believe the term polyp is appropriate here. It should be referred to as a "mural nodule". If its fixed or adherent then its probably not debris. Was there blood flow in the nodule on Doppler? As far as pointing out 2 of these, techs will often take an image in one plane then take one 90 degrees to the first and display both images in a split screen format. This is very common.
In order to get something to move within a cyst, the tech will ballot the cyst with the transducer hoping to get the internal echos to move. If there is a great deal of debris the cyst takes on the appearance of a snow globe.
Bottom line is that they describe a cyst with a possible mural nodule which should be designated a complex cyst (if it were just debris it would be called a complicated cyst). Personally these are the ones I aspirate and send the fluid to the lab. I also poke the nodule to see if its a ball of debris in which case it would break up. If it didnt I would do a core biopsy.
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Thanks for the feedback.
Yes, that first line was word for word exact. Thus my confusion. I agree is seemed more like a grammatical thing. The report did not say there were new microcalcifications - but it seemed to me they were following a group of ones from before. Usually I have mention of a cluster in a new area or something about wanting to be sure stable.
Usually the radiologist will poke his head in the room. Explain what they are looking at. And tell me why he wants me to come back.
This time he just said: want you back in 6 months. And I think I was still trying to process what a polyp was and said: okay instead of my usual: why?
Yes, the cyst with 'polyp' was new.
I tend to read enough online to learn about terms used and then tend to back away, but I finally broke and asked here because it seemed polyp wasn't a widely used term in what was described. And no doppler was done.
*Your reply did bring to mind an ultrasound from 6 years ago that noted a septated cyst in the report. And I do recall the radiologist telling me that a complex cyst like that might need to be aspirated to check in out. No doppler done then either. I didn't have another ultrasound until this time when I pointed out what I felt was something new. Usually it's just mag views and spot compressions to check microcalcifications and nothing else. (Which sometimes bothers me that we're going to miss something when I'm told over and over how dense my tissue is.)
And aha to the two images --- maybe that's why they said neither moved. See, I learned something new!!
I've been trying to decide if I wanted to ask for a second opinion on this. But nothing sounded alarming enough to push for much at the moment. I'm now armed with more info gleamed for you. I might consider making an appt in a moth or so to discuss with my regular GYN to get her thoughts. Thank you so much!!!!
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djmammo,
I posted yesterday with my screening report, went for diagnostic mammo and ultrasound today. 7mm hard nodule (is that a mass?) Found on both. Definitely not a cyst, radiologist doesnt think its a fibroadenoma because there aren't smooth edges. There were also calcifications inside of it. Scheduled for core biopsy on Monday morning. I havent recieved the report yet, but they general way they spoke to me (very soft and slow as if I was going to freak out) didn't give me a reassuring feeling as I left. What could this possibly be? I would rather know details going into the biopsy...
Thanks again!
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I am going for my lumpectomy Monday, for atypical ductal hyperplasia proliferation, 2 separate groups of clustered needle tip microcalcifications measuring 6cm. Nuclear grade 2 ,er strongly positive. Cribiform architecture with rare mitotic figures in the cells.
One dr said DCIS another said she needs to wait until pathology from lumpectomy comes back to diagnose.
What is your opinion?
Thank you
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The biopsy report is based on a very small amount of tissue that is hopefully representative of the composition of the mass, sometimes it isn't. The lumpectomy path report comes from the evaluation of a much larger amount of tissue so thats the one treatment is based on. Sometimes there is something more worrisome in the lumpectomy specimen compared to the biopsy and that is referred to as an "upgrade".
From the portion of the path report you posted it sounds like they will find DCIS but no way to know if there is any invasive present until after the lumpectomy path report comes back.
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What is your opinion? How concerned should I be?
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Well, that could go either way depending on the appearance of the calcifications. If they are "large" as calcs go, it could very easily be a fibroadenoma. They develop large internal calcifications that can grow quite large over time and actually look like popped corn. If they are small irregular microcalcifications it would lean the other way.
Isoechoic is better than hypoechoic, 6mm is better than 10mm, big calcs are better than small calcs etc
In any event, if its new it gets biopsied, anything with a border that is not well defined all the way around it gets biopsied, anything with irregular margins gets biopsied.
And yes even at 6mm it has to be called a mass by the strict BIRADS lexicon. Below 1cm i prefer to say nodule but I am in the minority on that one.
The only time to worry is when you have a suspicious mass and they DON'T want to biopsy it.
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thank you!
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djmammo, Can you answer questions about MRI?I’m wondering if breast MRI are always done with gadolinium contrast and would they be useless without it. Thanks
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Hi djmammo,
Do microcalcifications "grow back?"
I had a stereotactic biopsy June 21st. They removed a "cluster" of 6 calcs. The mammogram 6 months earlier only showed one calc, which they have been watching for several years. I've never had a totally normal mammogram or ultrasound between the one suspicious calc and many cysts.
Pathology was benign (report below), but a radial scar was recommended for removal.
Today I had the excisional biopsy. When they checked for the marker prior to placing the wire, they told me the marker had moved, so they were placing the wire in the area of calcs. I asked how many they saw, and she said maybe four or five. I said that they removed all the visible calcs in June, and did they come back? She said maybe the machine was better, etc... These are very close to the surface at the top of my breast, which seems easier to visualize (in my completely uneducated opinion).
Is there a benign condition associated with microcalcs that continuously multiply? This seems pretty suspicious to me. If it is benign, I am envisioning biopsies forever... I will get the results August 28th.
Here's the report from the June stereotactic biopsy.
Surgical pathology of the biopsy cores revealed radial scar with fibrocystic change including apocrine metaplasia and focal ductal hyperplasia without atypia. Microcalcifications were identified in benign ducts. There was no evidence of malignancy.
While radial scar is a benign lesion, there have been reports of associated malignancy
at surgical biopsy. Therefore, surgical excision of the biopsy site is recommended.
IMPRESSION:
Stereotactic biopsy of clustered microcalcifications in the right breast at 12:00 yielding fibrocystic change and radial scar.
ASSESSMENT:
BI-RADS 4 - suspicious.
RECOMMENDATION:
Surgical excision of the biopsy site recommended to exclude occult malignancy.
Thank you for any insight!
tina
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Thankyou dj, I wasn't aware that there were other contrasts available for MRI. Why aren't they used? Are there any that are safer than gadolinium? Is cost a factor?
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Yes there are very small calcifications that are produced by benign tissue. If some calcs are removed and the tissue remains intact, it can continue to produce calcifications. The point of the marker is to indicate to future rads reading your mammograms that any calcs left behind or that develop in that benign tissue have already been sampled and do not need to be re-biopsied.
Now it sounds like from your post that the calcs and the radial scar were very close to one another so when the surgery was performed the RS and all the calcs should have been removed along with the area that was producing the calcs.
You need to request the reports that were generated on the day of the wire loc and surgery. These reports will include that of the specimen radiograph. When the area of tissue is removed from your breast it gets its own xray and xray report. This ensures that the correct area was removed in its entirety. The number of calcs in the specimen may be mentioned in that report.
You will need to know if they got all the calcs as the biopsy marker previously placed will no longer be in your breast, as it was likely removed with everything else. In the unlikely event that some calcs were left behind they will be unmarked. Your next mammogram will tell the tale.
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Thank you, DJ.
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hello,
Can you explain the pathology report:
Moderately differentiated carcinoma with solid papillary features
Whatever you can tell me would be a great help!!!!
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Hi. I have IDC. I had a question about MRI modes and tumor visibility.
My first MRI was done on a 1.5T scanner and the tumor shows up easily as a well defined hyperintensity on STIR, Ph1 Dynamic VIBE with contrast, Ph2 Dynamic VIBE with contrast, and Ph3 Dynamic VIBE with contrast. They used a few other modes as well which, to my untrained eye, don't seem to show the tumor.
For my second MRI after a few chemo infusions, I went to a different facility with a 3T scanner. I don't know if they had my images from the previous facility at the time.
For most of the images they used a mode called dynViewsw 1+-4. I understand this is a timed contrast enhancement but the tumor doesn't seem to ever really show up except a small faint hyperentensity around the 4 minute mark.
I am having a mastectomy one way or another but I was curious how much of the reduction in visibility is due to the differences in MRI modes.
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Though I am not a pathologist, breast cancers show different degrees of deviation from normal and come in a variety of subtypes.
(from cancer.gov) "In biology (differentiation) describes the processes by which immature cells become mature cells with specific functions. In cancer, this describes how much or how little tumor tissue looks like the normal tissue it came from. Well-differentiated cancer cells look more like normal cells and tend to grow and spread more slowly than poorly differentiated or undifferentiated cancer cells. Differentiation is used in tumor grading systems, which are different for each type of cancer." Moderate would be somewhere between well and poorly differentiated.
The subtype depends on which type of breast cell predominates in the tumor. Here is a description of solid/papillary
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Without going into a lot of detail, the basis of MRI diagnosis depends on the fact that different tissues will appear more white/gray/or black depending on the MRI sequence used. The diagnosis involves knowing what both normal and abnormal tissue look like in all sequences.
Here is an article explaining the physics of MRI
I have worked with 1.5T and 3.0T units and I prefer the 3.0. In general the higher the field strength the better the images. In my opinion, if a patient is having neoadjuvant chemotherapy, the before and after images should be obtained on the same machine with the same sequences and interpreted by the same radiologist so as to be comparing apples to apples.
Most MRI sequences are derived from the two basic ones, T1 and T2 weighted images. T1 shows gadolinium as bright white, T2 shows water as bright white. With BrMRI T1 images are first obtained without gadolinium. Then T1 images are obtained with gadolinium which will be taken up by the cancer. The with and without images are subtracted from each other, and if the patient didnt move between imaging sequences, these should only show those things within the breast that enhance and that enhancement is white. This makes the cancers and other vascular masses easier to see. How fast they take up the contrast and how fast it leaves is expressed in the form or graphs which describe the tumor's "kinetics".
Not all sequences are meant to show to tumor but to show the state of the other tissues in the breast as well as lymph nodes in various locations. There are also special sequences to highlight silicone in those with possible implant rupture.
The ability to see a tumor (lesion conspicuity) depends on the size of the mass, the degree of vascularity of the mass, and the relative timing of image acquisition and contrast injection which in turn depends on the patient's circulation.
As far as those "modes" you described in your post are concerned, many MRI equipment companies have their own names for their pulse sequences and also have different names for the way their images are processed after acquisition and before viewing. All those terms in your post are unfamiliar to me.
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For those of you interested in the physics of MRI image acquisition here is an "extra credit" reading assignment
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