Interpreting Your Report
Comments
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Too early to tell whats going on, the compression views and US will tell you much more.
Mass vs Nodule: Technically the same meaning but only the word mass is in the Birads lexicon. Nodule is more in the domain of pulmonary imaging. Personally I use nodule for masses 1cm and smaller but thats not universally accepted. The report says "nodular" though, used as an adjective, perhaps in place of "lobulated".
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Thanks, DJmammo! I’m not that concerned just wish the wait wasn’t so long. I don’t feel a thing and am not having any issues. Just a hurry up and wait kinda deal.
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hi all!
My mom is 58 yo and had her 1st ever mammo. Her result states Birads 4a due to ill-defined hypoechoic mass on her left breast.
The radiologist said the mass is just new. Im not sure how she knew when it was my mom’s 1st time of having a mammo. Is there anyway to determine during the mammo how long was the mass been there?
The surgeon gave her 2 options. To have biopsy or to have a surgery to remove the mass which will be done after Christmas holidays.
Waiting is killing me. Any same experience/diagnosis? What is her chances of having cancer? I read that birads 4a have lesser chance of cancer. I am really praying it’s not.
ANd which is better? Have it biopsied first or already remove it?
Thanks a lot!
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Without priors you cannot know it is "new". If there is a tiny suspicious mass or small focus of suspicious calcifications one might say it looks like an "early" cancer. The standard of care amongst surgeons specializing in breast only, is to biopsy first so that they can know what they are dealing with and plan the surgery re: how much tissue to remove and whether or not to sample the lymph nodes. If its benign, surgery may not be necessary at all. If you do the surgery for diagnosis first and it turns out to be a cancer there may need to be a second surgery to take more tissue or sample the nodes.
HERE is an article on breast cancer risk
Can you post the whole report?
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Thank you djmammo for your reply.
I have been reading about birads. And what i have encountered so far is that all ill-defined masses usually fall under birads 4c or worse. Is it possible that it is ill-defined but falls only under birads 4a?
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The 4a, b and c designations are for keeping track of the accuracy of a radiologist's reports by the MQSA. They are not meant to convey any sense of probability of malignancy to the patient as these reports were never intended for the patient. Also there is no hard and fast rules for assignment of the letters so they vary from rad to rad.
The value of the probabilities is to help the pt and her doc decide whether they want to have it biopsied. Once a decision is made to perform a biopsy, probabilities have no more clinical value. At that point its 50:50. It will either come back normal or abnormal.
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Helengreen:
I had some similar findings in my recent mammo, one year post-lumpectomy: "scattered fibroglandular elements that could obscure lesion on mammography." Also noted were "post-operative findings." So, since they distinguished the "fibroglandular elements" from the "post-operative findings" and they weren't there in last mammogram, I'm assuming they must be new which is interesting. It is, though, a little unsettling when they say that the fibroglandular elements may obscure a lesion. Apparently, they're not concerned, since they described the findings as "benign" & recommended mammo in one year.
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Djmammo,
I realize I'm in the wrong forum since I have already been diagnosed, but couldn't find similar discussions elsewhere. Anyway, I had findings similar to "Helengreen" in my recent mammo, one year post-lumpectomy: "scattered fibroglandular elements that could obscure lesion on mammography." Also noted were "post-operative findings." So, since they distinguished the "fibroglandular elements" from the "post-operative findings" and they weren't apparently there on last mammogram, I'm assuming they must be new. which is interesting. I'm curious as to whether the fact that they could obscure a lesion is of concern? Apparently, they're not concerned, since they described the findings as "benign" & recommended mammo in one year. Also, could these have resulted from the surgery even though they're distinguished from "post-operative findings"? Also, are "post-operative findings" evidence of mass extraction, etc.?
Thank you!!
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DJmanno, this is the substance of my mammogram and ultrasound report. They’ve ruled out infection (clear culture). Is there anything it could be, from a radiological perspective, other than inflammatory breast cancer?
Mammogram: "...there is new asymmetry and trabecular thickening which is difficult to measure precisely, measuring approximately 7.0 cm SI x at least 4.5 cm T and persists in additional spot magnification views."
The ultrasound report references multiple ill-defined hypoechoic areas corresponding to the site of asymmetry on mammogram, largest focal area at 10:00 measuring 2.8 x 2.8 x 1.1 cm. The overall extent is difficult to measure sonographicaly. These hypoechoic areas extend to the subaerolar region. No organized fluid collection or abscess. Right axillarylymph nodes with maintained fatty hula and cortical thickness measuring up to 4 mm noted.“
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I'm assuming they must be new
The description of the pattern and density of the normal breast tissue (scattered fibroglandular elements, etc) is a required statement for all reports. The "...may obscure a lesion..." statement is a disclaimer common to all mammo reports all over the world.
Post op changes are fairly classic in appearance and will be mentioned every time beginning with the first post op set of images. They may include the scar, surgical clips, sometimes small fluid collections, and any other disruption of the breast tissue following surgery. It may be preceded by "Again noted are..." followed by a statement regarding any changes seen as the scar evolves and/or fat necrosis develops or if there is evidence of a local recurrence. I have never heard the term "mass extraction" but yes those changes are related to the removal of a mass by a surgeon.
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Hello! I'm new here and this is my first post so forgive me if I'm not posting correctly. I have a indention on my left breast had mammo and US. US found “focal shadowing no mass". To my untrained ears this sounds like a Coopers ligament issue not a BC issue? They did really dig into the area with the transducer and the shadow remained. This is the report they sent me.
***The parenchymal pattern is stable. There
are no mammographic features of malignancy. There is no lesion on mammography corresponding to
the palpable abnormality in the left breast.
Targeted ultrasound of the left breast reveals focal acoustic shadowing at the 4:00 position 12
cm from the nipple without corresponding identifiable mass lesion.
IMPRESSION:
Suspicious left breast ultrasound and negative mammogram. Recommend further
evaluation with MRI or with ultrasound-guided biopsy. The findings and recommendations were
discussed by Dr. xxxx with the patient. The patient opted to return for ultrasound-guided
biopsy.
BI-RADS: 4: Suspicious abnormality***They gave me two options MRI or Biopsy. I am claustrophobic so I chose biopsy. LOLThat was before I saw this report though. Is all of this a waste of time and resources? I am scheduled for biopsy the 28th.
Thanks for any replies!
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Here is a link to a related article
The top 2 in the differential are infection and malignancy for those findings, all other causes are pretty uncommon. There are some infrequent cases of benign inflammatory-like conditions related to diabetes type I and cigarette smoking but their findings are non-specific.
In general if a culture is taken after a round of antibiotics the sample taken may be sterile and appear not to be of infectious origin.
If it is IBC it would be getting steadily worse every week since you first noticed it. There should be significant skin thickening eventually.
The abnormal areas should be biopsied and/or evaluated by MRI if not already done.
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If you thought it might be a Cooper's ligament issue I have to assume that thought occurred to your breast imaging specialist as well. Let us know what the biopsy shows.
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The following contains personal opinions:
Is all of this a waste of time and resources?
This is actually a great question. This usually involves very subtle findings like the one you describe in an asymptomatic patient. The bottom line is we won't know until the end of the complete diagnostic work up which would include tissue sampling of one sort or another. This will involve many individuals in addition to the patient over many weeks and will cost thousands of dollars. At the end if its a cancer the radiologist is a hero for making a great pickup and saving a life but if its benign the rad is accused of recommending who knows how many unnecessary tests and putting the patient through hell physically and emotionally. Why? No one wants to get sued for missing a cancer.
The other common scenario is the patient with a lump that cannot be found on imaging but the patient has a "gut feeling" that its cancer. Since the radiology sub-speciality of breast imaging has one of the highest rates of being sued for missing a cancer, this becomes a patient-driven quest to find this cancer. Again every test and biopsy is performed in the unlikely case that it actually is a cancer and for similar reasons to the above: If it turns out to be benign you have done all those tests against your better judgement without imaging based findings to justify them and has wasted time and resources. If you tell the patient everything is fine despite her "gut feeling" and it turns out to be a cancer, you get to hear their attorney tell a jury "she told the radiologist she knew it was a cancer last year".
No radiologist is infallible but as discussed above, there are times when complete work ups are done to reduce a patient's anxiety when clinical and imaging findings do not warrant one (plus the workup also serves to reduce the rad's anxiety about being sued).
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Djmammo thank you for your response. I didn’t mean to come across as mistrusting my radiologists findings in anyway. At the US two radiologists and the ultrasound tech came into the room and said they were very concerned about this. The report didn’t express that level of concern or maybe I misread it.
I’m just wondering what warranted their expression of concern at the US if there is no lesion present? What else could this be? The only thing I could find about this is a Coppers ligament issue?
I know they want to be safe and do the biopsy but no one can tell me what else this might be? Sorry, this is all just scary to me and I don’t want to be a nervous wreck if this isn’t as concerning as they made it sound at the US.
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Shadowing seen behind a mass is a reliable US sign of a cancer.
Q: So if there is only shadowing, and no mass is seen what can one do?
A: Even though there is no mass, there is some difference in the architecture of the tissue in area that is shadowing when compared to adjacent tissue, which may be abnormal.
Q: Is it really an extremely early cancer or shadowing from a Coopers ligament?
A: No way to tell if no other Cooper's ligaments are shadowing in a similar manner. Even though the probability is low, biopsy is recommended to make sure we aren't missing something.
Q: Is this really necessary?
A: See my last post.
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Thank you, djmammo!
BTW: They did not say, "mass extraction"--in the report--that wat was just my giving an example of what I thought they might be referring to in "post-operative findings."
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djmammo:
I have another unrelated question: I had another 8mm mass in right breast that was not detected on mammo but was on MRI that I just happened to get. Biopsy showed it was vascular. They were concerned it might be angiosarcoma, (despite the fact that they're more commonly deeper & larger than mine, and occur in younger women), but could not determine that from biopsy, so they recommended removing the entire mass. It turned out to be a angiolipoma, which I'm assuming is very rare since I don't see it mentioned frequently & surgeon hadn't seen one before. Curious as to whether you've seen these and whether, given its characteristics, it was necessary to take it out? Also, do they ordinarily grow? If this had been an angiosarcoma, I guess it also would have been missed in the mammo which is kind of scary?
Thanks!
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"...was necessary to take it out?"
I actually addressed this in part in an earlier post. Sometimes you don't know if something is a cancer or not until the biopsy results come back. It also comes down to your definition of "necessary". Some people feel that if a biopsy is benign it was unnecessary which I don't think is fair. Knowing something is benign is also valuable information. If someone says it might be a cancer and you agree to a biopsy and it comes back benign would you be miffed and regret having had the biopsy?
===========the following rant contains some personal opinions=========
Mammograms are far from perfect and do not show everything. There are things they will miss if the abnormality is very small or the breasts are very dense or if the abnormality mimics normal tissue. A mammogram is a screening exam and as such is used to identity as many cancers in a population as possible (true positives) employing a (comparatively) convenient, quick, and affordable exam. In the US this used to be done for TB and large portions of the population were screened with chest x-rays some of which were on mobile trucks. One used to be required to have a chest xray before being admitted to a hospital, or the military, I believe that is no longer the case. In Japan stomach cancer was prevalent in their population at one time so many had screening upper GI barium exams as a screening tool.
Do screening exams find all cancers? No. Do they incorrectly identify people who do not have cancer as possibly having cancer? Yes. These screening exams were intended to reduce the overall number of cancers in the population that would eventually be life threatening and require aggressive treatment, by finding as many asymptomatic cases of that cancer as possible so that it can be treated earlier thereby saving lives and resources. Screening exams were designed to benefit the population as a whole, not the individual.
The analogy I like to use is tuna fishing nets and the size of the "holes" in the net. In a perfect world the size of the holes would be such that the greatest number of tuna would be caught and no dolphins would be sacrificed. Holes smaller than this would decrease the number of tuna and decrease profits. Make the holes too big and too many dolphins would be caught and both PETA and Greenpeace would start shaming you on social media let alone the fines. So how do you know how big to make the holes? Statistically you don't know if you are getting all the tuna you can, unless you get a few dolphins. You have to minimize the number if you can but those few dolphins are the indicator that you are getting as many tuna as you can.
This is the same with screening mammography. If every single person you call back and biopsy has cancer, you are not finding all the cancers. On one end of the spectrum you have all the cancers that are obvious, and at the other end all the benign lumps that are obviously benign. If all you call back are cancers, then you are missing many of the "indeterminate" cancers in the middle of that spectrum. If you decide to call all the indeterminate ones benign, you miss cancers. If you call all the indeterminate ones suspicious for cancer, there will be many false positives and you will inconvenience many people who have benign lumps but you will maximize the number of cancers found in the population and that is what makes a screening program successful, as it is based on the health of the population as a whole. To find all the cancers you have to adjust your net and inconvenience some of the dolphins.
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Thanks djammo, but I may not have made my questions clear: I was totally open to the biopsy; I was told that they could not determine, from the biopsy, that angiosarcoma could be ruled out. I asked whether it might be possible to then do a second biopsy, but oncologist thought a second one (for some reason) could yield similar inconclusive results, so might as well take it out. What's the likelihood of one sample of the mass yielding different results from the rest? Aside from the characteristics of the mass, which aren't typical of angiosarcomas in terms of depth, size, etc., apparently they're extremely rare in non-radiated breasts, like mine. Maybe it could have just been watched--one possibility. I do think doctors overreact at times.
My other question had to do with the fact that it wasn't seen in the mammo but was in the MRI that I wouldn't ordinarily have had. So, if this were an angiosarcoma, I guess it would have been missed had I not had the mammo? MRI's are not routinely done----so, are masses commonly missed as a result? I understand that 3D mammos may yield more accurate results?
Thanks again!!
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I was told that they could not determine, from the biopsy, that angiosarcoma could be ruled out. I asked whether it might be possible to then do a second biopsy, but oncologist thought a second one (for some reason) could yield similar inconclusive results, so might as well take it out.
It is standard of care to totally remove a lesion if the path on a core is inconclusive.
What's the likelihood of one sample of the mass yielding different results from the rest?
Depends on the size of the mass and its histology. We take multiple samples from different portions of the mass as not all cancers are homogeneous.
Aside from the characteristics of the mass, which aren't typical of angiosarcomas in terms of depth, size, etc., apparently they're extremely rare in non-radiated breasts, like mine.
In 30 years I have never seen one so you know more details about them then I do at this point.
Maybe it could have just been watched--one possibility. I do think doctors overreact at times.
Overreacting is in the eye of the beholder.
My other question had to do with the fact that it wasn't seen in the mammo but was in the MRI that I wouldn't ordinarily have had. So, if this were an angiosarcoma, I guess it would have been missed had I not had the mammo? MRI's are not routinely done----so, are masses commonly missed as a result? I understand that 3D mammos may yield more accurate results?
Depends on your definition of missed. All cancers are eventually found. It depends on what size it has grown to before it is either seen on mammography or felt by the patient. We endeavor to notice it first. A 3mm mass will be seen early in a fatty breast but a 1.5cm mass may not be seen until late in a dense breast so you are correct in assuming not everything is seen on everyone all the time. Yes MRI is more sensitive but still very expensive and time consuming so it is not yet offered as a quick screening to everyone, but is to those with a lifetime risk or 20% or more. Also the percentage of false positives for cancer on MRI is well documented another reason its not in wide use for screening and probably explains your result. If you had just had the mammo, and this were an angiosarcoma it would have continued to grow until you felt it or it was seen on a screening exam whichever came first. Would it have spread by then? I don't know.
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There are two ways to make a diagnosis in medicine. You can do every blood and imaging test there is on every patient for every disease there is every time they go to the doctor and not miss anything, or you can do tests that match the symptoms, age group and pre-test probability of a patient having a particular disease and delay the diagnosis of some of the more rare diseases.
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Hello, I had a call back to my annual MRI/mammo (I’m monitored as a high-risk). I was told it was “routine” and all of a sudden, the u/s tech is telling me, “don’t worry...yet”. It’s been a week and I’ve not heard results yet. Would appreciate some feedback on the MRI and U/S reports, please. MRI was done first. Nothing was found on mammo. Thanks in advance.
MRI Findings:
The breast parenchyma demonstrates heterogeneous fibroglandular tissue with mild background parenchymal enhancement, grossly unchanged.
Multiple subcentimetre simple cysts are seen scattered throughout both breasts.
There is a developing 10 mm oval and circumscribed homogeneously enhancing mass in the mid third of the right lower breast, at 6 o'clock, which demonstrates hyperintense signal on T2-weighted sequence and persistent kinetics (image 165, axial subtraction).
Otherwise, no abnormal enhancement seen in either breast.
No axillary or internal mammary lymphadenopathy, bilaterally.
Impression:
44-year-old high-risk patient presenting with a developing mass in the right breast, as detailed above. Based on the morphological appearance and kinetics pattern of enhancement, it most likely corresponds to a benign-appearing fibroepithelial lesion, such as fibroadenoma. Right targeted ultrasound is recommended. This test will be arranged through our department. If ultrasound is negative, MRI 6-month follow-up should be considered.
Ultrasound Findings:
Targeted ultrasound was performed. There is a circumscribed hypoechoic/heterogeneous mass in the right 6 o'clock location, 7 cm from the nipple measuring 12 x 4 x 8 mm. This was felt to correspond to the MRI enhancement and therefore ultrasound-guided core biopsy was performed.
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Hi Djmammo
My second look ultrasound if you'd please take a read for me.
Findings:
Right breast: multiple masses are identified.
1. Ovoid circumscribed, wider than tall, hypoechoic mass at the 3:00 position of the right breast measuring 16x28x4 mm. This is unchanged.
2. Ovoid circumscribed wider than tall hypoechoic mass with an echogenic center at the 3:00 position measuring 7x3x3 mm. This was not demonstrated on the prior ultrasound, but does not have worrisome enhancement kinetics on MRI.
3. There is a cyst at the 10 to 11:00 position of the right breast with a rounded solid component along its inferior margin. The entire structure measures 29x26x6 mm. The rounded solid component measuring 7mm in diameter. This solid component demonstrates indeterminate plateau kinetics on MRI.
4. Simple cyst appearing at the 10:00 position of the right breast measuring 9x7x4 mm.
5. Complicated cyst at the 9:30 position of the right breast measuring 6x7x6mm.
6. There are two mildly complicated cysts at the 11:00 position of the right breast, each measuring approximately 5x3 mm.
7. A few small axillary tail lymph nodes are noted.
Impression:
1. Cyst with a 7mm solid component at the 10 to 11:00 position of the right breast, not demonstrated on the prior ultrasound. The solid component demonstrates plateau enhancement kinetics on the recent breast MRI. Ultrasound guided biopsy recommended.
2. The abnormality in the far lateral aspect of the right breast at the 9 to 10:00 position appears to represent a lymph node. Because of the multiple findings seen on MRI, annual MRI recommended.
Birads 4b
Also, Merry Christmas & Happy New Year Thank you for everything you do Djmammo!! You’re amazing!!!!
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Hi everyone! On Monday I went for my yearly Breast MRI. My mother and sister both have had breast cancer. My mom is in remission and my sister passed away in 2011 after fighting for 10 years. I am also a positive high risk for Brevagen.
Anyhow, my dr called me on Wednesday evening and told me that there is an area at 3:00 that needs to be biopsied. He is doing it on Monday morning. He said he may not be able to find the area and I may be sent in to be done under MRI.
I did receive a copy of my report and they are calling it a new are of enhancement that is 1.3 cm. It is 7.6 cm from my nipple. Bi-Rad 4.
To top things off my breast dr, who also cared for my mom and sister, is retiring on Monday- the 31st... How worried should I be?
Thanks
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Hi djmammo,
It's been suggested I write to you in regards to the latest topic I posted. I'll repost here a brief summary of my US results-
1. Fibrocystic changes in breast, right more than left. 2. Multiple ovoid hypoechoic lesions in left breast demonstrating mostly b9 features and my represent complicated cysts or small fibroadenoma. 3. Indeterminate lesion right breast 1 o'clock 3 cm from nipple which may represent a cluster of complicated cysts. How ever given it's atypical features further assessment with US guided biopsy is suggested to exclude neoplastic lesion. 4. Prominent right axillary node with mildly thickened cortex measuring up to 5.3 mm is equivocal, pending the biopsy results of the right breast 1 o'clock lesion.
The 4th sentence of my results won't let my brain switch off the worry...
Getting straight to the point, does a thickened cortex suggest malignancy?
I hope you can shed some positivity on my day, many thanks.
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Sounds pretty straightforward. They expect it to be a fibroadenoma or something closely related, which is the proper conclusion for the findings. "Don't worry yet" is a common response to patients who express a concern that the path report will be bad news. I do not suspect there was any deep hidden meaning in that presumably off-handed comment. Let us know the results when you get them.
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Biopsy of item #3 is appropriate. They are not worried about all the other findings as they have all apparently shown benign features on two consecutive exams.
The "cyst with enhancing mural nodule" alway grabs out attention. It enhances since the solid component has a blood supply and we want to know why.
Here is an article on the subject that explains more
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Hard to tell without seeing the entire report.
An ultrasound exam of that are corresponding to the MRI finding needs to be done by an US with lots of experience in "second look" ultrasound exams. Is there an breast imaging center with a full time breast radiologist available in your area?
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Is what you posted the exact content and wording of the report or as you say just a summary?
5.3mm is clearly an abnormally thick cortex in an axillary node but lymph nodes react to things other than just breast cancer. If the findings in the breast come back benign other causes for abnormal lymph nodes will be sought. At that time it would be important to know if that is the only abnormal node on that side or one of many. Is there any history of infection or trauma in the arm on the side of the abnormal node? Are there large nodes in the other axilla? Are the enlarged nodes anywhere else in the body etc. Let us know what the biopsy shows.
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Thank you for your prompt response djmammo.
So does a thickened cortex in other words mean ‘reactive’ lymph node? Can the cortex fluctuate in size?
I have actually been seeing a haematologist since July this year for systematic lymphadenopathy. All palpabale (some reactive?) lymph nodes which we cannot find a reason for... yet. I had one in my left axilla which in my last US was reported as reactive, yet surprisingly in this report it was reported as normal but I can still feel the node- it’s a small pea size. I have 2 on both left and right sides of my groin which I can also feel. All a similar pea size. Along with a few in my kneck, behind my kneck just below the base of my skull etc. Some of these nodes have been up 12 months.
My haematologist has run extensive blood work every few months while monitoring me and all of my results have been perfect. I’ve had numerous US even on both sides of my axilla, last one was not long ago in November this year. It didn’t mention an abnormal lymph node on my right, but there was one reactive on the left.
Early December this year I opted for a CT scan from kneck to pelvis, which also came back all normal. I was offered the CT scan as extra reassurance and to help me make a decision on whether or not to go for a excisional lymph node biopsy . I met numerous times with a surgeon who planned to remove a groin lymph node and again with my haematologist who both expressed they felt a biopsy was not necessary after all of my results have returned “normal” and left the decision of surgery up to me. I decided against the biopsy and to take a watch and wait approach.
I guess that’s why I’ve now come to the conclusion that my lumpy breast /underarm pain along with current US report (indeterminate lesion, thickened cortex) and months of unexplainable swollen lymph nodes equals something sinister.
It’s been an emotionally draining 6 months plus of seeing multiple specialists and that’s why my name here is going around in circles...
Thank you for reading! I will report back with breast biopsy results
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