Interpreting Your Report
Comments
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Hi DjMammo,
I had a biopsy done 6/18 and still no results, so I'm getting concerned why it's taking so long. I was just diagnosed with IDC in the left breast on 5/16, so an MRI was ordered and then an MRI guided biopsy based on those results (which I've posted below). Any insight? Thank you!
Narrative
MRI of the breasts with and without contrast
HISTORY: The patient has a recent diagnosis of left breast
infiltrating ductal carcinoma, poorly differentiated.
Comparison: Correlation is made with recent mammograms and
ultrasounds. There are no prior breast MRIs for comparison.
Technique: Multiplanar imaging was performed through the breasts
using routine breast mass protocol. 10cc of intravenous
Multihance was administered for the dynamic portion of the
study. The examination was interpreted with the aid of a
computer aided detection system.
Findings: The breast tissues are fatty with scattered
fibroglandular densities.
Background enhancement: There is mild to moderate background
enhancement.
Right breast: In the central lateral breast, there is an 11 x 10
x 6 mm mass with irregular borders and washout kinetics, for
example series 601 image 343: Series 801 image 70. This mass is
suspicious. In the upper medial breast, there is a 14 x 11 x 7
mm elongated mass with washout kinetics, also suspicious. For
example series 601 image 259: Series 801 image 38.
Left breast: There is a solid mass with irregular borders,
containing biopsy clip, at 11:00 in the left breast,
biopsy-proven infiltrating ductal carcinoma. This measures 28 x
24 x 17 mm. For example, series 601 image 183. No other solid
masses or suspicious enhancement is seen in the left breast.
Secondary findings: There is no axillary lymphadenopathy or skin
thickening.
Impression:
1. 28 mm irregular mass at 11:00 in the left breast,
biopsy-proven infiltrating ductal carcinoma. No other suspicious
masses or enhancement in the left breast.
2. Two masses in the right breast as described with suspicious
morphology and kinetics. Biopsy is recommended. These would be
amenable to MRI guided biopsy.
BIRADS: Category 4: Suspicious
*#B4#*
RECOMMENDATION: MRI guided biopsy 2 masses in the right breast.0 -
The most common reason for a path report to take longer than expected is that the specimen/slides/etc were sent out for review to another lab, usually at a university medical center like Vanderbilt or MD Anderson. It could be for a second more academic opinion or it could be sent for testing that the lab at your local facility does not perform. Sometimes findings are borderline and these outside facilities will make the call and provide references from the literature to back up their opinions. Its neither a good or bad sign, just annoying.
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djmammo, I ended up finding some of your older response posts that answered some of my questions from my MRI report and the recommended follow up. The only thing I haven't been able to find reliable information about is what was likely meant by
"There is associated increased skin enhancement throughout the anterior aspect of the right breast."
I truly appreciate your insights to all of our questions.
Thanks again,
Carissa
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"I think I generally get the concept of what a nonmass enhancement is but I was hoping you could explain the difference between linear and segmental and what washout kinetics are. I also was curious what "increased skin enhancement" means typically. Is it referencing density or is it usually a reference to the skin absorbing contrast and being enhanced on the imaging, or something completely different
I love to learn so if there is a study or other resource that explains these terms I would be happy to read it if you point me in the right direction "http://www.radiologyassistant.nl/en/p47a585a7401a9
"I also was wondering if it is common to get another diagnostic mammogram or ultrasound so soon. Will it help with the imaging process to be able to look at a specific area of concern now that the MRI has pointed one out? I guess I am just wondering why they don't recommend a biopsy instead of additional imaging."
Once the MRI identifies a possible abnormality not previously noted, those areas are always re-evaluated with additional mammo and US imaging. They are called "second look" studies. They are always done before a biopsy is considered just in case there is a benign explanation for the MRI finding, plus if seen on routine imaging it can be biopsied that way and that saves you from experiencing the much longer MRI guided biopsy procedure.
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That actually makes a lot of sense, thank you for that explanation. I look forward to reading through that link you provided, it appears to have a lot of great information!
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Hello, Newbie here. Was hoping to find out exactly what "Focal Asymmetry" means. I went in for my yearly mammo a couple of weeks ago and was called back for a spot compression. They called me the next day after the spot compression and said I needed to have an US. I'm 51, have heterogeneously dense breasts. Also Had a complete hysterectomy 4 years ago and have been on Minivelle .05. Here's what the report says:
MAMMO DIGITAL SCREENING BILATERAL W TOMO
Digital Mammogram evaluated with Computer Aided Detection (CAD).
COMPARISON:
The present examination has been compared to prior imaging studies performed at
MD Anderson Cancer Prevention Center--Main Campus on 04/12/2016, 04/18/2017 and 05/01/2018.
FINDINGS:
There are scattered areas of fibroglandular density.
There is a focal asymmetry measuring 1 centimeter seen in the MLO view only in
the middle region of the right breast upper hemisphere at 12 o'clock located 5
centimeters from the nipple.
In the left breast, no dominant mass, distortion, or suspicious calcifications
are identified.
Tomosynthesis performed in CC and MLO projections.Thank you!!
After I submitted this, my spot compression result was released:
Additional evaluation was performed for the focal asymmetry in the right breast,
12 o'clock seen on 06/07/2019. On the present examination, there is an asymmetry
measuring 1 centimeter in the middle region of the right breast upper hemisphere
at 12 o'clock located 5 centimeters from the nipple. This is less conspicuous
when compared to the previous study.Asymmetry in the right breast requires additional imaging evaluation. An
ultrasound exam is recommended. If there is no sonographic correlate, she can
return to annual mammogram.
BI-RADS Category 00 -
In general, similar views of each breast are roughly mirror images of each other, in other words like a Rorschach ink blot test only white splotches instead of black splotches. If more "white splotches" are seen on one side that are not seen on the other we call this an asymmetry. If it iinvolves the whole breast we call it global if its just a small spot we call it focal. It is a neutral term, not meaning malignant or benign. It is either new or old, it is either unchanged, larger or smaller. If it represents a bad thing, it should get bigger each year. Yours was there previously and apparently is not bigger or it would be more conspicuous rather than less. It also depends how many prior studies show this finding. When something is there for 2 years or more and is unchanged we assume its benign.
https://radiopaedia.org/articles/asymmetrical-density-in-mammography?lang=us
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Hi, djmammo. It's the time of year for my annual screening imaging tests and after I received my digital mammo's report I sense that I must be facing yet another stressful breast-health-wise summer ahead... I'll have my 3D breast ultrasound done on Wednesday and visit my breast doctor/surgeon next Tuesday but in the meantime I'd be grateful if you could share your piece of mind regarding the findings of my latest digital mammo. Just to remind you, last year I had an excisional biopsy/lumpectomy performed on my lower right breast (6-7 o' clock position) with benign histology (you can review it below in my dx). Prior to the lumpectomy I underwent mammo, u/s, mri as well as contrast enhanced spectral mammo, I got BIRADS assessment only for the mri (Birads 4 with no further classification a, b or c) and in my mind the only unresolved issue after the histology (hence my decision to go for a 3D instead of a 2D ultrasound this year) were "some axillary lymph nodes on the right show slight thickening of the cortex with no visible vascularity and no changes between the June and October 2018 ultrasounds". The latter didn't seem to concern either my doctor/surgeon or the radiologist who had performed both those ultrasounds after the benign histology. It still concerns me, of course, hopefully I'll get some better insight after the 3D ultrasound is done the day after tomorrow... But let me go back to my today's mammo's results, an indeed taciturn report...
Post operative lesions on the left?
The radiologist is not the one mentioned above, she's the head of Radiology in the hospital where I had the lumpectomy and well aware that I had my right (and not my left) breast operated on, I had also left with her my full file of images all taken in her labs (the MCC shots of my right breast included), so she must be obviously seeing something in my left breast which was not there in last year's mammos… I wonder what that could be and by her phrasing I suppose it's some kind of scar... what do you think about that?
(now please do excuse my poor English) Breasts with scattered density and micronodular appearance.
That sounds pretty scary to me... What do you make out of it?
Nodular shadowing with indistinct borders on the outer of both breasts.
Those two correspond to two already known intramammary lymph nodes (one in each breast) which were so far considered (by all imaging methods) harmless and benign and all of a sudden today became entities "with indistinct borders" (measuring 0.7 and 1 cm)… Is it possible that they might have missed something or didn't follow it up due to the benign nature of the histology of the mass they had removed and now it starts showing up clearly?
Ultrasound test and clinical co-assessment is advisable.
Those four short sentences was all she wrote...
If you wish to share your insight it'd be greatly appreciated as I was really hoping for a negative or at least with only benign findings report this summer...
Thank you so much in advance for your time and attention,
Jo
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If indeed the entire official report consisted of only those 4 sentences, that is genuinely disappointing. I would have to give it a D- and that is generous. Most of the terms used are not acceptable BIRADS terminology. Maybe this is her handwritten notes about the study?
You are reading far more into this report than I can. It basically says nothing other than you need an ultrasound. Not really sure what the US term "shadowing" refers to on a mammogram. Odd.
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djmammo, thank you so much for your reply. The report was not handwritten, it was officially typed, sealed and signed on the letterhead of the biggest greek hospital dealing with breast cancer. The translation in english is my own (poor obviously) attempt to convey to you what the report reads, but if taken word to word is exactly what she reports. No I didn't abbreviate anything, the word count is the same in both the greek report and my translation in english. I myself felt instantly "deceived" by this taciturn report as if the radiologist didn't even pick her magnifying glass up to evaluate my condition... Needless to say that I regretted my decision not to have my annual mammo performed in the same place and by the same radiologist of last year's... I did so only in the hope for a more meticulous evaluation of my post operative breast health. Tomorrow I'll be having my 3d u/s performed in another place (private one this time) and I hope to get some solid information on everything that concerns me. Of course after this mammo report I'm back to where I was last summer psychologically wise, the same knot in my stomach, the same feeling that something wrong is going on with my breast health... Thank you so much for your response.
PS I translated as shadowing the term used when something appears whiter than the breast parenchyma in the mammo, sorry if I misguided you...
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As they say in journalism, you may have "buried the lead". :-)
I don't know that they would be governed by ACR or BIRADS reporting conventions.
I have used Google Translate on reports in the past and although not always totally accurate I can get a feel for which of two different translations might contain adjectives familiar to x-ray reports.
Let us know what the US shows.
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Thank you for your response. I ended up getting a call the next day saying both biopsies were benign. But I just got the path report back today and now I'm a little concerned because my breast surgeon didn't tell me about any further follow-up. Do you know why they would put appropriate follow-up is recommended? Does that mean they think the actual mass was missed during the biopsy?
Diagnosis:
1. BREAST, RIGHT. MRI GUIDED CORE BIOPSY.
FRAGMENTS OF BENIGN BREAST TISSUE WITH FOCAL FIBROCYSTIC CHANGES AND
APOCRINE HYPERPLASIA.
NEGATIVE FOR ATYPICAL DUCTAL HYPERPLASIA OR MALIGNANCY..
2. BREAST, RIGHT. MRI GUIDED CORE BIOPSY.
FRAGMENTS OF BENIGN FIBROADIPOSE BREAST TISSUE.
(SEE NOTE). Note: Appropriate follow-up is recommended to ensure
that the sample is representative of underlying lesion.
This case was reviewed at Departmental Consensus Conference on
6/20/19. .
Clinical History:
1. Right breast mass, known left breast cancer 2.
Diagnosis Pathologist:
Electronically Signed by: Fang Liu, MD
Procedure Date: 6/18/2019
Specimen Received: 6/19/2019
Date of Diagnosis: 6/20/2019
Gross Description:
1. The specimen is received in formalin labeled with the patients
name and target 1, #1 an
d consists of an aggregate of tan-yellow,
fibrofatty tissues (4.0 x 4.0 x 0.3 cm). The specimen is submitted
en toto in cassettes 1A - 1C. The tissues were placed in formalin at
12:05 p.m. on 6/18/19 and removed at 4:00 am on 6/20/19.
2. The specimen is received in formalin labeled with the patients
name and 2 and consists of five, tan-yellow, fibrofatty, cylindrical
soft tissues (ranging from 2.0 x 0.3 cm to 2.5 x 0.3 cm). The
specimen is submitted en toto in cassettes 2A - 2C. The tissues were
placed in formalin at 2:20 p.m. on 6/18/19 and removed on 6/19/19 at
4:00 a.m.0 -
When we radiologists perform a biopsy we take a number of precautions to make sure we hit the intended target and that the results of the path corresponds to what we saw. The first is the placing of the biopsy marker at the site we took the samples. If the marker we placed is at the location of the target on the post biopsy mammogram we know we biopsied the correct target. The second is the review of the path report.
When the path report is issued we bring up the pre and post biopsy imaging with their reports to refamiliarize ourselves with the case. If we had suspected a fibroadenoma (FA) and the path report says fibroadenoma we report that the findings are concordant, (rad findings match path findings). If they don't match it is discordant. It can come back a cancer when I thought it was a FA and that would be discordant and I would look bad but a diagnosis was made and treatment will follow. The reverse is also possible.
The problem comes when I biopsy a mass and my opinion is that of a cancer or FA or other specific mass and the path comes back "normal breast tissue". This makes me wonder if I actually hit the target at all. The addition of that phrase "Appropriate follow-up is recommended to ensure that the sample is representative of underlying lesion" makes me think the pathologist has that same question. The phrase that follows means he showed it to others in his department to make sure he was correct in his observations. If after reviewing the imaging I am sure there was something more than just normal tissue in that spot I would call it discordant and recommend re-biopsy or a surgical excision of the area for diagnosis.
The report you want to see is the one generated by the radiologist after they review the pathology report to see if they are satisfied that the path report matches the imaging (concordant findings) or if it does not match the imaging (discordant findings). There will be a recommendation at the bottom of the report as to what should be done next.
Keep us in the loop.
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Djmammo
Is the lack of information good news? Or did they just not give me much info?..I do have the disk though.
There are high volume heterogeniously dense fibrograndular elements present in each breast. There are adjacent ovoid nodular densities present at nammography corresponding with the area of palpable concern. Left breast ultrasound shows ovoid hypoechoic mass measuring 1.9 x 0.9 x 0.9 cm. There is some internal color doppler flow. Biopsy reccommended.
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I'm following up with my biopsy results, which are not complete, as we are waiting for a supplemental report. I wanted to mention it anyway as the wording is strange to me. My BS also mentioned it is an unusual finding. I mentioned previously that the MRI and second look mammo and US said that my mass had both well formed and spiculated margins, which I was told was not usual, as well.
Pathology Report:
-Atypical ductal hyperplasia (ADH) involving a fibroadenoma (9mm). See comment.
-Florid ductal hyperplasia
-Proliferative and fibrocystic changes
Comment:
-The atypical and proliferative changes involve a fibroadenoma.
-Additional H&E level and immunohistochemistry will be preformed for further evaluation, in order to assess for the possibility of a more severe lesion.
-Results and final interpretation will be reported in a supplement. -----
So, my understanding is at minimum it is ADH. I'm curious about the fibroadenoma portion. I had an US guided vacuum biopsy where 17-19 core samples were taken. Based on this wording would this mass have likely been a fibroadenoma that was surrounded by ADH? Or is it possible that a fibroadenoma can evolve into ADH? I'm just curious your opinion on what it means that the ADH involves a Fibroadenoma. Thanks so much.
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Finding atypia inside a FA is rare, finding a cancer inside a FA is super rare. I personally have never actually seen either but it is in the literature.
Here is an article on the subject of Atypia in a FA: https://www.ncbi.nlm.nih.gov/pubmed/11443606
Here is the conclusion of that study: "In this study of a large cohort of women with fibroadenoma, the authors found that atypia within a fibroadenoma cannot predict for the presence of atypia within adjacent breast parenchyma. They also found that atypia confined to a fibroadenoma does not incur a clinically meaningful risk of future breast carcinoma development greater than that of fibroadenoma alone."
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Thanks so much Djmammo
Last year I had a birads 4 amorphous grouped microcalcifications in the same breast but in a different location. Due to medical issues I got an excisional biopsy as I couldn't turn my head to lay on the table for the needle biopsy needed. That came back ADH. I chose to have an MRI at my 6 month follow up and it found a mass this time. This mass was not really visible via the second look mammography but given they knew the location they were able to find it on US. The radiologist told me it was fortunate that I had the MRI as the mass was hidden in dense breast tissue. So basically it may have been present last year and it was missed by the mammo and US, or it could be brand new, there's no way to know.
Given that two events occurred in the same breast but in different locations, and one was in a fibroadenoma and one incident was microcalcifications, does that change the perspective at all? I'm already scheduled with a medical oncologist to discuss hormone treatments but due to my other medical issues I will probably decline that treatment. Still, all of this will depend on the final pathology supplement. Thanks for your insight.
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I am not a pathologist or oncologist but I would assume that the more areas of atypia there are in the breast overall, the higher the risk. Sounds like there would at least be continued close monitoring . I know that there is a protocol for giving Tamoxifen (an estrogen blocker) or other similar drug for ADH, not sure what the criteria are. I am sure your oncologist will explain the options better than I can. Keep us in the loop.
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Hi djmammo i need your help. My daughter 32yrs old with a history of a sister dx in her 20's with stage IV, has been going for mamo/mri/sono every 6 mos. twice biopsy, calcifications. Not cancer. This month MRI- heterogeneously dense fibroglandular tissue with minimal background parenchymal enhancement. Within the superficial upper outer left breast minimalloy enhancing focal non mass enhancement measuring 0.5cm is present. No other testing has been done, because this was a 6 month follow up to mammo/sono.
They are on the fence, one Radiologist wants to biopsy, the other one thinks maybe wait 6 mos. It's very scary to us, because of the history, her age and she already had biopsies. What's your opinion? We are not in a hurry to do a biopsy, but also scared we let something grow.
Going crazy with worry. Thank you for your attention as always.
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Usually a "second look US" is performed for an MRI finding not previously seen on other imaging. If they confirm it on that scan, then they will usually biopsy it, if not they might opt for the 6 month follow up.
5mm is very small though, which is hard to characterize on MRI and sometimes hard to find on US.
Is she on a 6 mos MRI/Mammo rotation for hight risk? Does this finding correlate with anything previously seen on other imaging?
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djmammo i spoke to the 2 radiologists today, i asked what would you called what you saw,'m they say a nodule, but it's almost certain they would categorize it as benign. They said she already had 2 biopsies, both benign. They feel she could wait 6 mos and then see. The idea of a sono sounds about right. It's a private office. All they do is mamo/Mri/Sono all day long. So i shell out the big $. So they might also be looking to protect my cost. I am so panicked by what happened to my oldest daughter at 25, that i cannot bring myself to let the others and myself go to other places. Here they tell me the results immediately, and it's kinda private practice so...The main doc knows my daughters, myself and i i'd say i could almost trust her fully. I tell you the truth i can't trust any doc fully. Not because she's not a good person, but first I'm always thinking what are THEY thinking?? And second, docs make mistakes.
Maybe I could ask for a sono in 3 mos? Or you think I should insist on nowish? They told me today, that MRI's being MRI it could even not be something....And they don't want think she needs to be put through it now.
She's actually on a mamo/sono and then just sono then mamo/sono then mamo. And this time they went for Mamo and MRI. I think the reason she is on sono rotation, is that they found the calcifications on the US. What say you???
And thank you sooooo much for your caring. Seriously BCO should have you on salary.
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MomAll
If all they do is breast and know your family and their history well, I'd be more likely to take their advice over others'.
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ty djmammo - i will take this consideration.
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Djmammo
Path came back as a fibroepithelial nodule with myxoid stroma
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I posted this but this might be an appropriate thread. Could there be concern here for malignancy? My provider wants a follow up next week and i don't know why. I'm scared. They said at ultrasound it looks ok but now they've recommended a quick follow up.
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i am responding to this report let me know if its the correct one
There are only benign findings in this report. No mass is reported . It doesn't look like it was the radiologist that recommended the (very) short term followup. Was it your doctor that recommended the followup?
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Can you explain my ultrasound report to me? The doctor scheduled me for an ultrasound guided biopsy for Monday morning.
My history: BRCA 1 positive, family history of breast and ovarian cancer on both sides
BIRADS CATEGORY: 4 SUSPICIOUS ABNORMALITY
There is 0.5 cm round focal asymmetry in the left breast at 3 o'clock middle depth 7.7 cm from the nipple. Ultrasound demonstrates 0.5 cm x 0.8 cm x 0.3 cm oval mass with a circumscribed margin at 2 o'clock middle depth 4 cm from the nipple. This oval
mass is hypoechoic with no posterior acoustic features. US guided biopsy is recommended of the left breast mass.The exam was reviewed by a staff physician. Based on the Tyrer Cuzick version 8 risk assessment model, this patient's lifetime risk of breast cancer is 75.0%. Continue/consider annual tomosynthesis. Referral to a high risk clinic and annual screening. MRI in addition to mammography is recommended.
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The adjectives used are basically benign but with your history anything out of the ordinary will be recommended for biopsy unless its a classic benign cyst
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