Interpreting Your Report
Comments
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My report from my second mammogram in 2 weeks is as follows."an asymmetric density w/somewhat spiculated borders in the right breast, persist on rolled view best appreciated in the CC projection stereotactic guided biopsy is recommended. No microcalcifications in this area of architectural Distortion. ACR bi-rads 4. Suspicious lesion right breast w/ irregular borders. Recommend stereotactic guided biopsy.
My big concern is my risk factors. Breast cancer runs in my family, with my maternal grandmother, one aunt on the maternal side, and my sister.I was also on HRT for 32 years after having a hysterectomy at age 23. I have been a smoker for at least 25 years. What is your opinion? I feel my chances ok f thus being benign are slim. I also have a lump.under my right aem that has been there for about at least a month.
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DJMammo -
I recently had a follow-up at my oncologist and she felt I had swollen lymph nodes (2 spots) and send me for a mammo and ultrasound. Additionally, I just finished radiation in mid-October and my cancer was in the upper outer quadrant at 2:00. In addition to radiation, I had a lumpectomy and oncoplastic reduction. The oncologist told me all was fine (including the lymph nodes) but when I got my report it said the following:
There are grouped calcifications in the upper outer left breast. There is no suspicious mass or architectural distortion.
1. Indeterminate calcifications in the upper outer left breast for which six-month follow up is recommended. May represent evolving fat necrosis.
Per the report, they did not ultrasound that spot, it was just identified on the mammo portion.
Can you tell me if it is normal to have calcifications again so quickly? I assume due to the timing that is has to be necrosis but since I had calcifications noted for 2+ years before IDC was found, I thought I should ask someone. I don't see my oncologist again until March but I will ask then also.
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I have had 3 core needle biopsies and an excisional biopsy, all on my left breast within 2.5 years. All have come back b9. Each 6 month follow-up finds some new area of suspicion: architechtural distortion with grouped microcalifications, then there was a new area of grouped microcalcifications, the last cnb showed "high risk papilloma", which is why I had the excisional. The excisional results came back with the following:
Flat epithelial atypia with microcalcification; Florid usual ductal epithelial hyperplasia; Apocrine metaplasia; Focal columnar cell change. Comment: The papilloma present in the biopsy is a microscopic finding present in a rare duct. A residual abnormality of that type is not seen.
During my most recent mammo, they found a new 2cm area of diffused microcalcifications at 3 o'clock in the outer posterior depth. I am scheduled for my 4th cnb on the 30th.
I don't have a family history, but can appreciate wanting to be cautious if something looks suspicious, but I seem to be on a crazy cycle that I can't get out of. Radiologist said that although calcifications are normal and mostly benign, he has not seen someone in my situation with the constant recurrent/new calcifications that I've had. I guess my question is, is it necessary to have a biopsy every time there are new calcs? If I don't have a family history and all other results have been b9, would it be acceptable to just keep an eye on them?
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DJ Mammo--
I have a quick question about a benign biopsy result, not a rush. Thank you deeply for providing this wonderful resource for so many women.
Though I'm feeling tremendous gratitude for this positive news and am not going to look a beautiful gift horse in the mouth, I just want to understand it a little better. I had a stereotactic biopsy for an architectural distortion that persisted on mammogram views but was not seen on ultrasound. BiRads 4b. According to my GP, the pathology came back as Usual Ductal Hyperplasia. She thought this was discordant and that I would be referred to a surgeon. But the radiologist subsequently found it concordant and they simply told me to go back to yearly mammograms. Cool! But ... also confusing.
I read about discordant results between talking with my GP and getting the report, and it does seem that Usual Ductal Hyperplasia is not generally thought of as a cause for architectural distortions. But maybe it can be in some cases if the clip is seen as properly placed? That's the part I don't know. Can that be a concordant finding? Is concordance in the eye of the beholder or are there clear guidelines for it? I'm thrilled to not need a surgical biopsy and not even a 6-month follow-up (which I had thought requisite for 4b). But I wanted to make some sense of this since the information kept changing.
Below is the report I was given in my portal but as you can see they give almost no information whatsoever. My GP told me on the phone the result was the usual hyperplasia. I have asked her for the pathology report but they don't like to give out a lot of info at this major university hospital.
Thank you in advance for answering my question! And happy holidays to you and to all reading!
---------- ADDENDED REPORT ----------
BIOPSY SITE: In the left breast upper inner quadrant at 11 o'clock located 5 centimeters from the
nipple.
PATHOLOGY REPORTED AS: Benign in the left breast upper inner quadrant at 11 o'clock located 5
centimeters from the nipple.
CONCORDANCE:This is concordant with the imaging findings.
RECOMMENDATION: Recommend routine annual follow-up imaging.
---------- ORIGINAL REPORT ----------
LEFT BREAST STEREOTACTIC CORE NEEDLE BIOPSY
HISTORY: 55 year-old female presents for a stereotactic-guided core needle biopsy.
PROCEDURE: After discussing the risks, benefits and alternatives to the procedure with the patient
and obtaining written and verbal consent she was brought to the stereotactic procedure room.
Using the Affirm prone biopsy system and superior approach, the biopsy target was mammographically
identified and the X, Y and Z coordinates were calculated.
The architectural distortion at 11 o'clock, 5 cm from the nipple, in the left breast was identified.
The biopsy site was prepared and draped in the usual sterile fashion. Local anesthesia was achieved
with a combination of 2% lidocaine and 1% lidocaine with epinephrine (1:100,000). Using a superior
approach and a standard EVIVA 9G vacuum-assisted biopsy device, multiple specimens were obtained. A
specimen radiograph demonstrates the biopsy target in the specimens. A cylinder-shaped microclip was
placed. Hemostasis was achieved with manual compression of the biopsy site. No immediate
complications were identified. The specimens were sent for histological analysis.
Post procedure digital diagnostic mammography demonstrates accurate placement of the microclip.
The patient was given the appropriate written and verbal aftercare instructions and discharged in
good condition.
IMPRESSION:
1. Status post stereotactic-guided core needle biopsy with microclip placement(s) as above.
2. The pathologic results are pending. This report will be addended with final management
recommendation once final pathology is available.
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What did the US show?
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Calcifications develop with fat necrosis at the surgical site, after radiation usually right in the area of the lumpectomy scar. The classic appearance is a white circle / curved calcifications. The problems in interpretation arise when this calcifications are just beginning to form when they look like microcalcifications. If the location and timing are right I would usually bring them back in 6 months just to prove it.
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75% or so of patients who develop breast cancer do not have a family history. The decision whether to biopsy or to watch depends on what the calcs look like to the reader. We know what to do with calcs at each end of the spectrum but it's the ones in the middle, the indeterminate ones that make us all crazy. We are basically afraid not to recommend a biopsy.
I guess you and your doc can come to an agreement to watch them at 6 month intervals if you are both agree not to regret doing that if they turn out to be malignant.
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With AD on the mammo and a normal US I would expect to see "radial scar" in the path report. If any report comes back with "normal breast tissue" or similar wording, I call it discordant as there is a) no cancer and also b) no specific benign entity mentioned (such as a fibroadenoma or whatever the initial impression was).
When I got back path reports like this where I could not make the path results fit with the imaging results I would call the pathologist on the phone and discuss the results with them. Sometimes they would mention something not in the official report that would suddenly make sense to me, how what I saw, could be what they saw and make the results concordant when at first glance they weren't. Of course I can't say thats what happened here but it has happened to me.
I guess the good news is if the bx was in the right place it's not a cancer. All the breast surgeons I know always ordered a routine 6 month follow up on all of their pts that had a benign core biopsy so I picked up that habit and always followed up no matter how benign the result.
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I think you are asking what the ultra sound showed? They did not do one, said the did not need to.
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Thank you djmammo for your thorough response. That helps a lot. I think I was discombobulated by the sudden switch from discordant to concordant without any real explanation as to what changed, but if there can be high confidence that it is not a cancer then I'm good with feeling lucky and resuming yearly mammograms. After the holiday, I'll push to get the full pathology report just in case there is more there for any future understanding. (No one mentioned a radial scar, though I did read that is the most common benign cause of architectural distortion.) While I think I might feel safer under the circumstances with a 6-month mammogram, I also don't want to fall into over-reaction. As you said, there may be other facts to which I'm not privy that make the case more clearcut. But I do wish more medical personnel would explain things as openly and clearly as you do! Here's to a great 2020 for you and yours.
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Interesting. I did an ultrasound on 100% of cases where a mass was suspected on mammo. Tells me much more about the mass plus its so much easier to biopsy with US than with stereo.
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Any thoughts as to why the ultra sound was skipped.
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djmammo, i want to ask a preliminary question. I am waiting for a pathology report after lumpectomy for DCIS(area of calcification was biopsied and DCIS was found).
It will be ready probably monday-tuesday. Is it ok to ask you interpretation of this one if i will be confused?
thank you
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No clue. If you find out let me know.
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Sure. You can post the entire/complete path report here or in a PM.
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I sent you a private message but I don't know if you look at those, sorry I am new here
I have a breast specialist apt Tuesday.
high-resolution real-time imaging is performed in both radical and auntie radical plains, limited to the area of mammographic abnormality. No underlying sonographic abnormality. patient was recalled for later in the day for physician direct observation and scanning. Review of Miami graphic images reveals a 5 by 3 by 7 mm oval Mass with both micro lobular and indistinct margins. No suspicious calcifications or architectural distortion. Mass is roughly 10 to 11, 7 cm and the nipple
Impression, suspicious abnormality. Recommend consideration for biopsy.
Bi rads category 4 suspicious
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djmammo, I've been reading through this thread over the past few days and I want to tell you how appreciative I am that you give up your free time to answer the questions we have regarding our test results. I find that incredible and inspiring. Thank you!
I had a routine mammogram on 20 Dec and had to return for more imaging. On 24 Dec another 3D mammo was performed and I'm a little perplexed by the report; it doesn't state specifically what they saw (size of calcifications, amount, etc). Here's the reports:
20 Dec 2019
The breasts are heterogeneously dense, which may obscure small masses. Grouped amorphous calcifications are seen posteriorly in the upper outer right breast. Other more scattered calcifications are similar. A 6 mm modular asymmetry is seen in the central left breast on the MLO projection. There are no suspicious skin changes or axillary adenopathy.
24 Dec 2019
There are regional scattered and grouped calcifications extending over a 40 mm area in the superior portion of the outer breast at the 10:00 position 7 cm from the nipple. Additional benign appearing calcifications are present in both breast.
The 6mm focal asymmetry observed in the left lower breast 4.5 cm from the nipple on the posterior mediolateral oblique views near the 7:00 position spreads out resembling glandular tissue on these views. No dominant mass or focal architectural distortion is appreciated.
Impression:
Mildly suspicious right breast calcifications which should be further evaluated work stereotactically guided biopsy.
ARC BIRADS 4 suspicious abnormality-biopsy should be considered (subcategory 4a).
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I would feel a lot better with more specifics! Thank you!
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Since I got my pathology report, I thought I would post it here. I believe the dense stromal sclerosis can explain the architectural distortion (I've seen that result here on this forum from other people who had excisional biopsy), so that helps a lot. But I've never seen anything before about "hemosideren laden macrophages." From what I could understand, this has to do with remnants of bleeding? (I've had no prior surgery, biopsy or trauma, except for all the mammograms, haha!) DJMammo, do you have any insight into why these might appear? Just curious and maybe it will help someone else who has this in their pathology report as well.
BREAST, LEFT, ARCHITECTURAL DISTORTION, 11:00, 5 CM FROM NIPPLE (CORE NEEDLE BIOPSY):
- Breast tissue with dense stromal sclerosis, focal unusual ductal hyperplasia (UDH), and rare hemosiderin laden macrophages
- Negative for atypia or carcinoma
- Multiple deeper levels examined
COMMENT:
Clinical/imaging correlation recommended.
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Did you have a mammogram last year or the year before? If you did are these new?
The description of the calcifications doesn't suggest what they are one way or the other. The fact that they are bilateral is good, but the area where they are concentrated is where they will likely want to do the biopsy. Could be totally benign or be ADH, ALH or perhaps DCIS thought the latter usually presents as "linear / branching" in its pattern. The nodule went away on compression so that area is being considered ok. If they were worried about it they would have done an US. The biopsy should tell you what's going on. Sounds like they occupy a large enough area to be easy to target and sample.
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Yes, that means those cells were there to clean up a little bleed at some point in the past. "Rare" means there were only a few amidst all those other cells so it may have been a micro-trauma so small you forgot about it. Do you have a dog that jumps up or held a child with heavy shoes? Those are the most common. Either way it's a benign finding of no clinical significance so we don't usually investigate such things.
Also the U is for "usual" not "unusual" ;-)
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Thanks djmammo! I did have a mammo last year, was called back for a bilateral ultrasound, and it showed everything was normal. Calcifications were present last year but the amount has increased locally, from what I understand.
It’s a frustrating process that provokes annual anxiety and dread, (how did I get put in the Dec annual mammogram - really a bad choice on my part, lol!). Quite honestly, if given the choice I would chose bilateral prophylactic mastectomies- keeping my breasts just isn’t that important to me... my peace of mind is of much greater importance.
Thanks again- I appreciate your insight.
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DJMammo and others, I haven't been on here in quite some time, but 7 years after ALH, here I am. I have now been diagnosed with ADH (4 sites of clustered microcalcifications, but only 1 site was ADH). I am waiting to hear from my BS as to next steps, probably excisional biopsy. I am highly considering a PBMX instead. I have been doing the "wait and see" game for 10 years now, too long and tired. My BS talked me out of a PBMX in 2012. I am glad then, but now I am highly considering it. I also have heterogeneously dense breast along with mild background parenchymal enhancement seen on MRI. I think with the ALH, ADH, dense breast tissue and mild background parenchymal enhancement my risk factors of getting IDC is a bit too high for my liking. Any thoughts and input are well appreciated. Thank you everyone for listening, just needed a familiar place to confide in others with the same story/journey. May you all be blessed with continued health. Regards, Valerie
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Talk to your doc(s) and check with your insurance company to see what they will cover. If you don't actually have a cancer diagnosis you may have to have a risk of 20% (?) or better for a prophylactic mastectomy. Many want to have the reconstruction done at the same time to make it one procedure instead of two and there are insurance considerations there too. Good luck.
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DJMammo, thank you for your response. I will discuss further with BS. She was onboard in 2012 when I was diagnosed with ALH. Do you know if 20% risk factor is at 5 years or over lifetime? Thank you.
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DJMammo, thank you again for your response. I’m at 42%, MRI even states 42% risk. I was surprised it’s mentioned on my last MRI report, none before. Thank you, Valerie.
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This is the report from an MRI on Dec. 15/19. I have regular yearly mammogram and MRI due to high risk family history. In Jan. 2018 I was diagnosed with 4.5 cm of DCIS in my right breast. I have lumpectomy and radiation. This finding is in the left breast. Over the years I have had quite a few biopsies but always in the right breast.
I guess I want to know what is concerning in the information below and what is not...if that make sense?
In the left upper slightly lateral breast middle 3rd image 16 there is a bilobed heterogeneously enhancing mass measuring 7 mm in size. This has rapid early and delayed plateau enhancement. This appears increased in size from the prior examination. It is adjacent to a cyst.
No lymphadenopathy seen.
OPINION: Mass in the left upper slightly lateral breast image 16 is indeterminate. An MRI guided biopsy is suggested. Appointment will be facilitated.0 -
"... bilobed heterogeneously enhancing mass measuring 7 mm in size. This has rapid early and delayed plateau enhancement. This appears increased in size from the prior examination"
Not much info. A few questions. Report says it was there before, on prior exam. How long ago was that prior exam and how big was it then? Was it ever evaluated with US and what did they call it back then? If you have a prior US that mentions it please post.
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WIthout additional information, things that are bilobed or dumb-bell shaped could easily be a fibroadenoma. The kinetics are also compatible with an FA. The fact that they saw it before and it wasn't biopsied or removed back then I would have to assume they thought it benign. If a FA enlarges biopsies are often recommended.
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Djmammo, thanks for your response.
I didn't have an ultrasound this year or last year.
The prior MRI exam was 12 months ago. The December 2018 report read: No suspicious mass or nonmass enhancement in the left breast that is concerning for malignancy.
I did check the image (my hospital has mychart on-line) in the December 2018 MRI after finding where the mass reported this year is located (there is an arrow pointing at it) and see the smaller mass. It looks to my eye to be about half the size in the MRI last year. It is lit up like this year's but not bilobed yet. I guess it didn't seem suspicious last year. The radiologist noted that she also compared the images to the 2017 MRI but the images for that one are archived so I couldn't check it.
Don't know if this is significant but I'm 55 years old and was almost postmenopausal (11 months without a period but in Nov. 2019 had a period). I called to ask for my MRI to be moved up to have it at an optimal time but they couldn't fit me in and I didn't get a period in December so just had my MRI as scheduled. I have dense breasts. The MRI report stated: FINDINGS: There is heterogeneous fibroglandular tissue with moderate amount and intensity diffuse and stippled background parenchymal enhancement in the left breast. This limits diagnostic accuracy. Asymmetry is consistent with prior right breast therapy.
I think I read that fibroadenoma's usually grow in younger women. I had a biopsy on the right side many years ago that was diagnosed as a fibroadenoma. But maybe since I'm still premenopausal.. Anyway hoping for a fibroadenoma or something else benign.
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