Interpreting Your Report
Comments
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djmammo...thank you for providing these insights!! It makes a world of difference to just be able to ask questions and then be able to have time to process.
I am trying to decide on a second opinion regarding pathology after a bilateral mastectomy. I had a significant history of fibrocystic disease beginning when I was 21 (52 now) and had my first cyst removed. Plus my mom is a BC survivor, but I am BRCA negative, so I went for the big guns first and had surgery. Below is kind of the imaging and pathology history leading up to this and at the end the question of whether a second opinion at MD Anderson would be worth it.
Screening MRI... architectural distortion R breast
Diagnostic MRI...confirms suspicious mass R
Ultrasound...recommends MRI
MRI...recommends biopsy
US Guided biopsy pathology...invasive micropappilary carcinoma...grade 2...1.9cm...ER+, PR+, HER2+... high grade dcis focally present.. lymph vascular space extension not identified.
Surgical Pathology... infiltrating micropappilary carcinoma, grade 2...2.6x2x1.9cm...margins of resection are greater than 1 cm from tumor...area suspicious for lymphovascular invasion are present...definite in situ carcinoma not identified... right sentienal node negative for metastatic tumor.
So, I had decided if there was no considerable differences in the 2 pathology reports I would not send it away for another opinion because sometimes too many opinions are not a good thing. I was not overly concerned with the size difference I waited 70 days from dx to surgery and knew the risks there. BUT...
...what happened to the dcis from the biospy? Shouldn't it be seen on the surgical pathology as well?
... and the big question is the biopsy seemed to say no lymphovascular involvement but the surgical path says suspicious for. Can they confirm lymphovascular involvement some other way?
My assumption would be if lymphovascular invasion is confirmed, even with negative node, it would prompt more aggressive treatment.
Open to other thoughts I might not be considering with regard to 2nd opinion.
Thank you again!!!
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djmammo....Hi, can you please help me. I'm a medical coder and can't help but to keep looking over My mammogram report. I had my breast implants removed with a lift on 9/3/19. I went in for my annual mammogram 3 months later. Had a screening then got a callback for a diagnostic mammogram and ultrasound. Now I need a biopsy. BIRAD-4C Suspicious abnormality-moderate concern but not classic for malignancy. Could this be from the breast surgery? My diagnostic mammogram and ultrasound last year was fine.
The tissue of the right breast is heterogeneously dense. This may lower the sensitivity of mammography. The irregular 2 cm density with spiculated margins is visualized on the MLO compression mammography but the area could not be included on exaggerated CC or ML views due to posterior position. No malignant calcifications are seen. Targeted ultrasound demonstrates an irregular hypoechoic-mass like lesion in the 9:00 area 5 cm from the nipple corresponding to the mammographic irregular density, Sonographically the lesion is measured approximately 1.6 x 2.2 cm. There are benign calcifications and a lymph node right breast. No significant masses, calcifications, or other findings are seen in the breast on the mammogram or right targeted ultrasound.
IMPRESSION: SUSPICIOUS OF MALIGNANCY, TARGETED ULTRASOUND SUSPICIOUS OF MALIGNANCY
The spiculated mammographic density and corresponding irregular hypoechoic sonographic lesion are very suspicious for malignancy. Biopsy is recommended.
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Does the report say it was compared to your prior mammogram? Did they have the history of your recent surgery? I suppose you could ask them to dictate an addendum clearly stating that the finding is not a surgical scar and that the biopsy is necessary. That will make them review your study with this in mind and if they are still worried about it, then maybe you will at least feel better about having the biopsy.
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djmammo...yes the report was compared to exams dated: 12/6/2018, 12/6/2018, (which were a diagnostic mammogram and ultrasound) and 12/7/2019 screening. I reviewed my screening report from 12/7/2019 and the impression there states: The 2 cm irregular density in the right breast resembles a post surgical scar and is indeterminate. Mediolateral, exaggerated CC, and compression views as well as a possible ultrasound are recommended. This report also references that my breast implants have been removed
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My diagnostic mammo report says group of 5 x 3 mm branching, coarse heterogenous calcs seen. My stereotactic biopsy pathology says ADH. The biopsy procedure notes say not all the calcs were removed. Why wouldn't they remove all the calcs, and since they didnt, how can they say that it is only ADH? Can you have coarse heterogenous and branching calcs? My birads was 4C. Have an appt scheduled with a BS next week, but now I'm a bit nervous. Do I need a second opinion?
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The purpose of the stereo biopsy is to sample the calcs not to remove them. Although a marker is always placed, breast surgeons have asked us not to remove all of them in case there is a problem with the placement of the marker.
Once there is any abnormality seen an excisional biopsy is performed with good margins to see what is in that whole area. This is standard of care. Most just show what the biopsy showed but occasionally there will be an "upgrade" where something more abnormal may be seen by the pathologist. If there were actually linear branching calcifications present, this is a fairly reliable indication of DCIS. Let us know what the path shows.
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djmammo
Thanks for the reassurance. That makes sense about the marker, but I'm still scratching my head about the linear branching which both mammos showed, read by two difference radiologists. The fact that my mom had BC at age 40 makes me more nervous. Also, I was scheduled for breast augmentation Dec 12, which was the reason for the initial screening mammo. Is this most likely something I need to give up on having? Does it increase my risk or make it more difficult to screen closely?
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Deleted post...sorry did not read clearly that this was pre-diagnosis discussions.😊
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I'm afraid I have inflammatory bc
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Burton - if you have an imaging report, this is the place to post that if you don't understand the jargon.
This thread is not really for wondering if you might have IBC. You can start your own thread under "not diagnosed" if you want.
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Djmammo: I was rude before by not thanking you for taking time to answer my questions. So thanks...Here is the path from the stereo. It seems more reassuring to me. Do I have reason to continue worrying?
Page: 1 of 2
Surgical Pathology
Temporary Copy
Case: GS-19-0003550
Collected: 12/19/2019 17:21 EST
Ordered by: LUFT MD, KIMBERLY NHU-MAI
HOANG
Patient: shari t
ID: 1030042
Location: GOR
Final Diagnosis
LEFT BREAST, UPPER-OUTER-MIDDLE DEPTH, STEREOTACTIC-GUIDED CORE
NEEDLE BIOPSY:
FOCAL ATYPICAL DUCTAL HYPERPLASIA WITH PUNCTATE
MICROCALCIFICATIONS.
(SEE COMMENT)
DRF ***Electronically signed by RICHARD D FERNANDEZ, MD on 12/26/2019 14:04***
Surg Path Comment
Atypical ductal epithelial cells are confined to a single ductal unit. 12/20/2019
Microscopic Description
Multiple sections of the entire specimen demonstrate a relatively demarcated nodular lesion composed
of dense fibroconnective tissue surrounding small ductal structures. Focally ductal structures are
distended by atypical cells with enlarged hyperchromatic nuclei and prominent nucleoli. Punctate
intraductal calcifications are noted
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Hi djmammo,
It is so helpful that you offer your professional insights, thank you.
I think I understand my report and situation, but I would be very grateful for your insight and confirmation or redirection.
I went in on 12 December for a wire guided surgical biopsy of amorphous loosely grouped micro calcifications.
The report says:
Final Diagnosis Breast, Left, Needle localized excision: - Benign breast parenchyma with numerous intraluminal calcifications and foci of duct dilation. - Negative for atypia and malignancy.
They are having me come in 6 months for a mammogram of left breast as well as a f/u with the breast surgeon. On the medical access site where patients can see their information, I see the doctor has listed this in the problem section as “benign mammary dysplasia”.
I’m so glad it’s benign! But my impression is I should only be tentatively glad because in six months if it’s grown back that’s not a good benign sign? The original radiologist told me after the failed stereotactic biopsy that the suspicion is dcis so it sounds to me that in spite of the benign findthat dcis is not entirely ruled out yet?
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This is exactly why plastic surgeons order a mammo prior to augmentation so the system worked in this instance.
If the excisional bx shows DCIS I believe you will need to complete the treatment before considering implants. Ask the surgeons involved how plausible it is to have an augmentation after lumpectomy and radiation which is often the combination used for DCIS. If you can find a breast surgeon with oncoplastic training they are part onc surgeon / part plastic surgeon and really know how to get the best cosmetic result after lumpectomies etc.
Whether implants interfere with early detection is controversial. IMO, if they are placed behind the muscle which is the current standard, it actually pushes the breast tissue forward and into the field of view of the mammogram so you know you are not missing anything in the posterior breast. The implants are mobile and are displaced out of the compression plates/field of view during acquisition of the mammo images.
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On a related subject:
Because Angelina Jolie had/has a high lifetime risk (I think she is BRCA+) she had an elective bilateral mastectomy with immediate reconstruction, she had no mass or cancer diagnosis at the time. This way her risk is diminished and the reconstruction was done on breasts not previously scarred or radiated. This approach suited her well since her livelihood depends on her appearance and insurance coverage was not a concern.
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I'm 48 and have never had a mammogram. A few months ago I found a hard-lump about grape-size near my nipple and am now scheduled for a diagnostic mammogram. Since the lump is hard and can be felt easily by touching, is a breast ultrasound needed?
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Hi. Happy New Year! I'm having a little conflict in my mind over the post surgical changes and a seroma in my left breast well beyond surgery which I'm certain was caused accidently while exercising. You may remember I posted prior for better understanding of the BIRAD system as 6 months ago this thing showed up and my score was a 3 on MRI. I was totally expecting this score again and hoping it was resolving. I don't feel the pulling and minor aching that I had months ago. An interim MO visit said she can't feel anything and was not concerned. Had my 6 month follow up MRI last Friday:
HISTORY: Follow-up enhancement in left breast. Personal history of left breast carcinoma.
Additional history: Left breast invasive mammary carcinoma in 2018 with lumpectomy and radiation. 1 cm area of progressive enhancement adjacent to the hematoma/seroma in the left breast on the 6/10/2019 breast MRI for which follow-up 6 month MRI was
recommended.
LEFT BREAST
Postsurgical changes are again noted in the upper inner left breast. A seroma is again noted in the upper inner left breast measuring 1.4 x 0.8 x 2.1 cm (image 108 on series 2 and image 112 on series 18). There is a slightly larger irregular area of
progressive enhancement at the anterolateral wall of the seroma now measuring 1.1 x 0.7 x 0.7 cm and previously measuring 1 x 0.7 x 0.4 cm (image 137 on series 6 and image 108 on series 18). There is an area of enhancement is in the upper inner right
breast approximately 5-6 cm from the nipple. Second look ultrasound is recommended for biopsy planning. If this area is not identified on ultrasound, MRI guided biopsy is recommended. There is no axillary or subpectoral adenopathy.
BI-RADS CATEGORY: 4 Suspicious
The BS called me on Monday said don't worry too much and she saw that I was also scheduled the following day for the diagnostic mammo and explained that I would most likely have an ultra sound as well. We agreed to see what these showed and I will see her at my scheduled March appt. or sooner if need be. I do not have these reports in my portal yet, however, the US tech could not see this and the Dr. on call there reading my Mammo and ultra sound came in to say looks fine, I heard the word "healing" and all I asked was what my score was and it is a BIRADS 2. Normal findings. That was good enough for me at that moment as it was New Years Eve and I had places to go and people to see.
Now that the holiday is over and I'm thinking about it again, is it unusual to get two different scores like this?
Is it possible the measurements are wrong? Does it matter both MRIs were read by different radiologists?
Thanking you in advance for any input. I really don't think I need to undergo a biopsy at this time for .1 of a cm. If I did do a biopsy how in the world would they do an MRI guided one? I picture the Dr. laying on the floor to get to this spot.
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Well never mind dj. The radiology coordinator just called and BS still wants the bio so I'm scheduled for the MRI guided one. Hope they can find the target which I suppose they will with contrast.
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Thank you djmammo
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There are many variables affecting measurement of an enhancing lesion including the difference if done on two different machines, if the calipers on not placed on exactly the same parts of the mass each time, and the degree of enhancement on that day which can be affected by how soon after the injection the images are acquired, your heart rate, the imaging sequence its measured on among other things. The measurements as well as the birads might also be different when MRI is compared to mammo or US as they "see" different physical aspects of the mass or don't see them at all.
There is as special breast coil for biopsies that has an opening on the side with an alphanumeric grid used to locate and guide the biopsy needle to the target.
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djmammo,
I wanted to update you on the pathology report. I had the stereotactic bx for increased regional and local amorphous calcifications. The report came with fibrous and cystic age related changes with microcalcifications, follow up in one year. I am relieved, and also wondering what the future holds- last year I was called back for additional imaging and an ultrasound, this year additional images and subsequent biopsy. Does the fact that I have increasing calcifications put me at a higher risk?
Amy
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If there are increasing calcifications then I will assume this will not be your last biopsy. I would ask the pathologist about any real increase in risk of IDC with these findings, as not knowing all things about cases I read here, I don't wish to accidentally mislead anyone.
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Hi. Iam 35 and found tiny lump in June 2019 had 1st ever Mammogram and US in Aug 2019.
Results seem straight forward, but still worried and cant stop thinking about the lump. It is driving me crazy and very unlike myself. Just is always in the back of mind and uneasy feeling.
CLINICAL HISTORY: 35-year-old female presenting with palpable abnormality of the left breast.
COMPARISON: Baseline
BREAST DENSITY: The breasts are heterogeneously dense, which may obscure small masses.
DIGITAL MAMMOGRAPHY FINDINGS:
There are no dominant masses, suspicious microcalcifications or unexplained architectural distortion to suggest malignancy. A triangular marker localizing the area of palpated abnormality overlies the superomedial periareolar left breast. No mass or
suspicious lesion is present underlying this marker.
LEFT BREAST ULTRASOUND FINDINGS:
Corresponding to the area of palpated abnormality, at 9:30, 1 cm from the nipple, there is a 1.3 x 0.5 x 1.2 cm hypoechoic lesion with mildly irregular margins but appears to be a cluster of cysts on real-time scanning. No internal vascularity is identified.
"IMPRESSION"
IMPRESSION:
BI-RADS Category 3-Probably Benign Findings.
RECOMMENDATION:
Six-month follow-up is recommended. Six month sonographic follow-up of the left 9:30 lesion is recommended.
Tech during the US told me she wasnt sure what it was and that Radiologist asked her what she thought it was and she said she thinks cysts, but that I can always get a 2nd opinion and trust my instincts.
I have had benign tumors, cysts, and hemangiomas in other parts of my body. But this did not look like a cyst to me on US. But Iam not trained.
My maternal grandmother was DX with Breast Cancer at 35 years old.
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Hi @djmammo, thank you for providing your educated opinion on everything, it's been super helpful!
Last January, I had a mammo/ultrasound for pain & nipple discharge: Birads 4c that turned out to be a radial scar, papilloma, and ADH. It was excised in February. I had a clear ultrasound in July, then on Friday, had a follow-up mammo/ultrasound, and got the following report (way more vague than last year's):
In the left breast, there is an intraductal mass with internal vascular flow in the 3:00 periareolar region. The mass measures at least 0.8 cm in length. It is suspicious and ultrasound-guided core biopsy is recommended.
My questions:
1) Would a papilloma have grown this quickly (between late July and now)?
2) Is it typical for a papilloma to have vascular flow?
3) The nipple discharge and pain for which I was originally referred didn't stop after the lumpectomy, and in fact, the pain got worse but nowhere near the current mass (mostly at the edge of my breast, in underarm, and up to my collarbone). The radiologist thinks this mass/suspected papilloma is probably causing the discharge but would it have been there for the last year and not seen on any imaging?? I'm confused as to how this could've been the original cause and wondering if something else has been missed.
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I had my biopsy and although I don't have the full pathology report, I do have the biopsy report:
IMPRESSION: STEREOTACTIC GUIDED BIOPSY BENIGN Stereotactic guided biopsy of the area of calcifications in the left breast at 3 o'clock middle depth was successful with no apparent post procedure complications. Pathology indicates benign fibroadenomatoid change and fibrocystic changes (FC) with calcifications present. Pathology results are concordant with mammography findings. Although calcifcations are present in sample, there are many residual calcifications and clip is proximal. The patient has had a previous high risk breast lesion. Stereotactic Re-biopsy is therefore recommended. Sampling is difficult given the breast volume and breast implant. An attempt should be made from a lateral approach. If this cannot be accomplished surgical excision would then be recommended.
I haven't scheduled the re-biopsy yet. I also have not had my appointment with my doctor yet to go over the results. I'm not sure I understand why the re-biopsy is neccessary, is this just a common practice in my situation? They made two attempts during this last biopsy, thru two separate incisions. I'm happy/relieved to hear benign, but don't understand why the re-biopsy is recommended. I've had 4 biopsies and an excisional to remove the high risk mass already. It's just a lot and I'm worried about another already.
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I have received my pathology report after lumpectomy for DCIS.
What i was told by a doctor first: where clip was put during biopsy, now result : benign. And this is because it was removed by biopsy, during calcification sampling during biopsy.
Margins are good on 3 sides ...but medial margin on one side has an issue: small DCIS was found there, which makes this margin 1.5 mm ...when others margins : 2mm.
He did not recommend to re incision but it is my choice. And i wanted to do re incision ...which we will be done on 1/16.
He said that all tissue on this re incision could be clean...and if this will be the case: i might not need radiation.
Here is what report says:
Diagnosis:
1)Breast, right, 12:00, lumpectomy
Breast parenchyma: fibroadenoatoid changes, apocrine metaplasia, Cyst(s) Biopsy site changes
Calification: in benigh epithelium
2)Breast, right superior margin: Breast Parenchyma: Benign breast parenchyma
3) Breast, right medial margin:
DCIS, size: involving 1 singel duct, spanning less than 1 mm
Grade 2
Architectural pattern: solid
Surgical margins: DCIS is 1.5mm from the medial margin(0.5mm front)
Benign Breast Parenchyma: Atypical ductal hyperplasia(ADH)
ER+ 100%
Note: the DCIS is morphologically similalr to the prior biopsy.
4)Breast right inferior margin: Breast Parenchyma: Benign breast parenchyma with usual ductal hyperplasia
Calification: in benign epithelium
5)Breast right lateral margin: Breast parenchyma: benign breast parenchyma
6) Breast, right posterior margin
Breast parenchyma: benign breast parenchyma.
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What is worrisome for me: it is like another DCIS is found...and how do we know that no more there somewhere in this breast.
The calcification area they first biopsied which was DCIS and doctor said not there anymore(was removed by biopsy) was the most suspicious after mammogram. After biopsy showed DCIS there, i had also 2 more biopsied : calcification on the left in the same breast and also biopsy on left breast(also calcifications). I was told they were low suspicious, but because the first one was bad, they did those 2 to make sure. and they both were benign.
please comment, thank you
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"But this did not look like a cyst to me on US"
What did it look like to you?
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If you are concerned and do not wish to wait the 6 months ask for a cyst aspiration. If they are cysts they should decrease in size or disappear once punctured by a sharp needle. This may make the diagnosis for you.
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1) Would a papilloma have grown this quickly (between late July and now)?
Having multiple papillomas is not uncommon. How rapidly do they grow? I really don't the answer to that.
2) Is it typical for a papilloma to have vascular flow?
They are very vascular and that is a feature we look for when scanning. This is done with the Doppler imaging (vascular function) turned on.
3) The nipple discharge and pain for which I was originally referred didn't stop after the lumpectomy, and in fact, the pain got worse but nowhere near the current mass (mostly at the edge of my breast, in underarm, and up to my collarbone). The radiologist thinks this mass/suspected papilloma is probably causing the discharge but would it have been there for the last year and not seen on any imaging?? I'm confused as to how this could've been the original cause and wondering if something else has been missed.
Was the original discharge from more than one duct opening in the nipple? If so that would have been a clue that there was more than one present. If it came from only one duct and a subsequent US shows a papilloma then the diagnostic question would have been answered. Not all papillomas are visible at all times, depending upon how much debris is in the duct as that can mask their presence on routine US. Also not all papillomas cause discharge all the time.
As far as the pain is concerned I don't believe that would be related to the papilloma and if still present should be evaluated, as it may not be breast related.
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"I'm not sure I understand why the re-biopsy is necessary"
This brings up an excellent point. "Are the cacls in the images the same as the calcs in the sample?" One place I practiced had a similar question.
After some stereo biopsies at our facility, although no calcs were visible in the cores obtained at biopsy, the path report said there were indeed calcs present so our post biopsy report said the results were concordant when they actually were not. To solve this problem we had the pathologist indicate the size of the calcs seen in the samples under the microscope. If they were the type that was too small to be seen with the naked eye on films of the cores, then we know we missed the ones we saw on the mammogram and that they needed an additional biopsy.
Another way to determine if the correct calcs were sampled is to see if there are any visibly missing when comparing the pre and post biopsy images of the breast. Since they mentioned the position of the marker was a little off target they may be wondering if the correct area was not sampled or if the correct area was sampled but the marker moved which is not uncommon.
Perhaps someone could review the case independently with all of the above in mind.
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"What is worrisome for me: it is like another DCIS is found...and how do we know that no more there somewhere in this breast."
I have seen this before scenario before, but there are actually two different things going on here.
1) If the calcifications in a very small area and are completely removed it is possible to remove all of the DCIS that was present in that spot with no residual found on lumpectomy. Was this area grade 3 DCIS? Some surgeons have actually asked us not to remove them all and this is one of the reasons.
2) Only grade 3 DCIS makes the classic irregular branching calcs characteristic of DCIS on mammo. Grades 1 and 2 do not. The area of grade 2 that they saw under the microscope in your case was likely without calcification and completely unexpected.
Ask your radiologist if an MRI would help identify any additional areas of grade 1 or 2 DCIS in either breast.
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Hi djmammo! Can you help me understand this? Thanks so much.
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