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Biopsy tomorrow- anyone have time for questions?

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Usergreen
Usergreen Member Posts: 9
edited July 2021 in Not Diagnosed But Worried

Not ready to share too much as my biopsy is tomorrow and I don't know enough yet but this has me sick. Has anyone heard of a clinical guideline stating an interventional radiology fine needle aspiration sample can be discarded based on whether it contains blood or not? I am a 35 year old female with 10 breast cysts/nodules of the left breast, one of which classified as Birads 4 and this is my initial biopsy scheduled at the hospital for a non palpable mass (ultrasound guided aspiration) During my pre procedure call they explained the sample will only be tested if it appears to have blood in it. Someone please weigh in. Does anyone know about the insurance reimbursement for biopsies? Is testing included with the fluid collection? I know there would be a radiologist or other doctor charge and a pathologist charge?? (Correct me if I'm wrong. I've read so much, it's all jumbled!) But what about the hospital reimbursement? Trying to be educated tomorrow when I ask that my fluid be tested regardless (asked today and didn't receive a call back) I am asking about the insurance to know if I can dispute the bill stating it was an aspiration and not a biopsy as no testing was done on the sample. (OnlyIf they still trash the sample after I request that they test it)

I've only told 2 people in my life and I need more feedback. Thank you so much. I am so thankful for your dedication of time on here in helping others going through this. Reading these posts about the fight you've all had….Prayers and good thoughts to everyone of you!!

Comments

  • kathabus
    kathabus Member Posts: 45
    edited July 2021
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    Hi--I don't know TOO much about what you're asking about. Let me ask a followup question to understand....are they assuming that it is not cancer if what they pull is blood? So there would be no need to send to pathology?

    From my experience with claims, fluid collection and testing would be two completely different claims.

    You will most likely sign paperwork tomorrow that protects them from nonpayment of their services. So really....it serves to have a detailed conversation to understand their standpoint before you even get started. Good luck!


  • Usergreen
    Usergreen Member Posts: 9
    edited July 2021
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    I apologize if this is a double post.

    They are saying bloody fluid sample will go on to be tested as it’s more likely to be cancer. But clear fluid will be considered normal and discarded. It doesn’t seem like a biopsy to me if it’s clear fluid. It could be some standard procedure per so and so guideline. I just haven’t heard of it and wondered if anyone had experience with it.

  • jhl
    jhl Member Posts: 174
    edited July 2021
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    User,

    As its late & your biopsy is soon, can I suggest you don't mind trying to discern what the fluid/tissue will be? Their goal is to try to find out what is causing the change in your breast.

    Are you in the United States? The reason I ask is because it is standard in the US to just test whatever they withdraw.

    Good luck!

  • beesie.is.out-of-office
    beesie.is.out-of-office Member Posts: 1,435
    edited July 2021
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    In my experience (I've had more fine needle aspirations than I can remember) the fluid has always been sent to pathology. But I am aware that some guidelines suggest that this isn't necessary. So to your question, "Has anyone heard of a clinical guideline stating an interventional radiology fine needle aspiration sample can be discarded based on whether it contains blood or not?, read here:

    Fine Needle Aspiration Of Breast Masses https://www.ncbi.nlm.nih.gov/books/NBK470268/

    "If the FNA reveals a non-bloody aspirate and the cyst resolves, no more follow up is required. Some physicians do follow up with an ultrasound to ensure that the cyst has completely resolved. Re-evaluation is usually done 4 to 6 weeks later.

    If the cyst persists after aspiration or contains bloody fluid, the patient should be referred to a surgeon for a formal biopsy."


    Breast Cyst Aspiration
    https://www.aafp.org/afp/2003/1115/p1983.html


    "EVALUATION OF ASPIRATE

    Cystic fluid is seldom colorless. It is typically white, yellow-green, brown, or frankly bloody. If the fluid is nonbloody and watery, and the mass completely disappears with aspiration, the fluid can be discarded, and the patient can be reassured that the mass was cystic. Routine examination of watery, non-bloody cystic fluid is not indicated."



  • Usergreen
    Usergreen Member Posts: 9
    edited July 2021
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    Yes I am from the US. Perhaps I am misunderstanding it, but two people have explained it to me and I have understood it the same way both times. It was actually explained to me that if it’s red it gets tested. So they either have someone not educated in the area making their calls or they do minimal testing on it and discard it if it’s clear. I asked if my results were automatically released to my portal like all other results or if, because of the sensitive nature, they wait for the appointment. And she said it would only be tested if it was bloody and red and never answered my question.
    I can’t find anything about the guidelines they follow on their website. All I see are radiology accreditation.
    I know with my results from my ultrasound, everything is likely to be benign. But I want a test that actually says benign or likely benign or whatever biopsy results come back as. I also know I am my own advocate, but it stinks to go into tomorrow ready to battle them if they try to throw out fluid ?? Every time I think of it, I think I have to be misunderstanding. I’m stressed and not understanding. But I know what she told me.
    I have already called my insurance to check on a second opinion just in case.

  • Usergreen
    Usergreen Member Posts: 9
    edited July 2021
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    thank you Beesie! At least I feel less insane. It still seems crazy to toss any sample!! I know the night before nerves have me going, but I don’t think I will ever understand discarding fluids without proper testing!!!!

  • ShetlandPony
    ShetlandPony Member Posts: 3,063
    edited July 2021
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    Part of what Beesie quoted says "If the fluid is nonbloody and watery, and the mass completely disappears with aspiration, the fluid can be discarded, and the patient can be reassured that the mass was cystic." There are two parts: Clear fluid AND the cyst collapses. As I understand it, a simple cyst will collapse it the fluid is withdrawn, whereas a complex cyst or tumor will have a solid component, in which case a core needle biopsy should be done and sent to pathology. Part of the frustration here is that you can only talk to the phone people, and your reasonable question should be answered by the radiologist. So I would ask for a moment with him/her to ask your question before you get set up. If you still want pathology done no matter what, you could ask for it to be done and agree to pay for it if necessary.

  • beesie.is.out-of-office
    beesie.is.out-of-office Member Posts: 1,435
    edited July 2021
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    ShetlandPony, to your point, the question is: Why was the cyst in question classified as a BIRADs4? Does it have the appearance of a complex cyst, and if so, in what way?

    Usergreen, do you have the imaging report? How is the BIRADs4 cyst described?


  • ShetlandPony
    ShetlandPony Member Posts: 3,063
    edited July 2021
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    Why indeed. Wouldn't a BI-RADS 4 merit a core biopsy?

    Could this all be a case of the phone person not understanding the guidelines and/or the question?

  • Usergreen
    Usergreen Member Posts: 9
    edited July 2021
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    yes the cyst they’re aspirating is described
    5 o'clock position, 2 cm from the nipple, 11 mm lobulated complex cystic
    nodule with partial internal septations, increased in size/volume, previously
    at 9 mm.



    The beginning of the report says: There are several hypoechoic nodules in the left breast as above. Many of
    these contain internal debris, likely complex cysts. Some of these have
    increased in size compared to the prior study. No shadowing lesions are
    demonstrated. Suggest ultrasound-guided aspiration of the dominant 11 mm
    cystic nodule 5 o'clock position, 2 cm from the nipple. The probable complex
    cysts which are slightly larger in the left breast could also be aspirated
    under ultrasound guidance versus followed sonographically in 6 months.


    The imaging follow up visit stated with the doctor entering and saying there is a spot that has changed and we want to do what’s called a fine needle aspiration biopsy. She let me know it was the 11 mm spot. She said a little about procedure and there was a pause.
    So I asked about one other spot being aspirated, saying it was mentioned that others could be and this spot gave me a lot of pain and reminded her this pain was how I was referred there in 2019. I told her I know that’s not a usual initial symptom of breast cancer but it did worry me. The doctor responded aspirating may not help the pain. I said I was more concerned. The response was something along the lines of “I will put on the next ultrasound order to pay special attention to 11 o’clock” there was no explanation as to why it couldn’t be done. I didn’t press it further because I was already planning a second opinion appointment based on the doctor. The NP is always great and pulls up images and explains the oval shape is normal looking. No one reviewed any images this visit (with the doctor) but I watched the tech during my ultrasound and they aren’t so oval anymore.
    It’s hard not to worry, but I know that won’t do any good. I really appreciate the responses!!

  • Usergreen
    Usergreen Member Posts: 9
    edited July 2021
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    this is the spot I asked about being aspirated as well

    11 o'clock position, 3 cm from the nipple, 9 mm gently lobulated probable
    complex cyst with internal debris, slightly larger compared to 7 mm


    so it certainly seems it’s one of the spots mentioned in the beginning of the report that could be tested now vs. ultrasound follow up. If there is reason not to test, I would like to know what the reason is and not be brushed off.


    sorry. I didn’t mean for this to turn into a rant. I just didn’t feel heard

  • ShetlandPony
    ShetlandPony Member Posts: 3,063
    edited July 2021
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    I don't know, I think if I felt that I was not being heard and that I still had important questions about the procedure, I would reschedule and try to get that second opinion before letting someone mess with me. If they don't do it right, you can't start over. Mind you, I have no expertise about fine needle aspirations, but I do sense that you don't have confidence in this place. I have learned to trust my intuition and believe that my questions deserve answers.

  • Usergreen
    Usergreen Member Posts: 9
    edited July 2021
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    it’s a little complicated. I have a very limited network. Basically if this healthcare system offers it, I have to use them for it.

    I tried to explain to the insurance rep that they may not even test the fluid therefore a guaranteed biopsy is not an offered service and should be covered elsewhere. She said just because they use different guidelines than I want to follow doesn’t make it a service they don’t offer. It does cover a second opinion with a referral (from outside the healthcare system) but I thought I could still do that after this appointment if needed.

  • rah2464
    rah2464 Member Posts: 1,192
    edited July 2021
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    Usergreen - I had a fine needle aspiration of the cyst once years ago where the physician upon extraction indicated the fluid was fine, no need to test. I requested the fluid be evaluated anyway. Just me, my body, you pull something out lets make absolutely sure nothing else is there.

    I hope you continue to push to get clarity on the evaluation of your complex cysts and I hope your medical team responds to your concerns. Best of wishes today as you have the procedure.

  • moderators
    moderators Posts: 8,081
    edited July 2021
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    Hi usergreen, and welcome! We just wanted to check in to see how the biopsy went today and if you found out anything more?

    Keep us posted!

    --The Mods

  • Usergreen
    Usergreen Member Posts: 9
    edited July 2021
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    Thank you for asking. When I went to the room, before I even undressed, I asked if my fluid could be tested regardless. They were very nice and said yes. They did tell me I would be responsible for the testing bill if it didn't meet the guidelines. I agreed and we got everything started. I have to say sorry for the comment about my doctor because she did listen to me after all. I just misunderstood. When she said she would mark for that spot that concerns me to be looked at too, she meant on my FNA order, not a follow up ultrasound order. So she did listen and I just didn't understand correctly. Feeling much better about that.

    It was my favorite radiologist.Nerdy

    They told me we would aspirate both spots so they started with 5:00 (11mm) and aspirated saying it was clear. (Report says milky) They added a clip. Then the radiologist spent some time on the 11:00 9mm spot that gives me pain. That is the spot I requested be aspirated. Finally he declared it to be solid and I said "so you're converting to a needle core biopsy?" And he paused and said "what do you do?" (Thinking I was clinical) and I replied "I just read a lot when I can't sleep" trying to lighten the mood, as I'm stressing.

    They did the needle core biopsy there and used the vacuum. It was only one "suck" and it was gone. The report says one core only. Added a clip there and did a post procedure mammo. Then I was back to work, keeping busy.

    So it wasn't the best news ever, but the radiologist remained upbeat and said he feels positive for me. Probably the standard speech when results aren't really the most desirable.

    I made sure the new CPT code has already been approved with my insurance (since breast biopsies need authorized with my insurance, date specific) so now we wait for results (estimated 5-7 days - auto release to my portal) I hope insurance covers the pathology for the milky fluid too. But peace of mind is worth the cost anyway. I follow up in office next Tuesday.

    Thanks for the support. I checked for responses all hours of the night last night. Each time I woke up, I grabbed my phone. I value the information you share here.

  • gailmary
    gailmary Member Posts: 435
    edited July 2021
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    Usergreen, I'm thinking of you. I'm feeling much the same way with questions about biopsies and confused by drs. It's difficult to understand them when you are in pain or shock at the news, they have an accent, they are going fast, they are wearing a mask and use unfamiliar words. Ugh.

    Yes, my recent experience. Day after tomorrow I get results of scans and I'm bracing myself for bad news. I question if/or when a biopsy is even needed with progression And know nothing of different kinds. A foreign language, indeed. And I read alot too. Difficult to prepare questions when you don't know what you don't know.

    I wish you all the best.

    Gailmary



  • ShetlandPony
    ShetlandPony Member Posts: 3,063
    edited July 2021
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    Usergreen, I came here to see how it went for you. I am so glad to hear that things went well with good communication, the availability of pathology on both. I like your answer to What do you do. I have to admit I like it when doctors ask me if I am in the medical field. Usually I say something like, "No, I've just been at this game a long time and have learned a lot."

    But not everyone is a research wonk, and that is ok too. I hear you about sometimes not knowing what questions to ask, gailmary. The important thing is to be involved to your own comfort level, and find providers that you feel you can trust.

  • exbrnxgrl
    exbrnxgrl Member Posts: 4,853
    edited July 2021
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    user green,

    Happy to hear the biopsy went as well as it could. I don't know that radiologists have standard speeches when they are thinking there may be bad news. I think they simply know that theirs is not the final word on the situation. They can afford to be non-committal

    Gailmary,

    Imaging alone cannot confirm mets with 100% accuracy. Additionally, ones hormone profiles can change and that can only be confirmed by biopsy so that's very important in terms of formulating a tx plan. However, sometimes imaging shows possible mets in an area that can't be biopsied safely. In those cases they they treat based on what info they have garnered, minus a biopsy and the info it could have yielded.

  • Usergreen
    Usergreen Member Posts: 9
    edited July 2021
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    Thank you for the kind words and thoughts. gailmary I will be thinking of you!

    I am trying to process this enough to start knowing which questions to ask. As I'm sure you all know, solid mass search online brings up Fibroadenoma. Here's my breakdown of the common Fibroadenoma characteristics I foundvs. me

    Painless. It's not painless. It's a burning pain I have there sometimes several times a day.

    Mobile. It's not mobile. It doesn't roll around. My doctor 's exam says non palpable and we've both never felt much. Maybe an occasional "possibly something" but it doesn't move.

    Solitary. It's not solitary. I have 10 spots mentioned on my last report of left breast. The right has never been checked by ultrasound due to lack of symptoms.

    Rapidly growing solid lump with rubbery consistency and regular borders. It's not rapidly growing. My first breast ultrasound was June 2019 and was due to the burning pain. That result showed 8 spots. Maybe it rapidly changed…I don't know, I guess I can't say it didn't rapidly grow. I'm not educated in the area.

    Dec 2020 7mm complicated probably

    cystic mass

    June 2021 9 mm gently lobulated probable

    complex cyst with internal debris.

    The only characteristic I had for sure was that it was solid. I know I can have a complex type, but still worrying.

    Not trying to be funny but I would like to recall my first statement on my first post. "Not ready to share too much"

    I am in full information gathering mode so if anyone has info they think could help, but need to know information from me first, you can ask. If I'm uncomfortable sharing, I will say so.

  • beesie.is.out-of-office
    beesie.is.out-of-office Member Posts: 1,435
    edited July 2021
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    Usergreen,

    I'm sorry that the aspirations didn't resolve both lumps.

    Could the second lump be a fibroademona? Yes. Painless? It wouldn't be if it's near a nerve. I've had tiny tiny cysts that are painful, just because of where they happen to be located. Mobile? If it's not palpable, you wouldn't know if it's mobile. In any case, the medical definition of "mobile" is different than how it might feel to you. I've had two large fibroademonas, and they certainly didn't feel mobile to me, quite the opposite in fact. Solitary? Where did they get that? Women who have fibroadenomas sometimes have more than one. And "solitary" doesn't mean that you might not also have a breast full of cysts. Rapidly growing? I think this refers to the initial growth spurt. Both of mine came out of nowhere and grew large in a short time. Then they never grew again (and I had one for 4 years before I decided to have it removed, since it was so large and it wasn't shrinking, as they sometimes do).

    Good luck. I hope it is a fibroadenoma.