Expert: Claes-Gustaf Nordquist, M.D. - 12/3/2008

Question
QUESTION: I have had a breast mri and am currently scheduled for a mri guided multiple biopsies. Unfortunately, the only info my doctor gave me was "several nasty looking lesions on both sides" and "biopsy". I am scheduled for the biopsy but am left feeling uninformed and not in control of my own health issues.  There is a strong family history breast cancer, so this diagnosis would not come as a surprise. I did manage to get the radiology report.
What is a category 5 MRI?

ANSWER: BI RAD category 5 means a lesion that looks to be a cancer with a very high degree of probability on mammography, ultrasound or MRI. With your family history that makes it almost a certainty. So probably your dr. gave you a rather accurate description of what could bee seen though a much better explanation should have been provided. MRI guided needle biopsies are indeed needed to be sure of the diagnosis and all its details in order to plan the best treatment. Please do keep me posted!


---------- FOLLOW-UP ----------

QUESTION: Thank you. I am not one to want sugar coated vague answers. The report says multiple findings: 1. there is a large 1.3 to 1.4 cm mass in the upper outer quadrant of the right breast with aggressive kinetics and a spiculated morphology virtually pathognomonic for neoplasm. There is a second nodule in the retroareolar portion of the right breast at approx. 12 o'clock which I would recommend a tissue diagnosis with mr guidance for as well.  This is probably in the 3-4 mm size range however it would be out of the upper outer quadrant and may affect the management if positive.

2. On the left side there is a dot-like enhancement present in multiple locations, however there is a more worrisome focus of increased enhancement at 12 o'clock worthy of tissue diagnosis here. This lesion size is in the range of 5mm.

I had a normal mammogram in 2007 and in October my yearly mammogram found the one lesion on the right side but nothing else.

How did I go from normal to so positive in a year?  I did have have a duct papiloma removed on the left side in 2006 but it was benign.

ANSWER: So I have noticed! I'm not in the habit of providing them either! I prefer to be honest, frank and even blunt (a 15 year long period as a senior military dr. - Royal Swedish Army, chief medical officer of the Royal Guards - and an equally long period as a medical examiner and police surgeon of the Stockholm Police Department have both provided a lot of training for that). Back to your report. 1. This lesion in your right breast is probably the most important one. It is rather big, even rather big for a lumpectomy (1.3-1.4 cm, 1 inch = 2.54 cm) and if the second nodule in the same breast also turns out cancer positive I do think that a mastectomy must at least be considered. It (the big one) does look nasty according to the report and is probably a cancer. The other one is much smaller 0.3-0.4 cm (3-4 mm) in size but it is quite far away from the first one and would if positive too make management of the situation more difficult - that is why I mention a mastectomy. So I completely agree with your radiologist on that point. Your radiologist is also rather convinced already that the big one is a cancer and based on the description I would probably agree too. 2. This MAY be a cancer too in the size of 0.5 cm (5mm) in the opposite breast - left one. In all these cases biopsies are indeed VERY important to KNOW what these lesions are! MRI guided needle biopsies should be able to provide the information and are easiest, quickest and simplest for you too! Now to your question why these things have not been found earlier. From the fact that they were not found on earlier mammography examinations but were found now with MRI I conclude that you most probably have quite dense breasts! Am I correct in this assumption? If so it is a fact that mammography has difficulties in finding cancer lesions in dense breasts. In that situation MRI scans and to some degree ultrasound scans are better in finding such lesions. That is probably the reason for this situation. Your dr. may not be talking much but seems to know what to do in this situation since MRI was ordered! A ductal papilloma usually also has other symptoms like nipple discharge that makes it easier to find. If a galactogram was done (a mammogram with x-ray contrast fluid injected into the discharging milk duct) diagnosis is made even easier. IF it turns out that you have 2 cancer lesions in your right breast and one in your left I would suggest a bilateral (double) mastectomy (of both sides). That can probably be done in such a way that your breasts can be reconstructed. Radiation therapy, chemo- therapy and maybe hormonal therapy must also be considered. If you have children this genetic trait may have been passed on to them too which they must consider. Good luck/Mazel Tov! Please do keep me posted!



---------- FOLLOW-UP ----------

QUESTION: Hello again.  I have the results of my biopsy. If you don't mind, I would very much like your opinion once again. The mri at the time of biopsy showed nothing in the left side, good news. Here is the report for the right:

Right breast density #1: right breast, upper outer, core biopsy: invasive ductal carcinoma, well-differentiated, and in-situ carcinoma, cribriform type with low nuclear grade and no necrosis.

Right breast density #2:  right breast, retroareolar, core biopsy:   
a) focus of atypical ductal hyperplasia with borderline features of in-situ ductal carcinoma, micropapillary type.  Rare microcalcification.

b)  radial scar with surrounding atypical ductal hyperplasia.

c) fibrocystic changes with rare microcalcifications.

d) no evidence of invasive malignancy.

Gross description:

1. received in formalin, labeled right breast upper outer, are several predominantly fatty core biopsies measuring
2.3 x 1.8 x 0.4 cm in aggregate. Submitted in block 1.

2. received in formalin, labeled right breast retroareolar, are several fibrofatty core biopsies measuring 1.5 x 1.5 x 0.4 cm in aggregate. submitted in block 2.

Your thoughts?  

Answer
Well at least one, probably 2 cancers were found in your right breast. Based on that and what I have written before I have to suggest a mastectomy. Your cancers must be tested for genetic traits and hormonal receptors and any further treatment if necessary should be based on that. I'm happy there was nothing on your left side!