Expert: Claes-Gustaf Nordquist, M.D. - 8/16/2010

Question
I am a 40 year old woman with left breast pain for 5 months.  The pain is on/off most of my cycle and the area that is sore (outer upper and side) when pressed.  I have a 2 year old child (last of three) and have never breast fed.  I had a normal diagnostic breast mammogram in March, and two normal breast u/s in March and June.  Last month I had a MRI on day 7 of my cycle...there was a non-mass 5cm with regional progressive enhancement in the area that I describe the pain.  One week following this study, I had 'second look' ultrasound that was again, negative.  Last week, day 21 of my cycle I went in for a MRI guided biopsy and in this study...none of the breast showed regional enhancement and the tissue morphology was not the same.  The breast appeared normal.  They did not preform the biopsy because 'there was no focal area to biopsy'.  The radiology team is going to review and get back to me this week on what to do next.  They briefly mentioned a six month follow up due to the possibility this was 'cycle related'.  This worries me due to the pain and my main concern 'lobular breast cancer' since I know this hides on mammogram and ultrasound.  My left breast is described as heterogeneously dense but does not say it is cystic. My breasts feel lumpy on both sides and this is only in the last year I noticed this.  What would be your opinion on how to proceed?  I am in good health...and a healthy appropriate weight for my build.  My mother's mother and father's sister had breast cancer in their 50's #unsure what type#.  Both survived.  One note...the two MRI's were preformed on different machines.  The radiologist mentions the possibility of the breast coil causing the discrepancy...and/or my cycle timing.  Please advise.  Thank you in advance.

Answer
I think that it is quite probable that this indeed was "cycle related" (= due to hormonal effects). Pain like you described it is also not often associated with breast cancer. It is however often associated with hormonal effects especially (as in your case) in dense breasts. A lobular breast cancer should if it existed be possible to see on a breast MRI scan.  What was seen on your breast MRI scan does not fit the description of such a cancer (or any other cancer really). It is probable that that too was a hormonal effect. But to be sure a biopsy was needed. But you can only do a biopsy if you have something to take it from. That it was no longer there further supports the hormonal theory. Technical factors as described may also have enhanced this situation. So I think that a control MRI breast scan should be done and since you do have dense breasts that 1. Somewhat enhance your breast cancer risks and 2. Make it much more difficult to find any breast cancer with just mammography I think your future mammographies should always be combined with both breast ultrasound scans and breast MRI scans! And if anything is unclear with stereotactic or ultrasound guided or MRI guided needle biopsies (if a mass can be felt such a biopsy can also be guided by touch). Good luck!





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