Expert: Claes-Gustaf Nordquist, M.D. - 7/13/2007

Question
QUESTION: I'm confused and would appreciate clarification. I had a stereotactic biopsy. There were two areas they were to biopsy. The first was an area of microcalcifications. That went fine thank God, and the results were "no malignancy".

The other sample they were to take was a retroareolar/central breast nodule that could be seen on the CC view. They said it may be localized within the 12 o'clock position but it was obscured by overlying fibroglandular tissue. The second look ultrasound failed to demonstrate the presence of a cyst. They assumed the area was solid.

When it came time for the biopsy of that area they could not detect it on the mammogram, so no sample was taken. I went back for a 3 month follow-up mammogram The doctor wrote the following:

"Vague nodule is identified at the site fo previous nodularity. No suspicious persistent nodularity is seen on today's study although the nodule still is seen on the medial breast. This is likely a nodular parenchymal pattern. Patient should return in 3/08 for bilateral mammogram and ultrasound."

That's 8 months away and corresponds with my annual exam. The Bi-rads category was 2: Benign findings.

My questions are:
1. what is this nodular area and what does all this mean?
2. Am I at higher risk for cancer because of it?
3. Why did she order an ultrasound in addition to the mammogram?
4. What is different that indicates I don't need the biopsy now?

Thanks so much for your help!

ANSWER: !. I do not know, no one does! Some kind of nodular lesion is seen but what it really is can not be determined from the pictures alone. What it really is can only be determined by a biopsy. If this lesion can be seen on a mammogram I can not understand why a stereotactic biopsy can not be done! It should be! Obviously from what you have written the cancer risk is deemed to be very low but anyway I think a biopsy SHOULD be done to determine what it is! 2. Not necessarily but it is impossible to give you a certain answer here. See 1. 3. To make the examination better! The 2 modes of examination to some extent complement each other. It would be even better if also breast MRI scans had been ordered.
4. As far as I can see nothing! A biopsy in my opinion should still be done! See 1.


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

QUESTION: Hi - thank you for your response. I just spoke with the Dr. who reviewed the mammogram results and wrote the report.  She says that when this type of thing doesn't show up on the stereotactic mammogram during the procedure, it's because it usually indicates that this is really benign glandular tissue which blends in with surrounding tissue.  She explained that the stereotactic looks at the breast from multiple angles in a 3 dimensional way and if it's a true mass it will stay visible.  

Does this sound right?  She did say that if I'm concerned she could order an MRI.  I'm so very claustrophobic but I'd do it if it were necessary.  With her explanation, would you still do the MRI?

Answer
I would do the MRI anyway - please see my previous answer! Yes certainly, to be able to guide the needle in a stereotactical biopsy you need a 3 dimensional "model" of the breast the biopsy is going to be taken from where the area - or rather volume - of interest for the biopsy is marked out (= the lesion) so you know what to aim for. This must be done with markers with fixed known positions on the breast and which are visible in the pictures in order to make the aiming possible. To make this 3D model possible a number of different mammography pictures from different directions must be taken. However beside that there is no difference between such pictures and those in which your lesion is visible so I would think that if it was visible in one it ought to be so also in the others. However I agree that if it is just barely visible the risk of any cancer is probably smaller. It may be possible to do the biopsy also with ultrasound or MRI guidance.
Good luck!