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Date of last update: 10/21/2017.

Forum Name: Breast Cancer

Question: normal mammography, ultrasound not so normal

 bridgegal - Sat Jul 24, 2010 4:18 pm

I am post menopausal. Had early stage uterine cancer last year, Grade1A/!. Had total hysterectomy, no further treatment needed.

Had a mammography this week, the first in four years. Mammography of both breasts showed no suspicious areas of microcalcifications, dominant masses or defined axillary adenopathjy in either breast.

Ultrasound was done because of dense breasts. Several cysts shown with no changes since last u/sounds done in 2001. However, the impression was as follows: "new left breast area of shadowing. Although this could represent effects of a new macrocalcification, because of the patient's personal history of uterine carcinoma, further evaluation via a biopsy to confirm the above impression will be performed in a few days. "

A note was also written that this was not present in 2001.

I had the biopsy (fna) two days ago and radiologist seems quite positive that this is benign, but on the report gave me a Bi-rads 4 which freaked me out. Now I have to wait for the result which hopefully will come Monday or Tuesday.

Should I be concerned. Radiologist mentioned that if I had not had the Uterine cancer he would not have biopsied but would have had me return in three months for another ultrasound. He is pretty sure that this is benign.

But I am concerned and can't think of anything else. Would really appreciate some feedback.

Thanks. Shirley Waller
 Dr.M.Aroon kamath - Mon Jul 26, 2010 5:27 am

User avatar Hi,
Ever since their introduction, mammography and ultrasonography for applications in breast lesions, efforts have been continuing to improve their sensitivities,specificities and predictive values.

One such effort resulted in the American College of Radiology "Breast Imaging Reporting and Data System" (BI-RADS-US) scoring system as a standard of comparison for rating mammograms.The score indicates the radiologist's opinion of the absence or likelihood of breast cancer(or Level of Suspicion (LOS)). An important component of the BI-RADS initiative is the lexicon, a dictionary of descriptors of specific imaging features.The BI-RADS-US lexicon is professed to be a living document, open to changes and periodic review.

The fourth edition of the BI-RADS for mammography was published (2003), along with the first BI-RADS for MRI and first BI-RADS for breast ultrasonography.

BI-RADS categories(fourth edition of the BI-RADS mammography -2003) are as follows:

Category 0:Need additional imaging evaluation
Category 1: Negative
Category 2: Benign finding
Category 3: Probably benign finding – Short Interval follow-up suggested
Category 4 (now subdivided): Suspicious abnormality – Biopsy should Be considered
Category 5: Highly suggestive of malignancy – Appropriate action should be taken.
Category 6: Known biopsy-proven malignancy, treatment pending .

By subdividing category 4 into 4A, 4B and 4C(with a small , moderate , or substantial likelihood of malignancy respectively) into the mammography lexicon, it is hoped that the result better informs the physician and patient as to the level of concern regarding the lesion and mentally prepares both the clinician and the patient for the likely biopsy findings and allow them to make an informed decision on the ultimate course of action.

Approximately 10% of women will be called back to undergo repeat mammograms or ultrasound to clarify some finding observed on the first test. Chances of this happening is higher in younger women (particularly < 40 years of age),or women of any age with 'dense' breasts and those having their first mammogram(the lack of a previous film for comparison).

Apart from the BI-RADS,there have been other suggestions put forward to improve on the results obtained from imaging. Some suggested modalities are,
- double reading of mammograms by radiologists (by two radiologists instead of the usual one),
- computer assisted imaging diagnosis,
- quadruple reading: by two radiologic technologists as second readers, in addition to two radiologists,
- systematic follow-up periods,and
- BI-RADS training courses for physicians.

"Using radiologic technicians could be helpful in countries, like the US, where mammography radiologists are increasingly scarce".
J Natl Cancer Inst 2007;99:1162-1170

As mentioned earlier, BI-RADS 4 lesions have an enormously wide range of probability for malignancy (2 - 95%).Your radiologist was(from personal experience and judgment) leaning more towards 2 rather than 95% - in other words towards 4A than 4C! For your sake, i hope he/she turns out to be right.
Best wishes!

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