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Thread: Mammograms and Ultrasounds - FAQs

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    Mammograms and Ultrasounds - FAQs

    "Increased density" on mammogram

    What exactly does it mean when a mammogram report states that there is increased density in the breasts?Increased density usually refers to the presence of more glandular tissue than fat. Often it indicates a degree of fibrocystic change. It is not associated with malignancy but the "denseness" makes it more difficult to read the mammogram and it is a way for the radiologist to say that the reading may be suboptimal but it can't be helped.

    After a mammogram the radiologist suggested ultrasound

    I recently had a mammogram to check a place on my breast which was sore and felt like a lump. After having the mammogram, the radiologist that was there wanted me to have an ultrasound too. However, in a few minutes the technician came back and said the doctor did not see anything and my doctor would get the mammogram report on Wednesday. Now I don't know what to think. I am very nervous. What would you think?

    It is often routine that when there is something palpable on the breast exam but the mammogram is negative, an ultrasound is performed to look for a cyst. The mammogram cannot pick up cysts very well; it is better at picking up solid lesions like fibroadenomas (benign) or cancers. If a cyst is seen on ultrasound, a needle aspiration of the cyst is done.

    Apparently your doctor did not want them to do the ultrasound or the radiologist did not have a standing order to do an ultrasound if the mammogram was negative or perhaps the radiologist did not feel a lump. You should relay to your doctor that the radiologist suggested an ultrasound but then did not do one and ask your doctor to follow through. If your doctor does not feel a discrete lump, then you probably do not need an ultrasound because the mammogram did not find a solid lesion which would be suspicious for cancer.

    Nodular density on mammogram

    My recent mammogram showed a nodular density and my doctor told me to make an appointment with the surgeon to see what he wants to do. What does this mean?

    The finding of a nodular density on mammogram refers to fibrocystic changes that are usually benign. However, the presence of nodular densities makes the mammogram more difficult to read because it is more difficult to see a small lesion on mammogram or to palpate a definite lump on physical exam. The denseness of the tissue thus makes it more likely that a cancer might be missed and your doctor wants the surgeon to recheck the exam and to make the decision whether there are any suspicious areas that should be biopsied. The nodular density finding itself is not a risk factor for breast cancer; many women have these changes. Your doctor and/or the radiologist is shifting the responsibility back to the surgeon who has more experience with looking at the combination of mammograms, physical exams, and postoperative pathology to decide if further evaluation is necessary. This is the way things normally work.

    Palpable lump but nonspecific findings on mammogram/ultrasound

    My 2 aunts (one died) had breast cancer and my mother died from ovarian cancer. I recently had a mammogram because of a small lump in my right breast that is about the size of an eraser. The mammogram report is quite confusing. It says: Complex adult glandular breast tissues predominating in the upper outer quadrants were seen. Vague nodularity suggested on the current study is not well appreciated on the previous examination, but we cannot confirm abnormality on two views suggesting this may be due to positional overlap on the oblique projection only. Ultrasound of the upper outer quadrant was performed at the site of clinical palpable finding and redundant fibroglandular change was identified without cystic or solid mass. Based on this constellation of finding, we would recommend clinical management of the questioned palpable finding. No definite focal target for biopsy is identified on these images. If clinical findings are not convincing to require surgical intervention at this time, we would recommend short term follow up with mammogram to confirm stability of the current presentation. It also states a finding of "probably benign."

    Can you please help me understand this better? The surgeon did not want to biopsy at this time. Should I get another opinion since I can feel a definite lump and there is cancer in the family?

    The report says that the radiologists did not see a definite mass on mammogram or ultrasound and if your surgeon feels there is a mass he should manage it as he thinks best. If the surgeon does not feel a mass that warrants immediate biopsy, you should be followed closely and the mammogram should be repeated certainly earlier than the usual one year. I understand your concern. The general rule-of-thumb is to biopsy a discrete lump even if the mammogram is negative because there is an incidence of about 15% false negative mammogram readings. There can be some exceptions to the "discrete mass" rule but only a very experienced breast surgeon should make those exceptions. If you do not feel satisfied with the options or plan suggested by the surgeon, that's what second opinions are made for. You said the surgeon did feel the lump even though it was small but you did not say what he planned to do. Does he want to follow you and repeat the mammogram in a month and then decide whether or not to biopsy? If he did not think it should be biopsied immediately, did you express your concern to him or did you just keep quiet? The management in a case like yours is not black and white but in that gray area of either approach is probably acceptable. Did you appear to be overly anxious about having the actual biopsy that might influence the decision to go ahead with biopsy now? In any case, express your concerns to the surgeon and ask for a definite plan. If you do not feel comfortable with that, then seek a second opinion.

    The surgeon thought it was too small to biopsy. He just said keep an eye on it and get another mammogram in 6 months to recheck the breast. I did not say anything. I just feel really disgusted, if they can feel a lump how can it be too small to biopsy?

    You need to say something. Call and tell the surgeon you are not comfortable with that and think you should have a biopsy. If he still does not think so, see another general surgeon, preferably one who does more breast work.

    Benign density on mammogram, no palpable masses

    I had a baseline mammogram about 2 years ago at age 30 due to family history of breast cancer (2 aunts). The results were abnormal - a benign-appearing density was found - but it was "not suspicious" for cancer. The radiologist explained that they wanted to be extra cautious due to my family history and a follow-up mammogram was done 6 months later, showing stability of the region. The same was true 6 months after that. I am due to go in again in 2 months, which will be 2 years from the original mammography. I can't help but wonder if a biopsy should have been done. I've been told all along that a biopsy would not be called for due to the findings. These are well-regarded radiologists but I can't help but worry somewhat. What should I do?

    In general, benign-appearing densities on mammogram do not require biopsies as long as there is not a palpable mass. Unless the surgeon can be directed to a specific area by physical exam or abnormal mammogram, just a random biopsy will not do any good. However, while radiologists see many xrays, they do not always get the same feedback linking the radiological picture to pathologic findings that a breast surgeon does. In our area, all decisions to operate or not based on a mammogram finding are made by breast surgeons, i.e., general surgeons who do primarily breast work. While there has been no apparent change in the density by mammography, I would suggest getting an opinion from a breast surgeon rather than relying on the radiologist to make the final decision as to whether or not a biopsy is indicated.

    Non-palpable, deep cyst on ultrasound

    I had physical 4 weeks ago and my first mammogram. It showed a suspicious area deep near the chest but nothing was palpable. I had an ultrasound and the radiologist said it looked like a cyst. My internist says a biopsy doesn't seem necessary. Should I go to a surgeon or another radiologist?

    Breast lumps need to be evaluated by surgeons, not internists or radiologists. See a breast surgeon who will review your mammograms and decide whether it needs aspiration, biopsy or just following the area with repeat imaging studies.

    Unsuspected 1 cm cyst on ultrasound

    I recently had a mammogram which showed what appeared to be a cyst. An ultrasound was done that confirmed a 1 cm cyst. I had no idea I had this cyst. I had a checkup with my gynecologist just a couple of weeks ago, and he didn't detect it either. I am 45 years old and have no history of breast cancer in my family. I was told that the cyst could be left alone or aspirated and that it was nothing to be concerned about. My doctor, however, advised me to have it aspirated because of where it is. I am having the cyst aspirated next week and I understand the fluid will be sent out to be analyzed. I am extremely anxious about what the results will be. Please tell me how common this is, and if I have reason to be concerned.

    Simple cysts are quite common. In fact when they aspirate a cyst most doctors now do not even send the fluid to cytology because the results always come back negative if the fluid is clear. The real test is if the cyst goes away. The general rule-of-thumb is to aspirate a cyst twice. If it recurs a second time, then it is excised.

    Breast cyst not able to be aspirated

    I have a 1 cm breast cyst that the doctor was unable to aspirate. He said there was a lot of "debris" in it and even tried a larger needle. The little bit of fluid that he did obtain is being sent to a lab, and I am very frightened. Both my doctor and the radiologist told me that they are almost sure it is benign and the chances of it being anything to worry about are very small. They have warned me that the results may come back inconclusive because the sample may not be enough. What will happen then? Should I be concerned?

    If the pathology report is inconclusive, your doctor will probably wait and redo an aspiration after a month. If that is unsuccessful, the next step would probably be to excise the cyst through an open biopsy even though it is most likely a benign process. That is just a safe rule-of-thumb to follow, i.e., aspirate and if it goes away, ok, if not, do a biopsy to make sure there is no malignancy. I do not think there is reason to be overly concerned other than the fact this is a problem that is taking some time to be resolved.

    I recently had a mammogram, it showed nothing, right after that I had an ultrasound which did show a lump, which was catergorized as BI-RAD category 4. I am having a biopsy next week. My question is is ultrasounds more accurate then mammograms, why do mammograms get done more then ultrasounds?

    Ultrasound is used to characterize a mass found on a can tell if the mass is solid ,ie:tissue or cystic, ie: a sac of fluid. A cyst is benign, a solid mass can be benign or malignant. BI-RAD cat 4 means suspicious.Approximately 8 out every 10 biopsies are benign...there's just no way to know without looking at a piece of it under a microscope.

    A mammogram can detect calcifications;tiny specks that can indicate a cancer- these would almost never be seen with ultrasound.So, generally a mammogram is the most appropriate first test. Doing an ultrasound first would be indicated in a young woman because cancer is very unlikely and she probably presented with a palpable lump, so the lump would be scanned and most often would turn out to be a cyst.Most breast ultrasounds are "targeted" meaning only the suspicious area is scanned.There are a few lesions that show up with ultrasound and not on a mammogram but not enough for ultrasound to be used a as a screening tool.

    I'm not sure why you had an ultrasound after a mammogram which showed nothing...unless you felt something or have a high risk for breast cancer.
    Most 'big bad cancers" are going to show up on a mammogram so since your mass did not...try not to worry!


    Your Diagnosis Views Please?
    Last edited by trimurtulu; 12-07-2008 at 06:56 AM.

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    What Are the Two Angles of View for a Routine Mammogram?

    During a routine mammogram, each of your breasts will be imaged separately with two different views of each breast. Each view shows somewhat different details and territory.

    •Cranio-caudal (CC) view is taken from above a horizontally-compressed breast

    •Mediolateral-oblique (MLO) is taken from the side and at an angle of a diagonally-compressed breast

    Cranio-Caudal View (CC) A CC view of your breast may be taken during a routine mammogram as well as during a diagnostic mammogram. It will show as much as possible of your glandular tissue (ducts and lobes), the surrounding fatty tissue and the outermost edge of your chest muscle. Your nipple will be shown in profile. The CC view can't capture much of the breast tissue that is in your armpit and upper chest.

    Mediolateral-oblique (MLO) An MLO view of your breast may be taken during a routine mammogram. The angle of an MLO allows more of your breast tissue to be imaged (it covers the main area of your breast) as well as the tissue in your armpit. It will show glandular as well as fatty tissue, and it gives a larger area than a CC view.

    Other Views May be Taken for a Diagnostic Mammogram

    •Lateromedial (LO) - from the outside towards the center

    •Mediolateral (ML) - from the center towards the outside

    •Spot compression - compression on only a small area, to get more detail

    •Cleavage view - both breast compressed, to see tissue nearest center of chest

    •Magnification - to see borders of structures and calcifications.

    Why Use So Much Compression?

    The goal of a mammogram is to get the clearest possible image of your breast tissue, while using the least amount of X-ray dose to get that image. Proper compression helps create the best image because:
    •less motion results in clearer edges (less blurring)
    •more breast tissue can be seen all at once if it’s compressed (spread out, fewer shadows)
    •X-rays can pass through a thinner amount of tissue more efficiently
    •a smaller dose of X-rays are needed to create the image


    General Info:

    Most of the time, a mammogram will show only normal healthy breast tissue. But if breast cancer is present, having a mammogram is one of the best ways to detect it early enough for effective treatment. Since the breast is composed of soft tissue, special X-ray machines and techniques have been developed exclusively for making X-ray images of the breast, and certain radiologists specialize in reading mammograms.

    Examples: If a mammogram shows only normal tissue, your doctor can compare it with a later mammogram to see if anything has changed. A baseline mammogram is the earliest record of a breast X-ray that your doctor has to refer to, when checking for changes with your breast. A diagnostic mammogram will use magnification or more power to produce greater detail of specific areas of the breast that your doctor may need to see clearly.
    An ultrasound is used to check on specific areas in your breast.

    Mammogram and Ultrasound Together Improve Spotting Cancer

    It seems that mammogram doesn’t give a precise view over whether a woman is exposed to breast cancer or not. Using ultrasound in addition to mammography allegedly leads to detect more breast cancers in high-risk women compared with mammograms alone, researchers said Tuesday.

    “Mammograms saw only half of the breast cancers that were present. If we added ultrasound to mammography, we saw 78 percent of the cancers.” said Dr. Wendie Berg of American Radiology Services at Johns Hopkins at Green Spring Station in Lutherville, Md., who did the study.

    A study on the issue was published Wednesday in the Journal of the American Medical Association. The research involved more than 2,700 women over the age of 25. Specialists analysed data from April 2004 to February 2006.

    Some of the women have had previous breast tumors. In such women, mammograms found cancer in eight out of 1,000 women screened. Adding an ultrasound let doctors find cancer in 12 out of 1,000. Together, the tests found 78% of cancers.

    Besides finding real breast tumors, ultrasounds also notice many more suspicious spots that are later found to be benign. On the other hand, 90% of the ultrasound findings in the study proved harmless. That is rather unpleasant for women, because it determines needless anxieties and biopsies.

    Dr. Wendie Berg of American Radiology Services at Johns Hopkins at Green Spring Station in Lutherville, Md., who did the study, admitted that this is a significant disadvantage of ultrasound investigations. She asserted that she would carry on an analysis to see whether it was appropriate or not to introduce ultrasound examination as a routine test.



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