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Posted by Betsy Mullen on 8/12/2000 from 152.163.194.183:

In reply to: Repeat Mammograms posted by Diane Hunt on 8/12/2000 from 152.163.194.183:

Dear Diane:

I wanted to touch in with you to see how you are doing. I am sorry that you have been going through so much. Sunnie is correct – most breast lumps (over 80%, including cysts) do turn out to be benign. Are you fully recovered from thyroid cancer? One of our top staff members has had thyroid cancer and she is a wonderful resource on both the thyroid and breast cancer fronts.

With respect to your radiology slip indicating "other" with the numbers 174.9- 610.1; "other" could indicate just what Sunnie said, a close-up or "mag" (magnified) view of the area. The numbers could be internal codes for billing or other purposes. Regardless, you absolutely deserve full explanations of any and all tests, procedures, paperwork; you name it – with respect to your health and what is going on.

Cysts can go away and can be impacted by hormonal changes. *Cysts are less common in postmenopausal women who are not receiving hormone replacement therapy (HRT) and should be regarded with suspicion. The question of solid versus cystic can be resolved using fine needle aspiration (FNA) or ultrasound. In postmenopausal women, aspiration is the first step in the diagnostic evaluation. (*Source and Suggested Resource: Diseases of the Breast, Second Edition; Editors: Jay R. Harris, Marc E. Lippman, Monica Morrow, C. Kent Osborne; Publisher: Lippincott Williams & Wilkins; 2000; ISBN #: 0-7817-1839-2.)

If you are very uneasy, perhaps you should discuss having the cyst aspirated with your doctor(s); and please bear in mind that I am not a health care provider. I am a strong advocate of second opinions and suggest that you do discuss your questions and concerns with any and all members of your health care team who you think will be helpful to you.

I would like to provide you with some good information about breast calcifications. I am using a pamphlet produced by the U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health as the source of this information (NIH Publication No. 91-3198).

Breast calcifications are small calcium deposits in the breast that can be detected by mammography. They are divided into 2 categories: 1. Macrocalcifications and 2. Microcalcifications.

1. Macrocalcifications are coarse calcium deposits that most likely represent degenerative changes in the breasts, such as aging of the breast arteries, old injuries, or inflammations. These deposits are associated with benign (noncancerous) conditions and do not require a biopsy (a procedure that removes the tissue for examination under a microscope). Macrocalcifications are found in about 50% of women over the age of 50, and in about 10% of women under the age of 50.

2. Microcalcifications are tiny specks of calcium in the breast. These tiny calcifications are usually in an area of rapidly dividing cells. When many microcalcifications are seen in one area, they are referred to as a cluster they may indicate a small cancer. A large percentage of the cancers detected by mammography appear as a cluster of microcalcifications.

Question and Answer: What if microcalcifications are found on a mammogram?

An area of microcalcification that is seen on a mammogram does not always mean that a cancer is present. In some cases, the microcalcifications do not even indicate a need for a biopsy. Instead, a doctor may recommend a follow-up mammogram within 3 to 6 months. In other cases, the microcalcifications are more suspicious and a biopsy is recommended.

Question and Answer: How can a breast biopsy be done if there is no lump?

A mammogram and ultrasound may show an area of abnormal tissue that is too small to be felt. Here is some information straight from our web site (winabc.org):

When Your "Lump" Can Be Seen But Not Felt

Sometimes you can have an area of concern that cannot be felt in the breast but shows up on pictures of the inside of the breast. These pictures are taken by either mammography (a type of x-ray) or ultrasound, a process that shows harmless soundwaves as they travel through a breast. In these cases you may have one of two biopsy procedures:

1. Needle Localization Biopsy

Using a mammogram or an ultrasound as a guide, a doctor places a needle or fine wire into the suspicious area. The area is then removed with a surgical biopsy. A second picture of the biopsy area may be taken later to make sure that the area of concern was entirely removed.

2. Stereotactic Needle Biopsy

This procedure pinpoints the area of concern with a double-view mammogram. A computer plots the exact area and guides a fine needle or a large-core needle so that a doctor can remove a sample of tissue for the pathologist.

If your biopsy result is negative, your treatment is over. It still will be important to have your breasts checked regularly for any future signs of change. If the result is positive, the cells did contain cancer and you will need to make decisions about your treatment options. Remember, "early detection is a key to protection"; and there are people who can help you through this process.
(Adapted from "A Woman's Guide to Breast Cancer Diagnosis and Treatment",
published by the California Department of Health Services, and "The Breast Buddy
Volunteer Training Curriculum", © WIN ABC 1994.)

Question and Answer (same source from the US HHS/NIH): Why is a biopsy done if there is no lump?

Breast cancer can be present in the absence of a lump. A biopsy is done to find breast cancer in its earliest stage, before it has spread and when it is most curable. As a rule, breast cancers discovered as a result of mammography tend to be small, and they are ideal for treatment with lumpectomy and radiation, treatment that preserves the breast.


I know first-hand how scary this all is, but always try to keep in mind that you are the boss – health care providers work for you and with you – it needs to be a team effort and you should always feel free to ask questions and ask for, and receive full explanations of what is taking place before, during and after any medical examination and/or procedure.


Now, let’s get to some specific information/questions you should discuss with your doctors:

1. Do you have a family of breast cancer?

2. Do you have any known risk factors?; Do you know what some of the breast cancer risk factors are?

3. Do you know how to do a proper breast exam? You can receive this information and register for monthly breast self-exam reminders right on our web site (www.winabc.org)

4. Was your current mammogram compared with previous mammograms?

5. Did you receive a copy of the radiologist’s report/findings from this last mammogram? Your previous mammograms? If not, you are fully entitled to the written reports.

6. Did your physician(s) mention whether or not the calcification(s) were a cluster of microcalcifications, and if so, where the affected areas are in your breast?

7. Did you physician(s) discuss the possibility of a breast ultrasound?

8. Have you ever had a breast biopsy prior to these findings?


These are all things to think about and discuss with your health care team.


Here is some additional information that I hope you find helpful:


Excerpts from: Breast Imaging Frequently Asked Questions


Source: Richard L. Ellis, M.D.
Memorial Medical Center, Department of Radiology
Division of Breast Imaging. Springfield, Illinois 62794


Q: At what age should a woman have her first screening mammogram and how often thereafter?

The American Cancer Society guidelines for the detection of breast cancer in asymptomatic women are:

1. Women 20 years of age and older should perform self-breast examination every month.

2. Women 20-39 should have a clinical breast examination of the breast every three years, performed by a health care professional such as a physician, physician assistant, nurse, or nurse practitioner.

3. Women 40 and older should have a physical examination of the breast every year, performed by a health care professional.

4. Women 40 and older should have a mammogram every year.

The American College of Radiology also recommends yearly mammograms and yearly physical examinations starting at age 40.

The most recent clinical trials for screening mammography indicate that the benefit of screening mammography for women in their forties is at least a 24% decrease in death rates due to breast cancer. It is very important to remember than approximately 90% of all breast cancers can be detected by mammography. Therefore, monthly self-breast examinations and yearly health care professional examinations are very important for detection of cancer not visible with mammography. When yearly mammography, monthly self-breast examination, and yearly health professional examination are utilized in combination as recommended, potential detection of cancer at its earliest stage is possible.

Also, a new policy that became effective January 1,1998, allows one screening mammogram per year for women with Medicare insurance beginning at age 40.


Q: What is the difference between a screening and a diagnostic mammogram?

A screening mammogram is an examination using low dose X-rays to evaluate the breast for potential abnormalities, and it provides a general overview of the breasts. A screening mammogram is not intended to diagnose cancer but rather screen out patients who will require additional evaluation in the search for potential breast cancer. If a questionable abnormality is detected on the screening examination, then a more detailed diagnostic mammogram is required. The diagnostic mammogram is performed using special X-ray views (i.e., magnification, spot compression, etc.) that allow a detailed evaluation of the region of interest. Approximately 10% will be recalled after the screening mammogram for additional diagnostic evaluation.


Q: Are the recommendations different for women who have a positive family history of breast cancer?

For women with a positive family history of breast cancer in a premenopausal first-degree relative (mother, sister, or daughter diagnosed before age 50), screening is suggested to begin ten years before the earliest breast cancer occurrence in the family, but not before age 25. Example: If a mother is diagnosed with cancer at age 45, then all daughters and younger sisters should start screening mammography at age 35. Currently, there is no information to suggest that screening intervals shorter than one year are beneficial, even in women who have a strong family history of breast cancer.


Q: What is the appropriate exam for a patient under the age of 30 with a palpable lump? With breast pain or tenderness?

In general, young, pregnant, or lactating women with abnormal breast lumps should be evaluated with breast ultrasound as the first imaging study. Mammography is reserved for young patients when the ultrasound examination is inconclusive or suggests the presence of breast cancer. However, in young women with fatty breasts or who have several children, mammography can frequently provide valuable information since dense breast tissue is no longer a limiting factor. What is important to understand is that although the examination sequence to evaluate patients younger than age 30 may be different, the same diagnostic process to arrive at the diagnosis is still used. This individualized work-up requires a breast imaging specialist well-trained in breast disease.

Patients with diffuse breast pain or tenderness usually require reassurance, without the need for breast imaging studies. Localized breast pain, which the patient repeatedly pinpoints the region of pain, is rarely associated with breast cancer. However, when present and persistent, such cases merit a diagnostic evaluation with ultrasound and/or mammography. If a young patient presents with secondary signs of breast cancer (skin thickening, retraction, bloody nipple discharge, large mass, etc.), the initial examination is usually mammography, supplemented by additional examination and biopsy, if needed.


Q: Why is ultrasound performed in addition to mammography?

Ultrasound is an excellent adjunctive examination to mammography, but it cannot be a substitute for the screening mammogram. As noted above, ultrasound is the primary examination in young, pregnant, or lactating women with palpable abnormalities. It is also routinely performed on women with clinical findings whose mammograms are unrevealing and on those whose mammograms show an area that requires further evaluation. Ultrasound is also used to guide interventional procedures, such as needle localization, fine needle aspiration, core biopsy, and percutaneous ductography.

A reliable aid in the diagnoses of most breast cysts, ultrasound can be used to guide benign cyst puncture for those who are symptomatic or do not meet stringent criteria for diagnosis of a benign cyst on ultrasound. In addition, it can provide reassurance that no mass underlies a questionable palpable area. According to recent evidence, ultrasound can aid in the benign-malignant differentiation of solid breast masses and prevent biopsy for many noncancerous masses, such as fibroadenomas.


Q: What other diagnostic procedures are performed in mammography?

Once an abnormality (abnormal mass, calcifications, distortions, etc.) is detected on the screening mammogram, a diagnostic mammographic examination is generally performed in order to obtain special views of the abnormality allowing a more detailed evaluation. This additional mammographic examination may include the use of special X-ray maneuvers and magnification of the abnormality in question as mentioned previously.

Ductography is an examination that allows detailed evaluation of the breast milk duct and is indicated when there is a bloody nipple discharge or persistent discharge from a single duct in the nipple. There are approximately 15 to 20 major milk ducts that converge to the nipple. If the discharge is noted from multiple ducts or from both nipples, a ductogram is not indicated. The cause for multiduct discharge is usually related to a systemic cause (hormonal effect, pituitary disorder, etc.) and is not cancerous. The examination is usually performed by inserting a small cannula (thin tube) directly inside the duct ostium in the nipple and contrast (X-ray dye) is injected to fill the duct. If the cannula cannot be placed through the ostium, the abnormal duct (which is usually enlarged) can frequently be filled percutaneously with ultrasound guidance.

Magnetic resonance imaging is a special radiologic scanning method that is extremely accurate for evaluation of breast implants when there is a suspicion of implant rupture or leakage due to trauma or implant breakdown due to age. In addition, MRI is beginning to show promise as a tool that in the future may allow differentiation of benign and malignant lesions in the breast and provide better demarcation of the size of the lesion to assist surgery. In addition, MRI may help determine recurrence of cancer in the breast after treatment.

Nuclear Medicine Imaging, using sestimibi (Miraluma), is currently available as an additional diagnostic examination for selective patients. We are also using monoclonal antibodies for breast cancer under clinical research trials to evaluate their efficacy in selected patients with the hope of helping to differentiate between benign and malignant breast lesions.


Q: What are the procedures used to remove breast tissue for pathologic diagnosis?

The type of breast biopsy performed is predicated upon the type of breast lesion and using the following basic principles, understanding that many breast biopsies are benign (noncancerous):

Most accurate diagnosis with the smallest amount of tissue removed;
Least amount of trauma to the patient; and
Most cost-effective biopsy method.


Fine needle aspiration biopsy removes a small sample of cells from an abnormal breast lesion and requires the aid of the cytotechnologist and cytopathologist for preparation and interpretation. Preliminary results are usually available in a few hours with this procedure. Also, fine needle cyst aspiration is usually performed with ultrasound guidance in order to remove the fluid contained in breast cysts. Although cyst puncture for palpable lesions can be performed without guidance, it is more reliably accomplished when the cyst can be entered and completely evacuated under direct vision with ultrasound.

Core biopsy is performed with either ultrasound guidance or stereotactic guidance and allows the removal of small strips of tissue that the pathologist can analyze. Although this procedure can be performed to confirm malignancy in a highly suspicious lesion, more commonly the biopsy provides verification that a lesion is benign and thus prevents surgical biopsy or multiple follow-up examinations. Results from a core biopsy are generally available in 48 hours.

Needle localization breast biopsy is performed to guide surgical excision of nonpalpable lesions. The placement of the small wire may be done with mammography or ultrasound guidance. Mammography guidance is generally used for lesions presenting with microcalcifications without a mass. Once the small wire is placed in the correct location, the surgeon then has a guide wire to direct the removal of the breast abnormality. Once the abnormal tissue is excised from the breast, a specimen X-ray obtained on the tissue in order to demonstrate that the abnormality was removed from the breast. Generally, results from a needle localization biopsy are available in 48 hours.


Diane, WIN Against Breast Cancer has several resources that I think will be very helpful to you. We would be happy to send you educational materials, free of charge regarding breast self-exam, breast health, understanding breast changes, questions to ask your health plan about exemplary care (found on our web site under help yourself – 10 key questions for women to ask their health plans), breast cancer myths and much, much more depending upon your needs. We have trained information specialists in our offices that can speak with you one-on-one to determine the best materials to send you (all free of charge). WIN ABC also has published an in-depth resource guide with additional resources and suggested reading.

AN IMPORTANT REMINDER: It is very difficult to render an opinion without knowing all the facts of any one particular case. But one strong recommendation we would like to make is that you pursue your question(s) with your own physicians. You should feel fully empowered to obtain a satisfactory answer and feel free to seek a second or third opinion. We have some great tips on partnering with your health care team and key questions to ask your doctors, communication tips and informed decision-making tips to help you get the information you need. There is a special form on our web site (blue link at the top of this page) that you can fill out and e-mail to us to help us best meet your needs and you are also welcome to call us at (626) 332-2255. Your information will be kept confidential.

I will close with this thought and a saying of mine: "When in doubt, check it out." You know your body well and are your own best advocate. Pursue any concerns with your health care team. We are strong advocates of second opinions.


Please feel free to telephone our office and to fill out the Personal Profile Form via the link at the top of this page so that we can best meet your needs. Your information will remain confidential. Please keep us "posted" on how you are doing and how we can best help and support you, Diane.


My warmest regards,

Betsy Mullen
Founder, President/CEO
WIN Against Breast Cancer
www.winabc.org
(626) 332-2255

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