Mammogram, US, MRI, stereotactic & surgical biopsy - oh my!

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snackcakegirl
snackcakegirl Member Posts: 5
edited June 2019 in Not Diagnosed But Worried

First I want to say how amazing this community is - I am so impressed with how helpful and kind everyone is. I appreciate in advance any kindness you throw my way by taking the time to respond.

I have a strong history of cancer and breast cancer on my Mother's side (Grandmother and Aunt dx in their 30s/40s - both passed away from the disease). I was tested for BRCA and was negative. Regardless, my family went through a genetic counselor to understand if we had any genes predisposing us to certain types of cancers, and while we don't, they said it is safe to say we have something that predisposes us to the big C.

I have been fairly diligent about getting screenings every 1.5 - 2 years since I turned 35. Outside of being extremely dense and having cysts in my left breast, everything has been normal until this year. Apparently since my 2017 3D mammogram, new loosely grouped (2 groups) and one tighter cluster of microcalcifications have been found in my right breast on my most recent screening in May. I was sent for magnified views, an ultrasound and even an MRI because I am apparently a "complicated case" due to my density and profound amount of calcs in both breasts. Normally MRIs are ordered after a biopsy, but my radiologist wanted to confirm that a biopsy was really needed because in his words "it is a procedure I don't perform without it clearly being necessary". I had the MRI and outside of having extreme claustrophobia and a week long reaction to the contrast, there were no significant findings.

He re-reviewed all of my magnified images and came to the conclusion the cluster needed to biopsied. I went in for astereotactic biopsy and it was unsuccessful so he recommended a surgical biopsy (he could not get a sufficient view of the cluster using the magnification allowed for this type of biopsy apparently).

I guess where I am confused is, wouldn't the MRI have caught something potentially dangerous? Everything I have read has indicated it is the gold standard of diagnostics, actually has a false positive rate and a very low false negative rate. If this is the case, why am I am being recommended for something traumatic like a surgical biopsy? I realize it is better to be safe than sorry and I do have a significant family history and dense breasts, but what are the chances MRI missed something nasty?

Any wisdom you could share will be appreciated. My consult with the BS is next Wednesday and I plan to ask her the same question :)

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  • Ingerp
    Ingerp Member Posts: 2,624
    edited June 2019

    Snack I too was told that “everything lights up” on an MRI and they have a 30% false positive rate. That said, if there is a potentially suspicious area, a biopsy is the only way to find out for sure. Maybe your BS is being super cautious given your history? Make sure you ask your questions, though. The good news is biopsies are usually really simple with a quick recovery—many women only use OTC pain meds for a day or two.

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  • Krose53
    Krose53 Member Posts: 148
    edited June 2019

    I had a 3mm and 5 mm IDC missed by a breast MRI.

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  • snackcakegirl
    snackcakegirl Member Posts: 5
    edited June 2019

    Thank you Ingerp - I had to get my MRI done during a very specific window of my cycle to avoid the false positive reading. Was your diagnosis missed on MRI?

    Krose53 - thank you for sharing your experience. I am sure it is difficult to relive and definitely helps with my decision.

    This has been a scary and confusing journey but I have always thought that if something was going to test my health, it will be my breasts. I will report back once I have had the consult. If anyone else has anything else to share, happy to take onboard.


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  • djmammo
    djmammo Member Posts: 2,939
    edited June 2019

    snackcakegirl

    If you have the complete MRI report, you can post it here.

    ====

    A few quick points about MRI interpretation:

    Normal breast tissue on MRI is composed of large aggregates of 5mm white spots so if a whole field of 5mm enhancing white dots are present on both sides in a fairly symmetric pattern, we are happy to call that "normal". In fact we tend to ignore anything 5mm and below so as not to overcall the findings; they are "too small to characterize" as we say. Anything larger than that is more conspicuous and grabs our attention. So one limitation of MRI is in cases where there is a cancer measuring 5mm or less. The upside of that is anything 1.4cm or less statistically has the best prognosis so in the long run (re: 5 year survival, quality of life, etc) there is little or no effect on outcome if there is a delay in finding a cancer that small. If there were a cancer present larger than 5mm on your study with the classic irregular margins and abnormal kinetics they would have mentioned it.

    DCIS is what comes to mind when we see calcs and that can be a problem on an MRI with very dense breasts (especially if the scheduling of the study is not done according to your LMP). If the calcs are seen in an area of "non-mass" enhancement then those are the ones they will want to biopsy. With dense breasts if everything is enhancing enough it may be difficult to see that patch of enhancement standing out against the otherwise normal background. If its not clear that there is abnormal enhancement, then one must go by the morphology of the calcs themselves. Some are obvious and some aren't.


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  • Ingerp
    Ingerp Member Posts: 2,624
    edited June 2019

    snack--I only ever had one MRI, of both breasts, with the 2016 DCIS. It didn't show anything additional on either side.

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  • snackcakegirl
    snackcakegirl Member Posts: 5
    edited June 2019

    Hi DJ Mammo - my results from the MRI are:

    Findings: Breasts are extremely dense. There is high background enhancement following contrast administration. In the upper outer right breast 9:30 position, 5.5cm from the nipple, there is a 5x3 mm well-defined mass with type 1 enhancement. This is visible on postcontrast imaging only. Given the enhancement patterns, it is most likely a small benign fibroadenoma. It is not appreciable on prior ultrasound or mammograms. There are no other discrete masses. There are no suspicious foci of type 2 or type 2 enhancement in either breast. Precontrast inversion recovery sequence demonstrates tiny (<5mm) cysts in outer left breast. These have no enhancement and are considered benign. There is no axillary lymphadenopathy.

    Impression: MRI demonstrates no spiculated or irregular masses. There are no suspicious foci of type 2 or type 3 enhancement in either breast. A single 5x3 mm low-density well-defined mass with type 1 enhancement is noted in the upper outer right breast 9:30 position, 5.5cm from nipple. The appearance is most consistent with a benign fibroadenoma. There is no corresponding visible abnormality on mammogram or breast ultrasound, likely because the overlying breast tissue is so dense and nodular. Follow up in 6 months is recommended.

    The most definitive cluster of microcalcifications on mammogram is visible on the non-magnified right ML view dated 5/15/2019, located in the upper outer right breast, 5.5cm from the nipple, and labeled #1 on the mammogram. Recommend attempting a stereotactive core biopsy of these calcifications for definitive evaluation.

    This biopsy was unsuccessful so now I have the recommendation for surgical biopsy. What I find interesting is it almost reads like the fibroadenoma is in the same position (upper outer right 5.5cm from nipple) as the microcalcs. Am I going crazy?

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  • Trying2staypositive
    Trying2staypositive Member Posts: 119
    edited June 2019

    snackcakegirl-nope you are not crazy! If they do mean its the same area...Cant benign things cause microcalcs? Thought I read that. Maybe they just want to double check this pprobably benign thing bc biopsy one wasnt clear or successful. Surgical biopsy will tell you for sure. Still a bummer to do anything surgical. I understand

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  • Meow13
    Meow13 Member Posts: 4,859
    edited June 2019

    I really like the radiologists at my imaging center they always review my images side by side from last year and show me what they see. I can literally see for myself what they look at and what it means.

    I guess the scientific nature in me finds it fascinating.

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  • djmammo
    djmammo Member Posts: 2,939
    edited June 2019

    snackcakegirl

    FA's can develop calcifications but usually only when the FA is older and bigger, also the calcs they develop are large and can usually be distinguished from the calcs of DCIS or ADH etc. They will have to do a pre-op localization procedure to direct your surgeon to the target calcs. This can be done with a wire or radioactive seed.

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