Imaging prior to biopsy

[AlaskaAngel]

I would like to post this question as a poll, to see what is commonly done in our group when a biopsy is recommended.

[StephN]

Hi AA -
Maybe you could redo this poll, as it does not apply to those of us who found our lump which did not appear on a recent mammogram.

Since my lump was palpable and mammogram was within 3 months, they went ahead a biopsied with no imaging.

Not quite sure what you are driving at with this one.

[AlaskaAngel]

Hi StephN,

Thanks for the question -- The reason I am asking is to try to nail down whether or not it is still standard practice to have to be recognizable lump found either by palpation or by imaging prior to going ahead with a biopsy.

In other words, I want to know whether a biopsy would be recommended without any evidence beyond something like calcifications on a mammogram.

A family member in the Lower 48 has been recommended to have a stereotactic biopsy, but no lump has been either felt or imaged by ultrasound or MRI or anything, and her mammogram shows just coarse calcifications, and she is having trouble getting any imaging authorized to verify that there is any lump. This is not standard practice as I know it and would result in an awful lot of benign biopsies (and the trauma both physical and emotional that goes with it all). So I am hoping to double check here with others to see if the standard has for some bizarre reason changed in this respect.

AlaskaAngel

[Becky]

I could answer both ways. As you know, I found my IDC in my right breast via self exam. I had a mammogram and since "lefty" needed to be done in 4 months, we mammogramed both sides. Lefty had clustered microcalcifications that were also surgically biopsied during my rightie lumpectomy. Lefty was dcis so I can answer yes to one side and no to the other. I have not voted due to this so I don't screw things up for you.

Secondly - prior to surgery the lump was biopsied via fine needle but the left was not and done surgically. It was small and they probably would have missed it anyway (as it was only 3mm of dcis)

[karenann]

AA,

I don't want to mess up your poll either... I found my lump via self exam. When I went to have a mammogram, even with the little sticky arrow they stuck right where the lump was, it was hard to see anything (very dense breasts), so they did an ultrasound and found the solid mass.

Karen

[dlaxague]

Hi AA,

I, too was wondering where you were going with this. I can't respond to your poll either because it doesn't apply to my situation.

My sense is that most of us on this list are not brand new to breast cancer diagnosis, so you will not be getting current practice information anyway. Someone recently told me that breastcancer.org has lots of forums on many specific topics - perhaps that would be a place to look for input on current practice standards.

But I do know that both DCIS and lobular cancer can present without a palpable or distinct lump. I'd even wager that most DCIS is found when they see calcifications rather than distinct lumps. But I don't know know much about this so don't count my opinion for much. I think that they are able to tell (sometimes) which are okay calcifications and which are suspicious.

Now that we have so many more imaging options after diagnostic mammography or U/S, I'm not sure if there is a standard of care regarding how to proceed and where the biopsy enters the picture. I'll be curious to hear what others have to say.

Debbie Laxague

[madubois63]

Well, I don't apply to this poll either. Inflammatory bc is not detected with a mammo and there is no lump. I found a small patch of hard, scaly, warm skin. I went to the gyno and he said "Go home, it's nothing. Put some warm pads on it and it'll go away." I was stage IV - idiot!! The next doctor ordered an ultrasound, and then that tech ordered a biopsy.

My mom could answer your poll as yes.

[AlaskaAngel]

I think my problem here is that the poll function allows just very short uncomplicated questions to be asked, with only very simple responses. Some have indicated that they found their own lumps themselves by being able to feel them.

What I want to know is how many people were biopsied without anyone (including themselves) determining that there actually was any lump at all TO biopsy.

I want to know if it makes any sense to all you people who have been diagnosed with breast cancer, if neither the doctor nor the patient has felt any lump or symptom AND the medical provider refuses to provide an ultrasound or MRI to show that there really is any lump at all, and yet advises the patient to have a biopsy just because the patient has calcifications on mammogram. In the case of the person I am concerned about, the calcifications are even not typical for cancer but instead are coarse calcifications (although there are a fair number in the clump). It makes no sense to me at all, but I'm trying to find out from all of you whether this is becoming standard practice for some strange and undetermined reason.

Inflammatory breast cancer would be the exception in that it would be seen as a sign on the skin, and then biopsied to verify it rather than imaging it or finding a lump. But what I am asking is if there is no sign or symptom other than calcifications, is it still standard practice to verify that there is a lump before doing a biopsy, or is it normal for a breast cancer imaging center to biopsy all women who have no sign or symptom and no demonstrated lump just because they have calcifications on their mammogram? This woman has tried to request further imaging from her HMO to verify whether there actually is any lump at all, and they are refusing and basically telling her she should have just the biopsy. Does that make sense to you? It doesn't to me.

Thank all of you for your patience with this question. I think something is not right about this. Not only that, but when she asked about possibly choosing an excisional biopsy, the doctor at the breast cancer center said "that would be pretty extreme, given her mammogram". Either she does need a biopsy or she doesn't; what kind should be entirely up to her. It makes me all the more suspicious when they are not willing to verify that there actually is ANY lump and just want to go straight to stereotactic biopsy.

Please help with further replies and by answering the poll as best you can. She is supposed to be biopsied on this coming Thursday. I just want to know if I am wrong about this or not, and if so, why?

Thank you,

AlaskaAngel

[StephN]

Hi AA -

Yes, it is not a simple question.

I do have a friend who is a nurse who had suspicious calcifications a few years back. She did not have a family history of BC, but pushed to have a lumpectomy and have the tissue removed.

They did find "atypical cells" which likely would have gone on to form cancer.

She was fairly flat chested and the place of the excision was on the side and not noticeable. She was most relieved not to have to keep going back and and be in the "watchful waiting" mode.

Seems to be a similar situation to the person you are asking for.

P.S. It took THREE biopsies for them to confirm my cancer. My actual tumor was quite small but there were "atypical cells" in the tissue surrounding the tumor since it was no longer in situ. This is why I think she needs to get more than what a needle biopsy can take.

[Montana]

Yearly mamo found calcifications (dcis) which were then immediately ultrasounded. No lump was felt. Stereotactic biopsy followed later in the week. The IDC was found during lumpy.

[lizm100]

AA-
I did not have a lump in my breast but the area for me felt different may be a little thickening. In a nut shell my gut said something is not right. I way my gyn in October and she said not to be concerned but I went back to her in January and she validated my concerns and said "a mammogram won't hurt" but to her everything feels fine. I was only 38 at the time. That afternoon I had a digital mammogram which showed intraductal microcalcifcations. I also had an ultrasound which showed nothing. My 20 minute mammogram appointment ended up taking almost 4 hours. The radiologist added many more films and after reviewing all of them, told me that he was pretty confident that I had early stage breast cancer. I saw a breast surgeon in 2 days (thanks to a cancellation or I would have to wait a couple of weeks). Had a mammotone biopsy about 2 weeks later confirming breast cancer. Lumpectomy 2 weeks later and re-excision 2 weeks after that.

[Becky]

If the calcification appear to be the type that look suspicious - clustered and small, not lucid, I wouldn't hesitate on a biopsy. I am the calcification Queen as is my sister - large, perfectly round boulders throughout both breasts. Many of them are what they call lucid - translucent at the top with "settled" calcium on the bottom (this is called a teacup presentation) and both types are always benign - just part of who you are. But the small, not perfectly round and clustered (clustered is key) are the ones to really watch out for.

I would never allow a needle biopsy again and would insist on a lumpectomy type biopsy. I did this for my mom who got a stereotactic biopsy where a wire was inserted so the surgeon could find the area easily.

[Henny]

I had a mammo which showed a few new calcs that weren't there the year before. I had no palpable mass The radiologist suggested waiting and redoing the mammo in 6 months. I suggested that I call a surgeon since if they weren't there the year before they shouldn't be there now.
I called a well know surgeon and made an appointment. In the meantime a clinic in town got a new breast only PET scanner (PEM) and I had a free scan there (since they were just getting started). It showed a big hot spot where the calcs were. I went to the surgeon with the PEM scan in hand. Turned out to be IBC and also a DCIS.
Imaging may be expensive but I still think it's cheaper than doing invasive procedures. My surgeon said her philosophy is to image twice and cut once
Alaska, If I were your relative I would ask for more imaging to get to the bottom of this. With mammos, Ultrasound, MRI, PEM, and BSGI (breast scinti gamma imaging-like PET but different isotope) there should be no reason to do a biopsy blindly
Henny

[AlaskaAngel]

Thank all of you who took the time to respond to the poll and the questions involved with this situation.

When I originally posted the 2 threads about it, I thought that I might simply not be clearly understanding the rationale of the breast cancer center in scheduling my relative for a stereotactic breast biopsy based on the second-hand information that I had, or that maybe there had been some legitimate change in the basis for the sequence of events normally used for biopsies. I don't claim to be an expert about the latest and greatest and to me that meant I needed to see what others might be seeing elsewhere in the world, but I am reasonably knowledgeable.

I remain concerned. The breast care center is where the patient was referred by her HMO. The concern I have is for those like this woman, who at age 48 had never had an abnormal mammo and has no knowledge as to what is standard practice for her situation. She is dependent upon her medical providers, her own slow research at a time of crisis, and her friends and family for guidance.

A mammogram and mammogram report are intended to provide the initial analysis by a professional radiologist for her PCP to help in making further decisions. This mammogram was designated as BI-RADS 4b and that is a recommendation for consideration of biopsy rather than "wait-and-see" if anything else develops in the short future. Normally in my experience the BI-RADS 4 level is not assigned unless the radiologist has either seen and mentioned clear evidence for it in the report or has done additional imaging that brought out additional supporting evidence for a reasonable need for a biopsy. The information given in the mammo report was more at the level of what one would see in a BI-RADS 3 level designation, so I questioned it. The fact that the radiologist had also specified the type of biopsy raised concern for me, as that in itself infers that neither the PCP nor the patient should authorize any other type of biopsy. That, to me, is highly questionable. A patient should always have the full range of options open and explained fully to her, whether she elects to have no biopsy, a fine needle biopsy, a core biopsy, a stereotactic biopsy, or an excisional biopsy. If there is a very specific reason why a stereotactic biopsy is preferred, it should be clearly so indicated on the mammographic report, and there was no such indication on her report.

Some here feel the need for the earliest possible confirmation by biopsy, and may not understand why the step-by-step approach is so important. But what I think is at stake here is the rush to sacrifice logic and patient choice for expediency and/or cost.

I consulted an online specialist, who confirmed both that a biopsy was needed (because that is the only way to definitively determine what the cells are doing), but also said that further preliminary imaging is important" "ultrasound & MRI scans NOT ONLY to find other ways of doing biopsies but ALSO to gain more information of/from the mass" prior to biopsy. Also, additional imaging can provide further information about any other questionable mass that simply hasn't shown up on the mammogram by calcification. Mammograms are usually the first step not because they do such a great job, but because they are inexpensive enough to reach the most patients for screening purposes.

The vast majority of biopsies show no cancer. At this point after considering this issue, I don't believe it is standard practice to biopsy immediately all patients based on mammographic clustering of coarse calcifications and patient history alone. I also believe that the specific recommendation of a stereotactic biopsy without any clear supporting reason for that particular type of biopsy is ethically problematic. I think going along with these practices does not protect the rights of the patients -- OUR rights and those of others.

Again, thank you all for taking your time to consider this issue.

AlaskaAngel

[BonnieR]

AA. I will add my experience to the mix. I had a "suspicious area, probably benign, return in 6 months" mammo. I decided to get a second opinion of this reading. Went to a doc who specializes in breast care. She did an ultrasound which confirmed calcifications. Also sent me for an MRI which did not show it. (I am having difficulty remember the sequence. It seems to have happened a long time ago although it was only 2007!) She followed with a sterotactic biopsy which then confirmed cancer. I am grateful for her dilligence. Hope this helps. I find it all very complex!

[Jackie07]

I thought I had posted the other day when I participated in the poll. Guess it was a 'false memory'.

I would rather have a doctor who is 'overly' diligent about finding cancer. I have a tiny spot in the underarm lymphnode scar area. Neither my doctor nor my husband can feel it with their fingers. But I can feel it because of the pain when pressed.

My next appointment is not until February (or March?) So I made an appointment with my family doctor in mid January - couldn't book anything earlier. I know I can walk in any time if there is something 'significant'. The
neuropsychologist I saw in July had stated that it is probably normal for me to be so concerned judging my 'very significant medical history'.

[Marlys]

Maybe you need to take me from the "Yes" as I found the lump when it caught on my bra when I was putting it on.. I had the mammogram 2 days later and the needle biopsy the 3rd day.
Love & hugs,
Marlys

[SoCalGal]

Hi AA - I had a core needle biopsy in the unaffected breast due to calcifications on the mammogram. My understanding is that calcifications often gather near cancer and the "tumor" is not always palpable. With the non-invasiveness of that biopsy I think that better safe than sorry is not a bad thing. On the other hand - I also had a core needle biopsy that removed the calcifications (this was the affected breast) and came back from the lab "benign". I rejoiced only to get a call from the radiologist that they did not think they sampled correctly - even tho the calcifications showed up in the sample scanned. (I was a witness to that part so I saw for myself the 3 dots in me and then the 3 dots in the needle). Long story short (it's too late for that) they recommended a surgical biopsy for a definitive answer and thank god they did because that was my first recurrence in '02. Had they given me a pass and had I not sought treatment - well we all know what the end of the story would be
Hope this helps! Happy Holidays. Flori

[Kimberly Lewis]

all I had were calcifications - when the surgery was finally done - they told me it was stage 0. When they got in however it was stage 3. Big difference and the tumors were not seen on the mamogram. In my case it was very important!