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Thursday, December 5, 2013
I am a 54 year old woman in excellent health. I exercise, eat well, don`t smoke and have no family history of breast cancer. I have never had an "abnormal" mammogram in all the years I have been getting screened since my 40`s, except for the one I had several weeks ago. I have moderately dense breasts and microcalcifications appear in "patchy asymmetric distribution, with a component of diffuse underlying modularity.". This last last examination, included a mammogram view and magnification of my left breast, which hadn`t been done in the prior two years. The left breast indicates numerous scattered calcifications with a "somewhat ductal orientation within the retroareolar 6-7:00 axis of the left breast." A biposy is advised; however, due to the superficial nature, this is not amenable to stereotactic biopsy, an excisional biopsy would be required.
Are there no other less invasive ways to determine if these microcalcifications are anything to be concerned about? Would an MRI be a conclusive test to identify what is difficult to see because of the location proximate to, and perhaps behind my nipple? If 80% of the time, these are benign, going under the knife seems drastic. Are there no state-of-the-art techniques out there to help me? I am opposed to surgery as the first step, unless I can have a biopsy or more conclusive evidence that it is necessary.
It does sound like a biopsy, however it can be done, is a good idea. One option would be to take your films to a second breast center to see if the mammographer there feels s/he can perform a stereotactic biopsy. However, most excisional (surgical) biopsies result in minimal scarring of the breast. MRI scans unfortunately do not help us decide if calcifications are benign or malignant. I also referred your question to the head of our mammography physician group and here is her answer:
Without seeing the mammogram here is what I think is going on: Calcifications are common in the breast. Most of the calcifications seen on mammogram are benign. There are certain calcifications that are more concerning. Calcifications that line up and point toward the nipple in a ductal distribution are concerning for possible early cancer or ductal carcinoma in situ (DCIS). That is why we biopsy those calcifications. We do not let how we need to biopsy a patient sway our decision to biopsy. If a patient refuses the excisional biopsy at least a 6 month follow up mammogram with magnification views should be done. That way with close follow up we can determine if there are any changes that may warrant biopsy at 6 months. If there is no change following the calcificatons every six months for two years then they probably do not need to be biopsied.
Stereotactic biopsy is the most noninvasive way to biopsy calcifications in the breast. However there are some patients that are unable to undergo stereotactic biopsy. If the breast thickness under compression is too thin the needle used to do the biopsy may not have enough tissue thickness to fit in the breast. If the calcifications are near the nipple there may not be enough breast thickness to fit the biopsy needle in the breast. The breast is thinner the closer you get to the nipple. Sometimes we are able to do patients with calcifications near the nipple it just depends on the breast.
Paula Silverman, MD
Associate Professor of Medicine
School of Medicine
Case Western Reserve University