Trying to raise my kids the best I can

Thursday, May 20, 2010

How to read a mammogram

Have you ever wanted to know how to read a mammogram? Well, I never did. lol. But this week I did a temp job, recording hundreds of mammogram results for a Doctor while she read them... and now I (sort of) know how to read them. It's fascinating and fun! It's like playing "Where's Waldo" and after reading this, you too, can know how to read a mammogram! (sort of).

The radiologist I worked with was just amazing. She was so patient with my questions. We really clicked. She was one of many doctors working on a study that Hologic is doing as they attempt to get FDA approval for their new alternative imaging to the mammogram. This one is called a Tomogram or "Tomo" for short. I honestly couldn't tell the difference between the two images if my life depended on it. She seemed to prefer the mammogram but, like she said, "if we can diagnose with the same, or better, accuracy, then who am I to say I prefer this one because it's more aesthetically pleasing to me". Also the Tomo is less radiation. It seems to cause more call backs for calcifications though.

Here is what you are looking for:

A Mass. It is, well, just like it sounds. A clump of cells. These warrant a call back. If they project a star-like-look, "tethering" to the tissue around it- they are really really bad. Cancer is a parasite to all the cells around it. It can even suck in a nipple, turning it inverted.

If you have a star-like area but no clearly defined mass in the middle you call these back too. They are categorized as architectural distortion.

Focal asymmetry is a density seen on only one view (or sometimes in only one breast). Mammograms come in two different views: lateral and vertical. (by smooshing the breast once in each direction). Actually the vertical one is a little bit more at an angle to get more axillary tissue in (since that's where the lymph nodes cluster). When you find a spot in one view you have to find the same spot in the other view. The trick is- since they are from different points of view they are at different positions! One shows location and the other depth. It's fun to look at the two pictures and try to pinpoint exactly in the breast where the mass is. To check to see if the two spots you've decided on are the same thing you have to measure their distance to the nipple, as that will coincide.

Calcifications. AKA Calcs. -calcified cellular debris. These are the bright white spots on the mammogram. If they are round, clearly defined, maybe popcorn in shape- those are benign and don't warrent a call back. If they look like a cracker has been crumbled over the page (as my radiologist put it) then they are probably linear calcs AKA intraductal calcs. These are usually malignant (comes from the Latin word for bad). Those are what you are looking for. A cluster of four or more is what you're looking for. Usually they are very very tiny and easy to miss. You have to look carefully for them. They indicate DCIS -Ductal carcinoma in situ which is the earliest form of breast cancer, yet to spread to other parts of the breast.

If the calcifications look like "train tracks" -and these are usually pretty clearly in the veins, they aren't anything to worry about. But it does indicate that the patient has diabetes (or is very elderly). High blood sugar is just murderous to blood vessels. If they are floating in precipitate- wide in one view, stacked in the other- it is benign. I'm not exactly sure what Susan (my Radiologist) meant by that, but I'm going to take a guess and say that since it's floating in precipitate it just kind of moves around to wherever the mammogram pushes it. It's not actually ON something.

While looking at the mammogram you may also see little pods of fat which are dark and oval-like.

There are also lymph nodes. These are generally kidney shaped (see picture), but can also be round. The round ones can have a fatty hylum (middle). As long as the cortex (outer edge) is thin, then it's OK. Cancer can metastasize to the lymph node, which is bad news, so that's always something to watch for.

Cysts are round, like golf balls. Usually pretty clear. If there are several circles that are questionably a mass but they have smooth clean edges, no distortions/asymmetry, no calcs, nothing suspicious, it is, in all likelihood cycts, but it is still a good idea to call the patient back for follow up.

Sclerosing adenosis in a lobule looks like an octagon. It is a benign mass. Nothing to worry about.

You may see a nevus (beauty mark on the skin). Sometimes the mammogram technician will mark it with a metal ring. Susan said she prefers not to have them because she can tell what a nevus is and she is concerned that the ring might block something. Also sometimes they mark/point to a scar. This, she says is more helpful. After breast reduction surgery they will have a scar around the areola and that is helpful to note because it can explain away some tethering or architectural distortion.

Veins. These are kind of obvious looking.

Oil Cyst: black with white rim. Perfect circle. Caused by trauma to the breast. Filled with fat. Susan and I had an interesting conversation in we discussed how an oil cyst in just one breast could indicate injury via seat belt during a car accident. And how, if you were the driver it would be on one side and if you were the passenger it would be the other. But it would be the reverse if you were in England, so it's not very useful information as an amateur Sherlock Homes clue.

  • If breast is pointing left it's a right breast and vice versa.
  • You can tell if a woman is wearing deodorant
  • The fat that surrounds the breast tissue indicates how fat the woman is (though some are blessed with fattier breasts despite small stature). You can also tell if a woman has gained or lost weight over the years by comparing mammograms.
  • Some radiologists rate the obvious ones a "0" or "100" percent chance of malignant tumor. Others say "1" or "99". Susan was the former. She made fun of herself by saying she has some hubris to call it definitive. And now hubris is my favorite word. It's like the educated way of saying ballz.
  • The radiologist can zoom in and out of the image at different depths. If something appears suspicious in one depth but disappears in the others than it is (usually) OK. Also, you can tell if an image- say a nevus- is on the surface because it will show up on the shallow depths.
  • Susan joked that Radiologists tend to be OCD.
  • After reviewing the mammogram or Tomo, the radiologist gives it a score of 0-5 called a BIRADS (Breast Imaging Reporting and Data System). 0=incomplete, 1= normal 2= benign 3= probably benign 4=possibly malignant 5= malignant
  • It's pretty much pointless to do a mammogram on a breastfeeding woman because the image will be fuzzy/gray.
  • Each breast has clearly defined breast tissue surrounded by a layer of fat. It was fascinating to observe that some of the largest breasts actually had very little breast tissue. Sometimes a breastfeeding woman will have supply issues. There can be many reasons for it, but I was thinking that a mammogram could be a very useful tool in eliminating or confirming breast tissue as the cause of low milk supply
Personal story: At my 6 week checkup post second baby my OB-GYN discovered a lump. Since I was breastfeeding they skipped the mammogram and went right to ultrasound to try to eliminate the possibility of a cyst, but there was no fluid in it, so they had to biopsy it. (Thankfully) I didn't see the needle til I worked this Hologic job and OMG- it is huge. I kid you not, it's nearly the thickness of a pencil. There aren't many nerves in the breast though, so they really only have to numb the skin. It wasn't that bad. Lot's of bruising after though. After the biopsy they didn't get back to me so eventually I called them and they were like "yeah, it's nothing. You don't have to come back". And I'm like "oooookaaaaaaay"- I felt like there were a lot of unanswered questions. Like what is "nothing"? A cyst? A benign tumor? I didn't pursue it though because I had a million other things going on in my life. It was pretty unprofessional though. I won't drop names because maybe they were just having a bad day or something.

Later I was able to participate in a breast cancer study: "Descriptive Biomarkers for Assessing Breast Cancer Risk". If you've ever had a biopsy and are currently breastfeeding you can participate too. It's for a good cause and they pay you a little too. :) contact
slenington AT nre DOT umass DOT edu

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  • At 8:14 AM, Blogger Amber Rardon said…

    I stumbled across this while doing some research into an area on my mammogram images that I am concerned about. I know your post is old, but I'm desperate for an opinion. My mammogram was done a couple months ago for another issue, but now I have a lump in the opposte breast and because my breasts are dense and I am young, I'm afraid the radiologist overlooked it. I know you are not professionally trained to read mammograms, but I can't get into my doctor for 2 weeks and I'm really nervous about what I see. I do have a palpable lump in the exact area of concern on the mammogram image. I am going to include the link to the image here. I circled the area where the lump is. I'm afraid it looks like a spiculated denser area. I'm not looking for a diagnosis, but just an opinion from someone who has seen a lot of mammogram images. Here's the link:

  • At 2:20 AM, Blogger Deena said…

    Hi! There wasn't a way of contacting you and I am not really comfortable discussing this publicly, so could you email me?


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