10. What to Expect After an Abnormal Mammogram Screening
The dreaded phone call…”The radiologist has seen an abnormality on your screening mammogram that requires additional imaging…” Although most women asked to return for additional imaging from a screening mammogram do not ultimately have breast cancer, I understand this is a stressful phone call to receive. In my previous post, I discussed the statistics that show the likelihood of being diagnosed with breast cancer after being called back from a screening mammogram. In this article, I would like to prepare you for the process involved when you are asked to return for additional imaging.
Understanding Diagnostic Imaging
When a patient is “called back” from an abnormal screening mammogram, additional imaging of the breast will be performed. This is referred to as diagnostic imaging. Most imaging facilities will contact the patient directly to explain that diagnostic breast imaging will be required to arrive at a final interpretation. Generally, a scheduler makes this phone call and will not be able to answer detailed questions regarding your specific mammogram. Additionally, most imaging facilities will contact your physician to request the necessary order to complete the diagnostic imaging.
General Guide to Diagnostic Imaging
Fair warning, this is intended to serve as a general guide. Every patient presents a unique case, and the diagnostic workup may vary based on your situation as well as on the protocols set forth by the imaging facility.
The most common reasons patients are asked to return for diagnostic breast imaging from a 3D mammogram include:
- Architectural distortion. Architectural distortion is more commonly seen in 3D mammography compared with 2D mammography.
- Breast mass.
- Calcifications.
- Focal asymmetry. A focal asymmetry is an area of tissue that looks more prominent than the surrounding normal breast tissue on the mammogram but a definable mass is not visible.
Diagnostic Imaging for Screening 3D Mammogram Findings
The diagnostic imaging performed for a 3D mammogram callback will vary from facility to facility. I will describe how we approach a callback evaluation in our practice, but please know this may not reflect the exact experience you may have at a different facility.
- Architectural distortion and focal asymmetry are evaluated similarly.
- An additional image of the entire breast is obtained in a slightly different projection than was done during the screening mammogram.
- 3D spot compression views: A smaller breast compression paddle will be used to apply more focal pressure on the region of interest in the breast. The most common cause of a focal asymmetry is the result of normal breast tissue being compressed in a way that makes it look more prominent on the screening mammogram, which can have a similar appearance to developing cancer. On the spot compression views, it is much easier to determine if there is a mass present amid surrounding breast tissue. If the abnormal area disappears on the spot compression images it is reassuring that the original abnormality represents normal breast tissue and not a developing cancer.
- Targeted breast ultrasound. Even if the additional mammogram views do not show a definite abnormality, the breast ultrasound will almost always be done at our facilities for further evaluation of a focal asymmetry or architectural distortion. Ultrasound images obtained by the ultrasound technologist provide unique information for the breast radiologist to evaluate with the mammogram findings. When used as part of a diagnostic examination, only the area of concern is evaluated with ultrasound. The decision to biopsy will be made by the breast radiologist, considering the imaging appearance of the abnormality on the mammogram and ultrasound images.
- Breast mass. The term mass in breast imaging is used to describe all benign (not cancer) and malignant masses- don’t let the term alone scare you! At our facilities, we start with breast ultrasound in most cases. If the finding is identified by ultrasound, additional mammogram views may not be performed. However, sometimes additional mammogram views are still required if there is no ultrasound finding to correspond with the screening mammogram finding, or if it is not clear if the ultrasound finding corresponds with the original mammogram finding.
- Targeted breast ultrasound is useful to evaluate the internal contents of the mass. The ultrasound imaging appearance plays a significant role when determining if a breast biopsy will be necessary.
- Calcifications. Calcifications are common, and most seen in the breast are benign. However, the very early form of non-invasive cancer called ductal carcinoma in situ, or DCIS, can be seen on a mammogram as calcifications. This is why we pay attention to calcifications. Additional mammogram views will be obtained.
- An additional image of the entire breast is often obtained in a slightly different projection than was done during the screening mammogram.
- Spot magnification views: These are also mammogram views that are obtained using a smaller paddle for breast compression similar to that used in the evaluation of focal asymmetries and masses. However, the technique is slightly different as the area of the compressed breast is magnified to better see the shape and distribution of the calcifications.
Hopefully, this will demystify the call-back process prompted by an abnormal screening mammogram. This should serve as a general guide, but by no means should be considered the gold standard that every facility must conform to adequately evaluate an abnormal screening mammogram.
If you have specific questions regarding your mammogram and diagnostic workup, ask to speak to the reading radiologist or make an appointment with your physician for further clarification.
Written by Danielle Carroll, M.D.
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