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 the majority of 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.  Today, 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.  Additionally, the process may vary for callbacks initiated from a 2D vs 3D screening mammogram.   I will discuss the diagnostic imaging for each separately.

The most common reasons patients are asked to return for diagnostic breast imaging from a screening 2D mammogram include:

1. 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.
2. 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!
3. Calcifications. I will dedicate a future article to calcifications, so for now just know that calcifications are quite common and the majority of calcifications seen in the breast are benign.
4. Architectural distortion. I describe architectural distortion in my article on 3D mammography.  This is more readily visible in 3D mammography compared with 2D mammography.

Diagnostic Imaging for 2D Mammograms

2D mammograms present a unique challenge for the breast radiologist, particularly in women with dense breast tissue.  Although you will not be told what prompted the callback, here is what you might expect based on the interpreting radiologist’s finding.    Remember, this is just a guide to familiarize you, the patient, with the process of diagnostic imaging- please don’t try to self-diagnose based on which imaging is ultimately performed!

1. Focal asymmetry and architectural distortion are evaluated in the same manner at my facilities:
   1. A combination of additional mammogram views typically comprises the first part of the callback examination:
      1. Image/s of the entire breast compressed in a slightly different position from the standard screening mammogram views.
      2. Spot compression views: A smaller breast compression paddle will often be used to apply more focal pressure on the region of interest in the breast.  The most common cause of a focal asymmetry on 2D mammography 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 in the midst of surrounding breast tissue.  However, if the abnormal area disappears on the spot in compression images it is reassuring that the original abnormality represents normal breast tissue and not a developing cancer.
   2. Targeted breast ultrasound. At the discretion of the interpreting breast radiologist, an ultrasound may or may not be performed following the additional mammogram images.  If performed, images obtained by the ultrasound technologist provide a unique set of information for the breast radiologist to evaluate in conjunction 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 taking into account the imaging appearance of the abnormality both on the mammogram and ultrasound images.
2. Mass:
   1. Spot compression views (discussed above) are generally utilized in an attempt to separate the mass from surrounding breast tissue for better evaluation of the mass margins.
   2. 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.
3. Calcifications
   1. Additional mammogram views
      1. As discussed for the evaluation of focal asymmetries, an additional image of the entire breast is often obtained.
      2. 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.
   2. Targeted breast ultrasound. Unless a mass or a suggestion of a mass is seen in the region of the calcifications, ultrasound does not have a role in the evaluation of calcifications.

The most common reasons patients are asked to return for diagnostic breast imaging from a 3D mammogram include:

1. Architectural distortion.  As stated above, architectural distortion is more commonly seen in 3D mammography compared with 2D mammography.
2. Breast mass.
3. Calcifications.
4. Focal asymmetry.  Focal asymmetry may still be seen, but is a less common reason for an abnormal mammogram with 3D mammography as the 3D technique usually alleviates the problem of overlapping breast tissue.

Diagnostic Imaging for 3D Mammograms

The diagnostic imaging performed for a 3D mammogram callback will vary from facility to facility as protocols have yet to be established for this new technology.  I will describe how I approach a callback evaluation in my practice, but please know this may not reflect the exact experience you could have at a different facility.

1. Architectural distortion and focal asymmetry are evaluated similarly. Since I usually have a good idea where the abnormality is located in the breast thanks to the 3D technology, I obtain a breast ultrasound first.  If I do not see anything on breast ultrasound, I will then obtain additional mammogram views to better characterize and localize the abnormality.  Depending on the circumstances, I may also recommend a breast MRI to further evaluate a mammographic abnormality that is not visible by ultrasound.
2. Breast mass. I also start with breast ultrasound and generally do not require additional mammogram imaging.
3. Calcifications.  The evaluation of calcifications seen on a 3D screening mammogram is identical to the evaluation of calcifications seen on a 2D screening mammogram, as discussed above.

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.  To illustrate the varied diagnostic imaging protocols from different imaging facilities, I encourage other breast radiologists to describe how their call-back protocols vary in the comments.

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.

About Danielle M. Carroll, M.D

Written by Danielle Carroll, M.D.

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