Treatment Options

I saw my family doctor on monday as I have 2 palpable breast lumps in right breast. I had my annual mammo also on monday which was negative except for slight asymmetry and dense stromal tissues. They state there are no significant new lesions.(I have always been told I have fibroscystic breasts) My family doc has referred me to the surgeon who did 2 wire location biopsies of the right breast last year due to cluster microcalc's which were benign. (first biopsy missed them completely)
One of my lumps is about an inch away from my incision site at about 12:30 o'clock and the other is at about 10 o'clock, same breast. I have had 2 previous biopsies for fibroadenoma on left breast about 15 years ago. Strong family history for BC.
My question is should I ask about an ultrasound and then FNA or would surgical biopsy be the best choice? Also, my lumps are palpable, so why would the radiologist not notice them on the mammo? Any info would be greatly appreciated. Thank you for a wonderful site. You help many, many people here.
Thank you.
Bet

[CCF-RN,MSN-rf]

Dear bet63:  Although there are exceptions, a palpable lump may not show on a mammogram because it is not likely to be malignant tissue.  In the case of a palpable lump, the easiest thing to do is a fine needle aspirate.  If it is a cyst the fluid can be removed and the lump will disappear.  If it is not a cyst, there is some tissue to analyze.  If the tissue looks okay, it is likely that the lump is okay.  If there is anything suspicious or inconclusive, a surgical biopsy may be needed to further clarify.  At this point, an ultrasound may just be an extra test.  If all signs point to benign, you should still be monitored more frequently, at 3 months and 6 months to be sure there is no further investigation needed.  Of course, if you are not comfortable with this approach, you and your surgeon could discuss different, and perhaps more objectively conclusive, options.

[Bet63]

I should also note that 1 lump is more like an oval thickening and the other is long and narrow with smaller nodules attached to it.
Thanks again for any info.
Bet

[surgeon]

Not all lumps show on mammogram: when they don't, much more often than not it's because they are are "normal" in the sense that they are just more prominant breast tissue. But sometimes -- particularly with a type known as lobular cancer -- cancerous lumps appear "normal" on a mammogram. So when there's a lump, it's reasurring when the xray is ok, but never is absolute. A lump needs a plan: if sometimes repeat physical exams is enough. It's my opinion that ultrasound for a palpable lump is a waste of time and money: what you learn mainly from an ultrasound is whether it's solid or liquid (a cyst). That can be learned at the time of the initial exam by putting a thin needle into it: if it's a cyst, it's fluid, which will be removed by the needle and the problem is solved.If it's solid, the needle can remove a bit of tissue that can be looked at microscopically: often that small sample is enought to decide what's going on. When to biopsy, and by what means, is a decision requiring more input than can be obtained via an online opinion. But there's a thing called the "triple test." When a look feels to the expert examiner like it's benign, and the xray is benign (which yours is), and a fine-needle sample is benign, then the chance of missing cancer is close to zero. I'm very comfortable with the triple test; even so, I always schedule a recheck in 3 months or so. The subjective part of the deal is the physical exam of the lump: both you and your surgeon need to be comfortable. Finally, just to be clear, since you addressed your comment to me: I'm an experienced surgeon who posts here to help; but I'm not the "official" answerer from the Cleveland Clinic. You'll be getting an answer from them, too.

[Bet63]

Thanks for the information. Given the fact that lobular cancer is not usually detected by mammo or US, how is it diagnosed? How does it present? I had not considered lobular cancer until now, I was mostly concerned with DCIS or IDCIS.(That's the only kind my dr talks about or tells me I should be worried about.) Thanks for enlightening me. I will push my surgeon for a biopsy when I go on friday.

Bet