Need for excisional biopsy after sterotactic core

[andreak]

I had one area of very, very small microcalcifications on my mammo given a birad 4b.  So small in fact, that the first try at biopsy, the computer was unable to target the depth correctly.  The second try (two weeks later!) again they were unable to exactly get depth - but fired anyway and ended up with some microcalcifications in the core sample.  All this was mentally terrifying - but physically unchallenging.

Result of biopsy - a total of 21 core samples - 9 with calcifications present and 12 without.  In the samples with calcifications the biopsy reads:  "Benign breast tissue with focally aypical columnar cell hyperplasia and columnar cell change with associated calcifications.  Stromal calcifications are also seen."

Radiologist suggests excisional biopsy to remove clip and area and be sure of diagnosis.  I don't think the microcalcifications are really apparent anymore - and I'm not sure they even put the clip in the correct spot.

Could I wait 6 months and have a follow up mammo and see if any changes result - or is it truly necessary to have the excisional biopsy?

[BhumikaMD]

Hi,

You need to get a copy of the mammogram and ultrasound report.

Because the radiologist has classified as 4b, it would need to be investigated for a confirmed diagnosis and to rule out malignancy.

You should talk to your doctor about this too, and discuss your reports and the radiologist's advise with him/her. see what he/she has to say.

I think it should be ok to wait for 6 months and get a re-evaluation done along with a proper clinical examination and repeat investigations and then decide about the excision biopsy.

But, you need to checj this out with your doctor. Because, if both he and the radiologist feel that you need to go ahead with the excisional biopsy right now - you should get one done.

They would be talking in your best interests only.

Do let us know what your doctor tells you.
Hope this helps.
Good luck.

[marydenise]

In my opinion, yes, you could wait, six months.

With your stereotactic biopsy results, ""Benign breast tissue with focally aypical columnar cell hyperplasia and columnar cell change with associated calcifications.  Stromal calcifications are also seen."

My August, 2007 stereo diagnosis was Atypical Ductal Hyperplasia.. For my part, an excisionial biopsy was recommended. Even though my surgeon said, it was a 11-17% chance, it was anything.

I did the excisional biopsy, and it was benign. And I only did it because my November, 2002 stereo, on my other breast, was a false negative. And in August, 2006, had turned into a 2CM IDC.

If you're comfortable waiting, WAIT. My surgeon, told me, worst case, it's DCIS. Totally treatable.

You CAN just wait and see.

[andreak]

Thanks....I needed that.

My husband went with me through all of this and he agreed that it was the best action - but it is nice to her someone else who "knows" to affirm my decision.

I'm sure at some point the science behind the medicine will catch up.  It does seem a little odd to cast such a wide net, freak people out with potential diagnosis and 80% is nothing.

But I guess if I'm in the 20%, and it is something - I'm totally appreciative.  Diagnosis and detection is getting better and better every year.  I hope by the time my duaghter needs screening - it will be simple and more diagnostially accurate.

[marydenise]

Good for you! I think that your decision to "wait and see" and not do the surgical, exisional biopsy, right now, is totally the way to go.

And from what you said your surgeon said, she's backing you up. i.e. "what was found was "focal neurological deficits – so tiny and not all microcalcifications showed atypia.  Matter of fact only  one slide of 8 showed any.  They took over 20 core samples!  She even suggested the the atypia could have been caused by the first mishap biopsy."

Plus, that she said it was slow-growing. If it is, anything.
And listen to the docs, but don't take what they're saying, like it's gospel. It's not.
You've made the totally correct decision.

But she's a doctor, and I've found out, they just want, certainty. Plus, doing the most that they can, for the patient. Your surgeon, as did mine, wanted to do everything she could, for you/me. No matter how small the chance, it was anything. She wanted to offer the solution, to find out.

But then, it's just up to us, as patients, to "read the data," for ourselves. Like you did, with your extensive research. Like I did, with mine. And make the final decision.

Which you did. And I did, too. I did have the exisional (negative) biopsy, but I had so much MORE prior ****, then you. Like a prior breast cancer diagnosis. On the other breast.

THAT was the deal breaker, for me. Why I did it. If I'd been in your shoes, no prior breast cancer, I would NEVER have done it. I would have waited six months.

And you will go back, in six months, and see what's what, then. (Most likely, nothing)

Isn't it great when you finally just figure out what is right, for YOU?

It really was, for me.

These medical treatments are based on the "latest study." That change, constantly. I'm happy to be in charge, of my medical life ... and not just blindly follow, some doctor.

I wish more people, would do that. Probably save a LOT of $$$$ on health care. All of these needless, biopsies ...

Mary

[jj552]

having a stereotactic biopsy of right breast in the morning...small microcalcification cluster was found on mammogram last Thursday...was not on last mammogram...wondering what to expect...

[metalgirl70]

I would go with the surgical biopsy now.  I had that procedure and it's not that bad at all.  That way, you'd know now what the situation was and not let anything potentially dangerous sit there for more time.

Good luck to you!

[andreak]

Saw the surgeon today.  She immediately suggested an excisional biopsy based on the pathology report.

After some discussion, (this is the personalizing the medicine for the patient part) she did acknowledge that what was found was focal – so tiny and not all microcalcifications showed atypia.  Matter of fact only  one slide of 8 showed any.  They took over 20 core samples!  She even suggested the the atypia could have been caused by the first mishap biopsy.

She indicated that the chances of this being cancerous or precancerous was less than 5%.  But she felt strongly that any atypia be biopsied.  She did also say that it was  a judgment call here – that if I surveyed 10 surgeons – 5 would say biopsy and 5 would say wait 6 months and see.

The surgeon also said that if this is anything – it would be slow growing – perhaps only doubling every 100 – 120 days and that the next follow-up mammo would have to be in 6 months to notice any real change.

After I decided to “wait and see” she wasn’t really very happy.  I’m sure she can’t understand what the big deal to surgical biopsy would be.  But as she indicted – there is no downside.  This is tiny and probably nothing – and 6 months time will only confirm either way.

I’m sure it was easier for her to try to convince me to biopsy now that to try to get me to be compliant and vigilant about the follow up mammo.

None the less – I have done extensive research, and have decided that the best course of action for this human pincushion would be to wait 6 months and see what happens.

[marydenise]

Please do report back on your surgeon consult, on Monday, January 14. I'll be checking this board.

And actually, if you do elect to not do the excisional biopsy, I agree with your primary physician ... get more mammos in three months. That seems totally reasonable.

I have my six month mammo, 2/1. That's cool.

And I hear you, about the CYA. I think it almost is all about that, instead of personal patient medicine.

In my excisional biopsy post-op visit, with my surgeon, she said, it's all benign. And then, went on to say, as I've said, you can take tamoxifen, but continued saying, or just keep being monitored, every six months. But her final comment, being, or you could just have a bilateral mastectomy. Huh? After we've spent the last two years, trying to keep my breasts?

That final comment was so out of left field, I was stunned. My reply was, no, I don't want a bilateral mastectomy.

What it was, was CYA. She offered it. If I die from breast cancer, someday, she offered the bilateral mastectomy. And I refused. She's covered.

Or maybe, I'm just too cynical. Ha.

I'll be looking to hear back, from you.

Mary

[andreak]

Thanks you for your explanation.  It is great to "talk" to someone who actually went through all these test.

I have a consult with the surgeon on Monday.

In the meanwhile - my primary physician called me just following up on the biopsy reports.  I asked what she thought.  She thought I should see a medical oncologist before making any decision.  She also thought I could wait and see what happens - but that 6 months would be too long and 3 months seemed more appropriate.

I agree with you about the tamoxifin and radiation.  Sometimes it seems as if the protocol is just CYA instead of personal patient medicine.

andreak

[marydenise]

My stereotactic biopsy results said:

"Micropapillary/flat atypical ductal hyperplasia, focal atypical lobular hyperplasia, and columnar cell alteration. Background fibrocystic changes. calcifications in association with atypical and benign ducts. No evidence of in situ or invasive carcinoma."


From all that I read, these findings "could" be DCIS, if they find enough of them. It's some pathology distinction. And if they don't find enough of "them," (the atypical cells) they can't rule it as DCIS, but they can't say that it's not. What was shown to them, was not DCIS, in the biopsy sample, but that was only a sample. Maybe the rest of the DCIS was in the tissue that was not sampled.

Because a stereotactic biopsy is only that ... a sample. It's not all of the tissue. So that's why they want to do the exisional biopsy and take all of the tissue. Then, it's not a sample, anymore it's everything.

And they will remove the entire area of calcifications, with the exisional biopsy. By putting in a localization wire that tells them what to take out. And while you're still in the OR, they go make sure they took it all of the calcs out. I know this, because I got my medical records from the surgical exisional procedure and read them.

And no, with an exisional biopsy they do not go for clear margins. Because you do not, yet, have any sort of cancer diagnosis. Just a suspicion. IF (big if) the exisional biopsy reveals cancer, they would have to go back, again, surgically, to get clear margins.

My exisional biopsy results said:

"focal atypical ductal hyperplasia with associated microcalcifications. Changes consistent with previous biopsy site. No evidence of in situ or invasive carcinoma."

My surgeon told me that meant they got it all, they STILL only saw the atypical cells, it was not cancer. benign.

And yes, my surgeon, again, recommended Tamoxifen. But, I'd refused that after my August, 2006 2cm IDC, on my right breast. Which my medical oncologist had only weakly recommended, then, since I had decided to not do the whole breast radiation. She had said, then, well, if I didn't do the radiation, the Tamoxifen won't provide much additional help.

For me, I accept the risk of the breast cancer coming back. In either breast. And it's higher, no doubt. But high enough, for me to risk the side effects of radiation and taking drugs for five years? For me, it wasn't high enough. If my breast cancer comes back, I'll have it cut out, again.

Which is why I went for the exisional biopsy, surgery makes sense to me. These other treatments, especially for the radiation that are based on studies done 30 years ago, do not. For me.

Everyone has to seek their own comfort level. I've found, mine, and now you just have to find yours.

I think you're fine without the exisional biopsy. Worst case, it is cancer, they'll see it in six months. Or a year.

I really feel for all that you're going through ...

Mary

[andreak]

Hmmm... I confused.  I would have thought they DID rule out DCIS because the biopsy came back benign.

Benign was the first word in the dx from pathology and then followed by the "atypical columnar cell hyperplasia".

Do you think they HAVEN"T ruled out DCIS?

This just stinks.  What is the chance they can even remove anything is there is just microcalcifications with no mass or lump?

ANd then I supposed the next statement from the surgeon will be no definate margins.

Marydenise - did they recommend tamoxifin?

Thanks.......

[marydenise]

Believe me, I KNOW how frustrated you are! It just seems like it never ends. They tell you need this stereotactic biopsy, you have the biopsy and then they still don't have the answer.

But from what I understand, the results of your stereotactic biopsy did not rule out DCIS. They didn't conclusively find DCIS, yet they did find "atypical columnar cell hyperplasia ..."

That is why the exisional biopsy is being recommended. They can take out the entire suspicious area and definitively determine what it is. Again, my surgeon told me that it was a 11-17% chance it's anything. OR, you can wait, six months. And continue being monitored.

You're right, your surgeon will most likely advise you to have the exisional biopsy. That is the standard of care. That way, you know for sure.

I initially said no, to the exisional biopsy. Like you, I was just sick of it all. And I told my surgeon, forget it. And she was like, OK, I think you should do it, but it's your decision. She was great.

But after I thought about it more, I decided in my case (my previous breast cancer, mostly) why not just find out now.

And for my part, the procedure went surprisingly well. I had a much better outcome from even the stereotactic biopsy. The stereotactic resulted in a bunch of bruising; nothing like that with the exisional. And then, a week later, the glorious news it was all benign. Which WAS a relief.I'm glad I had it.

But it's totally up to you, what you do. Again, it is perfectly fine, to wait six months. And see what's happened in that interim.

[andreak]

Thank you for your very thorough replies.

I have a consultation with the surgeon on Monday, Jan 14th.  I'm sure she'll press strongly for excisional biopsy right away.

I feel rather like a pincushion and a science experiment right now - and am rather MAD that i spend time, energy and mental anguish waiting for something conclusive , yet ended up with a diagnosis of no cancer....BUT..

I do have the copies of both the mamogram and the biopsy.

Mammogram said "clustered indistinct calcifications in the the left breast a posterior depth.  Have a differential diagnosis of DCIS and fibrosystic chand and are at intermediate suspicion for malignancy - BIRAD 4b  G0204"

So, as I see it - I did the biopsy and they have ruled out DCIS - cancer - but now what?   ARRRRGGGHHHHHHH!!