Mammogram – What does a radiologist look for?

When a radiologist is reviewing your mammogram there are three things in particular they are looking for to exclude possible cancer: mass, architectural distortion, and suspicious calcifications. We will discuss each feature, but many of these things may only be detected when comparing to prior exams, which is why you should have ANNUAL mammograms.

As mentioned in my previous post, mammography is heavily regulated with the Breast Imaging-Reporting and Data System (BI-RADS) providing dedicated verbage for describing imaging findings on mammography. A suspicious soft tissue density is classified as an asymmetric density when seen on a single routine screening mammographic view (CC or MLO), a focal asymmetry when seen on both views and has concave margins, and a mass if seen on both views with convex margins. So, when you read or hear the words mass, does it make you think of cancer? For some reason it suggests that to me. In reality, and according to BI-RADS, the description of a mass could indicate a solid lesion but it also perfectly describes a simple cyst that is completely innocent. It is often the descriptors that indicate the  degree of concern, particularly the margins. Are they circumscribed, smooth and well-defined suggesting a benign lesion or spiculated and irregular more suspicious of a malignant cancer.

Architectural distortion can be extremely subtle. Here is how I will describe it. As we said before, simplistically the breast is composed of fat and fibroglandular tissue. The glandular tissue makes milk, but the fibrous tissue  provides the supporting network for the glands, ducts and fat tissue. It is this fibrous network that forms what would be like a perfect spider web with the center radiating toward the nipple. Now, if you have a tumor, or had surgery, a biopsy, or serious trauma, then that network can become disrupted. It is  like a rain drop put a tear in the spider web. It no longer has that perfect appearance, but shows an area of architectural distortion in the web. The same thing happens to the breast. But instead of seeing a torn web pointing to wear the rain drop went through, we are looking for a cancer going through the normal fibrous connective tissue network in the breast. Cancers can distort the normal appearance of the breast on mammography. The ability to detect subtle architectural distortion catching cancers early is a tremendous strength and advantage of 3D breast tomosynthesis mammography.

Calcification occur in the breast for a myriad of reasons, mostly benign. Seriously, almost every breast has one calcification. They are exceedingly common, present as vascular calcifications, secretory calcifications, fat necrosis, and the hodge-podge term, dystrophic calcifications. So most of the time,  your breast will have calcifications but they will be benign. But when tiny so-called microcalcifications are present clustered in groups with differing sizes and shapes it could suggest a cancer. This is just one of many different, subtle patterns calcifications may present which could suggest cancer to your radiologist. Mammography, particulary in relation to calcifications, is definitely a science and an art.

So don’t go thinking you can read your mammogram based on anything I have written here. It has taken me nearly a decade to have the confidence that is still occasionally humbled when reading mammography. Additionally, an intake form filled out by the patient to include personal, family and genetic history, if known, should be assessed concomitantly by the radiologist with each mammogram to aid in their review of the case.

Okay, last shout out for this post: get your ANNUAL mammogram. You will have to trust me. Identifiers were removed to protect patient confidentiality. I saw this patient last week. Unfortunately she skipped her annual mammogram. 2018 is on the left and 2016 on the right. It doesn’t take a radiologist to see this cancer. I told you. It does happen!

Cancer after skipping 1 year of mammo

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I am an American Board of Radiology certified Diagnostic Radiologist with a certificate of additional qualification in Neuroradiology. I absolutely love my job. I have learned a tremendous amount about the human body, including its’ expected complications given our extraordinary complexity, and get to use that knowledge to help people. I personally have experienced emotional devastation and loss, which has made me compassionate and empathetic. I really care about people, and I hope I can use this site to help you. I graduated medical school in 2004 from New York Medical College. My wife and I had our first son in NY where we bought our 900 sf two bedroom one bath starter home. I stayed at Westchester Medical Center for radiology residency, where we had our second son. I obtained a neuroradiology fellowship position at Yale New Haven Medical Center commuting about an hour and a half each way for a year while we had our third boy. Upon graduation I was fortunate to return to Westchester Medical Center to work in Neuroradiology, Body Imaging, and Women’s Imaging departments, a rarity in academic medicine. Almost a decade later and I am living in a larger home in Reno working in a private practice community based outpatient radiology group which contracts with a rural hospital in Elko, Nevada. My wife and I now have four boys and gave up on the girl. We also have a male Bernese mountain Dog named Helmut and female Newfoundland named Lucy. Despite all its hardships and tremendous struggles, I have an absolutely amazing life, which is a gift I cherish. It’s down to my philosophy. I am a firm believer in teamwork. So much comes down to communication. When healthcare providers talk to each other one-on-one, the patient care is always improved, every time! We might not find an answer to your problem, but our collective knowledge sure can help improve your chances. At Yale the best conference I ever regularly attended was a head and neck tumor board. The head and neck surgeon (otolaryngologist = ENT) presented the patient’s clinical history, the radiologist showed the images, the oncologist discussed the tumor and chemotherapy options, and the patient came to the conference and we all did a physical exam looking into their mouth to directly visualize a tumor. It was incredible! Patients came from far and wide to see this highly trained, world-renowned, humble, Japanese, gentleman surgeon. It was also an epiphany. I found that when I see the patient, talk to them, listen to their story, examine them and discuss the patient with my colleagues, the patient felt better and I had a lot of fun. It’s weird but reminds me of seeing a comedy where it is always funnier in a packed theater with everyone laughing. Knowledge and compassion are both infectious and contagious. My greatest days are helping patients deal with some of their most difficult days, and I am good at it.

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