Questions to Ask Your Doctor About Your Mammogram

Mammography is primarily used for the detection of breast cancer.

Asymmetry in the Breast Tissue

Breast cancer can present either as an area of focal asymmetry. You may simply have more tissue in one breast than another (global asymmetry) or in one spot (focal nodular symmetry). An asymmetric area may indicate a developing mass or an underlying cancer.

Breast asymmetry occurs when one breast has a different size, volume, position, or form, from the other. Asymmetry is an area of increased density in one breast compared to the corresponding area in the opposite breast.

There are different kinds of asymmetry, from difference in size and tissue density. On a mammogram, an asymmetry typically means there’s more tissue, or white stuff on the mammogram in one area other than the opposite side.

Asymmetries require further evaluation, such as a diagnostic mammography, sonography, breast MRI or biopsy. Additional tests may uncover a mass such as a breast cyst. Benign, non-cancerous masses can appear as a focal asymmetry.

Questions to Ask Your Doctor about Asymmetry of Breast Tissue

• Is there asymmetry on the mammogram?
• Was there a difference in size?
• Was there a difference in tissue density?
• Was there more tissue in one breast?
• Is the asymmetry normal for me?
• Was the asymmetry present on other mammogram studies?
• Has the asymmetry always been there?
• What is making that area look different?
• Did you determine the cause of the asymmetry?

Enlarged Axillary Lymph Nodes

Lymph nodes are part of the immune system. Although they’re found throughout the body, they cluster in the neck, axilla (armpit), abdomen and groin. Their function is to clear lymphatic fluid from the body, which increases during infection or inflammation.

Axillary lymph nodes are often seen on MLO mammograms. Normal lymph nodes in the anterior part of the axilla are readily seen on routine mammography.

Swollen lymph nodes are a sign that the body is fighting off infection. Lymph nodes can also enlarge when cancer spreads through the body beyond where it originated.

When swollen lymph nodes show up on a screening mammogram, it calls for further testing. Abnormal axillary lymph nodes are predominantly due to nonspecific reactive hyperplasia, followed by metastases from primary breast malignancy.

When you see enlarged or prominent lymph nodes on screening mammogram within the axilla, the patient is called back for additional evaluation, which can include ultrasound of the breast and axilla. Ultrasound can differentiate between reactive and malignant diseases.

If patients have enlarged lymph nodes on screening mammography, serial ultrasound evaluation allows your doctor to monitor the lymph nodes more frequently, and ascertain that the enlargement is due to infection/inflammation and not malignancy.

Morphologic clues indicating the presence of disease include loss of the normal fatty hilum, loss of the normal oval or reniform shape, poorly circumscribed margins and increased size and opacity compared with findings on prior images. Abnormality of only one node in the axillary chain favors malignancy since metastatic disease tends to affect one node at a time. Abnormality of multiple nodes in the chain favors a reactive process because inflammation tends to simultaneously affect all nodes in a given chain.

Axillary lymph nodes that demonstrate at least 2 abnormal mammographic features and are either palpable or have shown substantial interval enlargement warrant further ultrasound evaluation. Pathological lymph nodes are characterized by increased attenuation, high density, a round or irregular shape, and lack of fat in the hilus. New lymph nodes without a clear, underlying cause should be considered for a biopsy.

In some cases, the nodes are biopsied to confirm that they are not cancer. Ultrasound guided core needle biopsy can be performed for lymph nodes that are in an accessible and safe location (to avoid damage to the axillary vessels or nerves).

Questions to Ask Your Doctor about Enlarged Lymph Nodes in the Armpit

• Is there an abnormal lymph node?
• What is the shape of the lymph node?
• Is this bilateral axillary lymphadenopathy? (swollen lymph nodes in the right and left armpits)
• Did the lymph node increase in size compared to the previous mammogram?
• Did the lymph node increase in opacity [density] compared to the previous mammogram?
• Was the lymph node a normal shape?
• Was this a new finding?
• Should I have a biopsy of the lymph nodes?
• Were the lymph nodes enlarged in previous mammograms?
• How would you describe the shape and size of the axillary lymph nodes?
• Was there a change in the size of the lymph nodes compared to my previous mammogram?
• What is your differential diagnosis for the enlarged lymph nodes?
• Is cancer on your differential diagnosis?
• What is the cause of the enlarged lymph node?

Abnormal Clusters of Calcifications

Calcifications don’t develop into breast cancer. Rather, they are a marker for some underlying process that is occurring in the breast tissue. Sometimes, calcifications can be a marker of underlying cancer development. Calcifications typically don’t show up on ultrasound and they never show up on breast MRI.

When abnormal cells grow inside the duct, the cells may get so crowded that some of them die and they body can’t clear them away. If this happens, those cells can harden (or petrify) and areas of calcium form.

Microcalcifications that very in size and shape are more of a concern and they may be clustered in a specific area of the breast. They may be referred to as pleomorphic calcifications. If calcifications are clustered together or concentrated in one segment of the breast, they tend to be viewed with more concern.

Calcifications are more likely to be associated with a cancerous process if they: (1) are smaller than 0.5 mm each; (2) vary in size and shape; and (3) are clustered in one area of the breast. Standard sizes and shapes are less suspicious. If calcifications are suspicious, further tests are needed.

Questions to Ask Your Doctor about Calcifications

• Did the calcifications change in number or size compared to previous mammograms?
• How would you describe the shape of the calcifications?
• How many calcifications are there?
• Do the calcifications vary in size and shape?
• Are the calcifications clustered in one area of the breast?