There's Waldo in Here Be Dust

Next month will mark my first follow-up mammogram since I had completed active treatment for breast cancer. In the case of lumpectomy, mammograms are recommended about six months after finishing radiation: “Radiation can cause some changes in the breast tissue and skin. This 6-month mammogram will become the new ‘standard’ against which future mammograms of the remaining breast tissue are compared.”

I have already written about learning that my tumor had been fully visible for years prior to being flagged as suspicious. I was able to get images from only 2013 and 2014 on a CD; the rest were on film. But since I must switch diagnostic imaging centers, I opted to pick up the films and deliver them to the new facility, myself. That way, I could get a good look at them.

Some facilities can convert films to digital, so I will see if that’s possible at the new place. In the meantime I did my best to make my own digital images. I was unable to get my flatbed scanner to produce anything usable. Finally I held each film (as steadily as I could) in-between fluorescent lights, so that it was both front- and backlit. I ended up with some light flares and reflections, but the photographs are passable for my purposes.

The years 2004 through 2010 are films; 2013 and 2014 had come on CD. I had gotten mammograms prior to 2004, but those had occurred before my move from Massachusetts to Florida in 2003. The omission of 2011 and 2012 are my own oversight. Those were very tough caregiving years for me; to be honest, I had been neglecting my own health.

Large
Larger
Largest

Especially in the bottom row, I can see what was eventually identified as my tumor, going all the way back to 2004. That’s at least ten years that cancer had been growing inside me: 20/20 photographic hindsight as I go from right to left. The notes below indicate that the tumor had been noticed early as well, but no further steps had been taken beyond watching and waiting.

Below are quotes taken from my mammogram reports. From 2004 through 2013, I had received only the boilerplate letter stating that my mammograms had been normal; I have these other reports only because I had asked for my records. As I have written, Dr. W told me that grading these images as “benign” is “standard of care,” and that she had actually exceeded that standard when she flagged my 2014 images.

Until my lumpectomy, my tumor had been described in both my diagnostic mammogram and ultrasound in 2014 as being about 1 cm in diameter; when removed its diameter was revised upward, to 1.8 cm. As far as mammograms go, the tumor’s “approximately 1 cm nodular density” had first been mentioned back in 2007 and was reported to have been unchanged from 2006.

The ACR category is the American College of Radiology Breast Imaging Reporting and Database System (BI-RADS™). As described here, “The BI-RADS™ categories or levels are used to standardize interpretation of mammograms among radiologists. They are useful for statistical analysis of mammography practice and BI-RADS™ results are compiled on a nationwide basis in the U.S. to help refine mammography procedures everywhere.”

Dr. H had reviewed my images for all the mammograms on film. In 2013 that fell to Dr. K. In 2014, Dr. W finally requested further analysis, which uncovered my cancer.

August 2004 (Dr. H)

“There are noted to be multiple small, less than 1 cm nodular densities in the bilateral breasts which are probably benign. No evidence of spiculated mass or suspicious cluster of microcalcifications is seen. Mild to moderate residual fibroglandular tissue is noted bilaterally.

“Probably benign, multiple less than 1 cm nodular densities in the bilateral breasts are seen. A six month follow up study of the bilateral breasts is needed to document stability of these findings.”

ACR category 3 (Probably benign finding; short interval follow-up suggested)

March 2005 (Dr. H)

“There is no evidence of a dominant or speculated-type mass seen. No evidence of suspicious microcalcifications or skin thickening is noted. Small, benign-appearing, less than 1 cm nodular densities are seen bilaterally. Moderate residual fibroglandular tissue is seen bilaterally.

“No mammographic evidence of malignancy. No significant change from prior study of 08/20/04 is seen.”

ACR category 2 (Benign finding)

April 2006 (Dr. H)

“There is no evidence of a dominant or spiculated-type mass seen. No evidence of suspicious microcalcifications or skin thickening is noted. Small, benign, less than 1 cm nodular densities are again seen bilaterally, as well as areas of asymmetry in the bilateral breasts which are not significantly changed from the prior study. Mild to moderate residual fibroglandular tissue is seen bilaterally.

“No mammographic evidence of malignancy. No significant change from prior study of 03/04/05 is seen.”

ACR category 2 (Benign finding)

April 2007 (Dr. H)

“There is no evidence of a dominant or spiculated-type mass seen. No evidence of suspicious microcalcifications or skin thickening is noted. There is again noted to be an approximately 1 cm nodular density in the inner lower portion of the left breast which is unchanged from the patient’s prior examination. Mild to moderate residual fibroglandular tissue is seen bilaterally.

“No mammographic evidence of malignancy. No significant change from prior study of 04/04/06 is seen.”

ACR category 2 (Benign finding)

[Note the phrase, “There is again noted to be…” In the records I received, this marks the first specific mention of the object that was identified, seven years later, as invasive colloid carcinoma.]

May 2008 (Dr. H)

“There is no evidence of a dominant or spiculated-type mass seen. No evidence of suspicious microcalcifications or skin thickening is noted. Mild to moderate residual fibroglandular tissue is seen bilaterally. Areas of asymmetry in bilateral breasts are again seen and have not significantly changed from the prior examination.

“There is again noted to be an approximately 1 cm nodular density in the inner lower portion of the left breast seen, which has also not significantly changed from the prior study. A few benign-type calcifications are seen bilaterally.

“No mammographic evidence of malignancy. No significant change from a prior study of 4/25/07 is seen.”

ACR category 2 (Benign finding)

June 2009 (Dr. H)

“There is no evidence of a dominant or spiculated-type mass seen. No evidence of suspicious microcalcifications or skin thickening is noted.

“There is again noted to be an approximately 1 cm nodular density in the inner lower portion of the left breast which is unchanged from the prior examination. Areas of asymmetry in the bilateral breasts are again seen and not significantly changed from the prior study. Mild to moderate residual fibroglandular tissue is seen bilaterally. A few benign-type calcifications are seen bilaterally.

“No mammographic evidence of malignancy. No significant change from the patient’s prior study of 5/20/08 is seen.”

ACR category 2 (Benign finding)

June 2010 (Dr. H)

“There is again noted to be an approximately 1 cm nodular density in the inner lower portion of the left breast which has not significantly changed in size from the patient’s prior examinations and thus documents multiple years of stability.

“No evidence of spiculated mass or suspicious cluster of microcalcifications is seen. A few benign and vascular-type calcifications are seen bilaterally. Mild to moderate residual fibroglandular tissue is seen bilaterally.

“Areas of mild asymmetry in the bilateral breasts are again seen and not significantly changed from the prior study.

“No mammographic evidence of malignancy. No significant change from the patient’s prior examinations is suggested in the nodular density in the inner lower portion of the left breast.”

ACR category 2 (Benign finding)

February 2013 (Dr. K)

“Scattered fibroglandular densities. Again noted is the density in the left breast. There are no definite new suspicious mass or abnormal cluster of calcification.

“A benign study.”

ACR category 2 (Benign finding)

February 2014 (Dr. W)

“Fatty parenchyma is present bilaterally. There is no suspicious microcalcifications nor any architectural distortion.

“Nodule is present in the lower inner left breast, middle third with an [sic] questionable very mild increased [sic] compared with 2009. Additional imaging is recommended to include magnification lateral views as well as sonography.”

ACR category 0 (Need additional imaging evaluation)