Lydia Liao, M.D.: Breast density refers to the relative amounts of different tissue in the breast as seen on a mammogram. Dense breasts have more glandular (milk-producing) and connective tissue than fatty tissue. Low-density breasts have a greater proportion of fatty tissue. Younger women usually have denser breasts than older women. As a woman ages, the amount of glandular tissue normally decreases and the amount of fatty tissue increases. Because breast cancers tend to develop in the dense tissue of the breast (not in the fatty tissue), those older women whose mammograms show more dense tissue are at an increased risk of breast cancer. Abnormalities in dense breasts can be more difficult to detect on a mammogram.

Lydia Liao, M.D.: Almost all breast cysts identified as “simple cysts” by ultrasound are benign and never become cancerous. It is estimated that 1 in 1,000 cysts contain a tumor (but they are usually benign). These tumors can be identified by ultrasound in most cases. Women with cysts are not at greater risk for cancer although this risk may be slightly higher if there is a family history of breast cancer (mother, sister, or daughter).

Lydia Liao, M.D.: When the breasts are unsupported or bras fit poorly, the bouncing that occurs can irreparably stretch the breast’s connective tissues, causing sagging and pain, no matter what size your breasts are. Breasts have little natural support, and proper support is critical. Dr. Scurr, a breast biomechanics expert, and her team are the first to conduct research in the 3D movement of breasts and how effective bras are at reducing it. They tested 50 or so bra designs on 200 women with a wide range of breast sizes. The women, who had sensors on their bodies, walked, jogged and ran on a treadmill while wearing different bra types. The researchers found that breasts bounce up to eight inches during exercise and that they move not only up and down, but also side to side and in and out. Slow jogging caused as much movement as did a full-out sprint.

Lydia Liao, M.D.: Keloids occur from an overactive healing response and the buildup of collagen around a wound. The wound might be very small, such as a surgical incision, but the resulting keloid might be many times as big as the original cut. A raised scar can occur in virtually any patient.

There are several options, but nothing ideal for everyone:

1. You can use silicone sheeting - chance of improvement: minimal
2. You can use cordran tape (cortisone tape) - chance of improvement: minimal to moderate
3. You can use steroid injections - chance of improvement: moderate
4. You can use laser - chance of improvement: moderate
5. You can use radiation - not advisable in the breast area

Your individual case can be best managed by seeing a dermatologist or your cosmetic surgeon.

Lydia Liao, M.D.: Cysts are fluid-filled pockets ranging from the size of a pinhead to the size of a walnut. They are hard and round, and move easily when touched. Breast pain may be an additional symptom of breast cysts.

Although the level of female reproductive hormones appears to influence the development of cysts, no one is exactly sure what causes them. Women who experience one breast cyst are likely to have others in the future. Young women, peri-menopausal women, and especially women on estrogen replacement therapy, are more prone to breast cysts. Breast cysts are most common among women over the age of 35 who have not yet reached menopause. They occur more frequently as women approach menopause and usually cease after a woman is menopausal. However, they have been found to occur among post-menopausal women who take hormone replacement therapy (HRT).

Lydia Liao, M.D.: Without reviewing your particular case and all performed breast imaging studies, I can only describe to you why women can get nipple discharge and the possible treatments:

Nipple discharge refers to any fluid that seeps out of the nipple in a nonlactating woman. Nonmilk discharge comes out of your breasts through the same nipple openings that carry milk.

One or both breasts may produce a nipple discharge, either spontaneously or when you squeeze your nipples or breasts. A nipple discharge may look milky, or it may be yellow, green, brown or bloody. The consistency of nipple discharge varies from thick and sticky to thin and watery. Most bloody or watery (serous) nipple discharge (approximately 90%) is due to a benign condition such as papilloma or infection. A papilloma is a non-cancerous, wart-like tumor with a branching or stalk that has grown inside the breast duct. Papillomas frequently involve the large milk ducts near the nipple. Multiple papillomas may also be found in the small breast ducts further from the nipple. Suspicious nipple discharge is due to cancer in about 10% of cases. That means, the vast majority nipple discharges are noncancerous. Discharge caused by a malignant condition is commonly on one side only.

The standard treatment for nipple discharge that has no hormonal involvement is duct excision. Duct excision is usually performed on an outpatient basis with local anesthesia. The procedure is usually done through a small circular incision near the areolar border around the nipple. It is not uncommon for the pathology found to be so microscopic that it is invisible without the assistance of a microscope. Typically, nursing ability and nipple sensation are preserved after duct excision. Breast-feeding in the other breast should have no affect from the duct excision in the opposite breast.

There is usually not a significant change in breast size/shape after duct excision since only a small amount of tissue is removed. There is no evidence of increased future risk of breast cancer from the procedure. Some suggest that there may be a slight increase in risk of breast cancer for patients with a papilloma, but this possibly higher risk has nothing to do with the treatment chosen.

If there is continued one side “blood” nipple discharge clinically such as in your case, a surgical evaluation (including procedure) may be necessary to exclude a small possibility of breast cancer in the side of discharge, even when other radiological studies reported negative.

Lydia Liao, M.D.: While I cannot comment on your particular case without looking at your imaging studies, I can explain a little about densities seen on mammograms, the aging process on the breasts, and why we recommend a six month follow up exam:

About 5% of women having a screening mammogram will have an abnormal result, finding microcalcifications, masses, or areas of distortion. The radiologist looks for unusual shadows, masses, distortions, special patterns of tissue density, and differences between the two breasts.  Masses may be due to cysts, benign tumors such as fibroadenoma or breast cancers. Areas of distortion may be seen with scar tissue but occasionally may be a very subtle sign of a breast cancer.

With aging, a woman's breasts lose tissue and subcutaneous fat, reducing their size and fullness. There is also a decrease in the number of mammary ducts. Breast density can change through life. But a certain proportion of women will remain extremely dense throughout their lives. For many women, breast density will change with age or be related to factors such as relative body mass index, age at first childbirth, postmenopausal hormone replacement use and/or genetic make-up.
When you stop having menstrual periods (menopause), your hormone levels drop, and your breast tissue becomes less dense and more fatty. You may stop having any lumps, pain, or nipple discharge that you used to have. And because your breast tissue is less dense, mammograms may be easier to interpret.

The American College of Radiology (ACR) has established the Breast Imaging Reporting and Database System (BI-RADSTM) to guide the breast cancer diagnostic routine. Radiologists sometimes refer to each BI-RADSTM category as a "level.”  BI-RADS 3 means that your mammogram is probably normal but a repeat mammogram should be completed in 6 months. The chance of breast cancer is approximately 2% in this category. You should make sure that these follow-up mammograms are completed as requested.  As a general rule, once a density has been followed at short interval for a period of over two years without any significant change in size or morphology, it is deemed a stable finding and is considered benign.

Lydia Liao, M.D.: Having dense breasts — areas that show up light on a mammogram — is strongly associated with increased breast cancer risk, but "why" remains to be answered. Breast density is just one of many risk factors for breast cancer. Young women tend to have dense breasts, but this is generally not a concern if they don't have other risk factors. Breast density becomes more of an issue after menopause, when other risk factors such as age, weight and activity level may come into play.

Getting regular mammograms is especially important if you have dense breasts. If you're at average risk for breast cancer, start getting yearly mammograms and clinical breast exams at age 40. If you're at high risk, you may need to start screening earlier.

Ask your doctor if you should get a digital mammogram. Compared to the traditional film test, digital mammography seems to be better at finding breast cancer in women who have dense breasts. But it is more expensive, and it's not widely available.

You can also make efforts to lower your overall cancer risk through healthy choices:

• Don't smoke. This is the number one way to lower your cancer risk.
• Stay at a healthy weight. Try to avoid weight gain, especially around your waist.
• Try to get at least 30 minutes of physical activity every day.
• Make healthy food choices. Eat plenty of high-fiber, plant-based foods such as whole grains, beans, fruits and vegetables. Limit red meat, saturated fat and salt.
• If you drink, limit alcohol to no more than one drink a day.

Lydia Liao, M.D.: Breast cysts are common, particularly in women age 40-60. Although larger cysts can sometimes be felt as “lumps”, many cysts cannot be felt by physical examination. Cysts that cannot be felt may be found during a mammogram or ultrasound.

When a mammogram shows a possible cyst, a breast ultrasound is usually done. An ultrasound shows whether the lump is a fluid-filled cyst or a solid lump. It also shows whether a cyst is a “simple cyst” or “complex cyst.” Breast ultrasound is the best way to identify and diagnose breast cysts because it is accurate 95 to 100% of the time.  Breast cysts often change in size. Breast cysts can look different or disappear entirely on mammograms from one year to the next.

Breast cancer risk is higher among women whose close blood relatives have this disease.
Having one first-degree relative (mother, sister, or daughter) with breast cancer approximately doubles a woman's risk. Having 2 first-degree relatives increases her risk about 5-fold.

Although the exact risk is not known, women with a family history of breast cancer in a father or brother also have an increased risk of breast cancer. Altogether, about 20% to 30% of women with breast cancer have a family member with this disease. This means that most (70% to 80%) women who get breast cancer do not have a family history of this disease.)

If there is a persistent clinical concern, further evaluation with a breast ultrasound will be helpful to confirm the presence of benign simple breast cysts. 

Lydia Liao, M.D.: Some radiologists document every finding whether it is significant or not, while others will only address important findings that warrant further examination.  The actual mammogram report should not be confused with the report a woman is required by federal law to receive within 30 days of her mammogram. The latter is not a copy of the official radiology report, but rather, it is usually a short letter stating whether her mammogram was normal or if an abnormality was detected.

As a general rule, any significant history should be included in the history/indications portion of the radiologist’s dictated report.  You are correct that ductal and lobular cancers present themselves in different ways but all breast imaging studies should be fully evaluated for any abnormality in either breast.

Breast imaging studies cannot provide a definitive tissue diagnosis including types of breast cancer (lobular vs. ductal breast cancer). The definitive diagnosis is from surgical pathological evaluation of the breast specimen from breast biopsy.

When there is an established diagnosis of lobular cancer for a woman, especially invasive breast cancer, such diagnosis shall be incorporated in to the procedure report (breast biopsy) and the following breast imaging studies as part of history. As you have pointed out, detailed information of type of breast cancer in history section will be helpful to raise the awareness for more careful evaluation, since invasive lobular breast cancer is more difficult to be detected and carries a increased risk for Contralateral breast cancer.

Lydia Liao, M.D.: Women with breast implants should follow the same American Cancer Society (ACS) program of recommended mammograms as women without breast implants.  However, due to the implant, several special mammography views must be taken to allow visualization of both the breast tissue and the implant. Examination of the augmented breasts is more time consuming; so be sure to tell the staff that you have breast implants when you schedule your mammogram. Patients with implants should also inform the physician and the technologist performing the exam that they have implants.

The x-rays used for mammographic imaging of the breasts cannot penetrate silicone or saline implants well enough to image the overlying or underlying breast tissue. Therefore, some breast tissue (approximately 25%) will not be seen on the mammogram, as it will be covered up by the implant. In order to visualize as much breast tissue as possible, women with implants undergo four additional views as well as the four standard images taken during diagnostic mammography. In these additional x-ray pictures, called Eklund views or implant displacement (ID) views, the implant is pushed back against the chest wall and the breast is pulled forward over it. This allows better imaging of the forward most part of each breast. The implant displacement views are not as successful in women who have contractures (formation of hard scar tissue around the implants). The ID views are easiest to obtain in a woman whose implants are placed underneath (behind) the chest muscle. 

Otherwise, the same preparation is needed for a mammogram on a patient without breast implants.

Lydia Liao, M.D.: Without looking at all your breast imaging studies, I can only give you generalized advice on the best way to manage your particular case.  One of the most important tools to interpreting mammograms is the comparison of old films to the most recent study to evaluate for any change in appearance.  This will be helpful to reduce unnecessary diagnostic mammographic studies.

Your prior mammograms may help show that a mass (or in your case scarring) has not changed for many years, which would mean that the area is likely a benign condition and a biopsy would not be needed. Having your prior mammograms available to the radiologist is very important and if it is possible to obtain your old films, you may want to take them with you to see if that is helpful for diagnosis.  If in fact after comparing these images there is a change in your mammogram, then further action would be required and likely the benefits would outweigh the risks.

Lydia Liao, M.D.: Beginning in their 20s, women should be told about the benefits and limitations of breast self-exam (BSE). Women should know how their breasts normally look and feel and report any new breast changes to a health professional as soon as they are found. Finding a breast change does not necessarily mean there is a cancer.
A woman can notice changes by being aware of how her breasts normally look and feel and by feeling her breasts for changes (breast awareness), and using a specific schedule to examine her breasts. If you choose to do BSE, the best time for a woman to examine her breasts is when the breasts are not tender or swollen. Women who examine their breasts should review the  technique with their doctor during an appointment. .

Without any risk factors such as a family history and in the absence of any palpable abnormality, current guidelines from the U.S. Department of Health and Human Services (HHS), the American Cancer Society (ACS), and other specialists recommend screening mammography every year for women, beginning at age 40. Research has shown that annual mammograms lead to early detection of breast cancers, when they are most curable and breast-conservation therapies are available.

Lydia Liao, M.D.:

Lydia Liao, M.D.: Women who are at higher than average risk of breast cancer should talk with their health care provider about whether to have mammograms before age 40 and how often to have them.

Many healthcare providers will start screening mammograms for high-risk patients at age 35.