I am anemic, my ESR is raised, and I feel my spleen is enlarged in chest X-ray. Kindly help me.

Hi,

Welcome to icliniq.com.

Please do not worry so much that you turn hypochondriac. Worrying will bring in illness that you do not have. Just eat healthily, be happy, exercise, have good close friends & family, stay away from alcohol and smoking.

The X-ray you have provided (attachments removed to protect the patient's identity) does not show any significant abnormalities in the region of the liver and spleen.

However, if you are very much concerned and want to ascertain the healthiness of the liver, spleen, and other abdominal organs, I would suggest you get an ultrasonography of the whole abdomen done. In that, ask the sonographer for liver size, echotexture, fatty liver, cysts, etc., and also the gall bladder if there are any stones or polyps within.

For functionality assessment, get a baseline blood investigations done comprising complete blood count, liver function tests, lipid profile, blood sugars (fasting, post-lunch, HbA1c (hemoglobin A1c), and creatinine.

I will help and comment more if you can share images of your CT (computed tomography) scan.

I hope this was helpful.

Hi,

Welcome back to icliniq.com.

Firstly, the spleen and lymph node cannot be adequately assessed on a chest X-ray. Like I told you before, ultrasonography is a modality to assess the same (CT scan will be even better). Lymph Nodes can be seen on X-ray when they are calcified. So I will not be able to comment on the status of the spleen or lymph nodes on X-ray.

Secondly, if you have an enlarged spleen, it may be connected to long-standing anemia, as you mentioned. Raised ESR (erythrocyte sedimentation rate) also may be related to it. We also need to rule out tuberculosis in cases of raised ESR, for which a TB-PCR (tuberculosis-polymerase chain reaction) test and Mantoux test are advised.

Obesity is an independent risk factor for metabolic syndrome, hypertension, diabetes mellitus, and adverse cardiovascular events. So please try to reduce weight by exercise and diet. That will also help in curbing symptoms of adenomyosis and improve your reproductive health and overall well-being.

I hope this was helpful. Please follow-up with the reports.

Hi,

Welcome back to icliniq.com.

Yes, few cases of iron deficiency anemia may cause an enlarged spleen. I would like to know if the cause of your anemia has been confirmed as iron deficiency and nothing else (such as sickle disease, thalassemia trait, etc.). A few blood tests are required to confirm the diagnosis of iron deficiency anemia, such as serum ferritin, total iron-binding capacity (TIBC), and transferrin saturation. If the cause of your anemia is something else, then taking iron capsules may harm rather than cure.

Temporary enlargement of the spleen is very common in many illnesses. So do not worry. Birth control pills and adenomyosis may raise the ESR a bit but not up to 41. Similarly, obesity and hypercholesterolemia may alter the ESR to some extent.

However, severe anemia will cause more rise of ESR, which may be the thing in your case. Please share your hematological reports to give me a better insight into your issues. Once your anemia gets better, the ESR will also improve.

Sprained ankle usually resolves in a couple of weeks with adequate rest and anti-inflammatory medications. I suggest you do the blood investigations mentioned above.

I hope this was helpful. Kindly follow up with reports.

Hi,

Welcome back to icliniq.com.

I understand your concern.

I went through the blood workup reports (attachment removed to protect the patient's identity).

I am happy that they are good. Your sugar level, as denoted by glycosylated hemoglobin (HbA1c) of 4.6, is very good, indicating good sugar control. Also, Kidney function, as suggested by Creatinine ( 0.77), eGFR and electrolyte levels, is normal. Similarly, liver function, as indicated by normal values of proteins, bilirubin, AST, and ALT, is good. However, amongst your lipid profile, triglyceride levels are high, which can be managed by dietary modification (cutting down on the intake of fats), and lifestyle changes (cardio, aerobics, etc.). At this stage, I will not recommend medicine (Fenofibrate) for lowering triglyceride as it is slightly above the upper limit of the normal range and can be well managed by diet & exercise. Now, coming on to your anemia part. As per your reports your hemoglobin level is 13.5 g/dL which is well within the normal range and thus excludes the diagnosis of anemia. However, a slightly lower value of mean corpuscular volume (MCV) and mean corpuscular hemoglobin (MCH) with a slight increase in iron binding capacity (IBC) indicate mild iron deficiency. A higher reticulocyte count indicates that your bone marrow is responding well enough to keep red blood cell levels good in your body.

As far as oral iron tablets are concerned, you may take "Ferrous or Iron carbonate" preparations as they are shown to have fewer side effects and are better tolerated by patients. Overall, your reports are good, and you seem to be in a good state of health. Do not lose your sleep over the isolated finding of raised ESR (which can be just incidental and innocuous). I suggest you get the following tests done after eight weeks and follow up: Serum Lipid profile. Complete blood count with ESR, Reticulocyte count. Iron studies.

Hi,

Welcome back to icliniq.com.

I understand your concern.

I hope your earlier health issues and concerns have been resolved and you are in a better state of physical and mental health. I went through your current query. I also went thoroughly through the mammography and sonomammography images you have provided. It looks like you have scar tissue and complex cysts visible on the scan images. The cysts are usually water or fluid-filled structures. To the best of my knowledge and experience, it looks like a BI-RADS 3 (breast imaging-reporting and data system) lesion, which is most probably benign to me. Usually, the protocol is to follow up after six months. The biopsy is only done if clinically indicated, as these cases usually have less than a two percent chances of being malignant. So relax and get a scan done after six months.

Hi,

Welcome back to icliniq.com.

I understand your concern.

Yes, I did go through the compression spot images, and it is mid to high-density focal asymmetry. So its margins are not spiculated, or it does not show obvious signs of cancer. Depending on your clinical history, I would not recommend a biopsy at this stage and would like to follow up. Yes, as the cysts are atypical and there is focal asymmetry, I labeled it BIRADS 3.

Hope this helps.

Hi,

Welcome back to icliniq.com.

I understand your concern. I think the area labeled two on compression spot images is due to a scar with superimposition of breast tissue leading to apparent focal asymmetry. It does not look suspicious. I do second the other radiologist that it does not look like true focal asymmetry.

Hi,

Welcome back to icliniq.com.

I understand your concern. If it is not seen on ultrasound, it is a good sign and may indicate that what we saw on the mammogram may be due to summation or superimposition of shadows. I have been doing breast ultrasounds for the past 12 years and can say that it does not look suspicious, and you can relax.

Hi,

Welcome back to icliniq.com.

I understand your concern. Typical simple cysts have thin imperceptible walls with a clear anechoic lumen. However, I found low-level echoes in your cyst, which I labeled atypical. These echoes could be inflammatory in etiology or just plain inspissated secretions. A cyst may or may not be related to focal asymmetry on a mammogram. Fortunately, in your case, there was no sonographically appreciable lesion corresponding to the focal asymmetry on a mammogram. So in your case, I do not think they are related. Best regards.

Hi,

Welcome back to icliniq.com.

I understand your concern. The cyst does not show thick walls. However, I can see incomplete internal septations and minimal debris (secretion). No true focal asymmetry is seen in last month's mammogram images. Furthermore, ultrasound also does not reveal any suspicious lesions.

Hi,

Welcome back to icliniq.com.

I understand your concern. From the images provided (attachment removed to protect the patient's identity), no corresponding suspicious lesion was seen on ultrasound with respect to your first two queries. Focal asymmetry, we have discussed in detail earlier. Regarding the other three questions:- 1. The calcifications they have described are not worrisome and are sometimes seen in post-reduction patients.

2. No suspicious calcifications are seen in the right breast.

3. Time taken for tiny cysts to regress varies from 2 months to years. If there is no change in morphology or size over the years, then do not worry. If you are too worried, get a repeat ultrasound done by an expert in the field.

Hi,

Welcome back to icliniq.com.

I understand your concern. Firstly apologies for the late reply as I am out of the city traveling with no access to a good network. In my opinion, the equal-density oval-shaped mass seen on the mammogram with no corresponding lesion on ultrasound most likely represents an area of focal dense breast tissue. Similarly, focal asymmetry in the right breast also refers to an area of increased focal density. Mass is a very vague term sometimes few healthcare professionals use for any density seen. As no corresponding suspicious lesion is seen on ultrasound for either, you relax and stop worrying. Get a repeat ultrasound, and mammography is done if you notice a sudden change in the breast, lump, or nipple discharge size.

Hi,

Welcome back to icliniq.com.

I understand your concern.

I reviewed the breast ultrasound images you have uploaded (attachment removed to protect the patient's identity), and the following are my observations:-

The right breast's 1 o’clock position is a tiny 2.9 x 2.6 x 1.6 mm simple cyst.

The right breast, 5 o’clock position about 4 cm from the nipple, is seen as an oval 9.5 x 8.6 x 4.2 mm fibroadenoma. On color doppler imaging, this shows vascular flows within. So this can increase in size. Therefore, it will be advisable to repeat the ultrasound after six months to look for the same.

The right axilla shows a 15.7 x 13.2 mm non-necrotic node with a maintained fatty hilum, which is a normal finding.

The left breast shows an area of focal dense breast tissue (maybe forming fibroadenoma) at the 4 o’clock position about 14 cm from the nipple. This also appears benign. Not worrisome.

The left axilla shows a 16.3 x 14.2 mm non-necrotic node with a maintained fatty hilum, which is a normal finding.

Overall, I did not find anything alarming which needs urgent attention..

Hi,

Welcome back to icliniq.com.

I understand your concern.

Yes, I could compare them. I think the equal density mass lesion with irregular borders, which they were referring to on the mammogram, corresponds to the area of focal dense breast tissue (forming fibroadenoma) seen in the current ultrasound scan. Yes, this could be scar tissue. That is indeed a possibility. In the current ultrasound scan, I could not find any lesion corresponding to the focal asymmetry seen on a mammogram. The lymph nodes seen on the scan are of normal size. Not pathological. I do not think there is any cause for concern or something to panic about.

Hi,

Welcome back to icliniq.com.

I understand your concern.

The standard gold test to know whether a lesion is benign or malignant is a biopsy followed by a histopathological examination. We have come across a few cases wherein the sonographic features were of a completely benign nature, but on histopathological examination, they turned out to be malignant. I am about 95 % sure that the lesions seen in your case are benign in nature. I guess, to be cent percent sure, the physicians there are opting for biopsy. The biopsy will 100 % confirm the diagnosis. Do send me the reports of the biopsy.

Hi,

Welcome back to icliniq.com.

I understand your concern. Yes, I guess the 3.1 cm mass they are mentioning is the same, which I found to be focal dense breast tissue or forming fibroadenoma. Increased vascularity is usually due to an inflammatory response which happens in cases of scar tissue and infection, and the less common cause is cancer.

Hello,

All the best for biopsy.

Thank you.

Hello,

Welcome back to icliniq.com.

As you must have already read, Pseudo-angiomatous stromal hyperplasia (PASH) of the breast is benign, not cancerous. Moreover, it is not a premalignant lesion, which means it would not lead to increased chances of cancer. Therefore, the chances of developing cancer in usual ductal hyperplasia are practically nil. However, there is a marginal theoretical possibility. Therefore, to assess breast cancer risk in usual ductal hyperplasia, you will need to get your biopsy sample tested for estrogen receptor-α and Ki-67 expression. As of now, Short term follow-up with breast ultrasound is suggested. The following are my answers to your questions.

1. My pathology from the tissue sent out from my breast reduction two years ago came back completely clear. Why weren’t these conditions seen on that, then?

I c n think of 2 possibilities as of now. One is that hyperplasia occurs after the surgical process. Second, the part of the breast examined histopathologically was clear of hyperplasia.

2. I have been on Nuva ring for birth control for nine years. Would these conditions reverse themselves if I go off of my birth control? I want to go off and cleanse my body of synthetic hormones.

The ring is not preferred for females after 35 years of age or other conditions that may have hormonal or other medical issues. So, in my opinion, you better take the ring off.

3. Is UDH ever a precurso to AH?

Very, significantly less likely.

4. If anything else was present in the ducts in another part of the breast, would it show on this sample?

Yes, if any untoward thing we e present, it would have shown.

5. Could UDH showing be a temporary result of being in the 2nd half of my cycle at the time of th biopsy due to cyclic breast changes? My biopsy was about 7 to 10 days before the start of my period.

I do not think so.

6. Does the focal asymmetry or calcifications look any different?

No significant change.

7. They want me to have a stereotactic biopsy on the calcifications. I’m not comfortable doing this right now because of radiation from mammograms so close together. However, I’ve had other opinions that a biopsy isn’t necessary and that the calcifications from October’s mammogram had fat l cent centers suggesting fat necrosis. Do you agree with this? Are the calcifications associated with the ducts, or are they not near them?

I also think you can wait for a biopsy and not go straight ahead. Calcifications are usually associated with ducts. And is also the sequel to fat necrosis. Macrocalcifications are, however, benign.

8. What is this area that I circled on the picture with the black circle? Is that normal breast tissue?

I see such things frequently on mammograms, which are part of normal breast tissue.

Thank you.

Hello,

Welcome back to icliniq.com.

These calcifications are not worrisome as they have a benign pattern. In my opinion, and with my experience, I do not think you require a biopsy. However, for peace of mind, you can go ahead. With new technology and newer machines, the radiation dose is negligible. So do not worry about the radiation risks inducing cancer. Medicine is not 100 % full-proof science. However, I am pretty damn sure that if anything untoward were present, it would have shown on the biopsy report. Deeper levels, I guess, mean deeper parts of the tissue. Milk of calcium is a common and transient phenomenon. If your doctor thinks that the calcifications they want to biopsy are milk of calcium, better don’t biopsy it. The cysts and calcium deposits often superimpose on each other during mammography. Also, a group of cysts may have small calcium deposits, which are not visualized on ultrasound. Therefore, the possibility of Microcysts cannot be ruled out. When a calcified cyst disappears, calcification usually remains and gets absorbed over time.

Thank you.

Hello,

Welcome back to icliniq.com.

1. This thick linear streak, in my opinion, is a superimposed shadow of internal scar tissue (most likely along the plane of cut or incision) and the skin fold. During compression, while taking the MLO view, this may have got spread and, therefore, not visible on the corresponding view.

2. Tiny cyst is seen in the right breast at 1 o’clock position. I think there are 2 to 4 microcysts in the retro areolar region of the left breast near the nipple base. However, they are not problematic at all.

3. Focal asymmetry is most likely at the 4 o’clock position in the left breast.

Thank you.

Hello,

Welcome back to icliniq.com.

The scar tissue may show up as focal asymmetry. I could not appreciate any microcysts in the area of focal asymmetry in the images provided (attachments removed to protect the patient's identity).

Thank you.

Hello,

Welcome back to icliniq.com.

According to the natural healing process, it heals with scarring whenever there is an injury, cut, or breach of tissue. On long-standing, calcification occurs on the scar tissue to fortify it. I think after the reduction surgery, there was internal scarring and subsequent calcifications as part of the natural healing process of the body. However, please note that it is not a hard and fast rule that scarring will take place on all scar tissues. And calcifications do not occur all along the scar tissue. There are skip areas. So do not worry or think much if your report says that the calcifications would be 6cm from the nipple, but the scar is further than that, probably 14 cm. Furthermore, many of these calcifications get easily missed on ultrasound and are picked up on mammography or tomosynthesis. Therefore, these may not have been visualized on the ultrasound scan. Hence they were not seen.

Thank you.