Publications
Partners
If all of the above suggest the lump is benign, it may be watched and followed up. If one of the tests casts any doubt, the lump is removed.
Clinical assessment: Medical history and examination. The history includes history of the illness, family history and patient medical history. In a clinical examination, the doctor gently palpates (feels) your breasts, noting shape, texture, changes in skin and nipples; location of any lumps, and if these are attached to skin or deeper tissues. Lymph nodes under the arm and above the collarbone are palpated for swelling.
Mammography: Low-intensity breast X-ray, for screening (if no abnormalities were found in examination) or diagnosis. A mammogram takes about 20 minutes and can detect changes or abnormalities before they grow large enough to be felt. Diagnostic mammography may indicate whether a breast lump is malignant or not.
If a screening mammogram shows abnormal tissue that is probably benign, you should return in four to six months for a re-check. If it shows no serious abnormality, regular screening programmes should be followed. If the mammogram shows abnormalities, the radiologist may recommend another exam, such as a biopsy.
During the mammogram, you stand or sit in front of an X-ray machine while the radiological technologist lifts each breast and positions it on a platform that holds X-ray film. A plastic plate presses the breast against the platform for a few seconds: pressure allows the X-ray dose to be lowered and ensures it shows as much breast tissue as possible. This pressure is harmless and usually not painful, but can be uncomfortable. Avoid having mammograms when your breasts are tender, such as before your period.
If the mammogram shows masses, these are usually biopsied unless they are cysts (benign collections of fluid). Calcifications are mineral deposits, which may appear as white spots on the film. They may be caused by benign conditions or, less often, by cancer.
Ultrasound or removing fluid with a needle (aspiration) may confirm whether a mass is a cyst. Some masses are monitored with periodic mammograms; others require biopsy.
Mammography detects 85-90% of breast cancers. Approximately 10-15% aren’t visible on mammography, but are felt on physical examination. Mammograms are more unreliable in woman younger than 40.
Breast ultrasound: Sound waves are bounced off tissue and the echoes converted into a picture (sonogram). Ultrasound helps distinguish between cysts and solid tumours. It is particularly useful in younger patients whose breasts are too dense for mammography.
MRI scan: Effective in detecting small cancers, especially in young women with dense breasts. Studies have shown it is useful in screening women with genetic susceptibility to cancer. The drawback is it’s expensive and unpleasant for the patient.
Nipple discharge examination: If blood is present a smear is done to check for cancer. Clear or milky secretions are very unlikely to mean cancer. A red-brown colour may indicate cancer, although benign conditions are more likely. Even when no cancer cells are found, cancer cannot be ruled out. If a suspicious mass is also present, biopsy is necessary.
Biopsy (tissue sampling): May be done as part of assessment of a lump even though the clinical and radiological examinations suggest it isn’t cancerous. Or, an abnormality on a mammogram may be sampled. Eighty percent of biopsies are non-cancerous.
Fine-needle aspiration biopsy: A needle is guided into the abnormal area and fluid drawn out. Clear greenish fluid usually indicates a benign cyst. Bloody or cloudy fluid can mean a benign cyst or, rarely, cancer. With a solid lump, tissue cells are aspirated. In most cases, microscopic examination determines whether abnormalities are benign or cancerous.
Core needle biopsy: A small cylinder of tissue is removed from an abnormality.
If after “triple assessment” the lump is suspected to be cancerous, or the diagnosis is still unknown, the lump should be removed.
Surgical biopsy: All or part of a lump is removed for examination. Excisional biopsy removes the abnormality along with a surrounding margin of apparently normal tissue, and is usually considered the first of a two-step procedure (diagnosis by needle biopsy can also be considered the first step.)
The second step is local treatment of the cancer through radiation or additional surgery.
With the two-step procedure, a diagnosis is known shortly after biopsy, but the extent of cancer is not known until after local surgery.
If the abnormality isn’t a lump but a change on a mammogram that can’t be palpated, then the tissue may be removed using a technique called a “hookwire biopsy”. The patient has another mammogram and the area of concern is located. The radiologist places a fine wire into the area using the X-ray machine to guide it into position. The surgeon then removes the wire along with a small area of surrounding tissue and sends it to be X-rayed to check the abnormal tissue has been removed.
