The specialist will begin your diagnostic evaluation with a thorough medical history. What symptoms do you have and how long have you had them? What is your age, menstrual status, general health? Are you pregnant? Are you taking any medications? How many children do you have? Do you have any relatives with benign breast conditions or breast cancer? Have you previously been diagnosed with benign breast changes? Have you recently had a screening mammogram?

The specialist will then carefully examine your breasts (see Clinical Breast Examination in the Screening and Early Detection section of this site) and will probably schedule you for routine imaging tests, such as a mammogram or ultrasound. If there are any questionable areas, additional imaging studies, such as direct compression mammograms or diagnostic ultrasound will be ordered. At times, tissue sampling such as a fine needle aspiration or other biopsy may be needed to reach a final diagnosis.

It is important not to become alarmed, as many findings eventually turn out to be benign. However, it is equally important to follow all instructions for evaluation so an accurate diagnosis can be made.

Deciding on a Biopsy

Not every lump or mammographic change requires a biopsy. Your doctor needs to thoughtfully weigh the findings from your physical exam and mammogram along with your background and your medical history when making a recommendation about a biopsy. In general, doctors feel it is wise to biopsy any distinct and persistent lump. Although benign lumps rarely, if ever, turn into cancer, cancerous lumps can develop near benign lumps and can be hidden on a mammogram. Even if you have had a benign lump removed in the past, you cannot be sure a new lump is also benign.

In some cases, the doctor may suggest watching the suspicious area for a month or two. Because many lumps are caused by normal hormonal changes and this waiting period may provide additional information. Similarly, if the changes on your mammogram are more consistent with benign disease, your doctor may advise waiting several months and then taking another mammogram. Sometimes, additional diagnostic mammograms will be recommended over the next two years. If you choose this option you must be strongly committed to regularly scheduled follow-ups during this period of observation. If you feel uncomfortable about waiting, express your concerns to your doctor. You may also want to get a second opinion, perhaps from a breast specialist or surgeon. See the Find a Physician section of this site at the top right of your screen.

Diagnostic Methods

Biopsy is the only conclusive way to learn whether a breast lump or mammographic abnormality is cancerous. A biopsy is a procedure in which cells or tissue are removed by a surgeon, radiologist, or other specialist and examined under a microscope by a pathologist. Fine needle, core needle or open surgical methods can obtain samples for biopsy. The doctor's choice of biopsy technique depends on many factors, including the nature and location of the mass.

Fine Needle Aspiration Biopsy (FNAB) is usually utilized when a cyst is suspected, but it can also be used on some solid masses.  This procedure, which uses a very thin needle and a syringe, takes only a few minutes and can be done in the doctor's office. Holding the lump steady, the doctor inserts the needle and attempts to draw out any fluid.

Example of fine-needle aspiration.

If the lump is indeed a cyst, removing the fluid will cause the cyst to collapse and the lump to disappear. (Cysts are so rarely associated with cancer that the fluid removed from a cyst may not always require testing and your doctor may discard the fluid.) Unless the cyst reappears, no other treatment is needed. If the cyst reappears at a later date, it may be drained again, or a recommendation may be made for complete excision (removal).

If the lump turns out to be solid, it may be possible to use the needle to withdraw a sample of cells, which can then be sent to a laboratory for further testing. Accurate fine needle aspiration biopsy of a solid mass takes great skill, gained through experience with numerous cases. Because FNAB only obtains cells (cytology) and not tissue (histology), it provides limited diagnostic information. Further testing may be necessary to ascertain a final diagnosis.

Sometimes fluid removed from a breast cyst may be discarded; at other times, it will be sent to a lab for investigation.

Core needle biopsy uses a larger needle with a special cutting edge. After numbing the breast skin with local anesthetic, the core needle is inserted through a small incision in the skin.  Usually, a few cores of tissue are removed. This technique may not work well for lumps that are very hard or very small. Core needle biopsy may cause some bruising, but rarely leaves an external scar, and the procedure is over in a matter of minutes. This type of biopsy offers a more accurate diagnosis compared with FNAB, since breast tissue samples, not just cells, are removed.

Stereotactic localization biopsy is a newer approach that relies on a three-dimensional x-ray to guide the needle biopsy of a nonpalpable mass. Using one type of equipment, the patient lies face down on an examining table that has an opening which allows the breast to hang through.  The mammography equipment and a maneuverable needle biopsy mechanism are set up underneath.

Alternatively, specialized stereotactic equipment can be attached to a standard upright mammography machine. The breast is x-rayed from two different angles, and a computer plots the exact position of the suspicious area. Once the target is clearly identified, the radiologist positions the equipment and advances the biopsy needle into the lesion.

Vacuum-Assisted Biopsies: A more recently developed form of core needle biopsy is the vacuum-assisted core biopsy (trade name Mammotome®). This type of biopsy is generally performed using ultrasound or mammographic stereotactic guidance and differs from core biopsy in the type of needle mechanism that is used. In the case of vacuum- assisted core biopsy, a small amount of suction is added to the needle core system in order to capture a larger piece of tissue.

Advanced Breast Biopsy Instrumentation: The Advanced Breast Biopsy Instrumentation (ABBI®) is another variation on the stereotactic, mammographically-guided biopsy. It differs from core needle biopsy in that a much larger core instrument is used. At times, if the suspicious area on the mammogram is very small, the much larger core instrument of the ABBI system removes the entire abnormality and a small amount of surrounding normal breast tissue.  If biopsy results are benign, nothing further is done.  However, if malignant (cancerous) further surgery will be needed. The ABBI biopsy may not result in the removal of the entire cancer with a safe margin of normal tissue.

Surgical biopsies can be either excisional or incisional. An excisional biopsy removes the entire lump or suspicious area. Many characteristics of the mass will determine if this approach is best.  Also, it may be used if a prior needle biopsy is inconclusive or suspicious and a final diagnosis is still needed.

An excisional biopsy is typically performed in the outpatient department of a hospital. After the administration of a local anesthetic (with or without a sedative) the surgeon makes an incision along the contour of the breast and removes the lump along with a small margin of normal tissue. Sometimes, a wire will be placed in the breast before the operation. (See Needle Localization Biopsy below.) Because no skin is removed, the biopsy scar is usually small. The procedure typically takes less than an hour. After spending an hour or two in the recovery room, the woman goes home the same day.

An incisional biopsy removes only a portion of the tumor for the pathologist to examine. Incisional biopsies are generally reserved for tumors that are relatively large. They are also usually performed under local anesthesia on an outpatient basis.

Whether or not a surgical biopsy will change the shape of your breast depends partly on the size of the lump and where it is located in the breast, as well as how much of a margin of healthy tissue the surgeon decides to remove. You should talk with your doctor beforehand, so you understand just how extensive the surgery will be and what the cosmetic result will be.

Needle Localization Biopsy (also known as wire localization) is a procedure that uses mammography or sonography to locate and target breast abnormalities that can be seen on mammogram or ultrasound, but cannot be felt (nonpalpable). Localization (i.e. targeting) may be used with fine needle aspiration biopsy, core needle biopsy or surgical biopsy.

For a surgical biopsy, the radiologist locates the abnormality on a mammogram (or a sonogram) just prior to surgery. Using the mammogram as a guide, the radiologist inserts a fine needle and wire so the tip rests in or near the suspicious area — typically, an area of microcalcifications or a small mass. The needle is anchored, and a second mammogram is taken to confirm that the wire is on target. Next, in the operating room, the surgeon locates and removes the targeted area. To make sure the surgical specimen contains the abnormality, it is x-rayed on the spot and it then sent to the pathology laboratory for processing. If it fails to show the mass or the calcifications, the surgeon is able to remove additional tissue.

Cells or tissue removed through needle or surgical biopsy are promptly sent to the pathology lab. After the tissue is processed, slides are prepared for review by a pathologist. The pathologist looks for abnormal cell shapes and unusual growth patterns. In many cases the diagnosis will be clear-cut. If you are diagnosed with breast cancer, your pathology report can provide information which can dictate treatment and prognosis. Most pathology reports are written for medical professionals, and therefore are not easily understood. Breast Cancer Network of Strength (formerly known as Y-me), a national breast cancer organization, offers a free brochure, "Understanding Your Breast Cancer Pathology Report" which can be obtained through their breast cancer hotline @ 1.800.221.2141 or it can be viewed online.

However, the distinctions between benign and some cancerous cells can be subtle, and even experts don't always agree. When in doubt, pathologists readily consult their colleagues. If there is any question about the results of your biopsy, you will want to make sure more than one pathologist has reviewed your biopsy slides. See Pathology Consultations at NS-LIJ.