Approach to Breast Lumps

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Ultrasonography

Ultrasonography can determine whether a breast mass is a simple or complex cyst or a solid tumor. It is most useful in the following circumstances:

  • In women under age 35
  • When a mass detected on screening mammography cannot be felt
  • When the patient declines aspiration of a mass
  • When the mass is too small or deep for aspiration


The risk of cancer is very low if the lesion is a simple cyst on ultrasound. Experts differ in their recommendations for women with palpable

masses. Some recommend ultrasonography in conjunction with mammography in women over age 35 and ultrasound alone in women under age 35, while others recommend skipping ultrasonography altogether and moving straight to fine needle aspiration.

Fine needle aspiration

Fine needle aspiration (FNA) is inexpensive, easy to perform (in skilled hands), requires no advanced preparation, and can be carried out in the office. To aspirate a palpable, suspected cyst, the mass is stabilized between the fingers of one hand and a 22 to 24-gauge needle is inserted with the other hand. Local anesthesia may be used but is not always required. FNA is especially valuable in evaluating cystic breast lesions and can be therapeutic if all of the fluid is removed.

There are three possible scenarios with FNA:

  • If fluid is obtained and is not bloody, it does not need to be sent for analysis. The mass should disappear with the removal of fluid and the patient can be reassured and checked in 4 to 6 weeks to ensure that the cyst has not reappeared.
  • Bloody fluid should be sent for pathological analysis; cancer is found in approximately 1 percent of such cases
  • When no fluid is obtained and the mass turns out to be solid, cells can be obtained for cytologic analysis with fine needle aspiration biopsy (FNAB) by aspirating cells from the solid mass.

Core needle biopsy

A core needle biopsy is different from FNAB; a larger needle is used with the former (14 to 18 gauge, compared with 21 gauge), thereby providing histologic material and not requiring special cytopathologic expertise for interpretation. Core needle biopsy is used most often for evaluating non-palpable breast lumps in conjunction with either stereotactic mammographic equipment or ultrasound guidance. The sensitivity of core needle biopsy is less than FNAB for the diagnosis of palpable carcinoma.

Triple diagnosis

Triple diagnosis refers to the concurrent use of physical examination, mammography, and skilled FNAB for diagnosing palpable breast lumps. Very few breast cancers are missed using triple diagnosis.

The following scenarios occur with the triple diagnosis approach:

  • Women in whom all three tests suggest benign disease are followed with thorough physical examination every 3 to 6 months for one year to make sure the mass is stable or regresses.
  • Women in whom all three tests suggest malignancy are referred for definitive therapy.
  • Women with any one of the tests suggesting malignancy undergo excisional biopsy.

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