• Needle biopsy is the procedure of choice to evaluate an area of concern on the mammogram or ultrasound.
• Open surgical biopsy to make the diagnosis of an area of concern on the mammogram is rarely indicated.
IAM FREQUENTLY ASKED by my patients, “What is a breast lump?” The confusion is understandable, since by nature breasts are lumpy. In general, we think of a breast lump as a localized prominence in the breast that stands out from normal, surrounding tissue.
Fortunately, most lumps are easy for the patient to detect. Nodules that are smooth, round, and movable are typically benign. Malignant masses are usually hard, irregular, and, in more advanced cases, fixed in place. For these women, the issue is mainly making an accurate diagnosis.
However, distinguishing the more subtle lumps from normal breast tissue can be challenging even for an experienced physician, who may be convinced that the questionable area is simply a variation of the normal breast pattern. Unfortunately, many physicians don’t understand that any new focal “area of concern” in the breast merits attention. If a woman can point to a specific area where she perceives a change, a directed ultrasound is indicated.
If the ultrasound is not definitive, a focused mammogram should be performed for women in their thirties. Although we do not advise screening mammograms for this age group, diagnostic mammograms to evaluate new symptoms are perfectly safe. In women forty and over, we opt for a diagnostic mammogram with magnification and compression views to the area. If it has been six months or more since the patient’s most recent mammogram, regular whole breast views should be included in the diagnostic workup.
If a lump can be visualized on the ultrasound or mammogram, a core needle biopsy is next. For patients in which the evaluation is completely normal, it is important for the physician to understand the need for close follow-up.
For certain malignancies, such as lobular cancer (also known as “the Devil’s Cancer”—see chapter ten), a subtle clinical finding may be the only indicator of a developing problem. For this reason we follow up on such patients with additional physical examination at two-, four-, and six-month intervals. A menstruating woman is advised to return five to ten days after the onset of her period. This approach has proven to be effective in avoiding a delayed diagnosis and has been much appreciated by my patients.
For some women a more aggressive approach is indicated. In patients forty and over who have persistent focal symptoms despite a negative workup, a diagnostic MRI should be considered as an additional option. For those in whom the MRI is normal, the likelihood of a hidden cancer is remote.
With all the advances in imaging technology, it is now rare to do an open surgical biopsy to make the diagnosis of a “hidden” breast cancer.
MAKING THE DIAGNOSIS—AS IT WAS YEARS AGO
Incredible progress has been made—not just in detecting breast cancers at an early stage, but also in how we go about making the diagnosis. Years ago when I was in residency training, we did a “traditional” one-step approach: The patient with a lump would sign a consent form allowing the surgeon to do a mastectomy if the pathologist determined during surgery that the area of concern was cancer. We told our patient that if the lump proved to be benign, she would wake up with a small Band-Aid–like dressing. If, instead, it was cancer, she would find a large dressing with drainage tubes coming out of her chest.
Understandably, this was a hard concept to explain to a young woman who almost certainly did not have cancer. One case stands out as a reminder of just how frustrating this was in “the old days.”
THE PATIENT WHO WAS SCARED AWAY
Monique was a twenty-one-year-old foreign exchange student I met during my surgical residency. She showed up at our clinic with a small mass in her left breast. She was alone and clearly apprehensive about being in a breast clinic in a foreign country. Even worse, a young and relatively inexperienced surgical resident was seeing her.
After introducing myself and asking a few questions, I did a careful exam. She had a marble-sized lump in the center of her left breast that was smooth, round, and very movable. I could tell with almost complete certainty that it was not cancer. I also knew in my heart that having her sign a consent form for mastectomy was the wrong thing to do.
At the time I was just a junior surgical resident. Before discussing options with the patient, I asked the chief of surgery for permission to remove the lump without having her sign the standard consent form.
His response sent chills down my spine: “That is not the way we do it here.” His tone clearly implied that if I wanted to continue my residency training, I had no choice but to have her sign the consent form.
I went back to the exam room feeling anything but comfortable. Monique appeared to be so vulnerable. I tried to explain to her that in the United States we require a woman to sign a consent form for a possible mastectomy before taking her to surgery to remove a breast mass. I emphasized the probability that her lump being cancer was probably one in a million.
As soon as I mentioned the word “mastectomy,” her mind seemed to go blank. I could tell she was not listening to anything else I said. Tears welled in her eyes. She simply turned and walked away. I never saw her again.
DIFFERENT KINDS OF BREAST LUMPS
Most breast lumps will prove to be benign. The younger the woman, the more likely it will not be cancer. However, new nodules in women over forty should be managed with the assumption that they are cancer until proven otherwise. Breast lumps can be divided into two basic categories: cystic and solid.
Breast Cysts
Breast cysts are fluid-filled sacs found mostly in women between the ages of forty and fifty, though they do appear in all age groups. Most cysts do not form lumps and are only detected on breast imaging. Except for the rare cyst that does not have typically benign features on imaging, the majority can be ignored if they do not form a lump.
Of those that can be felt by the patient, most are easily managed and present no risk. One of the truly rewarding events in my practice occurs when a patient has an obvious tender mass, which on ultrasound proves to be smooth, round, and fluid-filled, but, when the mass is aspirated with a needle under ultrasound guidance, the lump completely disappears—along with the woman’s fears. These are among the most appreciative patients in my practice.
In rare instances, the cyst is not smooth and round but has some irregular features. These cysts require clinical judgment, but if there is any concern about the possibility of malignancy, a core needle biopsy (see chapter seven) must be done to remove the entire cyst wall.
In other cases, the cyst will recur following repeated aspirations, and a core needle biopsy should also be done to remove the recurrent cyst.
Open biopsy for a cyst without some kind of tissue diagnosis is no longer a common procedure. If surgical removal is advised in the absence
