Updated: 4 July 2005

The diagnosis of a breast cancer depends on the presentation of the lesion by mammographic screening, other radiological imaging (such as ultrasound) or by physical presentation. In all cases it is important to combine the radiologic assessment of the entire affected breast and the contralateral breast with the general health of the woman, examination of the breast and nodal areas, and a pathological diagnosis. The treatment of the breast cancer will depend on combining the results of these investigations. Although most breast lumps are not cancerous, the practitioner must be aware that breast cancer can appear at any age, and if there is any suspicion, a definitive diagnosis should be obtained promptly.

Diagnostic mammograms should be done on any suspicious finding on a screening mammogram and for women with a palpable finding. In a woman with a palpable mass, however, the finding of a normal mammogram should not delay the histological diagnosis of the mass.

4.1.1 Abnormality Detected by Mammogram Alone

These abnormalities may take the form of either a mass, change in architecture or abnormal calcifications within the breast. If there is an abnormality that is not clearly malignant but new, further imaging with additional views and magnification views should be undertaken. A suspicious new finding should be further assessed with additional imaging (see below) and a pathological diagnosis. A stereotactic core biopsy under mammographic guidance may be undertaken and will allow a diagnosis of the mammographic finding.

4.1.2 Discrete Mass Lesions

If in the opinion of the diagnostic radiologist a mass is thought to be benign (e.g., there is a strong possibility of a non-palpable cyst or a small fibroadenoma), then an ultrasound examination may be helpful in distinguishing between a cystic and a solid lesion. If the lesion is thought to be cystic, then aspiration of the lesion under ultrasound control by the diagnostic radiologist may both diagnose and treat the abnormality and may be all that is needed.

If such a mass is found to be solid on ultrasound, or if the mammographic appearances are not clearly those of a benign abnormality, then one or more of the following are mandatory: fine needle aspiration under ultrasound guidance, or stereotactic core needle biopsy, or open surgical biopsy guided by fine wire localization, depending upon the level of suspicion, size and discreteness of the lesion.  In most cases a core biopsy is recommended to get adequate tissue for pathological diagnosis and to plan surgical intervention if necessary.

4.1.3 Cluster of Fine Calcifications

Where this abnormality is identified and if in the opinion of the diagnostic radiologist the appearance is sufficiently suspicious, a stereotactic core needle biopsy or an open biopsy is required. If the abnormality is less suspicious, then a follow up mammogram in four to six months may be recommended by the radiologist.

4.1.4 Widespread Calcification within the Breast

This finding is the most difficult to evaluate. It may be associated with an entirely benign condition such as sclerosing adenosis but it may also either mask or be caused by widespread in situ carcinoma (e.g., comedo carcinoma). In these instances there is often no one specific area that can be biopsied. The chance of malignancy is increased if, in addition to coarse calcifications, there are clusters of fine calcifications.

Repeat mammograms are not always helpful in this situation since it may be hard to distinguish new lesions against a background of calcification within the breast. Stereotactic core needle biopsies of the most suspicious areas may be helpful and are used increasingly. These are available at a number of locations throughout the province. Random biopsy may provide false reassurance but the alternative of mastectomy is clearly a very serious recommendation to make without prior proof of in situ disease. Members of the Breast Tumour Group would be happy to see these patients in consultation.

Further information about stereotactic core needle biopsy may be obtained through the Department of Diagnostic Imaging, BC Cancer Agency, Vancouver Cancer Centre, (604) 877-6098 ext. 2280.

4.1.5 Palpable Mass

Diagnosis with Mammograms

While mammograms may be helpful in the assessment of a palpable mass, their real importance in this situation is to assess the rest of the breast and the contralateral breast. A negative mammogram is not uncommon in the presence of a palpable mass in the following circumstances:

1. lobular carcinoma
2. women with very dense breasts
3. a very large palpable malignancy which may appear radiologically as though there is increased density in the whole of the breast
4. a lesion at the extreme periphery of the breast
5. young patient
6. lactating breast

In these situations further imaging of the breast with ultrasound or MRI may provide additional information.

A normal mammogram should not be a cause for delay in biopsy. All solitary breast masses require diagnosis by biopsy, unless their appearance is cystic.

In general, mammographic examination is recommended before biopsy of a palpable mass, in order to detect any other significant abnormalities, although it is not recommended in a pregnant woman. An ultrasound may be useful prior to biopsy in this situation.

Diagnosis with Ultrasound

If there are multiple lesions within the breast thought to be cystic and it is considered impractical to aspirate all of them, then ultrasound may be used to make sure that the lesions are indeed all cystic and that one of them is not solid. Ultrasound can be useful in the management of a solitary palpable mass to determine if biopsy is indicated.

4.1.6 Cystic Lesions

If it is thought that a lesion may be cystic, then aspiration of the cyst should be undertaken. If the cyst disappears following aspiration and the fluid is free of blood, then biopsy is not necessary. If the cyst recurs, repeat aspiration may be done. If a cyst is "simple" on ultrasound, biopsy and aspiration are not required but all "complicated" or partly solid cysts should be biopsied.

4.1.7 Solid Lesions

Fine needle aspiration, stereotactic core needle biopsy or open surgical biopsy should be done to establish a definitive diagnosis.

If, on clinical grounds, the lesion is thought likely to be a benign fibroadenoma, then excisional biopsy should be carried out directly, including a small cuff of surrounding breast tissue. In selected circumstances, such as mammographic findings compatible with a benign fibroadenoma, in a young woman who has a negative needle aspirate and no palpable mass, radiological and clinical follow up may be appropriate. If it is thought that the lesion may be malignant, fine needle aspiration cytology can be very useful. If the cytology report indicates the presence of malignant cells, investigations for the potential presence of metastatic disease should be undertaken (see Section 5 Staging).

If a needle aspiration cytology is negative, malignancy cannot be ruled out and a core or open biopsy of a solid lesion is necessary.

Positive cytology is regarded as sufficient to discuss the management of the breast mass with the patient. However, malignancy must be confirmed by frozen section at the time of either mastectomy or segmental resection if one-stage management is desired by the patient. A core biopsy may also confirm a malignancy prior to a surgical procedure.

4.1.8 Nipple Discharge

Bilateral nipple discharge is not associated with carcinoma, other than on a chance basis.

Clinical assessment of a patient with nipple discharge should determine the signficance of the symptom and determine the next step in management.  A history including the duration of symptoms, colour and spontaneity of the discharge, history of trauma, laterality (unilateral vs bilateral) of the discharge, and the history of medications, hormone use or hormonal imbalance. Clinical examination should include a general examination of the bresat with expression of the discharge. A trigger point may be identified.

Rarely is unilateral nipple discharge a sign of underlying breast cancer, but it is considered to be more likely indicative of malignancy under the following circumstances:

1. If it is associated with an underlying mass
2. If it is spontaneous (although spontaneous nipple discharge has been reported to occur in as many as 10% of women)
3. If on examination it comes from a single duct
4. If it is serous, serous sanguinous or bloody it may be papilloma, DCIS, hyperplasia or trauma

Both careful clinical examination of the breast and mammography are required for assessment. Galactogram should be considered as well. If there is a palpable mass or an abnormality on the mammogram, clearly a biopsy is indicated. Should the nipple discharge fulfill one or more of the criteria listed above, local excision of the involved duct system is indicated.

The commonest cause of a blood stained discharge is a solitary papilloma of the duct; this does not of itself confer a high risk of breast cancer. Sometimes multiple papillomatosis is identified histologically and does confer an increased possibility of subsequent malignancy. Mammography may be negative with a papilloma and ultrasound may be necessary as well as cytology of the discharge, galactography or ductography, MRI, ductoscopy, or duct excision. Cytology has variable results and the presence of negative cytology does not rule out an intraductal lesion. No one diagnostic test has been shown to be optimal.

Opalescent nipple discharge is least likely to be associated with malignancy.

As with all breast abnormalities, nipple discharge is much more likely to be associated with malignancy in the postmenopausal woman. Radiological investigation of the duct system is not often very informative but may provide a diagnosis of DCIS and/or a papilloma.

4.1.9 Eczema of the Nipple

Any eczematous lesion of the nipple and the areolar area must be viewed with high suspicion because of the possibility of Paget's disease. Repeated clinical examination of the breast is mandatory. If, after local treatment, it does not heal within seven days, mammography and a biopsy of the eczematous area is indicated. An MRI may be useful if the mammogram is normal in the prescence of diagnosed Pagets disease.

4.1.10 Male Breast

Breast cancer can occur in the male (ten to twenty cases per annum in B.C.). Persistent or suspicious lesions should be biopsied and malignancy investigated and staged as for women, including a contralateral mammogram. Gynecomastia may be unilateral and is relatively common in the normal population. A number of medications, particularly digoxin, cimetidine and estrogen, can cause gynecomastia. Male breast cancer is more common in older men, men with a family history of female breast cancer, obesity, alcohol abuse or if there has been excessive radiation exposure to the area.