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1.      Triple Assessment

2.      Clinical Assessment

3.      Mammography

4.      Ultrasound

5.      Fine Needle Aspiration (FNA)

6.      Core Needle Biopsy


1. Triple Assessment

Whatever a woman's symptoms, and especially if a lump is present, the normal way of investigation is by triple assessment.

Triple assessment comprises of (i) Clinical Examination, (ii) Cytopathology (either FNA or core biopsy) and (iii) Radiology (either mammography or ultrasound).

In each of these types of assessment/investigation, there are 4 possible results.

  • Benign
  • Suspicious
  • Malignant
  • Inconclusive

This is very important in terms of what further treatments or investigations should be performed. 

As a general rule, unless all three tests return a "benign" result, further investigation is almost mandatory.

To give an example, if a 25 year old woman presents with a 2cm lump that is clinically and radiologically benign, but that is suspicious on FNA, it must be biopsied formally to resolve the uncertainty.  If on the other hand all three results were benign, it could probably be left alone unless the patient felt very strongly about having it removed.

Each of these tests is now described in more detail.

2. Clinical Assessment

Clinical assessment involves the doctor or specialist taking a history of the patient's symptoms as well as performing an examination of the breasts.


The history of a problem within the breast is very important and helps to determine the time scale and nature of the problem, as well as the risk factors for various breast diseases.

For lumps, the time since first noticed, increases in size, and associated nipple or skin problems are all important factors.

Patients with pain will be asked whether there is any relation to the menstrual cycle and whether one or both breasts are affected.

Patient age, family history and previous history of breast disease are all important in establishing risk.  Menopausal status, parity (number of children and pregnancies), breast feeding and use of HRT or other hormonal medication are also needed.

Breast Examination

The patient is first sat on the edge of the examination couch and asked to remove all upper garments.

The breasts are then inspected for signs of asymmetry, skin or nipple changes and obvious lumps.  This is done with the hands at the sides and raised above the head.

Whilst lying on the couch the breasts are then examined.  The "normal" breast is examined first to determine the normal consistency and degree of "lumpiness".  After this, the affected breast is examined and the presence, nature and site of any lumps or tenderness determined.

The axilla is examined next (under the arm) to feel for lymph glands that might indicate spread of cancer or infection.  The neck is also examined for signs of enlarged lymph glands.

Finally, the abdomen (looking for liver enlargement), spine (for bony tenderness) and any other indicated body region are examined for signs that might suggest breast cancer.

3. Mammography


A mammogram is an X-ray of the breast.  It is taken by compressing the breast between two plates. 

Many women find the test uncomfortable but not unbearable.

Two views are normally taken.  A cranio-caudal view looking from above down, and a lateral oblique view from side-to-side. 

As a test, it is excellent for showing lumps, areas of distortion and areas of calcification in the breast (see figures 1 & 2).  It is often possible to predict the nature of a lesion seen on mammography by its appearance. 

Benign lumps such as fibroadenomas, which do not invade surrounding tissue, are usually very discrete with well-defined margins on the X-ray.

Malignant lumps on the other hand have a different mammographic appearance.  By nature, they tend to invade surrounding tissue.  This has the effect that their margins appear irregular.

The marginal features are not all that can be seen, and sometimes opacities can be "seen" that are in fact normal.  When breast tissue is compressed during the mammogram, normal tissue can be "squashed" together, creating apparently dense regions on the film.  This can appear as a tumour on one of the two X-Rays taken, but usually on the other view this disappears as the tissue becomes compressed in the opposite direction.  Sometimes women are alarmed to hear that there are lots of "opacities" on their mammograms, but for these reasons it should be remembered that an opacity does not always mean bad news.  Furthermore, a woman's age, her parity (i.e.whether she has borne children) and circulating hormone levels can all influence the appearances of the mammogram.  Young women (<35) often have dense-looking tissue on their mammograms and in these patients ultrasound can be more useful.

Another finding often seen on mammograms is micro-calcification.  Tiny speckles of calcium can be seen clearly, because they do not allow X-rays to pass, so appear white on the film.  It is known that a number of breast problems can cause microcalcification to occur, most of which are usually benign. 

Of note however, is that one of the early signs of Ductal Carcinoma In Situ (DCIS), is calcification of the ducts.  For this reason mammography is used in breast screening to detect cancers before they are clinically palpable.

Mammography does have its limitations.  In women under the age of 35, or in those who have not had children (nulliparous women), the breast tissue is usually more dense.  This causes it to absorb more X-rays during the test with the result that the view is mostly white.  Under such circumstances it can be difficult to detect abnormalities, because they do not stand out from the surrounding tissue.  In such patients where mammography is of limited value, ultrasound is better as a test.


Figure 1. Normal Mammogram                         Figure 2Abnormal mammogram

                                                                             showing dense opacity.


4. Ultrasound

Breast ultrasound is of great use in the investigation of breast lumps and cysts.   It is less useful for areas of general "lumpiness" where there is no discrete abnormality to feel.  It is also very useful in younger women who have dense breasts and in whom mammography is of limited value for the reasons mentioned above.The technique of ultrasound is simple.  A small quantity of gel is spread on the breast and a high frequency sound probe used to generate images on a computer screen of the breast tissue.  Cysts and solid lumps have characteristic appearances so are easily identified.Ultrasound is limited by its resolution - in other words the smallest abnormality it can see.  This depends on the quality of the scanner and on the operator's experience.  It is also limited in its ability to diagnose non-cystic and non-solid breast problems such as fibrocystic change where there is diffuse glandularity and lumpiness throughout the breast.


5. Fine Needle Aspiration (FNA)

Inserting a small needle into a breast lump allows a doctor to quickly tell whether a lump is solid or cystic.  It is slightly uncomfortable, but normally lasts for only a few seconds.  Depending on your local clinic, it may be done by your breast specialist or by a cytopathologist. Afterwards there can be a degree of bruising though this varies from patient to patient.  Some minor discomfort may be felt at the site for a few days but this invariably settles.

If a cyst is present, cystic fluid will be obtained and often the lump will not be felt afterwards.  In this way the diagnosis and treatment are achieved at the same time.

For solid lumps, a small aspirate of cells can be obtained by this technique and sent for microscopic examination.  This can be done relatively quickly (within 30 minutes normally), so means that women will not have to wait long for a diagnosis. 

As with all other forms of investigation, the results can be reported as benign, suspicious, malignant or inconclusive.  However, for very small lumps, especially in women with large breasts, a benign result can only be accepted if the needle definitely went into the lump.  If there is any doubt that the needle might have sampled normal breast tissue, the test result may be rendered unreliable and should not be used as part of the triple assessment process.

6. Core Needle Biopsy

Core needle biopsy is a more sophisticated test than FNA and provides a great deal more information about a lump. 

It is normally reserved for lumps that return a suspicious or malignant result, where more information is needed to establish the exact diagnosis before planning treatment.  

The test itself requires the use of local anaesthetic, since it would be too painful to have without.  However, with local anaesthetic it is normally painless.

A large hollow needle is used to cut a "core" of tissue from the lump.   This is then sent to the pathology department where it is analysed.  Results are not normally available for one week or so, but can be available sooner in some hospitals.

A core needle biopsy will provide information about the type of cancer present, whether or not it is invading surrounding tissue and whether or not it is likely to respond to hormonal treatment.  This information, especially whether it is invasive, is of paramount importance in determining what type of surgical treatment should be performed







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