Making a Diagnosis

Breast Self Exam
Mammography
Ultrasound
Biopsy

A diagnosis is the identification of a medical condition based on what is found when certain characteristics of the condition are closely examined. Establishing the diagnosis of a breast abnormality involves several important steps.

Physical Examination

Most changes that occur in the breast are first noticed by women themselves. If you practice regular breast self-examination, you are very familiar with the look and feel of your breasts, and will more than likely notice a change that might indicate a problem. It is important to realize that even a healthy breast will undergo certain changes over time, and that what you are feeling may be a variation of normal breast anatomy. Most irregularities that form in the breast are not cancer, and most of the diagnoses that are made identify relatively normal conditions such as benign tumors, cysts or calcifications that usually require no treatment.

When a lump, also called a mass or lesion, becomes large enough to feel, or palpate, it is said to be palpable. Conversely, a suspicious area that is too small to feel is said to be non-palpable. If you discover something that you think may be a change in your breast anatomy, the next step is to have your breasts examined by your gynecologist or internist. Your physician may want you to see a surgeon who specializes in breast cancer and has the necessary expertise to make a reliable diagnosis of any unusual condition. The surgeon may conclude that your condition constitutes one of several natural changes the breast undergoes over time and may recommend only follow-up. He or she will recommend that you continue observing your breasts by practicing regular BSE and having regular clinical breast exams.

The physician may suspect that an abnormal area is nothing more than a liquid-filled lump or mass called a cyst and attempt to aspirate it by inserting a very thin needle into the abnormal area. If it is indeed a cyst, aspiration will remove the fluid and the cyst will collapse. The vast majority of cysts are benign and the reason they are aspirated is so no further investigation to confirm their diagnosis is necessary. If the cyst does not collapse entirely, or if the fluid is bloody, the aspirated fluid will be examined microscopically by a cytopathologist to assess the nature of any cells present. Likewise, if the abnormal area turns out to be solid, the aspirate may contain cells that can also be evaluated microscopically. Only if the surgeon concludes that your condition is suspicious and requires further investigation, will he or she then recommend one or more diagnostic procedures.

Mammography

A mammogram is an X-ray picture of the breast. With today's advanced state-of-the-art technology, mammograms require less radiation and are more sensitive and informative than ever before. Surgeons can tell a great deal about what's going on inside the breast by reviewing the results of a mammogram and consulting with the radiologist who interprets it. A radiologist is a specialist in the use of X-ray technology to visualize certain parts of the human body. When you get a mammogram, you should make sure that the radiology equipment being used has been accredited by the American College of Radiology.

Mammography is the relatively painless procedure that is performed by a specially-trained radiology technologist who produces a mammogram. He or she will guide you through the steps of the procedure and can answer many of the questions you may have about the procedure itself. You should not hesitate to express feelings of discomfort to the technologist performing the mammography, or ask to speak to the radiologist if the technologist is unable to answer questions to your satisfaction.

The technologist will perform the mammography by compressing your breast between two plates attached to a specially designed X-ray machine. The breast is then "photographed" from two separate angles and the results are examined by the radiologist. Any discomfort you may experience is most likely the result of pressure exerted on your breast by the plates. This is necessary to achieve the highest possible detail while also minimizing radiation exposure. Some women are concerned about exposure during mammography, but studies have shown that the risks of exposure to radiation with state-of-the-art mammography equipment are minimal and far outweighed by the benefits of a thorough procedure.

Woman Having a Mammogram

Ultrasound, also called sonography, is a procedure commonly used during pregnancy, but it is also used frequently to distinguish a liquid-filled cyst (fluid-filled mass) from a solid mass in the breast. The ultrasound is performed by covering the breast with jelly and sliding an instrument called a transducer across its surface. The transducer produces sound waves that will pass through a cyst or will bounce off a solid tumor, creating highly distinct images on a screen. If a mass in your breast turns out to be a cyst, aspiration or observation may be appropriate.

If the mass turns out to be solid, a biopsy might be necessary. A biopsy is a procedure that removes a sample of abnormal tissue or cells from the breast so that it can be examined under a microscope by a pathologist for analysis and diagnosis. Pathologists are trained to identify the nature of the tissue or cells. If a pathologist determines that the tissue or cells are benign (i.e., a benign tumor, cyst or calcification) then you do not have cancer, and regular follow-up may be all that is recommended.

Cells that are considered benign, but not completely normal, may indicate a condition that, while not cancerous, puts you at increased risk for cancer. Atypical hyperplasia or hyperplasia with atypia is such a condition. The breast tissue is determined to have certain abnormal changes. While these changes are not cancerous, they do increase the chances that cancer will develop. For this reason, women with atypical hyperplasia are recommended to have more frequent clinical breast exams and mammograms.

If the cells turn out to be malignant (cancer), your condition will be diagnosed as cancer and your surgeon will discuss the various treatment options with you.

Biopsy Procedures

Your surgeon will determine what type of biopsy is needed. The type of biopsy depends on whether the suspicious area is palpable (can be felt), such as a mass or thickening. Non-palpable findings (cannot be felt), such as micro-calcifications, a very small mass, or vague density that have shown up only on a mammogram also require a biopsy.

We begin with the kind of biopsy required when a suspicious area is palpable.

Fine Needle Aspiration Biopsy

The physician - a gynecologist, a surgeon, or in some cases a pathologist - inserts a very thin needle into the suspicious area of the breast. This is called aspiration. A local anesthetic may be given to numb the skin. If the suspicious area is a cyst, it will yield fluid and the cyst will collapse. If the cyst completely collapses, the fluid is discarded. If the suspicious area is solid, the aspirate usually contains cells that the pathologist can examine microscopically. Even if no malignant cells are found, a surgical biopsy may still be necessary as cancer cells may exist in tissue not sampled by the needle. If malignant cells are found, however, definitive treatment planning can begin. Your surgeon will recommend a course of action.

Needle Biopsies

This process is similar to the fine needle aspiration biopsy described above, but a larger needle is used and fragments of abnormal tissue, not just cells, can be removed. When these tissue samples are examined microscopically by the pathologist, a definitive diagnosis can usually be made.

Both types of needle biopsy can be performed in an office setting.

Next Page->