Breast Lumps: Do I Need a Biopsy?

How to tell when a surgical biopsy is necessary.
By Dr. Rob for MSN Health & Fitness

Q: I'm a woman in my late 30s and found a lump on my breast. I had a mammogram and ultrasound, both of which came back negative. On my doctor's suggestion, I then met with a surgeon, who said it's not a cyst and wants to have a surgical biopsy done to know for sure. I'm confused. Should I get a second opinion?

A: Breast lumps are pretty common, especially in premenopausal women. Fortunately, most are benign (not cancerous) and tend to come and go during a menstrual cycle. However, finding one can be very scary, especially with the knowledge that it could be cancer. This fact makes it very important for every woman—or man, for that matter—to see a physician if any changes in the breasts or nipples, such as discharge or bleeding, is noticeable.

That being said, I want to reassure you that it sounds as if your physician has followed the proper protocol in evaluating your breast lump. However, if you have any doubts or want a second opinion, please listen to your gut: You need to be comfortable and trust your health care provider in this and all health issues.

Even though you did have some good news in that both your mammogram and ultrasound results were normal, I would recommend getting a further work-up by a breast health specialist "just in case" the lump is malignant, or cancerous. A breast health specialist is a surgeon, typically, who has done a fellowship in diseases of the breast or whose practice focuses on breast health.

During your visit the specialist will take a complete history, including the following information:

• When did the breast lump(s) appear?
• Did it go away with the ending of your menstrual cycle?
• Is it painful?
• Do you have a personal history of breast cancer?
• Does breast cancer run in your family?
• Do you smoke?
• Do you have more than one drink of alcohol per day?
• Have you had a previous breast biopsy? If so, what were the results?
• Have you ever had chest irradiation as a child or young adult for any types of cancer?
• The age you began having your menstrual cycles, as well as the age you reached menopause.

Next, the specialist will give you a thorough examination, including an evaluation of your breasts. Particular attention will focus on:

• Breast texture, size, symmetry and presence of any masses or lumps.
• The overlying skin and muscles around the breast area.
• The nipples for any inversion or discharge.
• Lymph nodes in around the armpit, as well as above the collarbone.

Even though you already had an ultrasound, the breast health specialist may repeat this test while palpating (feeling) the lump. This is done because ultrasound results are very dependent upon the technique used for the test and how the findings are interpreted.

Again, it is important to remember that most breast lumps are not cancerous. Some of the different types of breast lumps or masses include:

• Fibrocystic changes cause the breasts to feel lumpy and thickened. More than half of all women experience these changes, which may result in a dull pain or tenderness, especially with hormonal fluctuations during a menstrual cycle. Fibrocystic changes are usually harmless, but do present more of a challenge when performing a breast self-exam.
• Cysts are fluid-filled sacs that are more common in women in their perimenopausal years (ages 35-50). These can be tender to touch and often decrease in size or disappear by themselves when the menstrual period ends.
• Fibroadenomas are solid tumors that feel very firm, with a well-defined shape. These are benign and painless. While they can occur at any age, they are more common in women between 20-40 years of age.
• Injury to your breast can sometimes lead to fat necrosis. This results in scar tissue that can form a lump. It is often firm and moveable. These types of lumps often go away by themselves, but should still be checked out.
• A phyllodes tumor is a painless lump that tends to grow rapidly within the tissue of the breast. These tumors are usually benign; however, they have the potential to be cancerous.
• Calcium deposits can be anywhere in your breasts and tend to show up on mammograms. They are usually from other causes such as a previous injury, secretions from cells in the breast, prior radiation or inflammation. Most of the time they are harmless, but do have the potential to be precancerous or even cancer.
• Intraductal papilloma is a non-cancerous growth in a milk duct. This can cause a discharge, as well as a small lump near the edge of the nipple.
• Breast infection (mastitis) is more common in women who are breast-feeding. This can cause the breasts to be warm, tender and lumpy, and may be accompanied by a fever.
• Breast cancer can often be disguised as a hard, firm and painless lump. These lumps often feel different than the surrounding breast tissue and can sometimes cause changes to the skin overlying this mass.

The breast health specialist undoubtedly will want to do a breast biopsy. This involves removing a sample of the tissue and examining it to determine whether the lump is malignant or benign. The most recent guidelines state that the biopsy technique being used should be as minimally invasive as possible. Examples of these techniques include a core needle biopsy (which removes tissue from the affected area) or a stereotactic Mammotome breast biopsy, where small samples of tissue are removed using a specially designed vacuum-assisted needle that is guided to the correct location by X-rays.

In your particular case, however, the surgeon is recommending a surgical biopsy, which is more invasive than either of the techniques I mentioned. A surgical biopsy involves removing all (excisional biopsy) or part (incisional biopsy) of the breast lump and is usually done in a hospital or surgical suite setting. While I definitely agree a biopsy is needed, I would encourage you to discuss less-invasive options with your doctor before proceeding.

Although this is a very anxiety-prone time for you and your family, choosing a health care team with competence and compassion will go a long way toward relieving your stress.