Diagnosing a Breast Lump: Imaging, Biopsy and Why a Guided Biopsy Is Safe

When a lump or a change is found, the simplest and best next step is a mammogram, or an ultrasound in younger women. A mammogram is essentially an X-ray of the breast: the breast tissue is compressed between two plates and a beam of radiation is projected through it, and an abnormal tumour shows up clearly on the resulting film. It remains a very basic and effective screening technique for identifying lesions that need further evaluation.

Building the full picture before biopsy

When breast cancer is suspected, the workup covers the patient's history and menopausal status, a thorough physical examination, and routine blood tests, including blood counts and liver, kidney and cardiac function, alongside mammography, MRI and biopsy to confirm the diagnosis. Further tests then assess whether regional lymph nodes are involved and whether the disease has spread elsewhere.

Why a guided biopsy is safe

A common misconception is that a biopsy is dangerous, or that it can spread the disease. That is simply untrue: a biopsy done in a guided way is essential to reaching a definite, tissue-based diagnosis, and it does not cause physical harm. An ultrasound-guided biopsy taken from a breast mass, for example, can be done safely as a routine procedure.

The site of the biopsy depends on where the disease actually is. In early breast cancer, the sample is taken directly from the lesion itself, using a simple technique: fixation of the tissue, followed by histopathology, then immunohistochemistry to establish oestrogen receptor, progesterone receptor and HER2 status. If HER2 comes back equivocal on immunohistochemistry, a FISH test confirms it. In metastatic disease involving organs such as the lung, bone or liver, the biopsy is taken from whichever site is most accessible and least risky for the patient, often the liver or the lung. In patients too unwell for any other biopsy, such as those presenting with severe anaemia, a bone marrow biopsy can confirm metastatic breast cancer directly, including its subtype, allowing treatment to proceed with good results.

Why some early cancers are missed on a mammogram

A mammogram alone can be difficult to interpret in some cases: invasive lobular carcinoma, for instance, can look almost normal on a mammogram film. This is why an experienced radiologist should be reading and reporting every mammogram, and why any doubt should prompt a referral to a surgical or medical oncologist so that an MRI, a guided biopsy, or further scans can be arranged to catch the disease early.

Inflammatory breast cancer presents its own trap: it can look like cellulitis or an infection in a routine outpatient clinic, with redness and warmth over the breast, and may initially get a trial of antibiotics. Keeping inflammatory breast cancer in mind as a possibility, and referring to a surgeon or specialist for an opinion, matters because it can be genuinely difficult to distinguish from an infection without a proper evaluation or follow-up.

This article is based on a Jivo Masterclass session conducted by Dr. Sahil Bambroo, Senior Consultant, Medical Oncology, BLK-Max Super Speciality Hospital, New Delhi. The article has been summarised with the assistance of an AI tool from the original masterclass recording. Watch the full Masterclass recording

Looking for a breast cancer or medical oncology consultation or a second opinion? Get in touch with the Jivo team