The workup of a palpable breast mass detected by a woman or by clinical breast examination (CBE) must include further diagnostic tests. This evaluation may include bilateral mammography, ultrasonography, or breast aspiration. A woman under age 30 to 35 should not have bilateral mammography unless she has a strong family history of premenopausal breast cancer, previous history of breast cancer, or highly suspect findings on physical examination. Breast cancer is uncommon in this age group, and mammography is less effective in young women because of their increased breast density (Cady).

The most important diagnostic step is to distinguish between a cyst and a solid mass. This is effectively done with either ultrasonography or fine needle aspiration (FNA). FNA has the following advantages:

• If the mass is cystic, drainage will be diagnostic and therapeutic.
• FNA may relieve tenderness associated with a cyst.
• Fluid may be sent for cytologic evaluation, if necessary (Osuch).

Click here for information on how to do fine needle aspiration.

If the mass is a cyst, drainage with FNA should eliminate it. If the fluid aspirated is clear and the mass disappears, the fluid can be discarded. The woman should return for repeat CBE in 4 to 6 weeks to make sure the cyst has not recurred. If cysts are found at this visit, the patient should be referred to a surgeon for further evaluation.

Referral to a surgeon should also occur if the aspirated fluid is bloody or the mass does not completely disappear on aspiration. At this time, the fluid should be sent for cytologic evaluation. The exact site of the aspiration must be documented so that the surgeon knows precisely where to perform the biopsy.

Any woman over age 30 (or younger if she has a strong family history of premenopausal breast cancer in a first-degree relative) who has an FNA that does not produce fluid should have bilateral mammography. Not only will a mammogram better describe the palpable mass (for example, whether calcifications are present within the mass), but also it will help screen the rest of the breast tissue for suspect lesions. Any dominant, solid, persistent mass in a woman over 30 should be evaluated by a surgeon, even if the mammogram is normal. A normal mammogram does not rule out a cancer diagnosis in a woman with a suspect mass.