Referral to a breast clinic - types of test

What to expect from your visit

Once a doctor or nurse has checked your breasts and felt in the armpit (axilla) for the lymph glands you may need further tests. Along with the doctor’s examination, these are known collectively as a triple assessment and are made up of the following.

Mammogram

A mammogram is a breast x-ray.You will be asked to undress to the waist and stand in front of the mammogram machine. Each breast will be tested in turn between two x-ray plates so that it is gently but firmly compressed. Two images of each breast will be taken so that it can be seen from two different angles. This is sometimes uncomfortable, but it only lasts a few seconds.

The use of digital mammography is becoming more common. This technique is gradually being introduced into more breast units and is expected to replace conventional mammograms in the future. Instead of film being used, in digital mammography the image is taken electronically and stored directly on a computer.

Mammograms are usually only done on women over the age of 35, as younger women's breast tissue is generally too dense to produce a clear image.

Ultrasound scan

An ultrasound scan uses high-frequency sound waves to produce an image of the breast. While you lie on a couch with your arm above your head, lubricating gel will be spread on your breast and a scanning probe will be moved around it. You may also have an ultrasound of the axilla (under the arm).

An ultrasound scan is painless and generally only takes a few minutes. Regardless of age, an ultrasound scan will usually be done in addition to a mammogram to provide extra information.

If a lump or an area of concern is found during the breast examination, mammogram or ultrasound scan, a sample of breast cells or breast tissue will be taken from the breast. This can be a core biopsy or fine needle aspiration (FNA). Both these tests can be done with or without using ultrasound for guidance.

Core biopsy

A core biopsy uses a needle to obtain a sample of tissue. You will be given a local anaesthetic to numb the area before a sample is taken. The specialist may take several tissue samples at the same time and these are sent to the laboratory where they are examined under a microscope to establish a diagnosis.

Once the anaesthetic wears off you may find that your breast aches and it may also be bruised. You may need to take pain relief if the area is tender or painful.

Your result may be described to you as one of the following:

• B1 – normal breast tissue
• B2 – benign (non-cancerous)
• B3 – uncertain but probably benign
• B4 – suspicious and possibly malignant (cancer)
• B5 – malignant (cancer).

Further tests or treatment are usually needed for a result showing B3, B4, or B5 or where the findings of all the tests do not agree.

Fine needle aspiration

FNA involves taking a sample of breast cells using a fine needle and syringe. This can be uncomfortable but rarely requires local anaesthetic. Once taken, the sample is then sent to the laboratory where it is looked at under a microscope.

Your result may be described to you as one of the following:

• C1 – inadequate sample (not enough cells for diagnosis)
• C2 – benign (non-cancerous)
• C3 – unusual or abnormal or uncertain but probably benign
• C4 – suspicious and possibly malignant (cancer)
• C5 – malignant (cancer).

The specialist will use the result to help them decide if further tests and investigations or treatments are needed. Further tests or treatments are usually needed for a result showing C3, C4 or C5, or where the findings of all the tests do not agree.

Other tests

Triple assessment is usually all that is needed to make a diagnosis. However, sometimes you may need other tests.

If a previous biopsy has not given a clear result and more breast tissue is needed to make a diagnosis, or if the area of concern is difficult to target, you may be offered a 'vacuum assisted biopsy'. This may be referred to as a 'Mammotome' biopsy, which is one of the brand names of the equipment used.

After an injection of local anaesthetic, a small cut is made in the skin. A hollow probe connected to a vacuum device, is placed through this. Using ultrasound or mammography as a guide, breast tissue is sucked through the probe by the vacuum into a collecting chamber. This enables removal of several tissue samples without having to remove the probe. These samples are sent to the laboratory where they are examined under a microscope to establish a diagnosis.

In other cases, a 'wire localisation' is sometimes needed. This is when a guide wire needs to be inserted into the breast under x-ray or ultrasound guidance, after an injection of local anaesthetic. It is used to accurately mark the location of the area of concern that cannot be felt but is visible on mammogram or ultrasound. This ensures greater accuracy in removing a sample of tissue by biopsy, which will then be examined under a microscope.

Visit the Royal College of Radiologist website to take a virtual tour of a radiology department in your hospital to find out more.