Synopsis
Assess a new breast or axillary lump without delay, recognise infection and inflammatory cancer, complete concordant clinical, imaging and tissue assessment and route benign, uncertain and malignant findings safely.
- Triple assessment means clinical history and examination, appropriate breast imaging and pathological sampling when indicated; diagnostic confidence depends on concordance between all three components.
- Refer adults meeting suspected-cancer criteria promptly. A painful lump can still be malignant, and young age or pregnancy does not remove the need for assessment.
- Ultrasound is usually the first imaging test in younger patients and during pregnancy or lactation; mammography is central from the usual screening-age range and is commonly combined with targeted ultrasound.
- Core-needle biopsy is the preferred tissue test for a suspicious solid lesion because it preserves architecture and permits invasive, receptor and subtype assessment; FNA has selected roles, especially nodes or cysts.
- MRI is not routine first-line imaging for an uncomplicated lump; use it for a defined question such as occult primary, implant integrity or extent in selected known cancer.
- A simple cyst with complete symptom resolution may need no tissue, while a complex cystic-solid lesion, bloody aspirate or residual mass needs further imaging and biopsy.
- A benign pathology label is safe only when it explains the examination and imaging. Discordance requires radiology–pathology review and repeat targeted sampling or excision.
- Treat mastitis promptly, but drain an abscess rather than relying on antibiotics alone and reassess persistent non-lactational or atypical inflammation for inflammatory cancer.
- Document size, clock-face position, distance from nipple, skin and nipple findings and nodes so that clinical, imaging and biopsy targets can be matched precisely.
- Communicate results through a clear pathway: benign concordant discharge or surveillance, uncertain lesion review, and malignant breast MDT staging and treatment.
Key red flags
A hard irregular fixed breast mass, skin tethering, nipple distortion or a suspicious axillary or supraclavicular node requires urgent cancer-pathway assessment.
Diffuse erythema, oedema and peau d’orange affecting a substantial part of the breast can represent inflammatory cancer even without a discrete lump.
Bloody unilateral single-duct discharge, new nipple inversion, Paget-like eczema or nipple ulceration needs specialist assessment.
A breast abscess with fever, hypotension, immunosuppression, pregnancy, implant, skin necrosis or failed oral therapy needs urgent escalation.
Pregnancy or lactation must not be used to explain away a persistent mass; ultrasound and tissue sampling can be performed safely when indicated.
Rapid diffuse enlargement, erythema, peau d’orange and breast heaviness without convincing sepsis or antibiotic response requires urgent tissue diagnosis.
Investigation priorities
Localise the abnormality and identify skin, nipple, chest-wall and regional-node findings that determine imaging urgency.
Differentiate cystic and solid lesions, evaluate margins and vascularity and assess axillary nodes without ionising radiation.
Management branches
A patient reports a persistent breast or axillary lump or examination finds a focal abnormality.
- Take a focused cancer, reproductive, infection, trauma and family history and examine both breasts, nipples and regional nodes, documenting the target accurately.
- Arrange age- and context-appropriate mammography and targeted ultrasound through the symptomatic breast service rather than ordering isolated tests without review.
- Obtain image-guided core tissue for suspicious or indeterminate solid findings and close the loop only after clinical, imaging and pathology results are demonstrably concordant.