Which is best - breast ultrasound, mammogram/3D, biopsy?

In the same way as women have different shapes and sizes, breast examination can take different forms. Instead of asking which test is best, one should consider ‘which is the best test for me?’

Ultrasound vs. Mammogram

A mammogram uses a low dose of radiation (x-rays) to take an image of the breast. The breast is compressed between two plates to spread the glands and improve the quality of the image. Two standard images of each breast are taken, and they are compared with previous mammograms to spot differences.

An ultrasound uses high-frequency sound waves to create a real-time view of the breast tissue, one small section at a time. No radiation is involved. The soundwaves are sent through a wand called a transducer. No compression plates are used, and the breasts are not flattened. It is not painful. It is similar equipment to that used in pregnancy.

What is a 3D Mammogram or Tomosynthesis?

A 3D mammogram uses advanced technologies to create a more detailed picture of the breast by creating a special mammogram where each x-ray image is divided into multiple thin “slices/layers” reducing the overlapping of tissues and reduces the risk of missing small abnormalities. The radiologist can scroll through the layers to identify problems.

What are the benefits and limitations of using an ultrasound?

Ultrasound is a focused examination, providing detailed analysis of the small area beneath the ultrasound probe. It is usually the best examination in cases of breast lumps – it can determine if an abnormality is solid or filled with fluid (cystic). It gives an indication whether a lump is likely to be benign or likely to be cancer. It is used to monitor benign lumps and to guide taking samples from the breast.

Ultrasound is also the best initial test in women with small breasts, silicone implants, to examine the arm pits (axilla) and lumps in the skin.

Ultrasound is the examination of choice during pregnancy or breast feeding.

An ultrasound is not usually recommended in women with large breasts because it might not penetrate deeply enough. It is not ideal for routine screening of women over 40 who feel no symptoms because it might miss some early signs of cancer such as micro calcifications, which are tiny calcium deposits which can be missed on ultrasound.

What are the benefits and limitations of using a mammogram?

Mammogram is usually reserved for women over the age of 40. It is the ideal test for women who feel no lumps or symptoms and works best when repeated at regular intervals of 12 to 18 months to look for subtle changes in comparison to previous mammograms.

Mammograms can also detect some early signs of cancer such as micro calcifications, which are tiny calcium deposits which can be missed on ultrasound.

A mammogram is obtained in a standard, reproducible method, minimizing the chance of excluding parts of the breast from the examination. For this reason, mammograms are the most reliable method for large scale population screening.

An ultrasound is usually indicated whenever an abnormality/lump is seen on mammogram, in order to determine whether it is suspicious or not. In private practice, this ultrasound is usually performed during the same visit.

I am still unsure if I should I have an ultrasound or a mammogram – what should I do?

No matter which test you book, a specialist will discuss your needs and confirm which test is best for your case before it is performed.

Your doctor, surgeon or gynaecologist is also able to advise you which test to book.

What if I receive an abnormal test result?

The radiologist who reviewed your examination will explain your results and typically make a specific recommendation of what additional exams should be done.

Most commonly an ultrasound is recommended to examine the area of concern, sometimes additional mammogram pictures may be taken. Occasionally a CT scan or MRI might be needed.

If the ultrasound shows something which looks small and benign, a follow up ultrasound after a few months is the most common recommendation. If the abnormality is larger, there is greater concern or if the abnormality looks suspicious, a biopsy may be recommended.

What is a breast biopsy?

Biopsy involves removing a very small piece of the abnormality so it can be tested under a microscopy to determine if it is cancer. A core biopsy uses a special spring-loaded needle which is guided toward the affected area using ultrasound or mammogram. Small pieces of tissue are removed.

A fine needle aspiration biopsy is where a very thin needle is placed into the area of concern, and fluid or a few cells are removed.

The radiologist will give a detailed explanation both before, and during the procedure, but in general;

• First the skin is exposed and cleaned with disinfectant.
• A small injection of local anaesthetic is given in the area, to numb the skin and prevent any pain during the procedure.
• A tiny cut (1-2mm) is made in the skin, this usually heals without leaving a mark.
• Using imaging as a guide, a special needle is guided into the area of concern in order to take a small piece of material for testing.
• Pressure is applied to the area to reduce bruising. A small skin plaster is applied.
• You will be able to go home almost immediately. You should avoid straining/exercising and swimming for the first 24-48hrs after the biopsy to reduce the chance of bruising or infection.