Key teaching points:
High-grade breast cancer may present as nodal (or other!) metastases that are more conspicuous than the primary. Indeed in some cases, the primary lesion may remain occult in the presence of advanced metastatic disease.
New change in a longstanding circumscribed lesion may herald lymph node metastasis. It would be highly unusual for a primary circumscribed tumor to remain unchanged over such a long period of time.
Note the change in density, as well as in size and shape of the infiltrated lymph node from prior studies to current.
Procedural tip: use of local anesthetic with epinephrine prior to biopsy of a hypervascular lesion to reduce the risk of hematoma.