The management of a palpable breast mass starts with identification of the lesion and a suspicion of malignancy. While seemingly simple, the initial evaluation can significantly impact upon treatment options and outcomes. The management of two patients recently referred to this Institution highlights common pitfalls and technical considerations in the diagnosis and treatment of palpable breast masses. The case histories of two patients referred after open breast biopsy were examined. The English language medical literature was searched manually and by Medline for publications related to the evaluation of palpable breast masses. Imaging, diagnostic techniques and technical considerations in the management of palpable lesions were reviewed. The initial use of carefully selected diagnostic and therapeutic measures is critical in optimizing outcomes measured in improved quality of life and survival. Inappropriate choices at this first stage can have extremely negative consequences. The early evaluation of two patients highlighted these considerations. Management pitfalls included serial examination of a suspicious lesion, failure to obtain a mammogram prior to excisional biopsy and unnecessary testing. Technical problems included piecemeal excision of the tumor with positive margins, use of a drain, closure of deep tissues with dimpling of the breast, and incision placement in a location that subsequently necessitated mastectomy. Careful adherence to the clinical and operative principles of breast cancer management optimizes outcomes in the evaluation of palpable breast masses.