What is the next step in management for a 34-year-old lady with a retroareolar (behind the areola) breast mass of 3x4 cm and nipple retraction, after an ultrasound (US) has been performed?

Management of Retroareolar Breast Mass with Nipple Retraction

Next Step in Management

Core needle biopsy is the next appropriate step in management for this 34-year-old woman with a retroareolar breast mass and nipple retraction after ultrasound examination. 1

Rationale for Core Needle Biopsy

Core needle biopsy is the preferred diagnostic approach for this patient for several reasons:

• Core needle biopsy offers superior diagnostic information with sensitivity of 95-100% and specificity of 90-100%, providing definitive tissue diagnosis and allowing for histologic typing, which is crucial for determining appropriate treatment 1
• The presence of concerning clinical features (nipple retraction) and a sizeable mass (3x4 cm) warrant immediate tissue diagnosis rather than additional imaging 1
• Core biopsy is superior to fine needle aspiration (FNA) for diagnostic accuracy and tissue architecture preservation 1
• Core biopsy should be performed before additional imaging to avoid changes that may confuse image interpretation 1

Why Other Options Are Less Appropriate

1. Fine Needle Aspiration (FNA):

   • Less diagnostic accuracy compared to core needle biopsy 1
   • Insufficient for histologic typing, which is crucial for treatment planning
   • Not recommended if suspicious features are present, as in this case with nipple retraction 1

2. Mammogram:

   • While mammography is an important imaging modality, this patient already has suspicious clinical findings (nipple retraction) and an ultrasound-detected mass
   • Mammography has lower sensitivity in the retroareolar region compared to other breast areas 2
   • When a lesion has suspicious features on ultrasound, proceeding directly to image-guided biopsy is recommended 1

3. MRI:

   • While MRI provides excellent soft tissue contrast, it should not delay tissue diagnosis when suspicious findings are already present 1
   • MRI is more appropriate after tissue diagnosis to evaluate extent of disease if malignancy is confirmed

Clinical Considerations for Retroareolar Masses

• Retroareolar carcinomas typically present as palpable masses, and nipple retraction is a concerning clinical feature 2
• Ultrasound is valuable in assessing retroareolar malignancy, with most malignant lesions appearing hypoechoic 2, 3
• Retroareolar breast carcinomas on ultrasound commonly present with irregular shape (83%), non-circumscribed margins (94%), and hypoechoic echotexture (87%) 3
• A suspicious physical examination should prompt biopsy regardless of imaging findings 1

Important Caveats

• Ensure the core biopsy is image-guided for accurate sampling of the mass
• The retroareolar location may require special attention during biopsy to avoid the nipple-areolar complex
• If core biopsy confirms malignancy, referral to a breast center with multidisciplinary capabilities is recommended for comprehensive care 1
• If the core biopsy results are discordant with clinical and imaging findings, surgical excision may be necessary for definitive diagnosis 1