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

For a 34-year-old woman with a 3x4 cm retroareolar breast mass with nipple retraction who has already had an ultrasound, the next step should be a core needle biopsy (option D). 1, 2

Rationale for Core Needle Biopsy

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

• The clinical presentation (retroareolar mass with nipple retraction) is highly suspicious for malignancy, requiring tissue diagnosis 3, 4
• Core needle biopsy provides superior diagnostic accuracy compared to FNA, with:
  • Better tissue architecture preservation
  • Ability to perform histological typing
  • Capability for hormone receptor testing if malignancy is found 1
• The American College of Radiology (ACR) guidelines specifically state that "core biopsy is superior to FNAB in terms of sensitivity, specificity, and correct histological grading of palpable masses" 2

Why Other Options Are Not Appropriate

1. Fine Needle Aspiration (FNA) - Option A

   • Less accurate than core biopsy for suspicious masses 2
   • Cannot reliably provide histological grading or receptor status 1
   • ACR guidelines state core biopsy is preferred except in rare situations (e.g., lesion abutting implant) 2

2. Mammogram - Option B

   • While mammography is typically part of the evaluation, this patient has already had an ultrasound
   • For a suspicious retroareolar mass with nipple retraction, tissue diagnosis is the priority after imaging 1
   • Retroareolar carcinomas may have lower detection rates on mammography compared to other breast regions 3

3. MRI - Option C

   • Not indicated as the next step after identifying a suspicious finding on ultrasound 2
   • ACR guidelines specifically state: "There is no evidence to support MRI breast without and with contrast as the next step in evaluating a palpable mass with suspicious sonographic features" 2
   • MRI may be useful later for delineating extent of disease if malignancy is established 2

Clinical Significance of Retroareolar Mass with Nipple Retraction

The patient's presentation has several concerning features:

• Nipple retraction is associated with malignancy, particularly in retroareolar lesions 3, 4
• Retroareolar carcinomas typically present as palpable masses with characteristic ultrasound features including:
  • Irregular shape
  • Non-parallel orientation
  • Non-circumscribed margins
  • Hypoechoic echotexture 4

Important Considerations

• Ultrasound has high sensitivity (92.5%) for detecting breast lumps, but tissue diagnosis is essential for definitive diagnosis 5
• The retroareolar region requires special attention as mammography may be less sensitive in this area than in other parts of the breast 3
• After core biopsy confirms diagnosis, additional imaging including MRI may be considered for treatment planning if malignancy is found 2, 1

Common Pitfalls to Avoid

• Delaying tissue diagnosis with additional imaging when a suspicious mass is already identified
• Choosing FNA over core biopsy, which would provide less diagnostic information
• Assuming that a young age (34 years) makes malignancy unlikely, especially with concerning clinical features like nipple retraction
• Failing to recognize that retroareolar masses with nipple retraction have a high likelihood of malignancy requiring prompt tissue diagnosis