What is the recommended management for a female patient with a well-defined hypoechoic solid lesion in the left breast, measuring 9.7 * 5.3 mm, showing mild progression in size, with a macrolobulated margin and marginal angulation, internal vasculature, and no pathological lymph nodes?

Management of Progressive Hypoechoic Breast Lesion with Suspicious Features

This lesion requires image-guided core needle biopsy immediately due to the presence of multiple suspicious sonographic features including documented size progression, macrolobulated margins with marginal angulation, and internal vascularity. 1, 2

Rationale for Biopsy

The lesion demonstrates concerning features that place it in BI-RADS Category 4 (Suspicious Abnormality), warranting tissue diagnosis:

• Progressive size increase (from 7.9 × 5 mm to 9.7 × 5.3 mm) is a red flag that elevates suspicion for malignancy, as benign lesions typically remain stable 3, 4
• Macrolobulated margins with marginal angulation are suspicious features that deviate from the smooth, circumscribed margins expected in benign lesions like fibroadenomas 1
• Internal vascularity in a solid mass increases concern for malignancy, particularly when combined with other suspicious features 4
• The lesion does NOT meet criteria for BI-RADS 3 (probably benign), which requires oval shape, abrupt well-defined margins, and parallel orientation—this lesion has macrolobulated margins with angulation 1

Recommended Diagnostic Approach

Core Needle Biopsy is Preferred

• Ultrasound-guided core needle biopsy is superior to fine needle aspiration, providing better sensitivity, specificity, correct histological grading, and allows evaluation of tumor receptor status 1
• Core biopsy should be performed rather than short-interval follow-up given the documented progression and suspicious morphology 1, 2

Complete Imaging Assessment

• Obtain bilateral diagnostic mammography to fully characterize the lesion, assess for associated calcifications, and evaluate for multifocality 2
• Verify radiologic-pathologic concordance after biopsy—if benign pathology is discordant with suspicious imaging features, surgical excision is mandatory 2, 5

Critical Features Distinguishing This from Benign Lesions

While hypoechoic lesions can occasionally be benign (fibroadenomas, complicated cysts), this lesion lacks reassuring features:

• Progression in size excludes stable probably-benign classification 3, 4
• Macrolobulated margins with angulation are not consistent with typical fibroadenoma morphology (which should be oval with smooth margins) 1
• Although parallel orientation is present, this single benign feature is insufficient when other suspicious features coexist 1

If Malignancy is Confirmed

• Proceed with surgical excision with adequate margins, ensuring the specimen is removed in one piece with orientation markers for the pathologist 6, 2
• Perform specimen radiography to confirm complete excision 6
• Assess for axillary involvement with sentinel lymph node biopsy if invasive carcinoma is identified 1

Common Pitfalls to Avoid

• Do not pursue short-interval follow-up for lesions showing documented progression—this represents a change in BI-RADS category requiring tissue diagnosis 1, 3
• Do not assume parallel orientation alone indicates benignity when other suspicious features (progression, irregular margins, vascularity) are present 1, 4
• Do not rely on absence of pathological lymph nodes to defer biopsy—nodal status does not determine whether a primary breast lesion requires tissue sampling 1
• Do not accept discordance between benign pathology and suspicious imaging without proceeding to surgical excision 2, 5

Age Considerations

If the patient is younger than 30 years, core biopsy remains appropriate for suspicious features, though the pre-test probability of malignancy is lower 1. However, documented progression and suspicious morphology mandate tissue diagnosis regardless of age 1, 3.