From the Guidelines
The most diagnostic approach for a hard lump with serous discharge and an ultrasound showing a retroareolar mass with irregular borders is FNAC (Fine Needle Aspiration Cytology). FNAC is preferred in this scenario as it provides a minimally invasive method to obtain cellular samples for cytological examination, helping to distinguish between benign and malignant lesions, as suggested by the guidelines for breast cancer screening and diagnosis 1. The clinical presentation of a hard lump with discharge, combined with concerning ultrasound findings of irregular borders, raises suspicion for malignancy, making tissue diagnosis essential.
Diagnostic Considerations
- The use of ultrasound (US) is supported by the American College of Radiology for the evaluation of pathologic nipple discharge, including the assessment of the retroareolar region 1.
- Mammography can provide additional imaging information but does not offer a tissue diagnosis.
- Excision biopsy, while definitive, is more invasive and typically reserved for cases where less invasive methods are inconclusive or when therapeutic removal is indicated.
Recommendation
Given the clinical presentation and ultrasound findings, FNAC is the most appropriate initial diagnostic procedure because it balances diagnostic accuracy with minimal invasiveness, aligning with guidelines for diagnostic follow-up in breast cancer screening 1. This approach is consistent with the principle of minimizing morbidity while maximizing diagnostic yield, especially in cases where malignancy is suspected based on clinical and imaging findings.
From the Research
Diagnostic Approaches for Retroareolar Breast Masses
- The presentation of a hard lump and serous discharge, along with ultrasound findings of a mass retroareolar with irregular border, suggests a potential malignancy 2.
- Given the location and characteristics of the mass, the most diagnostic approach would be to obtain a tissue diagnosis.
- The options provided are:
- A. Mammogram: While mammography can be useful in detecting breast lesions, its sensitivity in the retroareolar region is lower compared to other areas of the breast 2.
- B. FNAC (Fine-Needle Aspiration Cytology): This is a minimally invasive procedure that can provide a cytological diagnosis. However, its accuracy may be limited in cases where the mass is complex or has a high likelihood of malignancy.
- C. Excision biopsy: This is a more definitive diagnostic approach that involves removing the entire mass for histopathological examination. It is particularly useful in cases where the mass is suspicious for malignancy or when a tissue diagnosis is necessary for treatment planning.
Considerations for Diagnostic Approach
- The study by 2 highlights the importance of ultrasound as a valuable adjunct in the assessment of retroareolar malignancy.
- Another study by 3 suggests that careful imaging surveillance may be appropriate for asymptomatic females with negative mammography and retroareolar masses or intraductal abnormalities detected on screening ultrasound.
- However, in cases where there is a high suspicion of malignancy, as suggested by the presence of a hard lump and serous discharge, a more definitive diagnostic approach such as excision biopsy may be necessary.
- The study by 4 demonstrates the accuracy of frozen section examination in detecting nipple involvement in breast cancer, which may be relevant in cases where the mass is located in the retroareolar region.
- Ultimately, the choice of diagnostic approach will depend on the individual patient's presentation and the clinical suspicion of malignancy.