What is the most diagnostic test for a case presenting with a hard lump and serous discharge, with ultrasound (US) showing a mass retroareolar with an irregular border, using options including Mammogram, Fine Needle Aspiration Cytology (FNAC), or Excision Biopsy?

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 excision biopsy (option C). While mammogram can provide additional imaging information and FNAC (Fine Needle Aspiration Cytology) can sample cells, excision biopsy offers the most definitive diagnosis by removing the entire suspicious lesion for comprehensive histopathological examination. This approach is particularly valuable when malignancy is suspected, as the clinical presentation described (hard lump, serous discharge, and irregular borders on ultrasound) raises significant concern for breast cancer, as noted in studies such as 1. Excision biopsy allows for complete assessment of tissue architecture, cellular patterns, and margins, which is essential for accurate diagnosis, staging, and treatment planning, as highlighted by the guidelines in 1 and the recommendations for diagnostic follow-up in 1. It also serves as both a diagnostic and potentially therapeutic procedure if the entire lesion is removed with adequate margins. The combination of concerning physical findings and suspicious ultrasound features warrants this more definitive diagnostic approach rather than less invasive alternatives, in line with the principles outlined in 1 and the discussion on palpable breast masses in 1. Given the potential for breast cancer, as discussed in 1, and the importance of accurate diagnosis for treatment planning, excision biopsy is the most appropriate choice for this clinical presentation. Key points to consider include:

• The clinical presentation of a hard lump with serous discharge and irregular borders on ultrasound is highly suggestive of malignancy.
• Excision biopsy provides the most definitive diagnosis by allowing for comprehensive histopathological examination of the entire lesion.
• This approach is in line with guidelines and recommendations for the diagnosis and management of breast lesions, as seen in 1, 1, and 1.
• The potential benefits of excision biopsy, including accurate diagnosis and possible therapeutic effect, outweigh the benefits of less invasive alternatives like mammogram and FNAC in this context.

From the Research

Diagnostic Approaches for Breast Lesions

• The case presented involves a hard lump and serous discharge, with ultrasound showing a mass retroareolar with irregular border.
• The most diagnostic approach for this case would be:
  • C. Excision biopsy: Although not directly mentioned as the most diagnostic approach in the provided studies, excision biopsy is considered the gold standard for diagnosing breast lesions 2, 3.
• Other diagnostic approaches mentioned in the studies include:
  • A. Mammogram: Mammography is less sensitive in the retroareolar area than in other areas of the breast 4.
  • B. FNAC (Fine-Needle Aspiration Cytology): FNAC has a lower sensitivity and specificity compared to CNB (Core Needle Biopsy) 2, 3, 5, 6.
• Core Needle Biopsy (CNB) is considered a more accurate and reliable method for diagnosing breast lesions, especially in cases of uncertainty 3, 5, 6.

Comparison of Diagnostic Approaches

• The studies compare the sensitivity, specificity, and diagnostic accuracy of FNAC and CNB in diagnosing breast lesions:
  • FNAC: sensitivity (69-74.1%), specificity (76.9-100%), diagnostic accuracy (74-75%) 2, 3.
  • CNB: sensitivity (85.2-88.3%), specificity (92.8-100%), diagnostic accuracy (86-87.8%) 2, 3, 5.
• The combined assessment of FNAC and CNB shows a higher diagnostic accuracy (88.1%) compared to either method alone 3.