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). This approach is supported by the American College of Radiology's appropriateness criteria for palpable breast masses, which emphasize the importance of tissue sampling for suspicious lesions 1. While mammography (option A) can provide additional imaging information, it does not offer the definitive diagnosis that excision biopsy provides. Excision biopsy allows for the removal of the entire suspicious lesion for comprehensive histopathological examination, which is crucial for diagnosing breast cancer and guiding further management.
Key points to consider in this diagnosis include:
- The clinical presentation of a hard lump with serous discharge raises concern for malignancy
- The ultrasound findings of a retroareolar mass with irregular borders are suspicious for cancer
- Excision biopsy is the gold standard for definitive diagnosis of breast lesions when imaging and clinical findings are suspicious
- Image-guided core-needle biopsy is an alternative to excision biopsy, but it may not provide the same level of diagnostic certainty as removing the entire lesion 1
In the context of real-life clinical medicine, prioritizing morbidity, mortality, and quality of life, excision biopsy (option C) is the most appropriate diagnostic approach for a patient presenting with a hard lump, serous discharge, and a suspicious ultrasound finding, as it provides the most definitive diagnosis and guides further management. This approach is supported by the most recent and highest quality evidence available 1.
From the Research
Diagnostic Approach
The case presented involves a hard lump and serous discharge, with ultrasound (US) showing a mass retroareolar with an irregular border. Given these findings, the most diagnostic approach would be:
- Excision biopsy, as it provides a definitive diagnosis by removing the entire lesion for histopathological examination 2, 3.
Rationale
The rationale behind choosing excision biopsy over other diagnostic methods, such as mammography, is based on the following points:
- Mammography may not always provide a clear diagnosis, especially in cases with irregular borders or dense breast tissue 4.
- Excision biopsy allows for the complete removal of the lesion, which can be beneficial for both diagnostic and therapeutic purposes 3.
- Studies have shown that excision biopsy can be an effective method for diagnosing breast lesions, with a high success rate in obtaining a definitive diagnosis 2, 5.
Considerations
When considering excision biopsy, the following points should be taken into account:
- The procedure may be associated with complications, such as hematoma or tumor residual, although these are not typically determinant factors for surgery options 4.
- The use of excision biopsy has decreased over the past two decades, but it remains a valuable diagnostic tool in certain cases, particularly when radiologic surveillance and repeated percutaneous biopsy yield indeterminate results 2.