What is the most likely diagnosis for a case presenting with a hard lump and serous discharge, where an ultrasound (US) shows a mass retroareolar with an irregular border?

From the Guidelines

The most appropriate diagnostic approach for a hard lump with serous discharge and an ultrasound showing a retroareolar mass with irregular borders is excision biopsy. This procedure involves surgically removing the entire suspicious mass for comprehensive histopathological examination. Excision biopsy is preferred in this scenario because the clinical and imaging findings suggest a concerning breast lesion that requires definitive diagnosis. The presence of a hard lump, serous discharge, and irregular borders on ultrasound raises suspicion for malignancy, and while less invasive methods like fine needle aspiration or core needle biopsy could be considered, they may not provide sufficient tissue for complete diagnosis. According to the most recent guidelines, such as those from the National Comprehensive Cancer Network 1, excision biopsy allows for complete removal of the suspicious area, providing adequate tissue for thorough pathological assessment including histological type, grade, and receptor status if malignant. This approach also has therapeutic value if the lesion is completely excised. The procedure is typically performed under local anesthesia with sedation as an outpatient procedure, with recovery usually taking 1-2 weeks depending on the extent of the excision.

Some key points to consider in the diagnosis of breast lesions include:

• The use of ultrasound for initial evaluation, as recommended by guidelines such as those from the American College of Radiology 1
• The importance of considering the clinical and imaging findings together to determine the likelihood of malignancy
• The role of biopsy in obtaining a definitive diagnosis, with excision biopsy being the most comprehensive method
• The potential for therapeutic benefit from excision biopsy if the lesion is completely removed

In terms of specific recommendations, the guidelines suggest that:

• A suspicious or highly suggestive finding on ultrasound should be biopsied, with core needle biopsy or surgical excision being options 1
• The use of imaging modalities such as mammography, ultrasound, and MRI can help to evaluate the size and morphology of axillary nodes and determine the need for further investigation 1
• The management of the axilla in patients with breast cancer should be individualized, with consideration of factors such as the presence of palpable nodes, the size and location of the tumor, and the patient's overall health status 1

From the Research

Diagnosis and Treatment of Breast Cancer

• The case presented involves a hard lump and serous discharge, with an ultrasound showing a mass retroareolar with an irregular border, suggesting the possibility of breast cancer 2.
• The diagnosis of breast cancer typically involves a combination of physical examination, imaging (mammogram and ultrasound), and fine-needle aspiration cytology (FNAC) or core biopsy 2.
• The most appropriate next step in this case would be to perform an excision biopsy to obtain a definitive diagnosis, as it is the most reliable method for diagnosing breast cancer 2, 3, 4.

Importance of Excision Biopsy

• Excision biopsy is considered the gold standard for diagnosing breast cancer, as it provides a complete tissue sample for histopathological examination 2, 3, 4.
• Core biopsy is also a reliable tool, but it may not always provide a complete diagnosis, and excision biopsy may be necessary to confirm the diagnosis 2, 3, 4.
• The accuracy of physical examination and imaging modalities, such as ultrasound, is dependent on the experience of the surgeon and the characteristics of the lesion, and may not always be reliable 2.

Treatment Options

• The treatment of breast cancer depends on the stage and type of cancer, as well as the patient's overall health and preferences 5, 6.
• Adjuvant radiotherapy is an essential component of the treatment of breast cancer, and is typically performed after conservative surgery or mastectomy 5.
• Chemotherapy and hormonal therapy may also be used, depending on the type and stage of cancer, as well as the patient's menopausal status and other factors 5, 6.