From the Guidelines
The next step for a patient presenting with a hard lump, serous discharge, and an ultrasound showing a retroareolar mass with irregular borders should be a diagnostic biopsy, specifically a core needle biopsy under ultrasound guidance, as recommended by the NCCN clinical practice guidelines in oncology 1. This approach is based on the high suspicion of malignancy, particularly breast cancer, given the clinical and imaging features. The core needle biopsy will provide a tissue diagnosis, which is essential for determining further management.
Key Considerations
- The patient's clinical presentation, including the hard lump and serous discharge, raises concern for a malignant process.
- The ultrasound findings of a retroareolar mass with irregular borders are suspicious for breast cancer, as outlined in the ACR Appropriateness Criteria for palpable breast masses 1.
- The NCCN guidelines recommend core needle biopsy for suspicious or highly suggestive findings, such as those present in this case 1.
- Additional imaging, such as mammography and breast MRI, may be considered to better characterize the lesion and assess for multifocality or involvement of the contralateral breast, but should not delay the diagnostic biopsy.
Diagnostic Approach
- The diagnostic approach should follow a triple assessment strategy, including clinical examination, imaging, and tissue sampling, as recommended by the NCCN guidelines 1.
- The patient should be informed about the suspicious nature of the findings and the importance of prompt follow-up.
- The core needle biopsy should be performed under ultrasound guidance to ensure accurate sampling of the suspicious mass.
Management
- The management of the patient will depend on the results of the core needle biopsy, which will provide a tissue diagnosis.
- If the biopsy confirms breast cancer, further management will be guided by the NCCN clinical practice guidelines in oncology, including consideration of additional imaging, surgery, and adjuvant therapy 1.
From the Research
Diagnostic Approach
The case presented involves a hard lump with serous discharge and a mass retroareolar with an irregular border on ultrasound. To determine the next steps, consider the following:
- The use of fine-needle aspiration (FNA) and core needle biopsy (CNB) are common methods for diagnosing masses, as discussed in 2, 3, 4.
- FNA and CNB have different strengths and weaknesses, and the choice between them depends on the specific case, as noted in 4.
- For detecting malignancy and tissue-specific diagnosis, CNB may be more accurate than FNA, as shown in 3, 5.
- The diagnostic accuracy of FNA and CNB can vary depending on the location and type of mass, as well as the operator's experience, as discussed in 5, 6.
Considerations for Mass Retroareolar
Given the location of the mass (retroareolar), consider the following:
- The mass may be related to the breast tissue, and further evaluation with imaging and biopsy may be necessary.
- FNA and CNB can be used to evaluate breast masses, but the choice between them should be based on the specific case and the availability of imaging guidance.
- The use of ultrasound guidance can improve the accuracy of FNA and CNB, as discussed in 5, 6.
Next Steps
Based on the available evidence, the next steps could include:
- Further evaluation with imaging studies, such as mammography or MRI, to better characterize the mass.
- Biopsy of the mass using FNA or CNB, depending on the specific case and the availability of imaging guidance.
- Consideration of the patient's medical history and risk factors for malignancy when interpreting the biopsy results, as discussed in 2.