What is the appropriate diagnostic test to confirm a diagnosis for a 45-year-old female with a hard mass measuring 3.4 cm under the areola, accompanied by retraction and irregularity on ultrasound (US)?

From the Guidelines

For a 45-year-old female with a hard 3.4 cm mass under the areola showing retraction and irregular features on ultrasound, the most appropriate next step to confirm diagnosis would be a mammogram, as the initial imaging modality of choice, followed by a biopsy if necessary. The clinical presentation strongly suggests a suspicious breast lesion that requires thorough evaluation. According to the American College of Radiology 1, diagnostic mammography or DBT is the initial imaging modality of choice for evaluating a clinically detected palpable breast mass in a woman aged 40 years or older. The National Comprehensive Cancer Network 1 also recommends a diagnostic mammogram and ultrasound as the initial evaluation for women with a palpable mass aged 30 years or older, with ultrasound being used to determine lesion size and guide tissue biopsy if necessary.

While fine needle aspiration (FNA) can provide cytological information, it often yields insufficient tissue for complete histological assessment and hormone receptor status determination 1. An excisional biopsy is too aggressive as an initial diagnostic approach and should be reserved for cases where less invasive methods are inconclusive. A ductogram would be inappropriate as this presentation suggests a mass lesion rather than nipple discharge pathology.

The key points to consider in this case are:

• The patient's age and the presence of a palpable mass warrant a thorough imaging workup 1
• Diagnostic mammography is the initial imaging modality of choice for women aged 40 years or older 1
• Ultrasound should be used to determine lesion size and guide tissue biopsy if necessary 1
• Core needle biopsy under imaging guidance provides adequate tissue for histological diagnosis, receptor status, and molecular testing while being minimally invasive 1.

From the Research

Diagnostic Approaches for Breast Lesions

To confirm the diagnosis of a breast lesion, several approaches can be considered:

• Fine-needle aspiration (FNA) is a method used to collect cell samples from the lesion for cytological examination.
• Mammography (Mamo) is an imaging technique used to visualize the breast tissue and detect any abnormalities.
• Excisional biopsy involves the surgical removal of the entire lesion for histopathological examination.
• Ductography is an imaging technique used to visualize the breast ducts, but it is not commonly used for diagnosing breast lesions.

Recommended Diagnostic Approach

Based on the provided evidence, a core needle biopsy (CNB) is recommended to confirm the diagnosis of a breast lesion 2, 3. CNB is a minimally invasive procedure that involves removing a small sample of tissue from the lesion for histopathological examination. The accuracy of CNB is higher for invasive carcinomas than for non-invasive cancers 2. Excisional biopsy may be necessary for lesions with anticipated sampling errors or when the CNB findings are discordant with clinical or mammographic findings 2.

Comparison of Diagnostic Approaches

The provided evidence compares the diagnostic accuracy of different approaches:

• CNB has a high degree of agreement with excisional biopsy findings, with a concordance rate of 91.3% 2.
• Stereotaxic core biopsy has a sensitivity of 85% for malignant lesions and a specificity of 100% for benign lesions 3.
• The combination of physical examination, imaging, and fine-needle aspiration cytology (FNAC) has a higher predictive value than any modality alone, with a positive predictive value (PPV) of 100% when all three modalities are positive for malignancy 4.
• Core biopsy is a reliable tool, with a diagnostic accuracy of 95.5% in one study 4.