A 35-year-old female presents with a solitary breast mass, and fine needle aspiration reveals bloody fluid but no malignant cells. What is the next best step?

In cases where a solitary breast mass is encountered, and fine needle aspiration (FNA) reveals bloody fluid but no malignant cells, the appropriate next step in management is typically an excisional biopsy. This approach is recommended for several reasons.

First, the presence of a solitary breast mass with bloody fluid raises concern for potential underlying pathologies, including intraductal lesions, such as papillomas or other non-invasive lesions, which may not be fully characterized by FNA alone. An excisional biopsy allows for complete removal of the mass and provides comprehensive histological examination, essential for accurate diagnosis.

Second, FNA can sometimes miss malignancies if the sampling is inadequate. Thus, an excisional biopsy can serve both as a diagnostic procedure and a therapeutic one if a benign lesion is encountered. It helps ensure that any potential malignancy is not overlooked, especially considering the patient’s age and the characteristics of the mass.

Monitoring through monthly follow-up may be applicable for benign-appearing masses, but given the bloody fluid and uncertainty surrounding the nature of the mass, active intervention is warranted for definitive diagnosis. Similarly, repeating fine needle aspiration might not provide additional clarity, as it could result in the same inconclusive findings and would not address the need for a definitive