With the increased emphasis on breast health, both large palpable lumps and small nodules found to be nonpalpable on ultrasound are becoming more common in the breast. For large palpable lumps, as well as nodules that are not palpable but highly indicative of breast cancer on ultrasound and other imaging tests, both doctors and patients opt for surgery, which is generally not controversial. However, for the inaccessible and ultrasound suggestive of benign possible large lumps, how to treat the opinion is very inconsistent, even among doctors, my diagnosis and treatment principles for this are as follows: 1. Pathological diagnosis and analysis of breast nodules First, define the scope of the ultrasound nodules to be discussed: examined by the regular hospital, inaccessible hypoechoic nodules. They are characterized by clear or unclear borders, regular or irregular morphology, homogeneous or inhomogeneous internal echogenicity, and the presence or absence of blood-supplying vessels. Secondly, the pathologic findings of surgical biopsy of these nodules are described: fibroadenoma (or forming) in about 50%, lobular hyperplasia in about 35%, cysts and other benign diseases in about 10%, and breast cancer in about 2-8%. And the proportion of this result in different ultrasound description of the mass and there are differences: such as morphology regular but the border is less clear lobular hyperplasia is more common, while the border is clear and morphology is regular or irregular fibroadenoma may be larger, and the possibility of benign multiple lumps is more likely. Multiple masses almost always have the same pathological diagnosis, or in rare cases, some of the masses are lobular hyperplasia, and it is extremely rare to see several tumors in the same patient at the same time, etc. These are just general patterns. These are just general patterns. In reality, the correspondence between diagnostic ultrasonography and pathologic diagnosis is still poor. Theoretically, any of the above mentioned nodules cannot be absolutely discharged from malignant possibility, but the possibility is not the same. 2, the premise of treatment is a clear diagnosis Almost all such patients see the doctor’s first words are: is it important? To operate? Take medication? In fact, before answering these three questions to figure out: this (some) nodes in the end what? A clear diagnosis is a prerequisite for answering the question of the severity of the disease and deciding on treatment measures. Ultrasound report is very often “nodules”, at most add “fibroadenoma may”, “breast disease may”, cautious ultrasonographer will also write If you are careful, the sonographer will also write, “Please combine with clinical examination”. Don’t be critical of ultrasound technology, and don’t blame ultrasound doctors for being “slippery”. Ultrasound, as a convenient imaging technique, is a big step up from a doctor’s manual palpation of the breast, but it is not the final diagnosis. The only way to know exactly what the nodule is is to have a surgical biopsy to obtain a pathologic diagnosis. Pathologic diagnosis is the highest of all diagnoses and is the “gold standard”. You don’t operate until you know what it is, you operate until you know what it is. Correct two very common misunderstandings: surgery is not only a treatment method, but also the most accurate diagnostic method; ultrasound (as well as some other imaging tests) has a great diagnostic value, but is not everything. However, surgery is a painful event for patients, and after all, most of these nodules are benign. At this time, patients of different personalities will have different decisions: cautious people will prefer to dig out and send to the “laboratory”, even if the results are only lobular hyperplasia only; fear of surgery will prefer conservative treatment and medication, rather than open surgery, even if it takes a little risk. Doctors can also be divided into two categories. Here, first analyze the pros and cons of these two categories of treatment options. 3, choose non-surgical follow-up program Non-surgical treatment to take three kinds of risk: 1, is it a tumor now? Especially is it cancerous?2, will it become cancerous later? There are some types of benign diseases that increase the risk of cancer, such as papilloma and moderate to severe ductal epithelial hyperplasia, which are called precancerous lesions.3 Even if they are always benign and non-cancerous, the nodules can grow from scratch, and in many cases, from small to large. This is especially true during pregnancy, when there are many concerns about surgery. In addition, if the nodules are large enough, they are no longer suitable for minimally invasive surgery, and the decision to operate is made to resort to traditional large incision surgery. For young women who love beauty, this is also considered a risk. In order to minimize the above risks, we need to start from two aspects: 1), minimize the possibility of the lump increasing in size. As we all know, although fibroadenoma and lobular hyperplasia are different diseases, the etiology of both is mainly due to the stimulation of the glands by sex hormones in the body. At present, the western medicine for treating lobular hyperplasia is basically to antagonize the effect of estrogen, and traditional Chinese medicine generally has the different effects of dredging the liver and regulating qi, activating blood circulation and removing blood stasis, and softening and dispersing the knots, etc. Pharmacodynamic research from western medicine shows that lowering and antagonizing the effect of sex hormones in the body is also its important mechanism. Therefore, I think it is possible to use Chinese and Western medicines for lobular hyperplasia to inhibit or block the increase in size of the lumps, including fibroadenoma, but for a longer period of time, usually 3-6 months. If the nodule is nodular lobular hyperplasia, it may disappear or decrease in size, and clinically, sometimes it can be seen that the nodule is no longer present on ultrasound; if it is a fibroma, it will not decrease in size, but it may inhibit its growth and the formation of new fibroadenomas, however, the effect is limited. Clinically, many patients will still increase the size of the lumps, which shows that there is no specific drug in this area. 2), long-term close ultrasound follow-up to detect changes in the disease. It is better to choose the period of menstruation similar to the previous ultrasound examination to increase the comparability. If the nodule becomes smaller, it can be regarded as basically lobular hyperplasia nodule; if the nodule maintains its original state, it may be lobular hyperplasia and benign tumor, basically do not consider the breast cancer, because breast cancer almost will not be honestly dormant, you can continue to follow up and observe; if the nodule obviously becomes “big” or “strange”, then the lobular hyperplasia nodule will be “big” or “strange”, then the lobular hyperplasia nodule will be “large” or “strange”. If the nodule becomes “big” or “strange”, then the possibility of lobular hyperplasia and benign tumors, but breast cancer may increase, should be timely surgical biopsy, generally not to have serious consequences. Interval time Generally speaking, an interval of about three months is appropriate, and the specific time can be determined according to the specific description of the ultrasound. How long is the follow-up period? Currently there is no uniform opinion, my personal opinion is to refer to the “Chinese Association Against Cancer Breast Cancer Diagnosis and Treatment Guidelines and Criteria” for the follow-up of BI-RADS grade 3 under the molybdenum target, which is also set at 2-3 years, and if there is no change in the ultrasound image of the nodule for a long period of time, the nodule can also be considered stable, and extend the interval of the follow-up to half a year to one year. Some patients take this as a piece of heart disease, repeated ultrasound examination to get annoyed, a ruthless surgical excision biopsy. 4, choose a surgical program Surgery can first be clear what the lump is, if it is benign, but also to achieve the purpose of treatment; if it is malignant, play a role in the early and timely detection. Patients who decide to undergo surgery like to ask one question: will the removal of the mass “stop the root of the problem”? This mood is completely understandable, the decision to “take a knife” is to make a great determination, of course, hope for the best results, there is no excuse. However, the reappearance of lumps after surgery is a risk that must be faced: whether the lumps will reappear or not can be divided into two situations: “reoccurrence” and “recurrence”, recurrence is the situation that the original lumps continue to increase in size after the residual lumps are left behind, which is also related to the nature of the lesion, e.g., lobular tumors are more prone to recurrence; in addition, any lump that is left behind is more prone to recurrence; in addition, any tumor is more prone to recurrence. In addition, any surgery has a certain residual recurrence rate, which is not to avoid responsibility, but to be realistic. Doctors should treat every case of surgery with seriousness and even with fear and trembling, and at the same time try to improve their own surgical skills to minimize the chance of residual recurrence, and should never use this as an excuse to relax their requirements. Reoccurrence is the growth of a new lump in another part of the breast, or even in the immediate vicinity of the surgery. The development of a lump is determined by the internal environment of the breast. Surgical removal of an existing lump does not change the internal environment and therefore does not increase or decrease the risk of recurrence. Moreover, the more frequent the nodules are, the more the patient has the “quality” of being prone to nodule growth, and the more likely they are to reoccur. Some patients believe that having old lumps will “scare” new lumps from appearing, and once the old lumps are removed, new ones will appear all the time, which is obviously rather humorous. Adjustment of diet and mood and timely treatment of active lobular hyperplasia will reduce this risk to a certain extent, but in many cases “internal causes are fundamental, external causes are conditions. Other patients think that after surgery, the breasts will be completely “peaceful”, and the pain before each menstrual period should disappear, this higher expectation is obviously impossible. This is obviously not possible because the surgery only targets the lump and does not change the widespread lobular hyperplasia, which is the cause of the pain. Surgery also always carries risks; minor surgery is a minor risk, no surgery is no risk. For example, infection of the incision and localized blood leakage, hematoma formation, etc. The more lumps removed at once, the greater these risks. This requires the patient’s understanding and the doctor’s active symptomatic treatment. 5, the choice of surgical options for multiple nodules Clinical also encountered a very headache: ultrasound report of many nodules, or even dozens of nodes, covering the breast. How to operate at this time? It is impractical to remove all of them, as the breast will become a “hornet’s nest”, which is very traumatic and requires general anesthesia. Moreover, this kind of patient is very prone to developing a large number of nodules again. My recommendation is that the patient selects for biopsy the nodules that are “large”, “strange looking” and “fast growing” on the ultrasound image. For bilateral nodules, the less likely tumor is removed first, or a separate set of instruments is used to perform the biopsy. The remaining nodules are followed up with medication as described above. The reasons for this are as follows: 1, such a mass carries a greater risk of malignancy. 2, even if it is completely removed, it may grow again. 2, even if it is completely removed, there is a high chance of regrowth, and there may be small nodules already present that cannot be detected by ultrasound at this time, making it impossible to cut. 3, the more frequent, the less chance of malignant tumor. By eliminating the “large”, “strange-looking” and “fast-growing” masses within the tumor, close follow-up is possible. At present, there is another radical approach has been carried out by doctors: subcutaneous adenotonsillectomy, complete removal of all glandular tissue, completely removing the basis of the growth of nodules, “skin does not exist, hair will not attach?” Then breast augmentation is done. There are still very few patients willing to do so. Personally, I think it is suitable for those who have a family history of cancer or previous biopsy of pre-cancerous lesions, such as the patient has a strong will can also be considered. 6. The guiding value of ultrasound BI-RADS grading for decision-making In 2003, the American College of Radiology (ACR) extended the molybdenum imaging BI-RADS grading formulated by the ACR to the field of ultrasound. Different levels of breast cancer malignancy rate and corresponding treatment recommendations are given: for example, grade II malignancy rate of 0%, grade III malignancy rate of less than 2%, can be closely followed up; IVa malignancy rate of 2-30%, IVb malignancy rate of 30-60%, IVc malignancy rate of 60-94%, needing surgical biopsy; V malignancy rate of 95% or more, early biopsy. This has made a great contribution to the timely and accurate detection of breast cancer. At present, there are more and more reports of ultrasonography giving BI-RADS grading in China. If the mass discussed in this article has not been given BI-RADS classification in the ultrasound report, according to my experience, it can be basically categorized as BI-RADS grade III, and a small part of it can be categorized as grade II or IVa. However, I think: this provision for class III lumps across the board that follow-up is sufficient, there is a suspicion of arbitrariness, and some cautious patients will be burdened with long-term thinking, which does not reflect the individualization of decision-making; in addition, these recommendations are only concerned with the issue of the non-missible diagnosis of breast cancer, but do not take into account the issue of the treatment of “benign” masses, as if there is only one type of breast cancer, breast cancer. It seems that breast cancer is the only disease in the mammary gland, and the hidden concept of “cancer is not a disease” is not humanistic enough. The latest 2011 edition of the Chinese Association Against Cancer Breast Cancer Guidelines and Standards has been updated: biopsy of BI-RADS grade III lesions on ultrasound can be considered if requested by the patient or if there are other clinical considerations. Obviously this is more reasonable. As already mentioned, a large proportion of these masses are fibroadenomas, and it is well known that surgical resection is the only treatment for non-malignant tumors such as fibroadenomas, regardless of the size of this tumor. Therefore, we routinely inform such patients about the cancer risk and the possible type of pathology of this mass, suggesting that surgical biopsy is preferred, with the option of close ultrasound follow-up. It is up to the patient to decide whether to operate or not. Surgery has dual attributes, diagnostic biopsy and therapeutic resection. 7. Conclusion and off-topic remarks In summary, breast masses with high suspicion of malignancy should be promptly biopsied. For those who do not have obvious signs of malignancy, the pros and cons of the two options of follow-up and surgery can be explained to the patient in conjunction with specific ultrasound descriptions, and the patient can decide for himself or herself. This is my family’s opinion. It can be said that the reason why it is easy to find so many nodules under ultrasound and difficult to distinguish between fibroadenoma and lobular hyperplasia nodules is due to the limitations of ultrasound as a technology itself, and the correspondence between diagnostic imaging, including ultrasound, and pathological diagnosis needs to be improved, with high sensitivity and low specificity in the detection of fibroadenomas. This technology, together with mammography, constitutes the two main weapons in the adjunctive breast examination, so it is no wonder that there are many patients who have such concerns and sufferings. While ultrasonographers and engineers are working to solve this challenge, clinicians need to be able to recognize the current state of the art and make appropriate decisions.