A 34-year-old woman comes to the office with bleeding from the right nipple. The patient has noticed blood staining her bra on several occasions over the past week but has no fever or breast pain. She has no chronic medical conditions and does not take any medications. Breast examination shows no palpable masses or skin changes. A thin, blood-tinged discharge can be expressed from the right nipple. There are no enlarged axillary lymph nodes. Which of the following is the most likely histopathologic finding in this patient's right breast?

Question

A 34-year-old woman comes to the office with bleeding from the right nipple.  The patient has noticed blood staining her bra on several occasions over the past week but has no fever or breast pain.  She has no chronic medical conditions and does not take any medications.  Breast examination shows no palpable masses or skin changes.  A thin, blood-tinged discharge can be expressed from the right nipple.  There are no enlarged axillary lymph nodes.  Which of the following is the most likely histopathologic finding in this patient's right breast?

Quizplus · Accepted Answer

11ec160b_378d_9687_9249_e7306f276cda_MD0001_00 Nipple discharge can be physiologic (ie, bilateral, nonbloody or milky, without masses or skin changes) or pathologic (ie, bloody or serosanguineous and unilateral with or without palpable masses and skin changes). The most common cause of pathologic nipple discharge is an intraductal papilloma, which classically presents as a unilateral, bloody nipple discharge with no associated breast masses, skin changes, or axillary lymphadenopathy. Although most cases of intraductal papilloma are benign, all patients with pathologic nipple discharge require evaluation with imaging (eg, mammogram or ultrasound, depending upon age) and possibly with biopsy. On microscopy, intraductal papilloma shows epithelial and myoepithelial cells lining fibrovascular cores forming papillae within a duct or cyst wall. The bloody discharge results from twisting of the vascular stalk of the papilloma in the duct. (Choice A) Paget disease of the breast occurs due to the ductal spread of atypical malignant cells to the nipple epidermis. Although patients may have bloody nipple discharge, they also have a unilateral erythematous, intensely pruritic, ulcerative lesion over the nipple and areola, which is not seen in this patient. (Choice B) Fibrocystic changes of the breast may show cysts with or without metaplasia and areas of fibrosis. Patients with fibrocystic changes typically have cyclic breast pain, not nipple discharge. (Choice D) Fat necrosis typically presents as an irregular breast mass with no associated nipple discharge after localized trauma or biopsy. Microscopy may show adipocytes undergoing necrosis with inflammation, including macrophages and giant cells. (Choice E) Fibroadenomas are small, firm, and mobile breast masses that occur due to proliferation of breast stroma and ducts. Fibroadenomas do not typically cause bloody nipple discharge. Microscopic examination shows stromal proliferation compressing the ducts to slits. Educational objective: Intraductal papilloma is characterized by epithelial and myoepithelial cells lining fibrovascular cores in a cyst wall or duct. It is the most common cause of bloody nipple discharge and typically presents without breast masses or skin changes. __________ References: Common breast problems. (http://www.ncbi.nlm.nih.gov/pubmed/22963023)

A 34-Year-Old Woman Comes to the Office with Bleeding from the Right