A 42-year-old woman comes to the office due to bloody discharge from her right nipple. She has had no breast pain, swelling, or trauma but stopped breastfeeding 3 months ago. She has never had mammography. The patient has no chronic medical conditions. Vital signs are normal. Examination reveals symmetric pendulous breasts without any ulceration, crusting, or scaling of the nipple-areolar complexes. Manual pressure elicits bloody discharge from a single duct of the right nipple. A firm, ill-defined, 2-cm mass is palpable in the lower outer quadrant of the right breast with retraction of the overlying skin. The left breast is normal to palpation, and no axillary or supraclavicular lymphadenopathy is present bilaterally. Which of the following is the most likely diagnosis in this patient?

Question

A 42-year-old woman comes to the office due to bloody discharge from her right nipple.  She has had no breast pain, swelling, or trauma but stopped breastfeeding 3 months ago.  She has never had mammography.  The patient has no chronic medical conditions.  Vital signs are normal.  Examination reveals symmetric pendulous breasts without any ulceration, crusting, or scaling of the nipple-areolar complexes.  Manual pressure elicits bloody discharge from a single duct of the right nipple.  A firm, ill-defined, 2-cm mass is palpable in the lower outer quadrant of the right breast with retraction of the overlying skin.  The left breast is normal to palpation, and no axillary or supraclavicular lymphadenopathy is present bilaterally.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d895_420e_bc81_3fc9eff2a8e6_MD0003_00 Nipple discharge not consistent with lactation (ie, breast milk secretion) is classified as physiologic or pathologic: Physiologic nipple discharge is usually bilateral, multiductal, milky or nonbloody and is expressed only with manipulation of the breast. Pathologic nipple discharge is usually unilateral, uniductal, bloody or serous, and spontaneous. Physiologic nipple discharge is typically caused by a benign process outside the breast (eg, hyperprolactinemia). In contrast, pathologic nipple discharge typically signals that an abnormal process (eg, papilloma, carcinoma, abscess) is present within the breast. This patient has pathologic, unilateral bloody nipple discharge and a firm, ill-defined breast mass. This presentation is most concerning for breast cancer (eg, invasive ductal carcinoma), especially given the skin retraction overlying the mass, which is typically due to tumor invasion into the breast suspensory ligaments. Tumor growth and/or necrosis within the lactiferous duct system can result in bloody nipple discharge. As the next steps for evaluating both the pathologic nipple discharge and the palpable breast mass, this patient should undergo breast imaging (eg, mammography, ultrasound) followed by biopsy. skin retraction nipple discharge breast mass (Choice A) A breast abscess can cause a palpable breast mass with nipple discharge; however, the mass is typically fluctuant (vs firm) with surrounding erythema, the discharge is typically purulent (vs bloody), and fever is usually present. (Choice B) Lactiferous duct blockage in the first few months following cessation of breastfeeding can lead to formation of a galactocele (ie, milk retention cyst); however, this typically presents as a soft (vs firm), cystic mass with fluid (via spontaneous discharge or aspiration) that is typically milky rather than bloody. (Choice C) Unilateral bloody discharge without a coexisting breast mass is most commonly caused by an intraductal papilloma (ie, papillary tumor originating from the breast duct lining); however, this benign growth is typically too small (≤1 cm) to be palpable on clinical breast examination. In addition, it would not cause overlying skin retraction (ie, invasion of suspensory ligaments). intraductal papilloma (Choice E) Mammary duct ectasia, characterized by subareolar ductal dilation, inflammation, and fibrosis, can cause a palpable breast mass (from scar tissue) with nipple discharge; however, the nipple discharge is classically green-brown and sticky (vs bloody), the mass is classically subareolar (vs peripheral), and involvement of the breast suspensory ligaments (ie, skin retraction) is not expected. Educational objective: Unilateral, spontaneous, bloody nipple discharge accompanied by a palpable breast mass is concerning for malignancy. References: Nipple discharge. (http://www.ncbi.nlm.nih.gov/pubmed/25733736) Breast imaging in patients with nipple discharge. (http://www.ncbi.nlm.nih.gov/pubmed/29307929) Management of nipple discharge and the associated imaging findings. (http://www.ncbi.nlm.nih.gov/pubmed/25447625)

A 42-Year-Old Woman Comes to the Office Due to Bloody