A 46-year-old woman, gravida 3 para 3, comes to the office due to left nipple discharge. She reports that the discharge began 1 month ago, is present almost daily, and stains her undergarments. It is typically yellow, thin, and sticky but occasionally stains her bra a rust color. The patient has no chronic medical conditions and takes no daily medications. Menses are regular and her last menstrual period was 3 weeks ago. The patient has 3 children; the youngest was born 6 years ago by cesarean delivery, and a bilateral tubal ligation was performed with the delivery. All 3 children were breastfed. There is no family history of breast cancer in her first-degree relatives. The patient drinks 8-10 alcoholic beverages a week but does not use tobacco or illicit drugs. She has no known drug allergies. Temperature is 37.2 C (99 F), blood pressure is 130/86 mm Hg, and pulse is 70/min. BMI is 33 kg/m². Serous discharge is expressed from the left nipple. No palpable masses, skin discoloration or retraction, or axillary lymphadenopathy is present. The right breast has no expressed nipple discharge, masses, or lymphadenopathy. Which of the following is the most appropriate next step in management of this patient?

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Explanation: 11ec2b69_bee3_4b81_8f63_fd559e2d4441_MD0005_00 Nipple discharge is considered pathologic if it is spontaneous, unilateral, or persistent. Pathologic nipple discharge can present as a spectrum of sanguineous to serous appearing fluid, the latter of which may indicate lymphatic involvement. The most common cause of pathologic nipple discharge is a benign papillary tumor (ie, papilloma) from the breast duct lining. Papillomas are typically benign but may have associated areas of atypia, ductal carcinoma in situ, and invasive intraductal carcinoma within the lesion. Therefore, patients with pathologic nipple discharge require further evaluation with age-based imaging (Choice B). In women age >30, as in this patient, imaging is with a mammogram plus ultrasound. Mammography has a high specificity rate (94%-100%) in the identification of suspicious breast tissue, and the addition of ultrasound increases the detection of small, noncalcified, or intraductal lesions. Because of denser breast tissue and high false-positive mammography rates, initial imaging in women age <30 is with a breast ultrasound with or without mammography. Papillomas (Choice A) Infectious causes of nipple discharge (eg, breast abscess) may be evaluated with Gram stain and culture to help direct pharmacotherapy. Breast abscesses typically present with fever and a fluctuant mass, neither of which is seen in this patient. (Choice C) Hyperprolactinemia can cause galactorrhea, a bilateral milky nipple discharge from multiple ducts, which is not seen in this patient. Causes of hyperprolactinemia include prolactinoma, medications (eg, antipsychotics, antihypertensives, oral contraceptives), hypothyroidism, and pregnancy. (Choice E) Cytology of the breast discharge has low sensitivity and specificity for detecting malignancy, so is not used in its evaluation. Educational objective: Patients with unilateral, spontaneous, or persistent nipple discharge require age-based imaging to exclude malignancy. Imaging in women age >30 includes a mammogram plus breast ultrasound. The most common cause of pathologic nipple discharge is papilloma. References: Practice Bulletin No. 164: diagnosis and management of benign breast disorders. (http://www.ncbi.nlm.nih.gov/pubmed/27214189)

A 46-Year-Old Woman, Gravida 3 Para 3, Comes to the Office