A 51-year-old woman comes to the office due to bilateral nipple discharge that she first noticed 3 weeks ago. The discharge is expressed only with manipulation and is not bloody or rust-colored. The patient has had no breast pain, masses, or skin changes. Since menopause at age 50, she has taken soy and vitamin E for frequent hot flashes. In addition, she has hypertension that is well controlled by a single medication. She had 2 cesarean deliveries. The patient drinks a glass of wine occasionally and does not use tobacco or illicit drugs. Her grandmother died from metastatic breast cancer at age 85. Blood pressure is 140/80 mm Hg and pulse is 80/min. BMI is 27 kg/m². Bilateral breast examination reveals no masses, tenderness, or skin changes. A clear yellow discharge is expressed from the nipples bilaterally. There is no axillary or supraclavicular lymphadenopathy. Urine pregnancy test is negative, and other laboratory results are as follows: Bilateral mammogram and breast ultrasound are both normal. Which of the following is the best next step in management of this patient?

Question

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Explanation: 11ec2b69_bee3_c0b3_8f63_21d3510b730f_MD0005_00 Benign (physiologic) nipple discharge is typically bilateral, multiductal, nonbloody, and expressed only with manipulation of the breast. Common etiologies include endocrine abnormalities (eg, hyperprolactinemia, thyroid disease), medications (eg, antipsychotics, gastric motility agents), stress, and excessive breast/nipple stimulation. However, nipple discharge can be a presenting feature of breast cancer; therefore, patients require further evaluation to exclude malignancy with breast examination, ultrasonography, and, for women age >30, mammography. Patients with a normal breast examination and normal imaging undergo a galactorrhea evaluation consisting of a prolactin level and thyroid studies. Patients with a negative evaluation have benign nipple discharge and no increased risk for cancer; therefore, management is reassurance and observation as well as routine screening with clinical breast examinations and mammography. Persistent or bothersome benign nipple discharge may be an indication for duct excision. (Choice A) Cytologic evaluation of nipple discharge is not recommended in the diagnosis of breast cancer due to its low sensitivity and specificity. (Choice B) Phytoestrogens (eg, soy, wild yams) and vitamin E do not cause nipple discharge and can be continued. (Choice C) MRI of the breast is used to evaluate for metastatic disease in patients diagnosed with breast cancer; it is not indicated for the evaluation of nipple discharge. (Choice D) A percutaneous breast biopsy is indicated to exclude malignancy in patients who have a palpable breast mass or suspicious ultrasound and/or mammogram findings. Educational objective: Patients with bilateral nipple discharge and a negative evaluation (eg, breast examination, imaging, laboratory studies) have no increased cancer risk and can therefore be reassured, observed, and followed with routine screening mammography. References: Common breast problems. (http://www.ncbi.nlm.nih.gov/pubmed/22963023) Management of nipple discharge and the associated imaging findings. (http://www.ncbi.nlm.nih.gov/pubmed/25447625)

A 51-Year-Old Woman Comes to the Office Due to Bilateral