A 41-year-old woman comes to the office for evaluation of nipple discharge. The patient has had 2 episodes of blood-tinged discharge from the right breast over the last 2 weeks. She has no associated breast pain, palpable masses, or trauma. On review of systems, the patient has had a slightly increased number of headaches; she takes ibuprofen at least twice a week for them. She has no chronic medical conditions. The patient takes combined estrogen/progestin oral contraceptives, and her last menstrual period was 2 weeks ago. There is no family history of breast, endometrial, or colorectal cancer. Vital signs are normal. Examination of the right breast shows no palpable masses, skin changes, or lymph node enlargement. There is scant discharge, which is guaiac positive, from the right nipple. Examination of the left breast is normal. Mammography is normal. Which of the following is the best next step in management of this patient?

Question

A 41-year-old woman comes to the office for evaluation of nipple discharge.  The patient has had 2 episodes of blood-tinged discharge from the right breast over the last 2 weeks.  She has no associated breast pain, palpable masses, or trauma.  On review of systems, the patient has had a slightly increased number of headaches; she takes ibuprofen at least twice a week for them.  She has no chronic medical conditions.  The patient takes combined estrogen/progestin oral contraceptives, and her last menstrual period was 2 weeks ago.  There is no family history of breast, endometrial, or colorectal cancer.  Vital signs are normal.  Examination of the right breast shows no palpable masses, skin changes, or lymph node enlargement.  There is scant discharge, which is guaiac positive, from the right nipple.  Examination of the left breast is normal.  Mammography is normal.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d9a9_bf03_bc81_c9e317050d49_MD0003_00 Nipple discharge is considered pathologic if it is spontaneous, unilateral, or persistent. Pathologic nipple discharge can range from sanguineous (eg, guaiac positive) to serous (eg, possible lymphatic involvement). The most common cause is a papillary tumor (ie, intraductal papilloma) originating from the breast duct lining. Intraductal papillomas are typically benign and may not be palpable on examination, as in this patient. However, they may have areas of associated atypia, ductal carcinoma in situ, and intraductal carcinoma. intraductal papilloma Therefore, this patient with pathologic nipple discharge requires further evaluation with age-based imaging. In women age ≥30, as in this patient, imaging is with both ultrasound and mammography. Mammography is typically performed first because it has high specificity (94%-100%) for identification of suspicious breast tissue. Even if mammography is normal, an ultrasound is required because this modality increases the detection of small, noncalcified, or intraductal lesions that can cause nipple discharge (Choice E). Age-based imaging for women age <30 is with a breast ultrasound (± mammography) due to the greater density of breast tissue and higher false-positive mammography rates in this population. (Choice B) Combined oral contraceptives can cause breast tenderness, particularly within the first several weeks of use; however, they do not typically cause pathologic nipple discharge. Although patients diagnosed with breast cancer require discontinuation of combined oral estrogen/progestin contraceptives, this patient first requires further evaluation. (Choice C) Antibiotics are used in the management of mastitis or breast abscess, which can cause nipple discharge. However, patients typically have a fever and tender breasts. In addition, those with an abscess typically have a fluctuant mass. None of these manifestations is seen in this patient. (Choice D) MRI of the pituitary can be used to assess for pituitary masses in patients with possible prolactinoma. In contrast to this patient with unilateral discharge, those with prolactinomas have bilateral nipple discharge. Educational objective: Patients with unilateral, spontaneous, or persistent nipple discharge require age-based imaging to evaluate for breast cancer. Imaging in women age ≥30 includes mammography plus breast ultrasound, which in combination increases the detection of intraductal lesions (eg, papilloma) that commonly cause nipple discharge. References: Breast imaging in patients with nipple discharge. (http://www.ncbi.nlm.nih.gov/pubmed/29307929) Intraductal papilloma of the breast: a case report. (http://www.ncbi.nlm.nih.gov/pubmed/23396758)

A 41-Year-Old Woman Comes to the Office for Evaluation of Nipple