A 30-year-old woman, gravida 1 para 1, comes to the office for evaluation of blood-tinged breast milk. The patient had an uncomplicated vaginal delivery 2 months ago and has been exclusively pumping her breast milk. She initially had bilateral breast pain with letdown and bloody-appearing milk due to nipple trauma that resolved with a lactation consultation and supportive measures. However, for the past 2 weeks, the patient has had intermittent blood-tinged milk from the right breast but no fever, chills, or breast pain. She has no chronic medical conditions, and her only medication is a progestin-only oral contraceptive. Temperature is 36.7 C (98.1 F) and pulse is 88/min. On examination, there is mild, diffuse breast tenderness and engorgement bilaterally. A firm density is palpable within the right breast at the 9 o'clock position, but no fluctuance or surrounding erythema is present. There is no axillary or clavicular lymphadenopathy. Which of the following is the best next step in management of this patient?

Question

A 30-year-old woman, gravida 1 para 1, comes to the office for evaluation of blood-tinged breast milk.  The patient had an uncomplicated vaginal delivery 2 months ago and has been exclusively pumping her breast milk.  She initially had bilateral breast pain with letdown and bloody-appearing milk due to nipple trauma that resolved with a lactation consultation and supportive measures.  However, for the past 2 weeks, the patient has had intermittent blood-tinged milk from the right breast but no fever, chills, or breast pain.  She has no chronic medical conditions, and her only medication is a progestin-only oral contraceptive.  Temperature is 36.7 C (98.1 F) and pulse is 88/min.  On examination, there is mild, diffuse breast tenderness and engorgement bilaterally.  A firm density is palpable within the right breast at the 9 o'clock position, but no fluctuance or surrounding erythema is present.  There is no axillary or clavicular lymphadenopathy.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d9cc_3b5f_bc81_ddac76dbfd2e_MD0003_00 Blood-tinged breast milk can be normal during initial milk letdown due to increased postpartum breast vascularity; it can also occur with initial breastfeeding attempts due to improper latch-on technique that predisposes to nipple trauma and bleeding. In these patients, supportive measures and reassurance are appropriate because nipple trauma and bleeding typically resolve with improved breastfeeding techniques (Choice E). latch-on technique However, this patient's unilateral, blood-tinged breast milk with associated new breast mass is concerning for breast malignancy and requires further evaluation. Bloody nipple discharge can be a sign of active intraductal tumor growth with necrosis, and a firm or fixed breast mass may indicate invasion into adjacent breast tissue. Therefore, patients with a new breast mass and pathologic (eg, unilateral, bloody) nipple discharge require breast imaging and possible core needle biopsy for diagnosis. Other concerning signs for breast cancer include axillary lymphadenopathy (ie, lymphatic spread to regional lymph nodes), skin retraction (ie, invasion of suspensory Cooper ligaments), and nipple retraction (ie, invasion of the lactiferous ducts). (Choice B) Progestin-only oral contraceptives (POPs) are the preferred hormonal contraceptive method for breastfeeding patients to avoid disrupting breastfeeding. However, POPs do not cause bloody, unilateral discharge or a discrete breast mass, so changing this patient's contraceptive method is not indicated. However, if ER/PR-positive breast cancer is diagnosed in this patient, estrogen- or progesterone-containing contraception should be discontinued. (Choice C) Cytologic evaluation is generally not recommended for nipple discharge (regardless of appearance) because it has low sensitivity and specificity for malignancy. (Choice D) Dicloxacillin is the first-line treatment for lactational mastitis, which is also unilateral and can cause nipple discharge due to ductal inflammation. In contrast to this patient with breast malignancy, those with mastitis typically have systemic symptoms (ie, fever, chills, malaise) and breast tenderness with erythema, induration, or fluctuance (eg, abscess). lactational mastitis Educational objective: Patients with signs concerning for breast malignancy (eg, unilateral, blood-tinged breast milk or bloody nipple discharge; new breast mass) require breast imaging. References: Contraception after pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/31001809) Common breast problems. (http://www.ncbi.nlm.nih.gov/pubmed/30990294)

A 30-Year-Old Woman, Gravida 1 Para 1, Comes to the Office