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Snapshot
  • A 32-year-old woman presents to her primary care physician with one day of painless, bloody discharge from the right nipple. She reports that she has otherwise been in good health. She is nulliparous. Examination of the right breast reveals no palpable mass, but blood is expressed from the nipple. There is no lymphadenopathy in the axilla.
Introduction
  • Overview
    • benign polypoid epithelial tumors in located in the lactiferous ducts of breast
    • most common cause of bloody discharge in a women under 50 
    • develops in close proximity to the nipple
  • Epidemiology
    • makes up 48% of cases of pathologic nipple discharge
  • Prognosis
    • 1.5-2x risk of breast cancer compared to general population
    • typically does not convert to carcinoma but can hide DCIS within the papilloma
Presentation
  • Symptoms 
    • painless unilateral nipple bleeding 
  • Physical exam
    • blood expressible from nipple
    • usually no mass found on physical exam
      • typically 1-5 mm in diameter
Imaging
  • Ultrasound
    • indications
      • any patient with pathologic nipple discharge
    • findings
      • intraductal mass
  • Mammography
    • indications
      • follow up to ultrasound in the following patients
        • ≥30 years old
        • <30 years old with suspicious abnormality on ultrasound
  • Core needle biospy
    • indications
      • intraductal mass on ultrasound or mammography
    • findings
      • if atypical cells found then follow up with excisional biopsy
  • Excisional biopsy
    • indications
      • patient with papilloma on imaging and atypical cells on core needle biopsy
    • findings
      • used to rule out intraductal papillary carcinoma
Studies
  • Serum TSH, prolactin, hCG levels
    • indications
      • used to rule out galactorrhea in patients with non-bloody discharge 
Differential
  • Intraductal papillary carcinoma
    • key distinguishing factors
      • evidence of carcinoma on core needle biopsy/excisional biopsy
  • Galactorrhea
    • key distinguishing factors
      • non-bloody, milky nipple discharge 
      • typically caused by pituitary prolactinoma
  • Nipple fissure
    • key distinguishing factors
      • skin irritation/fissure causing bleeding
      • no mass on imaging
  • Breast mastitis
    • key distinguishing factors
      • signs of infection
      • skin erythema
      • can occur secondary to breastfeeding
Treatment
  • Surgical
    • excisional biopsy
      • indications
        • both diagnostic and therapeutic
Complications
  • Risk of DCIS found within papilloma

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Questions (3)
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(M2.ON.16.99) A 32-year-old woman presents to her physician concerned about wet spots on the inside part of her dress shirts, which she thinks it may be coming from one of her breasts. She states that it is painless and that the discharge is usually blood-tinged. She denies any history of malignancy in her family and states that she has been having regular periods since they first started at age 13. She does not have any children. The patient has normal vitals and denies any cough, fever. On exam, there are no palpable masses, and the patient does not have any erythema or induration. What is the most likely diagnosis? Tested Concept

QID: 104739
1

Fibrocystic changes

0%

(0/2)

2

Paget's disease

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(0/2)

3

Breast abscess

0%

(0/2)

4

Ductal carcinoma

0%

(0/2)

5

Intraductal papilloma

100%

(2/2)

M 6 D

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Evidence (1)
EXPERT COMMENTS (6)
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