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 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 Studies Serum TSH, prolactin, hCG levels indications used to rule out galactorrhea in patients with non-bloody discharge 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 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 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