Review Question - QID 103458

Patients with unilateral nipple discharge should be screened for breast cancer with a mammogram.

Spontaneous, unilateral nipple discharge, especially if guaiac positive or grossly bloody, is suspicious for breast cancer. Mammography is therefore indicated, with follow up as necessary using fine needle aspiration or open breast biopsy.

Salzman et al. review common breast problems: "Most women presenting with a breast mass will require imaging and further workup to exclude cancer. Diagnostic mammography is usually the imaging study of choice, but ultrasonography is more sensitive in women younger than 30 years. Any suspicious mass that is detected on physical examination, mammography, or ultrasonography should be biopsied. Biopsy options include fine-needle aspiration, core needle biopsy, and excisional biopsy."

Chen et al., in a meta-analysis of 3110 patients, found that the color of nipple discharge is associated with the presence or absence of malignancy. In particular, bloody discharge is associated with the presence of malignancy.

Illustration A shows spontaneous bloody nipple discharge.

Incorrect Answers:
Answer 1: Pain and erythema in one breast associated with breast feeding is consistent with mastitis. Patients with mastitis are treated with hot compresses and antibiotics that cover for S. aureus. They should continue breast feeding during treatment.
Answer 3: Discharge from both breasts is more suspicious for an endocrine abnormality or, in a younger woman, pregnancy. An endocrine workup is indicated for this patient.
Answer 4: Screening mammograms are recommended every 2 years in women age 50-74.
Answer 5: Controversy exists regarding mammography for women in their 40s. Although a history of breast cancer in first-degree relatives (parents, siblings, children) favors mammography at an earlier age, this patient's grandmother's death from breast cancer does not constitute a strong family history.