What is the workup for a patient presenting with breast pain and nipple discharge?

Workup for Breast Pain and Nipple Discharge

The standard workup for breast pain and nipple discharge should begin with determining if the discharge is pathologic or physiologic, followed by age-appropriate imaging with mammography and ultrasound for patients over 30 years, or ultrasound alone for those under 30 years. 1

Initial Assessment

Characterizing Nipple Discharge

First, determine if the discharge is pathologic or physiologic:

• Pathologic discharge (requires further investigation):

  • Unilateral
  • Spontaneous (occurs without breast manipulation)
  • From a single duct orifice
  • Bloody or serous
  • Associated with a palpable mass 1, 2

• Physiologic discharge (generally benign):

  • Bilateral
  • From multiple duct orifices
  • Requires manipulation to express
  • White, green, or yellow in color
  • Not associated with a mass 1

Characterizing Breast Pain

Determine if the breast pain is:

• Focal: Localized to a specific area
• Diffuse/Cyclic: Affecting the entire breast, often related to hormonal cycles 1

Diagnostic Algorithm

For Patients ≥30 Years:

1. Diagnostic mammography with or without ultrasound as the initial imaging study 1

   • For focal breast pain
   • For all cases of pathologic nipple discharge

2. Ultrasound of the retroareolar region

   • Special techniques may be needed: standoff pad, abundant warm gel, peripheral compression, 2-hand compression, and rolled-nipple techniques 1

3. Further imaging based on BI-RADS assessment:

   • BI-RADS 1-3: Punch biopsy of nipple/skin if discharge is pathologic 1
   • BI-RADS 4-5: Core needle biopsy of identified lesion 1

4. If mammogram and ultrasound are negative but pathologic discharge persists:

   • Consider ductography or breast MRI 1, 3
   • MRI has higher positive and negative predictive values than ductography for detecting high-risk lesions and cancers 1

For Patients <30 Years:

1. Ultrasound as the initial imaging study 1

   • Can be used alone for focal breast pain and nipple discharge evaluation

2. Further management based on ultrasound findings:

   • Simple cyst: Consider drainage for symptom relief 1
   • Complicated cyst: Follow-up imaging every 6 months for 1-2 years 1
   • Suspicious finding: Core needle biopsy 1

Management Based on Findings

For Physiologic Nipple Discharge:

• Reassurance if screening mammogram is current and negative 1
• If galactorrhea is present (milky discharge not associated with pregnancy/lactation), check prolactin and thyroid-stimulating hormone levels 2

For Diffuse/Cyclic Breast Pain with Normal Imaging:

• Reassurance and symptomatic management:
  • Over-the-counter pain medications
  • Supportive bra
  • Ice packs or heating pads 1
  • Consider dietary and lifestyle changes 4

For Pathologic Nipple Discharge:

• Surgical referral if discharge is bloody, spontaneous, unilateral, or associated with a mass 2
• Intraductal papilloma (most common cause, 35-48% of cases) and duct ectasia (17-36%) are the most likely benign causes 1
• Risk of malignancy is 5-21% in patients with pathologic discharge who undergo biopsy 1

Special Considerations

Male Patients with Nipple Discharge:

• Higher risk of malignancy (23-57%) compared to females (16%) 1
• Mammography or digital breast tomosynthesis should be performed as the initial study in men >25 years old 1

Age-Related Risk:

• Malignancy risk increases with age: 3% in patients ≤40 years, 10% in patients 40-60 years, and 32% in those >60 years 1

Common Pitfalls to Avoid:

1. Dismissing pathologic discharge as benign without proper workup
2. Failing to perform imaging in patients with focal breast pain or pathologic discharge
3. Not recognizing that normal imaging does not exclude pathology in cases of persistent pathologic discharge
4. Overlooking male nipple discharge, which carries a significantly higher risk of malignancy

Remember that while breast pain alone rarely indicates cancer (1.2-6.7% risk), pathologic nipple discharge carries a higher risk of malignancy and requires thorough evaluation 1, 5.