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

Workup for Breast Pain with Warm Lump and Nipple Discharge

A patient presenting with breast pain, a warm lump, and nipple discharge requires immediate diagnostic imaging with mammography (or digital breast tomosynthesis) and ultrasound, followed by possible biopsy due to the high risk of malignancy with this combination of symptoms. 1

Initial Assessment

Characterize the Nipple Discharge

• Determine if pathologic (concerning) or physiologic:
  • Pathologic: spontaneous, unilateral, single-duct, serous or bloody 1, 2
  • Physiologic: provoked, bilateral, multiple-duct, white/green/yellow 1, 2

Evaluate the Lump and Pain

• Warm lump suggests possible infection (mastitis/abscess) or inflammatory cancer
• Focal breast pain with a palpable mass significantly increases malignancy risk
• The combination of a palpable mass with nipple discharge raises malignancy risk to 61.5% 1

Diagnostic Imaging Algorithm

1. Diagnostic Mammography and Ultrasound (first-line imaging for all ages)

   • For patients ≥30 years: Diagnostic mammography with possible digital breast tomosynthesis (DBT) AND ultrasound 1
   • For patients <30 years: Ultrasound may be used as initial imaging, followed by mammography if indicated 1, 3
   • Use special techniques for retroareolar imaging:
     • Standoff pad or abundant warm gel
     • Peripheral compression and rolled-nipple techniques 1

2. If Initial Imaging Negative but Symptoms Persist:

   • MRI of breast (higher sensitivity than ductography)
     • MRI detects underlying causes in 19-96% of cases when mammography and ultrasound are negative 1
     • Most common MRI finding is non-mass enhancement 3
   • OR Ductography/Galactography (if available)
     • Particularly useful for localizing intraductal lesions 1

3. Biopsy of Any Identified Lesion:

   • Core needle biopsy for solid masses
   • Fine-needle aspiration for cystic lesions
   • Excisional biopsy if other methods inconclusive 4

Special Considerations

Infection vs. Malignancy

• The warm lump requires urgent differentiation between:
  • Infectious process (mastitis/abscess) - may require antibiotics and possible drainage
  • Inflammatory breast cancer - requires prompt biopsy

Male Patients

• Nipple discharge in males has a much higher association with malignancy (57% vs 16% in females) 1
• More aggressive workup warranted even with minimal symptoms

Common Pitfalls to Avoid

• Don't dismiss symptoms as "just mastitis" without appropriate imaging
• Don't delay imaging when multiple concerning features are present (warm lump + discharge)
• Don't rely on clinical exam alone - sensitivity for detecting malignancy is limited 1
• Don't assume benign etiology even with non-bloody discharge - 5-21% of pathologic discharge cases reveal malignancy 1, 5

The combination of breast pain, warm lump, and nipple discharge represents a concerning clinical presentation that warrants thorough and prompt evaluation to exclude malignancy, particularly inflammatory breast cancer which can present with these exact symptoms.