What is the workup for a male patient with unilateral nipple crusting?

Workup for Male Unilateral Nipple Crusting

Male unilateral nipple crusting requires immediate and thorough evaluation due to the high risk of underlying malignancy (23-57%), with diagnostic mammography, ultrasound, and tissue biopsy forming the cornerstone of the diagnostic algorithm. 1

Initial Assessment

• Clinical Evaluation:

  • Document duration, associated symptoms (pain, discharge, pruritus)
  • Note any palpable mass, nipple inversion, or skin changes
  • Assess for lymphadenopathy (axillary, supraclavicular)
  • Evaluate for systemic symptoms (weight loss, fatigue)

• Red Flag: Male nipple discharge or crusting carries a significantly higher risk of malignancy compared to females, with studies showing cancer rates of 57% in males presenting with nipple discharge 1, 2

Diagnostic Algorithm

Step 1: Imaging

• Diagnostic mammography with ultrasound should be performed as first-line imaging regardless of age 3
  • Ultrasound can detect underlying masses, ductal abnormalities, and vascular patterns
  • Mammography can identify microcalcifications and architectural distortion

Step 2: Tissue Sampling

• Core needle biopsy is preferred over fine-needle aspiration for solid lesions 3

  • Placement of a tissue marker allows for subsequent localization if needed
  • CNB provides better histological assessment than FNA 3

• Direct nipple biopsy should be performed if no underlying lesion is identified on imaging but crusting persists

  • Critical for differentiating between:
    • Paget's disease (malignant)
    • Erosive adenomatosis (benign)
    • Nipple eczema
    • Other dermatological conditions

Step 3: Additional Imaging (if initial workup is negative)

• MRI should be considered if mammography and ultrasound are negative but clinical suspicion remains high 3
  • MRI has high sensitivity (86-100%) for detecting invasive cancer 3
  • Note: No specific literature exists on MRI use in male nipple discharge, but principles from female evaluation can be applied 3

Differential Diagnosis

Malignant Conditions

• Paget's disease of the nipple

  • Presents with unilateral nipple erosion, discharge, and pain 4
  • Ultrasound may show abundant blood flow and microcalcifications 4
  • May be associated with underlying DCIS or invasive carcinoma 2

• Ductal carcinoma in situ (DCIS)

  • Can present with nipple discharge alone 2
  • May progress to invasive disease if not treated promptly

• Invasive breast carcinoma

  • Often presents with both nipple discharge and a palpable mass 2
  • Delayed presentation associated with higher rates of node-positive disease 2

Benign Conditions

• Nipple adenoma

  • Can present with erosion, discharge, or palpable nodule 4
  • Ultrasound shows regular-shaped nodule with clear borders and blood flow 4

• Leiomyoma

  • Rare benign tumor presenting as nipple enlargement and pain 4, 5
  • Ultrasound shows regular nodule with absent blood flow 4
  • May cause pruritus 5

• Erosive adenomatosis

  • Can mimic Paget's disease clinically 6
  • Presents with erythema, crusting, and hardening of the nipple 6

Clinical Pearls and Pitfalls

• Do not dismiss male nipple crusting or discharge as benign without thorough evaluation 1

  • Studies show 57% of males with nipple discharge have underlying malignancy 2

• Time is critical - Delays in diagnosis are associated with higher rates of node-positive disease 2

  • Median interval between onset of symptoms and presentation was 16 weeks for patients with invasive disease and palpable mass 2

• Absence of a palpable mass does not rule out malignancy

  • DCIS can present with nipple discharge alone 2
  • Early presentation with nipple symptoms may represent a window for early diagnosis 2

• Consider age in your assessment

  • While rare, Paget's disease can occur in younger patients 7
  • The risk of malignancy increases with age

By following this systematic approach to male unilateral nipple crusting, clinicians can ensure timely diagnosis and treatment, potentially improving outcomes for patients with underlying malignancy.