What is the appropriate evaluation and management of a patient with a nipple lump and white, creamy, foul-smelling discharge?

Evaluation and Management of Nipple Lump with White Creamy Foul-Smelling Discharge

This presentation requires immediate diagnostic imaging with mammography and ultrasound to exclude malignancy, as pathologic nipple discharge carries a 5-21% risk of underlying cancer, with the presence of a palpable lump significantly increasing this risk to potentially 61.5%. 1

Initial Risk Stratification

The characteristics of this discharge are concerning and warrant urgent evaluation:

• White creamy discharge with foul odor suggests infection (abscess/mastitis) or duct ectasia, but malignancy must be excluded first 2, 3
• The presence of a palpable nipple lump dramatically elevates cancer risk - one study showed 61.5% malignancy rate when discharge accompanies a palpable finding versus 6.1% with discharge alone 1
• Foul-smelling discharge specifically suggests purulent material from an abscess, which requires drainage and biopsy of the abscess wall 2

Critical Gender Consideration

If this patient is male, the malignancy risk is extraordinarily high at 57%, compared to 16% in females - male nipple discharge warrants even more aggressive evaluation 1

Mandatory Diagnostic Workup

Immediate Imaging (Age-Dependent)

For patients ≥40 years:

• Diagnostic mammography is the mandatory first imaging step 1
• Ultrasound of the retroareolar region must follow, using standoff pad or abundant gel to eliminate acoustic shadows around the nipple 1

For patients 30-39 years:

• Either mammography or ultrasound may be used initially, as ultrasound sensitivity exceeds mammography in this age group 1
• Both modalities should ultimately be performed given the palpable lump 1

For patients <30 years:

• Ultrasound should be the initial imaging modality due to dense breast tissue limiting mammography sensitivity 4

Advanced Imaging if Initial Studies Negative

If mammography and ultrasound are negative but clinical suspicion remains high (due to the palpable lump):

• Breast MRI is preferred over ductography, with superior positive and negative predictive values (detects underlying causes in 19-96% of cases when conventional imaging is negative) 1, 5
• MRI can identify posterior lesions >3 cm from the nipple that ductography misses 1

Tissue Diagnosis Strategy

When imaging identifies a suspicious lesion:

• Image-guided core needle biopsy is superior to fine needle aspiration for definitive diagnosis 1
• Core biopsy provides adequate tissue for histologic diagnosis and guides management 1

If imaging is negative but clinical suspicion remains high (palpable lump + discharge):

• Major duct excision remains the gold standard to exclude malignancy, as negative imaging does not reliably exclude cancer 1
• This is particularly important because up to 20% of lesions causing pathologic discharge are >3 cm beyond the nipple and may be missed by imaging 1

Management of Suspected Abscess

If purulent discharge with foul odor suggests abscess:

• Drainage is required immediately 2
• Biopsy of the abscess wall is mandatory to exclude inflammatory carcinoma or underlying malignancy 2

Age-Specific Malignancy Risk

The cancer risk stratifies by age:

• <40 years: 3-10.5% malignancy risk 1
• 40-60 years: 10% malignancy risk 1
• >60 years: 32% malignancy risk 1

Common Pitfalls to Avoid

• Never dismiss white/creamy discharge as purely physiologic when accompanied by a palpable lump - physiologic discharge is bilateral, multi-duct, and non-spontaneous without masses 4, 6
• Do not rely on cytology alone - 11.9% of cancers had negative cytology in one series 2
• Do not assume negative mammography excludes cancer - 10.4% of cancers had negative mammograms 2
• Avoid vacuum-assisted stereotactic biopsy for duct abnormalities - 50% underestimation rate for high-risk lesions and 7% false-negative rate 1

Definitive Surgical Approach

For persistent pathologic discharge with negative comprehensive imaging:

• Complete central duct excision is recommended except in women <30 years or those desiring future breastfeeding 2
• This provides both diagnosis and treatment in a single procedure 7