What are the implications of a persistent lump on the areola (area around the nipple) that has remained unchanged in size for 3 years?

Evaluation of a Persistent Nipple Lump Present for 3 Years

A lump on the nipple that has remained stable and unchanged for 3 years is most likely benign, but requires imaging evaluation with ultrasound (and diagnostic mammography if age ≥30 years) to definitively characterize the lesion and exclude malignancy. 1

Initial Assessment Approach

The 3-year stability without change is reassuring but does not eliminate the need for diagnostic evaluation, as certain benign lesions (syringomatous adenoma, papillomas) and even some slow-growing malignancies can present as persistent nipple masses. 2, 3

Age-Based Imaging Algorithm

For patients younger than 30 years:

• Proceed directly to targeted ultrasound of the nipple-areolar complex as the initial imaging study 1
• Diagnostic mammography is only considered in select situations for this age group 1

For patients 30 years of age or older:

• Obtain both diagnostic mammography and targeted ultrasound of the nipple-areolar complex 1
• The combination provides optimal evaluation for both calcifications and soft tissue abnormalities 1

Differential Diagnosis Considerations

The nipple-areolar complex can harbor several distinct pathologic entities that require differentiation:

Benign lesions that may present as persistent nipple lumps include:

• Syringomatous adenoma (locally infiltrating but benign, often mimics malignancy on imaging) 2
• Intraductal papilloma (most common cause of nipple masses) 3
• Nipple adenomas 3
• Leiomyomas 3

Malignant considerations:

• Paget's disease of the nipple (found in >80% of cases presenting with persistent nipple lesions, often with underlying DCIS or invasive cancer) 4, 5
• Primary breast carcinoma extending to the nipple 3
• Rarely, malignant melanoma (though typically presents with color changes and ulceration) 6

Management Based on Imaging Results

If ultrasound shows a simple cyst (BI-RADS 2):

• Aspiration can be performed if symptomatic 1
• If blood-free fluid is obtained and mass resolves, monitor for recurrence 1
• Return to routine screening if no recurrence 1

If ultrasound shows a solid mass or complex cyst (BI-RADS 4):

• Image-guided core needle biopsy is required for tissue diagnosis 1
• Do not rely on fine needle aspiration alone, as core biopsy provides architectural information crucial for distinguishing benign from malignant lesions 2

If imaging is benign and concordant with clinical findings:

• Follow-up with physical examination with or without imaging every 6-12 months for 1-2 years 1
• If the mass remains stable throughout this period, return to routine screening 1
• If the mass increases in size at any point, repeat tissue sampling 1

If no abnormality is detected on imaging (BI-RADS 1) but palpable finding persists:

• Consider tissue biopsy (core needle or excisional) or observation at 3-6 month intervals with or without imaging for 1-2 years 1
• The 3-year stability in this case makes observation reasonable, but tissue diagnosis may be preferred for definitive reassurance 1

Critical Pitfalls to Avoid

Do not assume stability equals benignity without imaging confirmation. Syringomatous adenoma, a benign but locally infiltrating lesion, often presents with imaging findings suspicious for malignancy and requires histologic diagnosis to distinguish from tubular carcinoma. 2

Do not dismiss persistent nipple lesions based on duration alone. Paget's disease can present as a chronic, persistent nipple lesion and is associated with underlying breast cancer in over 80% of cases. 4, 5

Ensure image-pathology concordance. If biopsy results are benign but image-discordant or show atypical hyperplasia, LCIS, papillary lesions, or radial scars, surgical excision is recommended. 1

When Surgical Excision Is Indicated

Surgical excision should be performed if:

• Core biopsy shows atypical hyperplasia, LCIS, papillary lesions, or other high-risk pathology 1
• Biopsy results are benign but discordant with imaging findings 1
• Clinical suspicion remains high despite benign imaging and biopsy 1
• The lesion demonstrates growth on follow-up imaging 1