What is the workup for a small white bleb (blister) on the nipple of an 81-year-old male with tenderness but no discharge or palpable mass?

Workup for Small White Bleb on Nipple in 81-Year-Old Male

This 81-year-old male with a nipple bleb and tenderness requires urgent diagnostic mammography and ultrasound given the extremely high malignancy risk (23-57%) associated with any nipple abnormality in men, regardless of the absence of discharge or palpable mass. 1, 2

Critical Risk Stratification

The combination of male sex and age >60 years places this patient in an exceptionally high-risk category:

• Male patients with nipple discharge or nipple abnormalities have a 23-57% incidence of breast cancer 1, 2
• Patients over age 60 with pathologic nipple findings have a 32% cancer risk 1, 2
• The absence of discharge does NOT lower suspicion—imaging is warranted for any persistent unilateral nipple lesion 3

Immediate Imaging Algorithm

First-Line: Diagnostic Mammography

• Mammography should be the initial imaging study for male patients with nipple abnormalities 1
• Sensitivity ranges 15-68% for detecting malignancy, but remains essential for identifying suspicious microcalcifications associated with DCIS 1, 2
• Additional spot compression and magnification views of the subareolar region should be obtained if asymmetry or microcalcifications are detected 1

Complementary: Targeted Ultrasound

• Ultrasound is as useful in male patients as in female patients for identifying and localizing lesions 1
• Should be performed in conjunction with mammography to assist in diagnosis and provide guidance for potential biopsy 1
• Sensitivity of 63-100% for detecting intraductal lesions 2

Tissue Diagnosis Pathway

If Imaging Shows Suspicious Findings (BI-RADS 4 or 5):

• Image-guided core needle biopsy is preferred over fine needle aspiration for definitive pathologic assessment 2
• Ultrasound guidance can localize and direct biopsy of image-detected lesions 1

If Imaging is Negative (BI-RADS 1-3) but Clinical Concern Persists:

• Consider breast MRI with and without IV contrast, which has 86-100% sensitivity for detecting causes of nipple abnormalities 2
• Given the high malignancy risk in elderly males, a low threshold for tissue sampling should be maintained even with negative conventional imaging 1

Important Clinical Caveats

The white bleb appearance does not exclude malignancy—persistent unilateral nipple lesions warrant tissue sampling to exclude Paget's disease of the nipple, a rare form of DCIS that can present with nipple erosion, erythema, or other surface changes 3

Do not delay imaging based on the benign appearance of the lesion or absence of discharge—the one-month duration of tenderness indicates a persistent process requiring investigation 3

Avoid the pitfall of observation alone in this demographic—while observation might be appropriate in younger women with certain findings, the combination of male sex and advanced age mandates aggressive workup 1