What is the best course of treatment for a 59-year-old female patient with a history of breast mass and recent onset of bloody nipple discharge, hypertension, and bronchial asthma?

Surgical Excision with Microdochectomy and Wide Excision is Appropriate for This Patient

Given the BI-RADS 4A classification with a palpable retroareolar mass and bloody nipple discharge, the planned surgical approach of microdochectomy with wide excision is the correct management strategy, as this provides both definitive diagnosis and treatment while addressing the 10-32% malignancy risk in this age group with pathologic discharge. 1, 2

Rationale for Surgical Management

Why Surgery is Indicated

• BI-RADS 4A lesions require tissue diagnosis, and the presence of a palpable mass significantly increases malignancy risk from 6.1% to 61.5% 1, 2
• The patient has pathologic nipple discharge (spontaneous, unilateral, single-duct, bloody), which carries a 10% malignancy risk at age 59, increasing to 32% after age 60 1, 2
• Imaging has already been completed (mammogram and ultrasound showing mixed solid-cystic mass with dilated retroareolar ducts), fulfilling the standard diagnostic algorithm 3
• The combination of palpable mass + bloody discharge + BI-RADS 4A classification makes this a high-suspicion scenario requiring definitive surgical management 3

Surgical Approach Details

• Microdochectomy addresses the pathologic nipple discharge by excising the affected duct system, which is both diagnostic and therapeutic 3, 4
• Wide excision of the palpable mass ensures adequate tissue sampling for the BI-RADS 4A lesion, which has moderate suspicion for malignancy (5-10% risk) 3
• This combined approach is superior to core needle biopsy alone because papillomas (the most common cause at 35-48%) often require excision anyway due to 3-14% upgrade rates to malignancy 3, 1

Critical Considerations for This Specific Patient

Prior Surgical History Matters

• The patient had previous excision revealing trichoepithelioma and lipoma, but the current presentation is different (bloody discharge, new palpable mass, BI-RADS 4A) [@patient history@]
• Loss to follow-up for 2 years means interval development of pathology cannot be excluded [@patient history@]
• The dilated retroareolar ducts seen on current imaging were noted previously but now associated with bloody discharge, suggesting new intraductal pathology [@patient history@]

Perioperative Management

• Ampicillin-sulbactam prophylaxis is appropriate given the patient's penicillin allergy history (allergic to azithromycin, not beta-lactams) [@patient history@]
• Omeprazole for stress ulcer prophylaxis is reasonable perioperatively [@patient history@]
• Blood pressure control (currently 136/74 on amlodipine 5mg) should be optimized preoperatively given Stage II hypertension diagnosis [@patient history@]
• Bronchial asthma (not in acute exacerbation) requires continuation of maintenance therapy and anesthesia awareness [@patient history@]

What Happens After Surgery

If Benign Pathology

• Most likely findings are intraductal papilloma (35-48%) or duct ectasia (17-36%) 1, 2, 5
• If papilloma without atypia and imaging-concordant, no further surgery needed 3
• Resume routine screening mammography at appropriate intervals 3

If High-Risk or Malignant Pathology

• Atypical hyperplasia, LCIS, or papilloma with atypia requires re-excision to negative margins due to 3-14% upgrade risk 3
• DCIS or invasive carcinoma (5-21% risk overall, higher with palpable mass) requires management per breast cancer guidelines with oncology referral 3, 2
• The family history of breast cancer increases surveillance importance regardless of benign findings [@patient history@]

Common Pitfalls to Avoid

• Do not delay surgery for additional imaging (MRI, ductography) when BI-RADS 4A lesion is already identified—tissue diagnosis is required 3, 2
• Do not perform core needle biopsy alone for this presentation, as papillary lesions have high underestimation rates (50% for high-risk lesions) and surgical excision is often needed anyway 3
• Do not dismiss the bloody discharge as benign despite previous benign pathology—this is a new symptom requiring full evaluation 1, 2
• Major duct excision remains the gold standard when pathologic discharge persists, as negative imaging does not reliably exclude malignancy 3