[size=20px]A 17-year old female presents with bloody nipple discharge from the right breast. She has had the discharge intermittently for three months. She had no palpable breast masses on examination. She has Tanner Stage V breast development.

 

The next best step in the management of this patient with bloody nipple discharge is

 

A observation.

 

B ultrasonography.

 

C galactography.

 

D exfoliative cytology.

 

E selective duct excision.[/size]

B ultrasonography

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B

B

The correct answer

B ultrasonography.

 

For this patient, looking for a breast mass is the next step. For her age, an ultrasound is preferred over mammography since ultrasound may be more sensitive in picking up lesions in dense adolescent breasts. If a mass is not present, other modalities may be used to define ductal pathology. Galactography involves injection of ducts to identify ductal pathology; it is said to have a 20% false positive and 20% false negative rate. Exfoliative cytology has false positive results in three to four percent and a false negative rate of 30%. Fiberoptic ductoscopy is a modality that can visualize ducts; cytology can be performed on the effluent to rule out cancer.

 

Nipple discharge from the breast may be classified as pathologic, physiologic or galactorrhea. Physiologic nipple discharge is intermittent, usually serous and may be due to drugs such as estrogens. Galactorrhea may be due to hormonal imbalance such as hyperprolactinemia or hypothyroidism, drugs such as oral contraceptives, phenothiazines or tranquilizers. Galactorrhea and physiologic discharge are often bilateral and arise from multiple ducts. Pathologic nipple discharge may be caused by benign (e.g. papilloma, fibrocystic disease or duct ectasia) or malignant lesions.

 

In adults, bloody nipple discharge is often associated with three main causes: intraductal papilloma (35 to 48%), ductal ectasia (17 to 36%) and carcinoma (five to 21%). An intraductal papilloma is an epithelial growth within the duct. Ductal ectasia is dilation of the duct walls due to loss of elastin and is associated with an inflammatory infiltrate. Neither of these entities is associated with higher risk of breast cancer.

 

Bloody nipple discharge without a mass is associated with a three to six percent risk of breast cancer in adults; with an associated mass, the risk goes up ten-fold. When pathologic discharge is identified the source should be located. If there is an associated mass the mass should be biopsied. If no mass is found, either a terminal duct excision of the involved ducts or close observation can be offered. Close observation can be offered due to concerns about future breast feeding.