-: Let us learn how to help a lady
presenting with nipple discharge.
We dedicate this lecture to our great teacher,
Professor LE Hughes,
chief of Cardiff Breast Unit
at the University of Wales College of Medicine
who advanced our knowledge in this subject.
Nipple discharge is defined
as a spontaneous efflux of fluid from the nipple,
excluding physiological function
of milk discharge during puerperium and lactation.
It is an uncommon condition
with which a lady presents to a breast clinic.
95% of cases happen to be of benign etiology.
However, we should remember 4S,
that is if discharge is spontaneously occurring;
if it is serous or sanguinous,
that is blood related;
if it is emanating from single milk duct;
it is considered significant and pathological.
We should assess the entire mammary gland and axilla
as in any patient presenting with breast problem.
Please remember that 5 to 10% of all patients
may have a malignant cause for discharge.
The considerations to be given:
whether it is physiological
or due to some underlying pathology,
whether it is emanating from single duct
or from multiple ducts,
whether it is occurring unilaterally or from both nipples,
whether it is occurring spontaneously or only on pressure
or palpation of the mammary gland,
whether it is associated with an underlying inflammation
of the major milk ducts,
or if it is associated with a lump in the breast.
The types of nipple discharge are listed on this table.
A blood-related discharge can happen
due to hyperplastic condition of the milk duct
or a papilloma, duct ectasia.
Pregnancy may be associated with blood discharge,
and in pregnancy it is considered physiological.
Ductal carcinoma,
both invasive type as well as in situ DCIS,
can lead to blood-related discharge.
Serous or water discharge can occur
in patients with hyperplasia of the mammary duct,
epithelium duct hyperplasia, or duct ectasia.
A colored discharge is often seen
in patients with duct ectasia
or some patients with breast cysts.
Milk discharge is of course physiological during lactation;
however, it can be pathological
and then it is called galactorrhea.
Please remember galactorrhea is defined
as presence of copious amount of milk
emanating from multiple ducts bilaterally, spontaneously,
in a non-lactating lady.
Galactorrhea can be due to prolactin secreting lesions
either from the pituitary
or some ectopic secretion of prolactin hormone.
And number of drugs are listed
as the cause for increased prolactin secretion
and hence galactorrhea.
Drugs such as methyldopa, oral contraceptive pills,
and phenothiazines all can lead to galactorrhea.
Various types of discharges are shown on this slide.
Our left we have a lady presenting with blood discharge
from a single duct,
then we have clear discharge in the in the middle.
Toothpaste-like, creamy white discharge
is typically seen in patients with duct ectasia.
Serous discharge from, again, a single duct,
typical of a duct papilloma or ductal hyperplasia,
or sometimes ductal cancer,
is shown on this side.
And yellowish puss-like discharge
due to associated inflammation of the milk ducts,
a condition called periductal mastitis.
We should arrange the following investigations:
Triple assessment in the form of thorough clinical history
and examination,
followed by breast imaging;
and if a lesion is found,
its histological confirmation by a core biopsy.
High resolution ultrasound is recommended
to delineate any abnormality of the underlying ducts,
such as dilatation of the ducts deep to the areola,
which is often seen in as many as 75% of the lesions,
and it has very high accuracy
to the tune of 85% or more.
Mammography is recommended for patients presenting
above age 35.
MRI may be considered suitable
for patients who have blood discharge
and in whom there is no abnormality seen
on ultrasound or mammography.
Cytology of the nipple discharge
has low sensitivity to the tune of only 45 to 55%
and is currently not recommended.
Investigations such as ductography,
ductoscopy,
and fluorescence in situ hybridization
are all described in the literature
but have very little value in the management of a patient,
hence they are not routinely carried out.
The usefulness of nipple discharge cytology
to predict breast cancer was evaluated
in a recent meta-analysis.
Of 286 articles screened,
12 articles were selected
including information on 1,476 patients.
The meta-analysis results suggested
a pooled sensitivity of 63%,
which is significant statistically.
The specificity was 95%.
And a likelihood ratio for a positive result were 12.35,
indicating that the
possibility of breast cancer
is 12 times higher with an abnormal cytology
compared to not having breast cancer.
The likelihood ratio with a negative cytology
is very low, 0.39,
once again demonstrating the ability
of the negative cytology to rule out breast cancer.
The overall diagnostic odds ratio is 31.88,
which is very high with a statistically significant result.
So this meta-analysis suggests
that we should be evaluating psychological examination
of nipple discharge
in women presenting with blood or serous discharge
and get it evaluated by an experienced cytopathologist.
Management begins by identifying the underlying lesion.
For a patient presenting with galactorrhea:
try to eliminate any mechanical stimulation,
stop or change the medication
if that is the underlying cause,
measure the serum prolactin level;
and if it is elevated,
try to identify its source
in the form of in the form of pituitary lesion
by high resolution MRI or CT scan of the sella turcica.
Reassurance is helpful in majority of these patients.
A lady presenting with colored opalescent discharge, again,
needs to be reassured.
Major duct tech excision,
removing about an inch or 2.5 centimeter
of the major ducts till we find the dilated ducts,
may be helpful if patient has profuse discharge
which is socially embarrassing.
Treatment for patients with blood
or blood-related, serous,
or watery discharge
is undertaken in the form of microdochectomy
if blood is emanating from a single milk duct
or if lady is young, below age 35.
And major milk duct tech season, again,
removing a segment of five centimeter of major ducts
if she's above 35 and has completed her family.
An ultrasound guided mammotome excision
can also be performed in selective patients.
If you're not sure about the bloody nature
of the discharge,
you apply a white gauze piece
and then look at the colour,
that it changes to dark brown Coca-Cola colour
that is typically seen
in patients who present with blood discharge.
Blood discharge or blood-related discharges
are often seen in patients
who have hyperplastic ductal epithelium
in the form of either a solitary duct papilloma
or sometimes multiple papillomas;
ductal carcinoma,
which could both be in situ two or invasive cancers;
and sometimes in patient who have dilatation of the duct,
a condition called duct ectasia.
Risk of cancer in patient presenting with blood discharge
is directly related to the age of the patient.
So in patients below the age of 40,
the risk is indeed very low in the tune of about 3%.
When we come to age group of 40 to 60 years of age,
we find that about 10% of all blood discharges
can be related to cancer.
And in patients above age 60,
about 30 to 32% of patients may have underlying cancer.
Let us talk a bit about common conditions.
Intraduct papilloma,
which is the commonest cause
of blood related discharge in a lady.
It's a benign tumor arising from the epithelium
of the mammary ducts.
It has a typical stock and a fibrovascular core
covered by papillary epithelium.
And as the papilloma grows,
it's stock may undergo torsion and may break,
and this may lead to blood discharge from the nipple.
On operation we find papilloma
looking with a papillary surface
in the major milk duct under the nipple.
And on a histological examination,
we find fibrovascular core covered by papillary epithelium.
On operation of the major milk ducts,
we find a papilloma with a dilated duct
as shown in this area.
Histopathological examination reveals epithelial fronds
supported by a fibrovascular stroma,
and there can be multiple papillomata
present along a milk duct.
The term papillomatosis is applied
for presence of five or more
clearly separated papillomata
in single or multiple milk ducts.
These lesions are associated
with an increased probability of bilaterality,
presence of peripheral location of lesions,
palpable lesions,
and increased risk of cancer conversion
with the relative risk of about three.
A unique type of papillomatosis
is described in young girls, called juvenile papillomatosis,
also called Swiss cheese disease of the breast.
This occurs in young girls,
with the mean age of presentation being 23 years.
Lesions can be multiple, often palpable,
in upper outer quadrant.
There is family history of breast cancer
in a large majority of these ladies.
And microscopically they comprise multiple papillomata
with or without presence of atypia,
apocrine cysts, sclerosing adenosis,
and extensive ductal hyperplasia.
There is increased risk of recurrence
of these lesions after surgery
and increased risk of cancer conversion
in about 10% of ladies.
The treatment comprises excision of the lesion
and regular follow up.
The management of patient
presenting with blood-related discharge
is presented on this slide.
Below the age of 30,
a thorough clinical examination
followed by cytology of the discharge
and imaging by ultrasound may suffice
as most of these patients
happen to be benign causes of blood discharge.
However, in age group above 30 one has to be more careful
and choose to do microdochectomy,
removing a segment of about five centimeter
of the milk duct from the nipple.
So the management principles are as follows:
If a lady is between age 30 and 45 years
surgery is recommended
if there is family history of breast or ovarian cancer,
if she's very much worried,
or if there is nipple retraction.
In women above the age of 45,
where cancer risk is certainly high,
we should carry out a major mammary duct excision,
removing a five centimeter segment
of major milk ducts from the nipple
or till we find dilated ducts,
because this operation proves to be both diagnostic
or therapeutic,
it is also able to detect a condition called
multiple papillomatosis which is a risk factor for cancer.
In women who present with non-bloody nipple discharge,
especially if it is purulent, toothpaste-like,
or coloured discharge,
we need to appreciate two important causes,
that is periductal mastitis and duct ectasia.
We should send the pus,
either from the ducts
or from underlying subareolar abscess,
for culturing both aerobic as well as anaerobic bacteria.
Cytology of the discharge can also be obtained.
Imaging of the major milk ducts
with high resolution ultrasound is very helpful
in delineating the underlying pathology.
Antibiotics are recommended
in the form of either erythromycin
with tinidazole
or metronidazole
because there is a mixed flora
of staphylococcus and anaerobic bacteria
like fusobacteria and bacteroides.
If there is a subareolar abscess,
you should aspirate the pus
and send it for culture and sensitivity.
Limited drainage should be undertaken.
And once the inflammation has subsided,
after two to three weeks of antibiotic course,
we can then carry out a major milk duct excision.
Duct ectasia and periodically mastitis complex
were first described by Haagensen
who gave the name duct ectasia
for a condition where there was dilatation of the ducts.
It is often associated with inflammation around the ducts,
a condition called periductal mastitis
which is often associated with fibrosis
around the major ducts.
It is often bilateral.
The age group of presentation for duct ectasia
is between age 40 to 60,
whereas periductal mastitis presents in younger age group
between 18 to 48 years of age.
Presenting features can be thick, creamy,
or rarely bloody discharge from the nipple,
non-cyclical mastalgia
mostly confined to the areola
and central part of the breast.
Patient may have recurrent episodes
of subareolar abscess or sepsis.
Sometimes an abscess bursts at the edge of the areola,
resulting in milk duct fistula
or mammary duct fistula.
Due to fibrosis of the ducts and surrounding tissue,
the nipple undergoes retraction.
And there can be eczema of the nipple-areola complex.
Smoking has been considered an important risk factor,
especially in Western women.
Obesity,
diabetes,
nipple piercing,
and people of Black race
all have been listed as risk factor
for duct ectasia and periductal mastitis.
Its pathogenesis is relatively poorly understood; however,
it is thought that there is dilatation of the duct
due to loss of elastic tissue around the ducts
either due to hormonal changes
or due to obstruction of the duct
or due to some inflammation and fibrosis.
There's a theory that there is keratin plug
and squamous debris collects inside the duct,
leading to duct dilatation.
Duct ectasia typically presents
with toothpaste-like material coming from the discharge.
On histological examination you find a dilated duct
with very little inflammation around it.
Under high resolution ultrasound
we identify a dilated duct
which is more than three millimeter in diameter across.
Periductal mastitis is thought to be autoimmune in nature,
resulting in chronic inflammation
and deposition of mononuclear lymphocytes
and plasma cells around the milk ducts,
resulting in inflammation.
Sometimes bacterial infection,
super veins and subareolar abscess
or inflammatory mass forms.
The abcess may burst open,
resulting in mammary duct fistula.
The age group of presentation is relatively young,
between age 18 to 48 years.
Patient will present with typical purulent nipple discharge
and a fish mouth-like retraction.
This is transfer slit-like retraction
or fish mouth retraction as it is often called.
Incidentally this lady had an episode of subareolar abscess
which burst open at this point,
resulting in milk duct or mammary duct fistula.
Under the microscope you find inflammatory changes
and fibrosis around the ducts.
On higher power we identify these mononuclear lymphocytes
and plasma cells,
hence another name for this disease is plasma cell mastitis.
The management consists of aspiration of any pus
if present under ultrasound guidance,
and send the fluid for culture and sensitivity examination.
If there is suspicion of tuberculosis,
as in Asian community,
one cause of non-lactation mastitis is tubercular mastitis,
so we should also send this plus fluid for GeneXpert.
Antibiotics are commenced
in the form of anti-staphylococcal antibiotic,
along with anti-anaerobic cover
with metronidazole or tinidazole for two to three weeks.
If ladies are smoking,
encourage her to stop smoking.
Surgical treatment is then offered
two to three weeks later
after subsidence of acute inflammatory features,
which is in the form of a milk duct excision
which is indicated if there is profuse nipple discharge,
blood related discharge,
recurrent subareolar abscess,
persistent mammary duct fistula,
and correction of any nipple retraction.
In patient like this,
where there was a milk duct fistula,
we also performed removal of the fistulous tract
in the form of fistulectomy.
So the operation of major memory duct excision
was first described by John Hadfield in 1960,
which consists of removal of three to five centimeter
of the major ducts from the nipple.
So we remove a segment of three to five centimeter
of the major ducts,
which are shown here as blue ducts.
Its indication is listed on this slide:
blood-related discharge,
duct ectasia,
or copious non-bloody discharge
and periductal mastitis.
Initially Dr. John Hadfield
had suggested that we should remove
about one to one and half inch of the major ducts.
However later authors like Dixon
have suggested removal of a smaller segment
of only one to two centimeter of the ductal cone
because the inflammation is confined
only to the terminal part of the ducts
and not in deeper part of the duct.
For patients presenting with blood discharge,
we should remove a segment
of five centimeter length from the nipple
because papillomas are often located
up to five centimeter from the nipple.
The operation can be carried out under local anesthesia
or general anesthesia.
A circumareolar incision for 1/3 to 1/4 width
of the areola circumference is made.
And ductal cone is dissected
without raising an areola flap.
So we dissect the major ducts, shown here,
with the right angle forceps,
and then clamps are applied,
like towel clip cross clamps,
to dissect the major ductal system
which is then dissected off and removed.
The nipple end of the ductal cone is marked by a suture
to orient the specimen for the pathologist.
Any terminal part of the lactiferous sinuses
are then paired carefully by dissecting scissor
by inverting the areola.
The incision is closed
with a running continuous absorbable monofilament
subcuticular suture with a suction drain.
And this is the cosmetic appearance
seen about six months from the operation.
Microdochectomy is recommended
for women presenting with single duct discharge,
such as this young lady
presented with pus discharge coming from the single duct,
and she also had recurrent attacks
of subareolar abscess formation.
So we identified the dilated duct with a fine cannula,
injected a drop of methylene blue
to delineate this duct,
and then dissected this duct.
You can see the blue cannula
and the blue stained milk duct
which was dissected up to length of five centimeter
and then removed along with this.
The wound is then closed
with a running subcuticular absorbable suture
such as 4-0 MONOCRYL poliglecaprone suture.
And this is the final cosmetic appearance.
about six months from the operation.
The complications of milk duct excision
are listed on this slide.
They occur due to denervation or devascularization
of the nipple-areola complex,
presenting in the form of necrosis of the nipple
or nipple-areola complex and loss of nipple sensation.
And for obvious reasons,
the lady has inability to breastfeed
as the milk ducts are severed.
Some patients may suffer
from late re-retraction of the nipple
even after correction of the retraction deformity
during operation.
Some patients keep suffering
from recurrent episodes of subareolar sepsis
due to presence of a residual milk duct
or part of an abscess cavity wall.
In summary,
nipple discharge is often physiological
due to pregnancy or breastfeeding,
and it can continue for many years
after cessation of the breastfeeding.
However, some patients may present
with pathological discharge due to papilloma,
duct ectasia or periductal mastitis.
And rarely,
ductal carcinoma can be a cause of the discharge.
The final messages:
Triple assessment should be carried out
to rule out underlying cancer.
Microdochectomy is recommended
for single duct discharge.
And major duct excision is recommended
for patients presenting with multiple ductal discharge
or who have blood or serous discharge.
Thank you.