r www.ijpm.i The reported ve in early stage. stage. in early ve [2] invasi - ND may be physiological or or be physiological ND may [1] awareness, breast , cytology, nipple nipple cytology, cancer, breast awareness, Breast A majority of who manifest patients with International Journal of Preventive Medicine, Vol 3, No 11, November 2012 3, No 11, Vol International Journal of Preventive Medicine, [3,4] (ND) is common, accounting for 5% ofNipple discharge www.mui.ac.ir all breast related symptoms. incidence ofincidence to 7 between is ND in pathological carcinoma breast 15%. pathological (abnormal). Physiological discharge is usually is usually discharge pathological (abnormal). Physiological The common causes bilateral, emanating from many ducts. pituitary lactation, hypothyroidism, include pregnancy, and antihypertensives, adenoma, oral contraceptives, the Abnormal ND is often nonlactational (i.e., tranquilizers. from the last patient is not pregnant or is more than 2 years involving breast feeding), persistent, and unilateral, usually caused by a single duct. Abnormal ND is most commonly duct ectasia, benign conditions like intraductal papillomas, fibrocystic changes. , papillomatosis, INTRODUCTION ABSTRACT symptom presenting earliest the be can (ND) discharge Nipple of cases two present of hereby cancer We breast cancer. breast was which ND, isolated as manifesting mass palpable no with cytology of cases, both In color. in whitish revealed discharge the pleomorphichighly a high grade indicating cells malignancy. microcalcifications. extensive diffuse, Mammographyshowed Histology axillary with done. Simple was clearance carcinoma, intraductal spreading diffusely revealed cases in both of focus with ND if case. in one microinvasion or not scanty the times, at and patients the by ignored often is stained blood This article warning an early be ND can that highlights clinicians. sign of non are that carcinomas intraductal ofIrrespective of or nature color the unilateral discharge, the cytological assessment, clinical Proper evaluated. be to ND needs ofevaluation and performed be to ought ND, the of level low the Considering cases. in all such in women awareness regarding warning the signs of current the focus cancer, breast to sensitized should be Women awareness.” “breast create is to and report changes in their unusual any recognize their to earliest. the at providers care health Keywords: mammographydischarge (ND), 1 block, st main, 1 st Parthasarathy V, Rathnam U. Rathnam V, Parthasarathy 14.

Department of General Department of General 1 Mar 01, 2012 An early warning sign of breast cancer. An early warning sign of breast cancer.

R T Nagar, Bangalore - 560032, India. Bangalore T Nagar, R E-mail: [email protected] Surgery, ESI PGIMSR, Rajajinagar, Bangalore-10, ESI PGIMSR, Rajajinagar, Surgery, India 810 Nipple discharge: Int J Prev Med 2012;3:810- Date of Acceptance: this article: to cite How Date of Submission: Oct 28, 2011 Correspondence to: Veda, P. Dr. No- 10, Sri Devi Krupa, 1 Department of Pathology, ESI PGIMSR, Rajajinagar, ESI PGIMSR, Rajajinagar, Department of Pathology, Bangalore-10, India, Nipple Discharge: An Early Warning Sign of Breast Cancer Sign of Breast Warning An Early Discharge: Nipple Usharani Rathnam Parthasarathy, Veda

Case Report Veda and Usharani: Nipple Discharge in Breast Cancer with isolated ND have an early stage disease evaluation in Case A revealed DCIS – grade 4 associated with in situ ductal carcinoma (DCIS).[5] [Figure 4] with foci of microinvasion. Case B Clinical examination, cytological evaluation of the showed diffusedly spreading intraductal carcinoma ND, and mammography are first-line diagnostic with no evidence of microinvasion. Axillary tail approaches in patients presenting with abnormal contained 10 lymph nodes in Case A and 6 in Case ND. [2] B, largest measuring 1×0.5 cm all of which were reactive and did not show any metastasis. The surgical margins were free of tumor. Post-operative CASE REPORT follow-up was uneventful [Figure 5]. Patients were Case A advised chemotherapy and followed up for 1 year A 39-year-old woman presented with history and both are doing well. of scanty, whitish discharge from right nipple of 6 months duration. The discharge was barely visible and she had noticed it as her under garment would DISCUSSION often stick to the right nipple. She came to seek The incidence of malignancy in patients medical attention only after she developed itching presenting with abnormal ND is 7% to 15%[3,4]. The in the right nipple and areolar region. possibility of cancer increases when the discharge is accompanied by a lump, and when the patient Case B is over 50 years of age.[6] The proportion of breast A 42-year-old woman presented with carcinoma cases associated with ND ranges from spontaneous whitish discharge from the right 1.6% to 13%.[5] Most cancer-associated discharges nipple of almost 1 year duration. For the past 1 are the result of DCIS or papillary carcinoma and week, she had developed pain and noticed some are frequently associated with a clinically palpable excoriations over the nipple areolar region, which lesion or positive findings on mammography.[7,8] ND motivated her to come to our hospital. owing to DCIS has been shown to be a marker for In both these women, there was no history of extensive disease, which often requires mastectomy mass or pain in the breast. We tried to explore the to achieve adequate surgical margins.[9,10] reason for their delay in seeking medical attention. The awareness among women concerning the They replied that as there was no pain or swelling various warning signs of breast cancer as reported in the breast, it was unlikely to be cancer. Both in various studies is shown in Table 1. Montazeri of them knew about breast cancer, but had no et al[12] and Somdutta et al[11] have reported a low knowledge about other warning signs of breast level of awareness regarding the various warning cancer apart from swelling and pain. signs. Khokhar[13] in a study conducted among Clinical evaluation in both cases did not reveal Indian school teachers has reported higher level of any mass in the underlying breast, axillary, or awareness. However, it may be noted that in all these supraclavicular regions. In both cases, the discharge studies, awareness regarding ND was much lower was thick and whitish in color. In case A, it was (7–35%) compared to that of painless mass/lump so scanty that gentle massage had to be done to (42–90%). This shows that majority of women do extract material for making smears. Cytological not consider isolated ND as an early warning sign evaluation of ND smears in both cases showed of breast cancer, or a condition requiring medical highly pleomorphic cells with hyperchromatic intervention. In our study, both cases approached nuclei, prominent nucleoli, coarse chromatin us for relief of symptoms like itching, pain, and pattern, and increased nuclear cytoplasmic ratio excoriations. They did not regard isolated ND as a [Figure 1]. These features were suggestive of a high symptom requiring medical attention. grade malignancy. Mammography in both cases Many authors have regarded white, yellow, was positive showing extensive microcalcifications green, brown/black ND as physiological and [Figure 2]. benign.[1,14] Some studies have considered blood In view of the high nuclear grade and extensive stained, serosanguinous (), serous or clear ND microcalcifications, simple mastectomy [Figure 3] as signifying an increased risk of malignancy.[15] with axillary clearance was done. Histological However, in our study, both patients with DCIS

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www.mui.ac.ir Veda and Usharani: Nipple Discharge in Breast Cancer

Figure 2: Mammogram showing extensive microcalcifications Figure 1: Cytological smear of ND showing discohesive, pleomorphic cells, and a mitotic figure. MGG stain. 45×

Figure 4: Histological section showing dilated ducts with ductal carcinoma in-situ. HandE stain 4× Figure 3: Simple mastectomy specimen Table 1: Awareness among Women about Warning Signs of Breast Cancer, as reported in Different Population Studies Warning Somdatta Montazeri Khokhar[13] signs of breast et al. [11] et al.[12] 2009 cancer 2008 2008 Painless 42% 44% 90% mass/lump Nipple 7% 14% 35% discharge/ bloody ND Nipple - 16% - retraction Skin changes 1.6% - 34%

appearance, unilateral ND needs to be evaluated for Figure 5: Post-mastectomy status in case-A the possibility of cancer. Investigation of the ND presented with whitish discharge, which was not includes Triple Assessment: Clinical examination, blood stained. Therefore, regardless of the gross Cytological evaluation, and Mammography.[14]

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Mammography is recommended to any patient node involvement at detection, or cancer-related presenting with abnormal ND. However, some mortality.[22,23] Several studies have shown that studies have reported that mammography has a awareness regarding BSE is low and very few poor positive predictive value (16.7%).[2] It is also women practice it regularly.[11-13] reported to have a low sensitivity (59%) in the At present, the emphasis is to raise breast cancer diagnosis of malignant duct pathology.[16] However, awareness among women and furthermore raise most experts recommend that a mammogram their knowledge about the warning signs of breast should be performed in women over 30 years cancer.[12] Breast cancer awareness programs have presenting with nonlactational, spontaneous been very successful on several grounds including ND. [17] creation of greater compliance with breast cancer Ultrasonography, particularly with high- prevention and strategies.[24] Being “breast frequency probes (11–13 mHz) is complementary aware” is currently defined as a woman becoming to mammography and could be useful in many familiar with her own breasts and the way they patients.[2] Ductography involves retrograde change throughout her life.[25] This enhances her injection of water soluble radio opaque contrast sensitivity and alerts her to any abnormal change material into a discharging duct with subsequent in the breast, at the earliest. The important warning mammographic imaging.[5] Li Gui-hua et al.[18] have signs to be looked for are as follows. reported that selective mammary ductography is · Lump, thickening, continuous pain in one part of great value in patients with DCIS presenting of the breast. with ND and could detect 90.3% of cases, while · Change in size or lowering of one breast. mammogram showed positive signs in 25.8%. · Discharge from nipples, rashes over nipple, Mammary is a new technique that changes in shape or position of nipple, nipple allows direct visualization of the mammary inversion, any skin changes like puckering or ductal epithelium using sub-millimeter fiberoptic dimpling. microendoscopes.[19] Ductoscopy also allows for · Swelling or pain under the armpit or around , microbiopsies, and excision of the collar bone (lymph nodes) [19,20] intraductal lesions. However, these evolving Although the effectiveness of regular BSE [14] techniques are expensive and lack accessibility. remains controversial, it can be used as a strategy Surgery has traditionally been considered to create breast health awareness among women. the gold standard for confirming the diagnosis Teaching BSE can help women to get acquainted [1] and treating abnormal ND. Excision of the with their breasts and alerts them to any abnormal pathological duct(s) needs to be performed changes at the earliest. Trained female health if ND is persistent. The two most common workers were successful in creating this awareness surgical procedures performed in patients with among rural women.[26] It is important to create pathological ND are microdochectomy and awareness and educate the community through [14] Hadfield’s procedure. Microdochectomy community-based educational programs Indeed involves identification and removal of the affected the focus of primary health care providers should duct leaving intact the surrounding tissues and the be to raise awareness about breast care and to [2] unaffected ducts. Hadfield’s procedure involves encourage them to report “any unusual changes in radical subareolar duct excision. their breasts” to their health care providers.[12] BSE and breast awareness Breast self-examination (BSE) is a systematic CONCLUSION method of regular self-inspection and palpation of ND can be an early sign of breast cancer. Diffusely the breast and axilla.[21] Two large population-based spreading intraductal carcinomas which often have randomized controlled trials in Russia (388,535 no clinically palpable breast mass can manifest women) and Shanghai (260,000 women) followed as pathological ND. Isolated ND, particularly if up over a 5-year period could not demonstrate any not blood stained, is often ignored by the patient. beneficial effect of screening by BSE in terms of Awareness among women regarding the warning the size of primary tumor, incidence of lymph signs of breast cancer and BSE is low. Currently,

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www.mui.ac.ir Veda and Usharani: Nipple Discharge in Breast Cancer the emphasis is to raise breast cancer awareness and its Screening amongst Indian Teachers. Asian Pac J and to enhance their knowledge concerning the Cancer Prev 2009;10:247-9. warning signs of breast cancer. Women should be 14. Richards T, Hunt A, Courtney S, Umeh H. Nipple alerted to seek medical attention if they notice any discharge: a sign of breast cancer? Ann R Coll Surg Engl unusual changes in their breasts. 2007;89:124-6. 15. Salmon RJ, Merle S, Boue P. Demonstration of blood in nipple discharge using the Hemoccult. J Gynecol Obstet REFERENCES Biol Reprod (Paris) 1987;16:595-8. 1. Lang JE, Kuerer HM. Breast ductal secretions: clinical 16. Ito Y, Tamaki Y, Nakano Y, Kobayashi T, Takeda T, features, potential uses, and possible applications. Cancer Wakasugi E, et al. Non-palpable breast cancer with control 2007;14:350-9. nipple discharge: how should it be treated? Anticancer 2. Zervoudis S, Iatrakis G, Economides P, Polyzos D, Res 1997;17:791-4. Navrozoglou I. Nipple discharge screening. Womens 17. Gray RJ, Pockaj BA, Karstaedt PJ. Navigating murky Health 2010;6:135-51. waters: a modern treatment algorithm for nipple 3. Louie LD, Crowe JP, Dawson AE, Lee KB, Baynes DL, discharge. Am J Surg 2007;194:850-5. Dowdy T, et al. Identification of breast cancer in patients 18. Li G, Wang X, Cao G, Yang R, Yang J. Value of selective with pathologic nipple discharge: Does ductoscopy mammary ductography in the diagnosis of ductal carcinoma predict malignancy? Am J Surg 2006;192:530-3. in situ. Beijing Da Xue Xue Bao 2008;40:143-5. 4. Van Zee KJ, Ortega Perez G, Minnard E, Cohen MA. 19. Al Sarakbi W, Salhab M, Mokbel K. Does mammary Preoperative increases the diagnostic ductoscopy have a role in clinical practice? Int Semin yield of major duct excision for nipple discharge. Cancer Surg Oncol 2006;3:16. 1998;82:1874-80. 20. Kapenhas-Valdes E, Feldman SM, Cohen JM, Boolbol 5. Cabioglu N, Krishnamurthy S, Kuerer HM, Hunt KK, SK. Mammary ductoscopy for evaluation of nipple Singletary SE, Meric-Bernstam F, et al. Feasibility discharge. Ann Surg Oncol 2008;15:2720-7. of breast-conserving surgery for patients with breast 21. Baxter N; Canadian Task Force on Preventive Health carcinoma associated with nipple discharge. Cancer Care. Preventive health care, 2001 update: Should 2004;101:508-17 women be routinely taught breast self-examination to 6. Leis HP Jr. Management of nipple discharge. World J screen for breast cancer? CMAJ 2001;164:1837-45. Surg 1989;13:736-42. 22. Thomas DB, Gao DL, Self SG, Allison CJ, Tao Y, 7. Carter D, Orr SL, Merino MJ. Intracystic papillary Mahloch J, et al. Randomized trial of breast self- carcinoma of the breast: After mastectomy, radiotherapy examination in Shanghai: Methodology and preliminary or excisional biopsy alone. Cancer. 1983;52:14-9. results. J Natl Cancer Inst 1997;89:355-65. 8. Haagensen CD. Diseases of the Breast. 3 ed. Philadelphia: 23. Semiglazov VF, Moiseenko VM. Breast self-examination WB Saunders; 1986. p. 729-57. for the early detection of breast cancer: a USSR/WHO 9. Bauer RL, Eckhert KH, Nemoto T. DCIS associated controlled trial in Leningrad. Bull World Health Organ nipple discharge: A clinical marker for locally extensive 1987;65:391-6. disease. Ann Surg Oncol 1998;5:452-5. 24. Anonymous: Breast cancer awareness: too much of a 10. Obedian E, Haffty BG. Breast-conserving therapy in good thing? Lancet Oncol 2007;8:1041. breast cancer patients presenting with nipple discharge. 25. Linsell L, Burgess CC, Ramirez AJ. Breast cancer awareness Int J Radiat Oncol Biol Phys 2000;47:137-42. among older women. Br J Cancer 2008;99:1221-5. 11. Somdatta P, Baridalyne N. Awareness of breast cancer in 26. Rao RS, Nair S, Nair NS, Kamath VG. Acceptability and women of an urban settlement colony. Indian J Cancer effectiveness of a breast health awareness programme 2008;45:149-53. for rural women in India. Indian J Med Sci 2005;59: 12. Montazeri A, Vahdaninia M, Harirchi I, Harirchi AM, 398-402. Sajadian A, Khaleghi F, et al. Breast cancer in Iran: Need for greater women awareness of warning signs and Source of Support: ESI PGIMSR, Rajajinagar, Bangalore effective screening methods. Asia Pac Fam Med 2008;7:6. (Institute to which we are affiliated, as indicated in article) 13. Khokhar A. Level of Awareness Regarding Breast Cancer : Nil

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