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Nipple Discharge K Current Management of Nipple Discharge 6 Richard J. Gray and Barbara A. Pockaj Background and Pathophysiology by hyperprolactinemia, which may be secondary to medications, endocrine tumors (i.e., pituitary Nipple discharge is a relatively common complaint, adenoma), endocrine abnormalities, or a variety with a reported incidence of 2–5 % [ 1 ] and occur- of other medical conditions [16 ]. ring among 10–50 % of patients with benign breast Pathologic nipple discharge is characterized disease [ 1 , 2 ]. Typically, the primary concern and by a unilateral, spontaneous, persistent dis- initial fear of patients who experience nipple dis- charge from a single duct. Pathologic discharge charge is whether it is due to an underlying breast is not necessarily caused by an underlying car- cancer. The risk of carcinoma among those with cinoma, and in fact, most pathologic nipple nipple discharge has been reported to be between discharge is a result of a periductal mastitis, 6 and 21 % [ 2 – 10 ], with some reports including duct ectasia, or benign intraductal papilloma. only those patients undergoing an operation, while Periductal mastitis typically produces multi- others do not [ 3 , 7 – 10 ]. Nipple discharge can be colored, sticky discharge. Duct ectasia is the separated into categories of normal milk produc- result of increased glandular secretions by the tion (lactation), galactorrhea (physiologic nipple lactiferous ducts and results in multi-duct, col- discharge), or pathologic nipple discharge based ored discharge that can often be bilateral. on the characteristics of presentation [ 11 ]. Intraductal papilloma generally produces Lactation occurs as early as the second trimes- serous or bloody discharge from a single duct. ter of pregnancy and can continue for up to Other related nipple abnormalities that the cli- 2 years after delivery or cessation of breastfeed- nician should be aware of that can produce ing [ 12 ]. Lactating women may also have occult symptoms perceived by patients as nipple dis- or gross blood within their discharge, due to the charge include Paget’s disease of the nipple delicate capillary networks in the developing epi- and subareolar abscess. thelium [ 13 – 15 ]. Galactorrhea is manifested as The diffi culty in managing nipple discharge is bilateral milky nipple discharge involving multi- that the risk of carcinoma, despite being low [1 , 17 ], ple ducts not associated with pregnancy or recent cannot be eliminated without surgical duct exci- breastfeeding. Galactorrhea is frequently caused sion and histologic confi rmation. Thus, duct exci- sion in all patients with pathologic nipple discharge has been widely recommended [ 6 , 8 , 9 , 11 , 18 , 19 ]. In addition, although the risk of carcinoma R. J. Gray , MD (*) • B. A. Pockaj , MD has been reported to be as high as 21 %, most stud- Department of Surgery , Mayo Clinic Arizona , ies examining the risk of underlying carcinoma 5777 E. Mayo Blvd. , Phoenix , AZ 85054 , USA e-mail: [email protected]; include only those patients referred to departments [email protected] of surgery, specialty breast centers [ 4 – 6 , 20 ] or A.I. Riker (ed.), Breast Disease: Comprehensive Management, 113 DOI 10.1007/978-1-4939-1145-5_6, © Springer Science+Business Media New York 2015 114 R.J. Gray and B.A. Pockaj those patients who underwent duct excision horizontal crease that is associated with duct [ 7 – 10 ]. In a broader population of women with ectasia, an entity which can also produce nipple nipple discharge, the rate of underlying carcinoma discharge. Careful pressure can be exerted at the was found to be only 3 % [ 17 ], with referral pat- areolar margin circumferentially to examine for terns and selection bias likely playing a signifi cant discharge. The discharged fl uid can then be role in the reported incidence of carcinoma among inspected for origin from a single or multiple women with nipple discharge. Patients presenting ducts, color, and texture (thin, thick, sticky, etc.). with nipple discharge represent only 1 % of Hemoccult testing of the discharge is not usu- patients with DCIS and <1 % of those with inva- ally performed, as both serous and bloody dis- sive breast carcinoma [ 17 ]. charge can be associated with an underlying breast carcinoma [ 9 , 20 ]. Cytologic analysis is not regularly performed, as the results of such Diagnostic Approach to Nipple studies are neither sensitive nor specifi c for an Discharge underlying breast cancer [ 9 , 20 – 23 ]. Among patients with biopsy proven carcinoma, 29 % of Our current approach to the evaluation and man- cytology specimens of the discharge have been agement of patients with nipple discharge is sum- reported to show no evidence of carcinoma or marized in Fig. 6.1 . History taking and physical atypia [ 24 ]. If the patient is found to have sub- examination are the fi rst important steps. Older areolar tenderness and periareolar erythema with age predicts a higher risk of carcinoma [ 17 , 8 , purulent nipple discharge, this is consistent with 20 ] while a personal and family history of breast a subareolar abscess rather than true nipple dis- cancer is not predictive of an underlying can- charge. These patients are obviously approached cer etiology [ 8 ]. Recent onset of amenorrhea or differently and should be treated with an appro- other symptoms of hypogonadism (hot fl ashes, priate combination of antibiotics and possible vaginal dryness) should prompt consideration of incision and drainage and/or an excision of the hyperprolactinemia. subareolar major ducts [ 25 ]. The characteristics of the discharge should be obtained and recorded in detail with an attempt to categorize whether it is due to lactation, galactor- Imaging and Laboratory rhea, or pathologic discharge. The clinician should Investigations in Nipple Discharge be sure to understand if the discharge is spontane- ous or induced, unilateral or bilateral, the charac- There are no radiologic studies that are essential, teristics of the discharged fl uid (including volume), except for routine screening mammography, when the frequency of the discharge, and whether the the history and physical examination reveals that patient is stimulating his or her nipple to examine the discharge has characteristically benign features for discharge. This latter factor is important as (Fig. 6.1 ). Patients with lactation discharge need no regular self-examination for discharge can pro- further evaluation, including those with occult or duce ongoing, even spontaneous, discharge. gross blood in the discharged milk. Patients with Regular self-examination or other forms of breast galactorrhea need no further evaluation for breast stimulation can repress the secretion of hypotha- carcinoma, but should be evaluated for an underly- lamic prolactin inhibitory factor, resulting in ing cause of hyperprolactinemia including a careful hyperprolactinemia and galactorrhea [16 ]. review of medications, review of the patient’s his- The physical examination should include tory for possible causes of neurogenic stimulation careful inspection of the breast skin, nipple, and of the nipple-areola complex that would represses areola as well as palpation of all the breast paren- the secretion of hypothalamic prolactin inhibitory chyma, including the subareolar tissue and the factor, and review of the history and physical regional lymph nodes. Care should be taken to examination for signs or symptoms of pituitary examine the nipple for evidence of a central adenoma [ 16 ]. One may then perform laboratory 6 Current Management of Nipple Discharge 115 Nipple discharge Non-spontaneous; Spontaneous, multiple ducts; or bloody or serous, color is white/milky and single-duct or green discharge Routine Negative Abnormal screening mammography mammography or imaging and and subareolar subareolar examinations ultrasound ultrasound* Image-guided Counsel patient percutaneous biopsy as to low (≤3%) or Image-guided risk of subareolar major duct carcinoma excision* Major subareolar Q 6-month follow-up duct excision with imaging and exams preoperative until resolved or for ductogram to guide 1–2 years excision* Fig. 6.1 Algorithm for the management of nipple discharge. *If patient plans future breastfeeding, selective duct exci- sion is preferred over major duct excision workup of the galactorrhea with serum prolactin galactorrhea [26 ]. Galactorrhea in the absence of levels, though the serum prolactin concentration is hyperprolactinemia is usually not the result of any normal in nearly half of women who present with ongoing disease process. 116 R.J. Gray and B.A. Pockaj Table 6.1 Comparative rates of carcinoma risk Characteristic Carcinoma rates (%) p Age ≥50 vs. 6 % vs. 0 % 0.02 <50 years Unilateral vs. bilateral 4 % vs. 2 % 0.49 discharge Spontaneous vs. 5 % vs. 0 % 0.13 non-spontaneous Serous/bloody vs. 5 % vs. 0 % 0.10 other discharge Abnormal vs. normal 38 % vs. 3 % <0.01 mammogram Abnormal vs. normal 12 % vs. 1 % <0.01 ultrasound Abnormal vs. normal 6 % vs. 0 % 0.64 Fig. 6.2 Subareolar ultrasound demonstrating a 0.35 cm ductogram intraductal lesion ( arrow ) in a patient subsequently found to have ductal carcinoma in situ upon subareolar duct excision For those patients with pathologic nipple dis- charge and without clearly benign features (Fig. 6.1 ), we proceed to diagnostic mammogra- [ 4 , 9 , 20 , 31 ], it is still not sensitive enough to phy (for those 30 years of age and older) and sub- exclude the possibility of malignancy. In one areolar ultrasound. These imaging modalities series of 163 patients,
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