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Nipple Discharge: Evaluation and Management gineco ro mastology Nipple Discharge: Evaluation and Management S. Zervoudis(1,2,3), P. Economides(1), G. Iatrakis(1), D. Polyzos(1), K. Lykeridou(2), I. Navrozoglou(3) (1) Lito Hospital, Dept of Mastology, Athens Greece (2) ATEI University of Athens, Athens, Greece (3) University of Ioannina, Dept of Obst/Gyn, Breast Unit, Ioannina, Greece Corresponding author: Prof. S. Zervoudis Lito Maternity Hospital, Dept. of Mastology 7, Mousson Street, Athens 11524, Greece E-mail: [email protected] Abstract Nipple discharge is a common symptom carcinoma. Techniques used in nipple dis- women complain of. It is classified as nor- charge evaluation include mammography, mal or abnormal depending on features ultrasound, cytology, duct endoscopy, the such as laterality, cycle variation, quantity, mammary pump, ductography, immuno- color or presentation (induced vs sponta- chemical methods and surgical excision of neous). It can be related to benign condi- the pathological ducts. tions such as intraductal papilloma, duct Keywords: nipple discharge, galactor- ectasia, plasma cell mastitis, galactorrhea rhea, papilloma, duct ectasia, mammary or malignant such as ductal or papillary pump Introduction Local: herpes zoster, tuberculosis, thoracic trauma, and medications are Nipple discharge is a common pre- trauma, previous surgery of the included in the differential diagnosis. senting symptom women complain of. breast or the thoracic cage. The patient who is curious to check for Three out of ten women who present General: fever, headache, myxoede- discharge may cause continuous me- to their doctor for a breast examination ma, visual disturbances. chanical stimulation. In such cases dis- have nipple discharge. Nipple discharge The spontaneous or induced nipple continuation of the stimulation will dis- is 7% to 10% of all breast symptoms(1). discharge may be identified either by continue the process. Common features of nipple discharge the patient accidentally or during cli- Women should be advised to avoid are the following: nical examination. Less commonly it checking themselves for discharge It may be unilateral or bilateral. may present during mammography se- since benign discharge may resolve It presents cycle variation. condary to pressure. when the nipple is left alone(3,4). Medi- It is induced or spontaneous. 1ot all nipple discharge is abnormal. cations linked to nipple discharge are It may be clear, serous, milky, yellow, Therefore it is necessary to categorize antihypertensives, hormones, phenothia- green, pink or slightly bloody, brown it to normal, abnormal or to attribute it zines, tranquilizers, antidepressants, an- or black (old blood). to galactorrhea according to history and tipsychotics and others(5), summarized It may originate from one or mul- physical examination. in Table 1(6): tiple ducts In drug induced galactorrhea the It may be of small, moderate or large Normal Discharge discharge is milky, bilateral, it originates quantity. Normal discharge is non-spontaneous, in many ducts and it is copious in The discharge may be accompanied and is usually bilateral. It is serous quantity. The diagnosis is reached by a by other clinical findings such as: and originates in many ducts. Multiple good history and it will be confirmed by Breast findings: mastodynia, palpa- duct discharges are rarely caused by the discontinuation of the medication. ble mass, palpable lymph node, pru- cancer(2). In cases not related to breast No further workup is indicated in ritus or skin depression. pathology, mechanical stimulation, these cases and the patient should be pag. 230 Gineco.ro, 2008, Vol. 4, Nr. 4, pag. 230-237 gineco ro Table 1. Medications and herbs associated with Galactorrhea(6) Antidepressants and anxiolytics Phenothiazines - Alprazolam - Chlorpromazine - Buspirone - Prochloperazine - Monoamine oxidase inhibitors - Others - Moclobemide - Selective serotonin reuptake inhibitors Other Drugs - Citalopram - Amphetamines - Fluoxetine - Anesthetics - Paroxetine - Arginine - Sertraline - Cannabis Image 1 -Tricyclic antidepressants - Cisapride - Cyclobenzaprine breast disease even if the discharge Antihypertensives - Danazol contains blood. It is associated with an - Atenolol - Dihydroergotamine underlying malignancy in 1.2% to 15% Methyldopa - - Domperidone of patients(7-12). One should identify the - Reserpine - Isoniazid Verapamil quadrant that is involved by applying - - Metoclopramide pressure on the breast and this way the - Octreotide Antipsychotics - Opiates affected duct can be easily localized. - Histamine H2-receptor blockers - Rimantadine Lesions that may be linked to abnor- - Cimetidine - Sumatriptan mal discharge are intraductal papillomas, - Ranitidine - Valproic acid duct ectasia, mastitis, fibrocystic changes, - Farotidine carcinoma and Paget’s disease (Image 1). Herbs Bloody, unilateral and discharge ori- Hormones - Anise ginating from one duct are features - Conjugated estrogen and medroxyprogesterone - Blessed thistle associated with suspicious lesions(13). In - Medroxyprogesterone contraceptive injections - Fennel such cases an intraductal malignancy - Oral contraceptive formulations - Fennugreek seed cannot be excluded and therefore sur- - Marshmallow - Nettle gical intervention should not be delayed. - Red clover According to various reports, cancer is - Red Raspberry diagnosed in 5%(14), to 7.5%(15) or even in up to 11%(16). reassured. During pregnancy and post- Abnormal nipple discharge Galactorrhea partum (until after 2 years) nipple dis- Abnormal nipple discharge is defined Galactorrhea is typically bilateral, it charge is normal and milky in nature. as non-lactational, persistent, sponta- originates in many ducts and the dis- The same applies after a spontaneous neous and unilateral(7-12). It is usually charge is milky. This is typical in phar- abortion or termination of pregnancy in located in one duct. As it is usually spon- macological galactorrhea and disconti- the second trimester. taneous, it may as well disappear. It nuation of the medication will eliminate In the remaining cases, nipple dis- may be green or grey, serous or bloody the finding. charge may or may not be associated in appearance. The most common ca- Table 2 may be used to categorize nip- with malignancy. use of this discharge is usually benign ple discharge according to its nature. Table 2. Nipple discharge features based on its nature(17) Nature of Discharge Etiology Localization Ducts involved Postpartum Medications Milky Bilateral Multiple Hyperprolactinemia Chiari-Frommel syndrome Intraductal Papilloma Serous/Serosanguinous Unilateral One Intraductal cancer Intraductal Cancer Bloody Inflammation Unilateral One or two Trauma Green Fibrocystic Disease Bilateral Multiple Vol. 4, Nr. 4/decembrie 2008 pag. 231 gineco ro mastology Etiology of Nipple Discharge differential diagnosis between benign process proceeds or follows the di- 1. Benign diseases intraductal papilloma and papillary car- latation of the duct. We believe that Intraductal papilloma cinoma. the primary process is the dilatation Intraductal papilloma is a local intra- The management of a papilloma re- of the duct and the accumulation of ductal hyperplasia with simultaneous quires a surgical procedure: microdo- amorphous “cheese-like” secretion. The formation of a vascular and neural axis chectomy or pyramidectomy(15,24,25): it con- acute inflammation may be caused by that eventually becomes macroscopically sists of dissection of the affected duct. A epithelial rupture and diffusion of the visible. Solitary or multiple papillomas small sound is used to catheterize the contents into the fibrous duct-wall are the most common cause of nipple duct where the discharge is originating and the underlying structures. These discharge reported (35%-62%)(7,10,11,18-22). and methylene blue dye is injected in contents consist of neutral fat and lipid Sixty-80% of intraductal papillomas are order to visualize the duct branches. crystals that are typical of duct ectasia. accompanied by spontaneous or in- After the nipple has been stabilized, the The chronic granulation-type reaction duced bloody, serous, aqueous, or sero- dye colored duct is dissected from the may develop foreign body-like giant sanguinous discharge, one of its main nipple to the depth and the specimen cells and a multiform inflammatory cell clinical findings. A 5% risk of developing has a triangular shape. After meticulous population. As the whole process in duct into invasive carcinoma has been repor- hemostasis has been obtained, rebuil- ectasia is long in duration, sometimes ted(23). ding of the retroareolar area is performed plasma cells are dominant in the in- Papillomas affect women 35-50 years and a small drain is placed. flammatory infiltrations. This finding old, they vary in size, they are round or Duct ectasia impressed some pathologists who used lobular, they have a broad base or they Duct ectasia is the cause of nipple the term “plasma cell mastitis” in order are pedunculated, they may be located discharge in 11% of patients(7). to describe duct ectasia. in any quadrant, although the more There is a broad terminology used Other findings in duct ectasia are the frequent location is in a big duct behind in various reports for the same entity: following: the nipple, they may be single or multiple “varicocele-like tumor”, ”plasma-cell Serous or green-white nipple dis- and they are not usually accompanied mastitis”, “obstructive mastitis”, galacto- charge in 20% of the cases. by a palpable mass. Nevertheless,
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