Nipple Discharge

  • Definition of nipple discharge:
    • Fluid that leaks from one or both nipples is called a nipple discharge:
      • Each breast has several (15 to 20) milk ducts:
        • A discharge can come from one or more of these ducts
  • Nipple discharge accounts for approximately 2% to 10% of the symptoms that women report when they seek care at breast clinics:
    • Causing anxiety in patients because it can be a presenting sign of breast cancer:
      • However, it is usually benign in origin (papillomas and galactophore / mammary duct ectasia):
        • With a 5% to 21.3% risk of an underlying malignant lesion:
          • Mostly due to in situ carcinomas
  • Nipple discharge can occur normally during the last weeks of pregnancy and after childbirth:
    • When breast milk is produced
  • A nipple discharge can also be normal in women who are not pregnant or breastfeeding:
    • Especially during the reproductive years:
      • For example, in women, fondling, suckling, irritation from clothing, or sexual arousal can stimulate a nipple discharge, as can stress:
        • However, a nipple discharge in men is always abnormal
  • A normal nipple discharge is usually:
    • A thin, cloudy, whitish, or almost clear fluid that is not sticky:
      • However, the discharge may be other colors, such as gray, green, yellow, or brown
    • During pregnancy or breastfeeding:
      • A normal discharge is sometimes slightly bloody
  • If the discharge is considered to be physiologic on the basis of clinical information and characteristics of the nipple discharge:
    • No further imaging studies of the breast are warranted:
  • Although approximately 80% to 90% of patients with pathologic nipple discharge have been reported to have benign conditions:
    • Breast imaging enables the localization of the breast abnormalities causing the pathologic nipple discharge:
      • Which helps minimize the number of operations and / or the extent of surgery
      • In addition, localizing the origin of pathologic nipple discharge enables percutaneous biopsy under imaging guidance:
        • Which allows clinicians to be more confident when deciding upon management and when choosing whether to perform minimally invasive percutaneous vacuum-assisted excision
  • Abnormal discharges vary in appearance depending on the cause:
    • An abnormal discharge may be accompanied by other abnormalities:
      • Such as dimpled skin, swelling, redness, crusting, sores, and a retracted nipple:
        • A nipple is retracted if it pulls inward and does not return to its normal position when it is stimulated
    • If a discharge from only one breast occurs on its own (without any stimulation of the nipple):
      • It is considered abnormal
  • Causes:
    • Several disorders can cause an abnormal discharge:
      • A discharge from one milk duct or from one breast:
        • Is likely to be caused by a problem with that breast:
          • Such as a noncancerous (benign) or cancerous breast tumor
      • A discharge from both breasts or from several milk ducts in one breast is more likely to be caused by a problem outside the breast:
        • Such as a hormonal disorder or use of certain drugs
  • Common causes of a nipple discharge:
    • Usually, the cause is a benign disorder of the milk ducts, such as the following:
      • A benign tumor in a milk duct (intra ductal papilloma):
        • Intra ductal papilloma is the most common cause
        • It is also the most common cause of a bloody nipple discharge when there is no lump in the breast
      • Dilated milk ducts (mammary duct ectasia)
      • Fibrocystic changes:
        • Including pain, cysts, and general lumpiness
      • A breast infection or abscess
      • Less common causes of a nipple discharge:
        • Certain disorders stimulate the production of breast milk in women who are not pregnant or breastfeeding:
          • In most of these disorders, the level of prolactin (a hormone that stimulates production of breast milk) is elevated:
            • Taking certain drugs can have the same effect
        • Cancer causes fewer than 10% of cases:
          • Nipple discharge is a cause for concern when it:
            • Occurs without the nipple’s being squeezed or stimulated by other means (when it occurs spontaneously)
            • Occurs in women aged 40 or older
            • Comes from only one breast
            • Is bloody or pink
            • Is accompanied by a lump that can be felt
            • Occurs in a boy or man
  • Preferred examination:
    • Mammography or digital breast tomosynthesis (DBT):
      • Is the first-line study for a pathologic discharge in most patients:
        • Mammography is limited:
          • Because of its poor sensitivity of 20% to 25%
          • A negative mammogram in the context of nipple discharge:
            • Does not therefore exclude any underlying disease:
    • Ultrasound is performed immediately after mammography even if the mammogram is normal
  • According to the American College of Radiology (ACR) Appropriateness Criteria:
    • For women 30 to 39 years of age:
      • Either mammography or ultrasonography may be used as the initial examination
    • For women aged 30 years or younger:
      • Ultrasound should be the initial examination:
        • With mammography / DBT added when ultrasound shows suspicious findings or if the patient is predisposed to developing breast cancer
    • For men aged 25 years or older:
      • Mammography / DBT should be, performed initially:
        • With ultrasound added as indicated, given the high incidence of breast cancer in men with pathologic nipple discharge
    • Although MRI and ductography (galactography) are not usually appropriate as initial examinations:
      • Each may be useful when the initial standard imaging evaluation is negative

#Arrangoiz #CancerSurgeon #BreastSurgeon #BreastCancer #SurgicalOncologist #CASO #CenterforAdvancedSurgicalOncology #PalmettoGeneralHospital

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