Nipple Discharge

  • Nipple discharge is common:
    • With more than half of women of reproductive age able to express discharge with manipulation
  • A thorough history to determine whether a discharge is:
    • Physiologic or pathologic:
      • Is important to determine the need for additional workup
  • Characteristics of pathologic nipple discharge include:
    • Spontaneous
    • Bloody or clear
    • Unilateral / single duct
    • Presence of a palpable mass associated with the discharge
  • Nipple discharge should be further evaluated if considered pathologic with:
    • Diagnostic mammography
    • Retroareolar ultrasound
    • Clinical examination
  • The differential diagnosis of focal dilation on ultrasound includes:
    • Lactational changes
    • Duct ectasia
    • Malignancy
  • Based on ultrasound findings and if the nature of the nipple discharge is concerning that it is pathologic:
    • It should be further evaluated with tissue sampling:
      • An image-guided excisional biopsy of the duct in question:
        • Is a minimally invasive simple technique to definitively rule out malignancy and establish the diagnosis:
          • This can be accomplished with placement of an intraoperative probe into the offending duct, or by placement of a preoperative wire or seed marker into the imaging abnormalities
  • Failure to identify a cause of the discharge warrants further work-up:
    • Ductogram and MRI have also been considered in the routine workup of nipple discharge:
      • Though data is inconclusive on their effectiveness
    • Ductogram can be considered operator dependent:
      • Has a reported positive predictive value of 19%
      • Negative predictive value of 63%
    • Successful localization of an offending lesion by ductogram:
      • Occurs in 50% to 60% of cases
    • MRI, on the other hand, has a reported:
      • Positive predictive value of 24% to 56%
      • Negative predictive value of 87% to 98%
        • Suggesting discussion of the technique may be reasonable in some situations but the limitations should also be reviewed with patients
  • In the absence of any palpable concerns on examination or suspicious findings on conventional mammogram and ultrasound imaging:
    • Duct excision reveals an intraductal papilloma:
      • As the cause of the discharge about 50% of the time
  • While most studies suggest that duct excision is indicated for patients with pathologic nipple discharge for both diagnosis and treatment:
    • Observation may be appropriate for selected patients with pathologic discharge who have:
      • normal examination, mammogram, and subareolar ultrasound:
        • In whom the risk of carcinoma is 3%
  • References:
    • Cabioglu N, Hunt KK, Singletary SE, et al. Surgical decision making and factors determining a diagnosis of breast carcinoma in women presenting with nipple discharge. J Am Coll Surg. 2003;196:354-364.
    • Vargas HI, Vargas MP, Eldrageely K, Gonzalez KD, Khalkhali I. Outcomes of clinical and surgical assessment of women with pathologic nipple discharge. Am Surg. 2006;72:124-128.
    • Romanoff A, Nulsen B, Mester J, Jaffer S, Weltz C. Ultrasound‐guided wire localization of focal ductal dilatation in the evaluation and treatment of pathologic nipple discharge. Breast J. 2018;24(3):356–359.
    • Morrogh M, Morris EA, Liberman L, Borgen PI, King TA. The predictive value of ductography and magnetic resonance imaging in the management of nipple discharge. Ann Surg Oncol. 2007;14(12):3369-3377.
    • Woodward S, Daly CP, Patterson SK, Joe AI, Helvie MA. Ensuring excision of intraductal lesions: marker placement at time of ductography. Acad Radiol. 2010;17(11):1444-1448.
    • Sanders LM, Daigle M. The rightful role of MRI after negative conventional imaging in the management of bloody nipple discharge. Breast J. 2016;22(2):209-212.
    • Nelson RS, Hoehn JL. Twenty-year outcome following central duct resection for bloody nipple discharge. Ann Surg. 2006;243(4):522-524.
    • Gray RJ, Pockaj BA, Karstaedt PJ. Navigating murky waters: a modern treatment algorithm for nipple discharge. Am J Surg. 2007;194(6):850-854.

#Arrangoiz #BreastSurgeon #CancerSurgeon #SurgicalOncologist #BreastCancer #NippleDischarge @PathologicNippleDischarge #Mexico #Miami

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