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Breast—Nipple Discharge
Concept
Either from benign or malignant cause. Benign typically are non-spontaneous, bilateral, clear or milky, and from multiple ducts. Bloody discharge typically from an intraductal papil- loma (45%), duct ectasia (35%) or infection (~5%). However, it may be a cancer (~5%); this is a common curveball.
Way Question May be Asked?
“A 45 y/o female presents to your office with the complaint of unilateral bloody nipple discharge for the past one month.” May be given just nipple discharge and have to work through type, spontaneity, laterality, and recent med- ications that have been started. May also be given nipple discharge in young female.
How to Answer?
Full History
Risk factors for malignancy Trauma
Fluid characteristics (clear, milky, serous, bloody) Bilateral or unilateral
When discharge occurs stimulated or spontaneous (spontaneous worrisome)
Trauma
Thyroid disorder New medications
Full Physical Exam
Examination of both breasts in upright and supine positions
Examination of lymph node basins
Try to determine a responsible quadrant/responsible ducts
Diagnostic Tests
Must get mammogram
U/S (subareolar area images poorly on mammogram) Hemoccult test
Cytology (rarely helpful, and negative result doesn’t exclude malignancy
Ductogram (painful, and rarely helpful)
MRI (rarely helpful for papilloma, but may detect other lesions)
Then, if you have bloody discharge, you are in one of several situations:
(1) Negative mammogram/negative PE for mass/negative responsible quadrant
Have pt follow-up in several weeks and check for responsible quadrant on breast self-exam. Then, on follow-up:
(a) Negative mammogram/PE for mass/negative responsible quadrant
→ total subareolar ductal system resection (b) Negative mammogram/PE for mass/positive
responsible quadrant
→ subareolar wedge resection ductal system for that quadrant
(c) Positive mammogram/PE for mass/positive responsible quadrant
→ excisional biopsy of mass and subareolar wedge resection
(2) Negative mammogram/PE for mass/positive responsi- ble quadrant
→ subareolar wedge resection of the ductal system draining that quadrant
(3) Positive mammogram/PE for mass/positive responsi- ble quadrant
→ excisional biopsy or core-needle biopsy of mass on mammogram and subareolar wedge resection
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4 Breast—Nipple Discharge
Surgical Treatment
Circumareolar incision (some make incision at nip- ple/areola border)
Elevate areola
Dissect ducts leading to areola
Identify abnormal duct by dilatation, stent, dye or mass (if can identify single duct otherwise subareolar wedge resection of the ductal system draining that quadrant)
Tie off distal duct or will still drain out of nipple post- op (your seroma!)
Common Curveballs
The pathology won’t be a benign intraductal papilloma but a type of breast cancer (may range from LCIS and DCIS to invasive cancer→don’t forget about checking lymph nodes and adjuvant therapy!) The nipple discharge will persist after a subareolar
wedge resection
There won’t be a responsible quadrant
There will be a mass in the same breast, different quad- rant, or in the opposite breast
Not bloody discharge but persistent atypical cells on slide cytology (now what do you do?)
Pt will be pregnant Pt will be teenager
Strikeouts
Performing surgery for non-spontaneous, bilateral, clear/milky discharge
Failing to check the same breast for palpable masses or examine the other breast
Failing to establish risk factors for malignancy
Failing to check nodal status if pathology returns malignancy
Failing to order a mammogram/U/S Discussing ductoscopy
Performing mastectomy for bloody nipple discharge Not being able to shift into discussion of malignancy if
pathology doesn’t reveal expected papilloma, but rather an invasive carcinoma
Trusting slide cytology/hemoccult tests and not taking pt to surgery with suspicious nipple discharge Wasting time working up a prolactinoma
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