Diagnosis and Treatment of Nipple Discharge
The majority of cases of nipple discharge are benign (non-cancerous). However, any nipple discharge should be investigated immediately to exclude cancer. If a nipple discharge is caused by breast cancer, an underlying mass is not always present or palpable. Therefore the underlying condition is not always detectable by conventional imaging studies; including mammography.
Mammography has improved the detection of breast cancer due to the detection of microcalcifications. However, microcalcifications are rarely associated with nipple discharge.
Diagnosis studies in cases of Nipple Discharge
The cytological examination of a nipple discharge is useful in establishing a diagnosis. Nonetheless, there is always the possibility of both false negatives and false positives. However, the galactography is considered the treatment of choice for diagnostic purposes; for identifying ductal abnormalities and to detect carcinoma at an early stage.
The galactography has the advantage of being a minimally invasive procedure. Furthermore, galactography can also be used to compliment an excision of the breast duct, by both locating the abnormal duct as well as assessing the extent of the intraductal lesions.
A nipple discharge can contain:
- Serous fluid
- a mixture of blood and serous fluid
Moreover, a discharge that arises from an underlying cancer and contains blood usually involves the infiltration of a tumor within the ductal system. In addition, 13 % of cancers that cause nipple discharge present without a palpable mass. Doctors must rely on a combination of imaging studies and cytology to determine a malignancy.
The cytological examination of a nipple discharge carries an 18 % false negative rate and a 2.6% false positive rate. In comparison, a mammograph has a 9.5 % false negative rate and a 1.6 % false positive rate in the detection of breast cancer.
Taking into account the above statistics
Furthermore, the galactography is accepted as the procedure of choice in patients with nipple discharge. Previous diagnostic studies suggest that galactography is more sensitive than cytology or mammography; in the case of patients presenting with nipple discharge. Furthermore, benign lesions can not always be differentiated from malignant ones. The glactography does not usually prevent the need for surgery.
Findings on galactography that are suggestive of carcinoma include:
- Irregular thickenings
- Ductal irregularities
- Distortion or displacement
- Complete obstruction to the passage of the contrast fluid
- Extravasation: Leakage of the contrast fluid into surrounding tissue
However, do not worry, most solitary intraductal tumors that are found centrally are benign papillomas. However, findings of multiple papillomas increase the risk of malignancy. The papillomas tend to produce regular or smooth filling defects. But can also cause obstruction to the contrast fluid. In general, papillomas tend to be solitary lesions that are centrally located close to the nipple. In contrast, cancers tend to be more irregular and tend to be located deeper in the breast further away from the nipple.
- X-ray findings from a ductogram from a woman presenting with nipple discharge and breast pain show a dilated, partially obstructed breast duct.
- Photomicrograph of the histology of a transverse section of the obstructed duct shows an intraductal papilloma. (H&E x 20)
The primary value of the mammary galactography is to investigate cases of simple nipple discharge, without an associated mass. In addition, if the discharge contains blood a mammary galactography is indicated. Rongione suggests that the galactography should be performed in patients with abnormal nipple discharge to identify and locate the lesions prior to an excisional biopsy.
What other studies have suggested
Diagnosis with a galactography helps to localise intraductal lesions that are not palpable on breast examination.
The difficulties found in locating the affected duct can be overcome with the execution of a preoperative galactography using methylene blue. Definitively, the blue dye serves as a road map for the surgeon and allows a more accurate and precise resection. Furthermore, galactography also allows the abnormality to be more easily recognized in the pathological examination.
The most difficult part of the galactography procedure is the insertion of a blunt needle; or cannula, into the duct. Therefore, Hou (et al.); argue that the needle insertion is easier if a monofilament polypropylene suture strand 2.0 is used as a guide for the canalization catheter.
Even though a main duct excision can eliminate symptoms, a pathological correlation is not always found. Determining the cause of the lesion through preoperative galactography increases the probability of finding a specific pathology during surgery. Thus, the preoperative use of methylene blue in galactography should be considered in managing patients with nipple discharge.
The first cytological diagnosis of breast carcinoma from nipple discharge cells was made in 1914. However, the two modern elements of cytology, exfoliation and suction, were developed in parallel over the past 70 years. Exfoliative cytology, popularized by Papanicolau, is currently the main choice in screening and diagnosis of cervicovaginal cancer.
Nevertheless, the cytology developed by Hematologists; such as Hirschfield in 1912 was adapted for the diagnosis of solid tumors by Martin Ellis and others around 1930. In addition, Dudgeon and Patrick developed a wet film attachment technique to give a 98.6% accuracy in breast cancer detection.
However, the role of the fine-needle aspiration (FNA) in the diagnosis of palpable breast conditions and diseases is well established. The use of fine needle aspiration is popular around the world, with an acceptable sensitivity and specificity, in specialized centers.
Indeed, mammography alone has limitations in detecting cancer associated with nipple discharge in cases where the abnormality is impalpable. Dunn, in his study of 393 cases of nipple discharge, detected malignancy only by cytology. The incidence of malignancy in cases of nipple discharge was found to be 8%; which is comparable to the study results. However, the proportion of invasive carcinomas (55%) was higher than in other diagnostic studies.
C-erbB2 Gene detection diagnosis in the nipple discharge
The amplification of the gene c-erb B2 is more commonly found in cases of breast carcinoma-in-situ than in invasive breast cancers. Nonetheless, the detection by polymerase chain reaction (PCR) can help to diagnose non-palpable breast carcinomas with nipple discharge.
In patients with very few symptoms, determining the c-erb B2 could be an aid in the diagnosis of breast carcinoma. The amplification of this gene has never been identified in non-cancerous cells. Thus, the detection of the gene in cells from a nipple discharge could be considered a marker for cancer. In conclusion, the amplification of c-erb B2 is associated with malignant potential and also with high proliferative activity. This gene amplification may be a predictor of sensitivity to chemotherapy treatment. In addition, the gene amplification is useful in planning treatment for patients with breast carcinoma.
Therapeutic diagnosis approach to a nipple discharge
Decisions regarding the management of patients presenting with nipple discharge should be based on the characteristics of the discharge; or the pseudo discharge.
Medical interventions must be individualized and may include:
- Topical dermatological medications
- Dopamine agonists
- Elimination or reduction of lactogenic drugs
- Alteration of lifestyle habits; such as diet or exercise
- Possibly a psychiatric consultation
Treatment of a pseudo discharge begins with hygiene techniques for the nipple. The patient must rinse the affected nipple, as well as the areola, with a cotton swab using an antiseptic soap.
For patients presenting with an inverted nipple
Downward pressure should be applied to the areola. The downward pressure causes the protrusion of the nipple; which can then be properly cleaned. In addition, the patient should be instructed to wear a comfortable, well-fitted bra for exercise to prevent friction from clothing that may exacerbate the condition.
Eczematous lesions of the nipple and areola are treated with basic hygiene routines and topical steroid creams.
If medical treatments fail, abscesses and eczematous conditions of the nipple may require surgery. Fistulas are treated surgically with a fistulotomy; in order to remove abscesses and promote drainage. The remnant abscess cavity will heal once the abscess has been treated.
Moreover, when the nipple is everted by surgery, the underlying anatomical defects are corrected and recurrent breast fistulas of the ducts are prevented. An ongoing eczematous condition of the nipple should always be biopsied to exclude Paget’s disease and related conditions.
It is important to determine whether the nipple discharge is oozing out of one, or several pores. Conventionally, the management of a nipple discharge from a single duct is surgical. However, surgery can also play a role in the treatment of a discharge arising from multiple ducts.
According to Uriburu’s classifications:
Types of Discharge groups (single duct)
- Type A: A breast lump is not detected on clinical examination and thus, surgical treatment is not indicated. However, surgery for a nipple discharge is indicated if a tumor or dominant nodule is found.
- Type B: Nipple discharges not cured with medical treatment. Sometimes, if a nipple discharge has not responded to medical treatment surgery is indicated. If the patient is young the affected ducts will be resected via the areolar. If the patient is beyond child-bearing age, all the milk ducts will be resected. Urban Operation is to prevent recurrence in the remaining ducts. However, urban resection is not advisable in younger women due to the implications for breastfeeding.
- Type C: Type C group is sub-divided into C1 and C2 groups. Type C refers to a nipple discharge that arises under pressure from the glandular sector. In this case, a broad biopsy is always indicated. However, the results of this examination could report a papillary tumor, ductal cancer, hemorrhagic intraductal granuloma; or a focused dysplastic papillomatosis. Therefore, the specific care plan and treatment depends upon the histopathological results following the biopsy.
- Type D: Type D group is for a nipple discharge; in which the cytological results confirm a serious underlying condition or disease. The treatment in this instance is a wide biopsy. Once a diagnosis is given from the histopathological report a conservative operation; or a modified radical mastectomy may be indicated.
Types of Discharge groups (multiple ducts)
- Type A: If the discharge is caused by a physiological reason the underlying cause needs to be identified and treated. Furthermore, in the case of dysplasia, a medical treatment is indicated.
- Type B: However, a nipple discharge caused by an infectious process; or ductal ectasia is often resistant to medicine alone. Although benign, these lesions may still require surgery to resect all the terminal milk ducts. (the Urban operation)
- Type C: When the nipple discharge comes out of several pores, an intense proliferative adenosis; or multiple papillomatosis of minor ducts, must be differentiated from a multicenter ductal carcinoma. As these conditions are predominantly intraparenchymatous abnormalities, a subcutaneous adenomastectomía, removal of the glands, must be made with biopsy for histological results. The Urban operation is not indicated in this situation because it is incomplete. If the discharge is of a C2 subgroup, the presumed etiology would be an intraductal multiple hemorrhagic granuloma; in which case the Urban operation is the surgical treatment of choice.
- Type D: It is very rare that an underlying cancer produces a nipple discharge that oozes through multiple pores. Usually this presentation would suggest an intraductal cancer; or a multicentric papillary condition. However, a broad biopsy is necessary. If multicentric cancer is confirmed a modified radical mastectomy must be performed.
In most diagnosis cases
Furthermore, presenting with nipple discharge, usually results in a diagnosis of some sort of benign condition. However, a surgical biopsy is always necessary; in order to establish a precise etiology. This is essential to identify the rare cancer cases that present with nipple discharge as the sole symptom.
The role of the physician in the diagnosis of breast cancer will continue to expand in the future. An essential aspect of breast diagnosis in patients presenting with nipple discharge involves the physician having a good knowledge and awareness of the different potential diagnoses.
Nonetheless, an essential step in assessing any nipple discharge should involve the classification according to the risks. Indeed, the main aim is to arrive at an early diagnosis in cases of breast carcinoma.
In conclusion, the application of the above concepts will lead to appropriate decisions regarding investigations and early management of nipple discharge. Thus, the end result will be an early and accurate diagnosis. In consequence, the most effective and suitable treatment can be promptly given.
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