Nipple Discharge

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					Nipple Discharge

Dale Reynolds, M.D
UT Houston HSC
Division of Plastic Surgery
Nipple Discharge
Definition
 Fluid that escapes spontaneously from the
  nipple
Nipple Discharge
 5% of the referrals to breast clinics
 10% - 15% of patients with benign breast
  disease
 3% of patients with carcinoma
Assessment
 Complete history
 Complete physical examination
 Mammogram
 Cytology
 Record site and character of discharge
 Test for hemoglobin
 Ductography
Evaluation of Discharge
 Spontaneous or elicited
 Seek duct or ducts producing the discharge
 Number of ducts involved
 Color and consistency of discharge
 Trigger point on breast
 Any associated mass
 Presence or absence of heme
Types of Discharge
 Milky
 Multicolored and sticky
 Purulent
 Clear and watery
 Yellow or serous
 Pink or serosanguineous
 Bloody or Sanguineous
Physiologic/Non surgically
Significant Discharge
 Not spontaneous
 Arise from multiple ducts
 Usually bilateral
 2/3 of non lactating women can express
  fluid
Physiologic/Non surgically
Significant Discharges
 Purulent
 Multicolored and Sticky
 Milky/Galactorrhea
Purulent Discharge
 Produced by an infection
 Mostly child bearing age women
 Unilateral spontaneous discharge from
  multiple ducts
 Pain, tenderness
 Inflammation
Treatment of Purulent Discharge
 Antibiotics
 Incision and Drainage
 Biopsy of wall to r/o cancer
Multicolored Discharge
 Mostly green, yellow, white, brown, gray
 Ages 30-60
 Association with mammary duct ectasia
 Mammary duct - associated inflammatory
  disease sequence
Milky Discharge/Galactorrhea
 Bilateral
 Spontaneous
 Multiple ducts
 Child bearing years
 Non pregnant
 Not breast feeding
Galactorrhea Cont..
 Most common 1-2 years after pregnancy
 Increased production of prolactin
 Endocrine anovulatory syndrome
 Phenothiazines, tricyclics, rauwolfa
  alkaloids, methyldopa, oral contraceptives
 Hypothyroidism
 Pituitary adenoma
Galactorrhea Diagnosis
 Thin layer chromatography
 Radioimmunoassay for prolactin levels
 CT of Sella Turcica
Galactorrhea Therapy
 Large doses of estrogen and progesterone
 Bromocriptine mesylate
 Cabergoline
 Clomiphene
 Removal of adenoma
 Bilateral total duct ligation
Pregnancy
 Bloody Discharge is common
 20% of discharges during pregnancy
 Hypervascularity of the breast
 Benign
 No treatment required
Other Nipple Discharges
 Inverted Nipples
 Eczematoid lesions
 Traumatic erosions
 Herpes Simplex
 Infections
 Montgomery gland abscesses
 Mammary duct fistulas
Pathologic/Surgically Significant
Discharges
 Spontaneous
 Unilateral
 Localized to a single duct
 Persistent
 Intermittent
 Non lactation
Pathological/Surgically
Significant continued
 Clear or watery
 Yellow or Serous
 Pink or serosanguineous
 Bloody or sanguineous
Cancer Association
 Water 35%
 Sanguineous 28%
 Serosanguineous 13%
 Serous 6%
 Accompanied by a mass
 Age over 40
 Cytological and mammography findings
Etiology of Pathological
Discharge
 Intraductal Papilloma
 Multiple intraductal papillomas
 Juvenile Papillomatosis
 Carcinoma
Intraductal Papilloma
 Develop in major subareolar duct
 Most common cause of serous and
  serosanguineous discharge
 50% have bloody discharge
 1/3 have palpable mass
 Treated by microdochectomy
Multiple Intraductal Papilloma
 10% of intraductal papillomas
 Discharge is less common
 Increased association of breast carcinoma
Juvenile Papillomatosis
 Rare condition
 Ages 10-44
 Discrete mass lesion
 Treated by complete excision
Carcinoma
 14-34% of DCIS present with unilateral
  discharge
 25% of ductal carcinomas present with
  discharge
 Palpable mass
 Paget’s changes
 Microdochectomy for diagnosis
Operative Therapy
 Microdochectomy
 Total duct excision
The End

				
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