Nipple discharge

Nipple discharge is relatively common in the female population and is the third commonest cause of referral to a specialist breast clinic. However, it has been estimated that less than 10% of cancers are associated with breast discharge.

Nipple discharge can be categorised into several types: clear or watery, milky, serous, multicoloured or blood stained. In addition, the discharge may come from a single or from multiple ducts. The most common causes of the different types of nipple discharge are shown in Table 17.2. However, in a very small number of cases of watery or serous discharge coming from a single duct, an underlying cancer may be found. In a small number of women with prolonged,

Figure 17.15. Example of a mammary duct fistula.

profuse, bilateral milky discharge abnormal serum prolactin levels may suggest a prolactinoma of the pituitary gland.

After clinical examination of the breast various investigations are undertaken. The discharge should be tested for the presence of blood (e.g. Labstix testing) and examined microscopically for the presence of malignant cells. All patients over the age of 35 years should also have mammography; ultrasound examination of the breast may reveal the presence of dilated lactiferous ducts, particularly those close to the nipple and areola. In some patients, if there is discharge from a single duct, a ductogram (injection of contrast material into the duct) may demonstrate an intraduct papilloma, carcinoma or duct ectasia. In many women in whom no underlying cause for the discharge has been found, the discharge may resolve, be intermittent and/or of small amount which does not concern the patient (see Fig. 17.16 for management). However, if there is a large amount of discharge, if it comes from a single duct or tests suggest underlying pathology (e.g. prominent red blood cell content, atypical or malignant cells), then the duct should be removed surgically (microdochectomy). In older women or those not intending to conceive and breast feed, if the duct cannot be identified or the discharge comes from several ducts, then subareolar central duct excision is undertaken through a circumareolar incision.

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