nipple discharge

1. Nipple&oozes&–&When&to&
WORRY&and&why?&

2. Anatomy&
• The&glandular&por=on&of&the&breast&is&
composed&of&12&to&15&independent&ductal&
systems&that&each&drain&approximately&40&
lobules.&&
• Each&lobule&consists&of&10&to&100&milk&
producing&acini&that&empty&into&small&
terminal&ducts.&&
• Terminal&ducts&drain&into&larger&collec=ng&
ducts&that&merge&into&even&larger&ducts,&
which&exhibit&a&saccular&dila=on&just&below&
the&nipple&called&a&lac=ferous&sinus.&

4. Physiology&
• Terminal&ducts&near&the&acini&and&the&acini&themselves&
are&most&sensi=ve&to&ovarian&hormones&and&prolac=n.&&
• Most&forms&of&benign&and&malignant&breast&disease&
arise&in&these&terminal&ductOacinar&structures.&&
• Breast&epithelial&cells&proliferate&during&the&luteal&
phase&of&the&menstrual&cycle&when&estrogen&and&
progesterone&levels&are&increased,&and&then&undergo&
programmed&cell&death&at&the&end&of&the&luteal&phase,&
when&levels&of&these&hormones&decline.&&
• This&effect&is&mediated&&by&estrogenOreceptor&ac=va=on&
and&is&associated&with&an&increase&in&the&water&content&
of&the&extracellular&matrix&which&is&responsible&for&
premenstrual&breast&fullness&and&tenderness.&

5. Nipple&oozes&
• Fluid&can&be&expressed&from&the&nipple&
ducts&of&at&least&40&percent&of&
premenopausal&women,&55&percent&of&
parous&women&and&74&percent&of&women&
who&have&lactated&within&2&years.&
• Fluid&generally&issues&from&more&than&one&
duct&and&may&range&from&milky&white&to&
dark&green&or&brown.&
• Green&colora=on&maybe&related&to&the&
content&of&cholesterol&diepoxides&and&does&
not&necessarily&suggest&underlying&
infec=on&or&malignancy&

6. Physiological++
• Mul=duct&
discharges&that&are&
elicited&only&
following&manual&
expression&are&
considered&
physiologic&and&do&
not&require&
addi=onal&
evalua=on.&
• Spontaneous&
discharges&merit&
evalua=on.&
Pathological++
• Pathologic&nipple&
discharge&is&defned&as&a&
spontaneous&singleOduct&
discharge&that&is&serous&or&
bloody.&
• Most&pathologic&nipple&
discharges&are&caused&by&
benign&intraductal&
papillomas,&which&are&
simple&milk&duct&polyps.&

7. Classifica/on&
• Physiological:&AXer&child&birth&
• Pathological:&&
a) Benign(88%):&Duct&ectasia,&Duct&papilloma,&
Fibrocys=c&disease&of&breast,&Idiopathic,&
Prolac=nemia,&Infec=on,&Drugs&like&OCP&&&TCA,&
Dopamine&agonists.&
b) Malignant(12%):+Carcinoma&of&breast&

8. TYPE+OF+DISCHARGE&
• Milky:&Physiological&
• Bloody+discharge:+Duct&papilloma,&Duct&
ectasia,&carcinoma&
• Cream:+Duct&ectasia&
• S/cky+(green/brown/gray):&Duct&ectasia.&&
• Serous:&Fibrocys=c&disease,&ectasia.&
• Serosanguinous:&carcinoma,&infec=on.&
• Greenish:&Fibroadenosis&
• Black:&Duct&papilloma/carcinoma&

9. Types&of&Discharges&with&e=ology&
Lactation
Physiological
Pathological
• Milk
• Colostrum(canlastupto2yearspostpartum)
• Bloody/GuiacPostivein30%womenin2nd/3rdtrimester
• Hyperprolactnaemia:Neurogenicstimulation,medications,stress
• Exogenous/EndogenousHormones,Endocrineabnormalities
• Medical&surgicalconditions
• Papilloma
• DuctEctasia
• Eczemaofskin
• DCIS/Malignancy

10. CASES+

11. Case&1&
An&18&years&old&female&comes&c/o&
bilateral&nipple&discharge,&secondary&
amenorrhoea.&
&Pregnancy&test&was&nega=ve.&
On&Physical&examina=on&bilateral&serous&
discharge&oozing&from&nipples&seen.&
&
• How&will&you&proceed&?&

12. • A)&h/o&Drug&intake&O&
• &oral&contracep=on,&a&methyldopa,&
an=depressants,&&Dopamine&antagonist,&&
estrogen&therapy,&Opiates&
• B)&physiological&condi=onsO&intercourse,&
nipples&s=mula=on,&pregnancy,&
postpartum&nursing&with&suckling,&sleep,&
stress,&major&surgery&
• C)&h/o&hypothyroidism&in&family,&
tuberculosis&

14. • What&are&the&inves=ga=ons&you&would&like&to&
do?&

15. • Serum&prolac=nO&60ng/ml&
• Serum&TSH&&&&&&&&&O&10uIU/ml&
• Q)&When&&&How&will&you&draw&
sample&for&serum&prolac=n?&

16. • This&sample&preferably&is&drawn&
midmorning&and&not&aXer&stress,&
previous&venipuncture,&breast&
s=mula=on,&or&physical&
examina=on,&all&of&which&transiently&
increase&prolac=n&levels.&&
• Because&of&the&variability&of&
secre=on&and&inherent&limita=ons&of&
radioimmunoassay,&an&elevated&
level&should&always&be&rechecked.&&

17. • Would&you&ask&for&MRI/CT&in&this&
pa=ent?&
• In+pa/ents+with+a+clearly+iden/fiable+
drugPinduced+or+physiologic+
hyperprolac/nemia,+imaging+is+not+
necessary+unless+accompanied+by+
symptoms+sugges/ng+a+mass+lesion+
(headache,+visual+field+deficits).&

18. • Diagnosis?&
• Hyperprolac=nemia&secondary&to&
hypothyroidism.&

19. Treatment&

20. • Similar&situa=on&
• Inves=ga=onsO&
• Serum&TSHO&normal&
• Serum&Prolac=nO&84ng/ml&
How&to&proceed?++

21. • Imaging&–&MRI/CT&what&would&you&
prefer?&
• MRI&with&gadolinium&enhancement&of&
the&sella&and&pituitary&gland&appears&to&
provide&the&best&anatomic&detail&.&The&
cumula=ve&radia=on&dose&from&
mul=ple&CT&scans&may&cause&cataracts,&
and&the&“conedOdown”&views&or&
tomograms&of&the&sella&are&very&
insensi=ve&and&expose&the&pa=ent&to&
radia=on.&

23. • Diagnosis&&&Management&
• Microadenoma.&

24. • Medical&managementO&
• Bromocrip=ne&or&Cabergoline&

25. Bromocrip=ne&
• &The&dose&is&increased&gradually,&by&1.25&mg&
(oneOhalf&tablet)&daily&each&week&un=l&prolac=n&
levels&are&normal&or&a&dose&of&2.5&mg&twice&
daily&is&reached.&&
• A&proposed&regimen&is&as&follows:&oneOhalf&
tablet&every&evening&(1.25&mg)&for&1&week,&oneO
half&tablet&morning&and&evening&(1.25&mg)&
during&the&second&week,&oneOhalf&tablet&in&the&
morning&(1.25&mg)&and&a&full&tablet&every&
evening&(2.5&mg)&during&the&third&week,&and&
one&tablet&every&morning&and&every&evening&
during&the&fourth&week&and&thereaXer&(2.5&mg&
twice&a&day)&

26. • The&lowest&dose&that&maintains&the&prolac=n&
level&in&the&normal&range&is&con=nued&(1.25&
mg&twice&daily&oXen&is&sufficient&to&normalize&
prolac=n&levels&in&individuals&with&levels&less&
than&100&ng/mL).&&
• The&major&adverse&effects&include&nausea,&
headaches,&hypotension,&dizziness,&fa=gue&
and&drowsiness,&vomi=ng,&headaches,&nasal&
conges=on,&and&cons=pa=on.&&

27. Cabergoline&
• Cabergoline,&which&appears&to&be&as&effec=ve&
as&bromocrip=ne&in&lowering&prolac=n&levels&
and&in&reducing&tumor&size,&has&substan=ally&
fewer&adverse&effects&than&bromocrip=ne.&
Very&rarely,&pa=ents&experience&nausea&and&
vomi=ng&or&dizziness&with&cabergoline;&they&
may&be&treated&with&intravaginal&cabergoline&
as&with&bromocrip=ne.&&

28. • A&gradually&increasing&dosage&helps&avoid&
the&side&effects&of&nausea,&vomi=ng,&and&
dizziness.&Cabergoline&at&0.25&mg&twice&
per&week&is&usually&adequate&for&
hyperprolac=nemia&with&values&less&than&
100&ng/mL.&
• &If&required&to&normalize&prolac=n&levels,&
the&dosage&can&be&increase&by&0.25&mg&
per&dose&on&a&weekly&basis&to&a&maximum&
of&1&mg&twice&weekly.&

29. Which&is&safer:&&
Bromocrip=ne&v/s&Cabergoline&
• The&rela=ve&safety&of&bromocrip=ne&
in&reproduc=ve&females&suggests&
bromocrip=ne&as&the&first&choice&for&
hyperprolac=naemia,&micro&and&
macroadenoma.&

30. Other&Medica=ons&
• When&Bromocrip=ne&or&cabergoline&cannot&be&
used&then&pergolide&or&metergoline&may&be&
used.&

31. Follow&up&
• Follow&up&of&pa=ent&of&microadenoma&
• Repeat&MRI&scan&aXer&6O12&months&aXer&
prolac=n&levels&are&normal.&
• Further&MRI&scans&should&only&be&performed&if&
new&symptoms&appear.&

32. Dura=on&of&treatment&
• Discon=nua=on&of&bromocrip=ne&therapy&
aXer&2O3&years&maybe&amempted&in&
pa=ents&who&have&maintained&
normoprolac=naemia&while&on&therapy.&
• Discon=nua=on&of&cabergoline&therapy&
was&successful&in&pa=ents&treated&for&3O4&
years&who&maintained&
normoprolac=naemia.&But&in&these&a&
recurrent&rate&of&64%&was&noted.&

33. CASE&2&
35&yrs&/&Female&&
• &Presented&with&CYCLICAL&MASTALGIA&,&premenstrual&pain&&
• C/O&SMALL&LUMPS&PALPABLE&&
• C/O&&bilateral&nipple&discharge&&GREENISH&&
• Pt&is&scared&,&feels&she&has&BREAST&CANCER&&
• Her&maternal&aunt&had&Ca&breast&&
• ON&EXAMINATION&&&&O&&No&definite&lump&palpable&,&DIFFUSE&
GRANULAR&TENDER&&SWELLING&in&upper&,&outer&quadrant.no&fixity&
to&skin&,&muscle&.&SEROUS&OR&GREENISH&DISCHARGE&+&
• &&
• HOW&TO&INVESTIGATE&AND&TREATMENT&??&
&&&&&&&&&&&&&&&

34. CASE&2&
&
• &SONOMAMMOGRAPHY:&BIRADS&II&Benign&,&
sugges=ve&of&fibrocys=c&disease&
• STROMAL&HYPERPLASIA&,&ADENOSIS&(increased&
glands),&MICRO&CYST&FORMATION&&
• &&&&&&&Diffuse&,&small&mul=ple&cysts&are&main&
component&–&Schimmelbusch&disease&&
• &&&One&of&the&cysts&may&get&enlarged&to&become&
palpable&,&localised&swelling&BLUEDOME&CYST&OF&
BLOODGOOD&&

35. CYST&
• At&US,&breast&cysts&are&categorized&as&simple,&
complicated,&or&complex&&
• Simple&cysts&are&defined&as&anechoic,&wellO
circumscribed,&round&or&ovoid&
• masses&with&an&impercep=ble&wall&and&increased&
throughOtransmission&of&sound&waves.&&
• do&not&require&interven=on.&Painful&cysts&can&be&
aspirated&for&symptom&relief.&

36. CASE&2&
&
&
• Nipple&discharge&revealed&sheets&of&foamy&
his=ocytes&on&the&background&of&
haemorrhagic&material.&
• Duct&epithelial&cells&or&malignant&cells&are&not&
seen.&
• &&

38. CASE&2&
&
Diagnosis:&FIBROCYSTADENOSIS&&
Fibro&cys=c&disease&of&&breast/fibroadenosis&
• Most&common&breast&disease&&
• Due&to&Aberra=on&of&Normal&Development&and&
Involu=on&(ANDI)&of&breast&&
• Estrogen&dependant&condi=on&
• Exaggerated&response&of&breast&stroma&and&
epithelium&to&hormones&&&&&&&&&&&&&&&&&&&&

39. • ROLE&OF&FNAC&??&

40. • FNAC&&
• &CLASSIFICATION&&
• &&Nonprolifera=ve&–&moderate&hyperplasia&of&
ductal&luminal&cells&–&NO&life=me&risk&of&Ca&
• &&Prolifera=ve&without&atypia&(severe&hyperplasia)&
• &&Prolifera=ve&with&atypia&(ATYPICAL&Ductal&/
Lobular&hyperplasia&)—RISK&FACTOR&FOR&BREAST&
CANCER&.Florid&epitheliosis&is&premalignant&

41. • TREATMENT&??&

42. TREATMENT&
• CONSERVATIVE&&&
• &&&Reassurance&&
• &&&avoid&caffeine&,&chocolate&,&salt&
• MEDICAL&&
• &&&&&EVENING&PRIMROSE&OIL&–contains&Gamolenic&
acid&–it&reverses&saturated&to&unsaturated&famy&
acids&.&Also&contains&Linolenic&acid&and&Linoleic&
acid.&&&&&&&&&&&&&&&1000O3000&mg&/day&
• GAMOLENIC&ACID&CAP&&&120&mg&/&day&

43. • DANAZOL&–&very&effec=ve&but&not&used&due&to&
side&effects&–&acne,&hirsu=sm,&weight&gain&,&
amenorrhea&,&teratogenic&&
• TAMOXIFEN&–&an=estrogenic&&&10&mg&bd&&
• LHRH&AGONIST&(goserelin&)&is&reserved&for&
refractory&&
• Vit&E&,&B6&,&&NSAIDS&used&&

44. TREATMENT&&&WITH&&SERM&&
• ORMELOXIFENE&&&&
• Weak&ER&agonist&and&strong&ER&
antagonist&
• &&&30&mg&&alternate&days&for&3&months&
• Studies&have&shown&significant&
efficacy&for&treatment&of&mastalgia&
and&fibrocys=c&disease&

45. SURGERY&&
• INDICATIONS&&
• &&&&&Intractable&pain&
• &&&&&florid&epitheliosis&on&FNAC&
• &&&&&Bloodgood&cyst&
• &&&&&&Persistent&bloody&discharge&&
• &&&&&&Psychological&reason&&
• SUBCUTANEOUS&&MASTECTOMY&WITH&
PROSTHESIS&PLACEMENT&O&&only&in&severe&
persistent&disease&
• EXCISION&OF&CYST&OR&LOCALISED&EXCISION&
OF&DISEASED&TISSUE&

46. Case&3&
• A&45&year&old&female&comes&with&complaint&of&
discharge&from&the&nipples.&She&gives&H/o&nonO
cyclical&mastalgia.&
• O/E&there&is&&
1. periareolar&erythema&&
2. greenish&brown&nipple&discharge&&
3. periareolar&tender&mass&
4. Nipple&retrac=on&

47. WHAT+IS+THE+DIFFERENTIAL?+
HOW+TO+PROCEED?+

48. Inves=ga=on&
• Mammogram:opaquemassofdilated
ducts&skinindentation.
• Cytology:Paucicellular,withfew
scatteredcohesiveclustersofductal
epithelialcellswithmildatypiaand
peripheralmyoepithelialcells
• AlsoCD68+macrophageswithfinely
vacuolatedcytoplasm&

49. Ultrasonography+&
• US&is&quickly&becoming&the&new&standard&of&
reference&for&evalua=on&of&suspected&ductal&
disease.&&
• Ducts&are&visualized&as&tubular&structures&that&
are&typically&wider&at&the&level&of&the&nipple,&
then&taper&more&distally&as&they&arborize&
peripherally.&Normal&ducts&are&collapsed&or&up&
to&1–2&mm&in&diameter.&&

50. Galactography+&
• If&the&US&results&are&nega=ve,&Galactography&is&
performed.&&
• In&galactography&30Ogauge&bluntO=p&catheter&is&used&to&
cannulate&the&duct,&then&&0.2–0.3&mL&of&a&waterO
soluble&contrast&medium&is&injected&into&the&duct.&Two&
orthogonal&views&are&obtained&as&part&of&the&
evalua=on,&with&addi=onal&views&obtained&as&
necessary.&&
• On&a&normal&galactogram,&contrast&material&diffuses&
and&fills&branching&ductal&systems&extending&toward&
the&chest&wall.&Normal&ducts&have&a&branching,&
smoothOtapering&appearance.&&

51. DUCTOGRAPHY&

52. DIAGNOSIS?+

53. Duct&Ectasia&
E=ology:&&
Not&known.&Smoking&is&implicated&in&
pathogenesis.&May&&be&a&response&to&
stagnant&colostrum&
Pathological&feature:&&
Dilatedduct→engorgedwithbreast
secretion→infection→retroareolar
abscess→fibrosis→nippleretraction.
&

54. TREATMENT?+

55. Treatment&&
• Infection:aspiration&antibiotic.
• Abscess:drainage.
• Severedischargeorrecurrentsepsis:
mammadochectomy(nippleductsexcised
throughacircumareolarincisionpreserving
thenipple).

56. CASE&4&

57. CASE&4&
• 65&yrs,&Female&
• &Presented&with&breast&lump&in&leX&breast&central&
quadrant&with&haemorrhagic&nipple&discharge.&Il&
defined,&firm&to&hard&&and&non&mobile&lump.&
Nipple&areola&show&slight&retrac=on.&
• &Mammography:&BIRADS&O5&
• &Nipple&discharge&reveal&sheets,&groups&and&singly&
scamered&&atypical&cells&having&pleomorphic&and&
hyperchroma=c&nuclei,&increased&nuclear&
cytoplasmic&ra=o&&and&mitosis&on&the&background&
of&haemorrhagic&material.&&
• &Diagnosis:&Smears&are&posi=ve&for&malignant&cells&
(Duct&carcinoma&cells&seen)&

59. MALIGNANT&DISEASE&
The&most&common&malignant&disease&affec=ng&the&
ductal&system&of&the&breast&is&DCIS.&&
Ductal+Carcinoma+in+Situ+:Typically,&DCIS&manifests&as&
calcifica=ons&at&mammography&,&although&in&up&to&
14%&of&cases&it&may&manifest&as&a&solid&mass&with&
or&without&associated&calcifica=ons.&&
At&US,&DCIS&can&appear&as&an&intraductal&mass&or&a&
solid&intraparenchymal&mass&with&adjacent&ductal&
dilata=on&or&extension.&&
At&MR&imaging,&linear&nodular&or&ductal&enhancement&
or&focal&nonOmasslike&enhancement&with&
persistent,&plateau,&or&washout&kine=cs&may&be&
seen.&

60. Dilated+duct+with+intra+ductal+lesion+

61. • Invasive+ductal+carcinoma:+At&
mammography,&these&cancers&most&
commonly&appear&as&spiculated&or&
irregular&masses&with&or&without&
associated&calcifica=ons&or&as&developing&
asymmetries.&Focused&US&evalua=on&
typically&reveals&a&mass&with&classically&
suspicious&features.&&&
• A&mass&demonstra=ng&ductal&extension&
is&highly&specific&for&malignancy.&
&

62. • Paget+Disease+Paget&disease&typically&manifests&
with&symptoms&limited&to&one&breast,&including&
nipple&discharge&(serous&or&sanguineous),&nipple&
inversion,&a&palpable&mass,&or&an&eczemaOtype&rash&
involving&the&nipple.&The&diagnosis&is&made&with&
skin&biopsy.&&
• Most&of&these&pa=ents&have&an&underlying&
malignancy,&either&DCIS&or&invasive&carcinoma.&In&a&
minority&of&cases,&these&lesions&may&manifest&as&an&
intraductal&finding,&although&at&=mes&diagnos=c&
evalua=on&does&not&result&in&iden=fica=on&of&the&
primary&breast&lesion.&&&

63. MASS&&
INTRADUCTAL+EXTENSION+

64. Case&5&
• A&35&year&old&female&came&with&C/O&bloody&
discharge&from&nipple.&However,&she&couldnot&
feel&any&lump&in&the&breast.&&
• On&Examina=on:&
1. Bloodstained&discharge.&
2. Bleeding&from&a&single&duct&orifice&on&pressure&
over&a&certain&spot&or&the&palpable&mass.&
3. Small&mass&felt&

65. Differen=al&diagnosis&&
of&blood&stained&discharge&
• Papiloma&
• Malignancy&&
• Duct&ectasia&
• Infec=on&
• Forceful&expressing&of&milk&

66. HOW+TO+PROCEED?+

67. Inves=ga=on&
• USG/Mammogram
• Expressandidentifythe
pathologicalduct,cannulateand
performductography.
• Cytologyassessmenttoruleout
malignancy.

69. DIAGNOSIS?+
Duct&Papilloma&

70. TREATMENT?+

71. Treatment&
• Ductorifice(bleeding)isidentified:
microdochectomy.
• Ifnot:excisionofthemajornipple
ducts.

72. NIPPLE&OOZES&–&WHEN&TO&WORRY&&&WHY&?????&
• Nipple&discharges&are&&most&oXen&
PHYSIOLOGICAL&
• &&&&&SO&WHEN&TO&WORRY&&??&
• SPONTANEOUS&DISCHARGE&&
• UNILATERAL&&
• SINGLE&DUCT&DISCHARGE&&
• COLOURED&DISCHARGE&&&
• ASSOCIATED&WITH&LUMP&&
• ABOVE,&&MAY&BE&OFTEN&ASSOCIATED&WITH&
SOME&PATHOLOGY&&

73. Nipple&discharge&OF&CONCERN&
• Discharge&that&is&unilateral,&from&a&
single+duct,+&spontaneous,++serous,+
serosanguinous++or++bloody&is&of&
greater&concern.&Such&discharge&can&
be&from&papilloma&or&carcinoma.&

74. Causes&of&nipple&discharge.&
&
• &&Physiological&
• &&&&Fibrocys=c&changes.&
• &&&&&Hyperprolac=nemia&
• &&&&&Duct&ectasia.&&
• &&&&Inspissated&secre=ons,&infec=on,&hemorrhage,&
• &&&&&Papilloma&
• &&&&&Carcinoma.&
&
&&&&&&

75. &&&&HISTORY&&OFTEN&POINTS&TO&THE&DIAGNOSIS&&
&&&&CLINICAL&EXAMINATION&CLINCHES&THE&
DIAGNOSIS&
&
&&&&&Different&modali=es&used&are&
• SONOGRAPHY&
• Mammography&
• Galactography.&
• MRI.&

76. • In&specific&cases&and&clinical&
circumstances,&MR+imaging&with&
contrast&material&can&be&a&strong&
adjunc=ve&tool&in&the&seung&of&a&
nega=ve&imaging&workOup&with&
mammography&and&sonography&for&
nipple&discharge.&

77. THANKS&