Bloody nipple discharge tends to create panic and the clinician must do more than simply reassure the affected patient. Fortunately, most cases are secondary to benign pathologies and rarely malignant unlike the public perception. Nevertheless, a surgeon must be wary not to miss the rare malignant cases. Hence, it is important to adopt a systematic approach to dealing with such presentations. In a newly-wed, young woman, BND may spell disaster if not properly and convincinly handled, especially because it may lead to marital disharmony since the breast also serves a secondary sexual role.

1. DISCUSS THE MANAGEMENT OF
A 27 YEAR OLD NEWLY-WED
LADY WITH BLOODY RIGHT
NIPPLE DISCHARGEBy
DR ECHEBIRI, PROMISE
DEPARTMENT OF SURGERY, NATIONAL HOSPITAL, ABUJA
SUPERVISOR: DR O.O. OLAOMI
9TH SEPTEMBER, 2019

2. OUTLINE
• Introduction
• Pathogenesis of Nipple discharge
• Classification of Nipple discharge
• Differentials
• Clinical Evaluation
• Relevant Investigations
• Treatment Options
• Follow-up/Prognosis
• Recent trends/Advances
• Conclusion

3. INTRODUCTION
 Definition: Bloody nipple discharge (BND) is the presence of blood
coming from the duct orifices of the nipple,whether frank or altered.
 It is a subset of Nipple discharge which is the presence of any fluid from
the duct orifice(s).
 Epidemiology:
• In general, Nipple discharge is the third most common breast complaint
after breast pain, and breast lumps, comprising 7% to 10% of all breast
symptoms.

4. INTRODUCTION
• BND is usually caused by a benign lesion, such as intraductal
papilloma (35–56% of cases) or ductal ectasia (6–59%), but an
underlying cancer may be present in some cases (5 to 33%)
• If found, carcinoma is often associated with a palpable mass or
imaging abnormality
• 35% of patients with BND from carcinoma have no associated mass.
• In men, BND is rare.

5. INTRODUCTION
 Statement of Surgical Importance:
• Bloody Nipple Discharge (BND) is compels attention since it is
embarrassing to the woman.
• Furthermore, BND causes a high degree of anxiety in women because
of fear of breast cancer.
• The breast is a secondary sex organ, beyond primary role for breast
feeding. In a newly-wed lady, the development of BND may lead to
disastrous marital disharmony

6. PATHOGENESIS OF NIPPLE DISCHARGE
• The breast is composed of glandular and stromal tissues (adipose
tissue held together by a loose meshwork of fibers called Cooper’s
ligaments).
• The glandular tissues have a tree-like pattern beginning at the nipple
and branching through the stroma to terminate in lobules made up of
acini.
• These terminal ductal lobular units (TDLUs) are the functional units of
the breast.

7. PATHOGENESIS OF NIPPLE DISCHARGE

8. PATHOGENESIS OF NIPPLE DISCHARGE

9. PATHOGENESIS OF NIPPLE DISCHARGE
• TDLU consists of the extralobular terminal and intralobular terminal
ducts.
• Milk normally is expelled through the intra-lobular terminal ducts and
the extra-lobular terminal ducts into the subsegemental and
segmental collecting ducts and via the lactiferous ducts to the nipple.
• Each human breast has 15 to 20 lactiferous (milk) ducts.
• The Nipple (papilla) has 10 to 20 corresponding pores as the output
of the milk ducts

10. PATHOGENESIS OF NIPPLE DISCHARGE
• The skin of the nipple lies on a thin layer of smooth muscle called
areolar muscle fibers which are distributed in two directions: radial
(Sappey) fibres and circular (Meyerholz) fibres .
• This areolar muscle continues around the ducts into the breast
stroma. Its contraction is responsible for the expelling milk/ductal
secretion as well as, for the telotism of the nipple, “mimicking an
erection”. This is the basis for milk discharge during breast feeding
known as lactation.

11. PATHOGENESIS OF NIPPLE DISCHARGE

12. PATHOGENESIS OF NIPPLE DISCHARGE
• The ducts of the breast parenchyma are lined by actively dividing
epithelial cells which periodically slough to yield keratin debris.
• Orifices of the ducts at the nipple in nonlactating breasts are sealed
by keratin plugs
• This plug helps to prevent bacteria from entering the duct.

13. PATHOGENESIS OF NIPPLE DISCHARGE

14. PATHOGENESIS OF NIPPLE DISCHARGE
Composition of normal ductal secretion

15. PATHOGENESIS OF NIPPLE DISCHARGE
• The ductal epithelium is responsive to hormones (estrogen,
progesterone and prolactin), emotion and other substances e.g
medication. This scenario gives rise to physiological discharge.
• Pathological discharge is caused by structural changes of the ductal
epithelium such as proliferation. This induces neovascularization in
order to sustain the proliferating structures but the vessel walls are
weak and easily rupture leading to bleeding.

16. PATHOGENESIS OF NIPPLE DISCHARGE

17. CLASSIFICATION OF NIPPLE DISCHARGE
• NORMAL NIPPLE DISCHARGE (LACTATION): Milk production related
to pregnancy and breast feeding
• PHYSIOLOGIC NIPPLE DISCHARGE (GALACTORRHEA): Normal ductal
system
• PATHOLOGIC NIPPLE DISCHARGE (SUSPICIOUS): Abnormal ductal
system.

18. CLASSIFICATION OF NIPPLE DISCHARGE

19. CLASSIFICATION OF NIPPLE DISCHARGE

20. CLASSIFICATION OF NIPPLE DISCHARGE

21. DIFFERENTIALS
For a young woman with Unilateral, bloody, Nipple discharge:
• Non-malignant lesions:
• Intraductal papillomas
• Radial scar
• Usual ductal hyperplasia
• Atypical ductal hyperplasia
• Atypical lobular hyperplasia
• Fibroadenoma

22. DIFFERENTIALS
• Carcinoma: Ductal carcinoma in-situ (DCIS), Invasive ductal cancer,
Papillary cancer.
• Fibrocystic changes with an active intraductal component (eg
periductal mastitis, ductal ectasia)

23. CLINICAL EVALUATION
• Appearance: Clear, serous, creamy, yellow, green, purulent, bloody
• Unilateral vs Bilateral
• Spontaneous vs Provoked
• Persistent or intermittent
• Trauma e.g vigorous suckling by husband during honeymoon

24. CLINICAL EVALUATION
• Risk factors for breast cancer: Personal/Family history, Estrogen
exposure, Radiation exposure, Breast lump, Axillary swelling,
Metastatic foci, Breast skin changes, Nipple distortion
• Pregnancy status/LMP
• Coagulopathy e.g drug-induced
• Co-morbid illness: Asthmatic, Diabetic, Hypertensive, Seizures
• Skin changes, breast masses, axillary lymphadenopathy

25. RELEVANT INVESTIGATIONS
• Ultrasonography
• Mammography/Breast tomosynthesis
• Ductography
• MRI/MRD/CEMRI
• Ductoscopy/ Ductal lavage/ DNA PCR analysis
• FNAC/Core biopsy/Skin punch biopsy
• Microscopy/Culture, Occult blood test
• Base line investigations: FBC, Clotting profile, E/U/Cr, LFT, Urinalysis,
FBS
• Other indicated investigations: CT, Bone scan, Pregnancy test

26. RELEVANT INVESTIGATIONS

27. RELEVANT INVESTIGATIONS

28. RELEVANT INVESTIGATIONS

29. RELEVANT INVESTIGATIONS

30. RELEVANT INVESTIGATIONS

31. RELEVANT INVESTIGATIONS

32. RELEVANT INVESTIGATIONS
Masood cytologic index scoring system

33. TREATMENT OPTIONS
• Excision is generally indicated because there is as yet no group in
which surgical excision can be safely omitted
• Appropriate oncologic resection is indicated for underlying cancer
• For benign lesions, surgical excision of the involved lesion is advised
to rule out concomitant malignancy.
• Conclusively, benign aetiology may not require further surgical
excision at patients discretion.

34. TREATMENT OPTIONS
• Operative approach will involve single duct or the entire ductal system,
depending upon whether or not the pathologic nipple discharge can be
traced to a single duct.
• Lesion localized: Microductectomy is preferable since she is the
reproductive age group and there may be need for breast feeding
• Lesion not localized: Complete subareolar duct excision(Hadfield’s
procedure)

35. TREATMENT OPTIONS
• Postoperative care:
• Duct excision is usually performed as Day case procedure and patients
are allowed home on the same day .
• Analgesics are prescribed. Antibiotics are not indicated in clean
procedures.
• To ensure comfort, waterproof dressing such as Tegaderm is applied,
and the patient may shower while the primary dressing is in place,
otherwise, dressing must be kept dry and away from water.

36. FOLLOW-UP/PROGNOSIS
• Patient is seen at the outpatient department within a week of discharge.
• This will entail clinical evaluation for progress of recovery, fresh
complaints and wound status. Wound dressing is removed/changed as
necessary. Histology reports of excised lesions are reviewed for
completeness of resection and findings.
• Complications: Wound infection, nipple necrosis, duct fistula,
hematoma, nipple retraction, changes in nipple sensitivity

37. FOLLOW-UP/PROGNOSIS
• Further appointment(s) are influenced by wound status,
presence/absence of malignancy
• Overall prognosis is good for benign and early-stage cancers.

38. RECENT TRENDS/ADVANCES
• Zervoudis’s Mamary pump: sucking technique
• Personalised Medicine in Breast Cancer

39. CONCLUSION
• Nipple discharge is a relatively common breast complaint.
• Although, bloody nipple discharge is felt to be an ominous finding by
both patients and many surgeons, it is usually not due to an
underlying cancer.
• Determination of the exact cause of the discharge is key in effectively
managing it.
• Although cancer is not a frequent cause, it is important not to miss it
when it is the culprit.

40. NNobody wishes to bare herNIPPLES,
similarly,
Nobody wishes to bear a discharging
NIPPLE

41. REFERENCES
• Brunicardi, F., et al. (2014). Schwartz’s Principles of Surgery. 10th
Edition, McGraw-Hill Education, New York.
• Townsend, C. M., et al. (2017). Sabiston textbook of surgery: The
biological basis of modern surgical practice (20th edition.).
Philadelphia, PA: Elsevier Saunders.
• BAJA’s Principles and Practice of Surgery including Pathology in the
tropics.
• Leis HP, et al. Nipple discharge:surgical significance. South Med J 1998;
81:22-5.
• Florio MA et al.(2003). Nipple discharge: personal experience with 2.818
cases. Chirurgia Italiana; 55(3), 357-363.
• Morrow M (2000). Physical examination of the breast.In JR Harris, ME
Lippman, M Morrow, &CK Osborne,(Eds.),Diseases of the breast(2nd
ed.,pp.67-70).Philadelphia: Lippincott, Williams and Wilkins.

42. REFERENCES
• Zervoudis S et al. Transnipple pyramidectomy in pathological nipple
discharge; an original minimal surgery technique in a series of 80
cases.Eur. J. Gynaec.Oncol 2007;XXVIII, n4;307-309.
• Simmons R et al. Nonsurgical Evaluation of Pathologic Nipple
Discharge. Ann surg Oncol 2003; 10:113-116.
• Mouzaka L: Contemporary Mastology, Paschalides Publications
Athens 2007.
• Dawes LG et al. Ductography for nipple discharge: no replacement for
ductal excision. Surgery 1998; 124:685- 691.