This document discusses the evaluation and work up of a patient presenting with nipple discharge. It begins with the anatomy and physiology of the mammary ducts and hormones that can cause discharge. Pathological discharge is caused by growth in the ductal epithelium. Evaluations discussed include physical exam, mammography, ultrasound, ductography, cytology, biopsy and MRI which can identify etiologies like duct ectasia, papillomas or cancers. Discharge characteristics, diagnostic sensitivities of tests and management of different conditions are covered.

1. WORK UP WITH PATIENT
WITH NIPPLE DISCHARGE
Presented by : Samarah Majid
Supervised by : Dr.Suhad

2. Anatomy & Physiologyfv
• Mammary ducts lined by actively dividing epithelial cells which slough
• Orifice of non lactating women blocked by keratin plug
• Ductal system responds to estrogen, progesterone and prolactin.(Pituitary
Gland)
• Hormones interplay in Pregnancy, lactation and in non lactating women
Pathological discharge is caused by growth or proliferation of mammary
ductal epithelial lining
• Mammary ducts are the seat of origin of Breast cancer and hence of
significance. Stagnant pool

3. Breast cancer studies have
shown that majority of lesions are
multifocal
within the
confines of single duct

4. Definition of Discharge
When Secretions abundant/persistent enough
to
DISCHARGE
SPONTANEOUSLY
from
DUCT ORIFICE
DISCHARGE

5. If Ductal system is Normal Physiological
If Ductal system affected Pathological

6. Types of discharges associated with
cancer
Watery: 45%
• Sanguineous: 25%
• Serosanguinous: 12%
• Serous: 6%
•Bloody: < 3%

7. Types of Discharges with etiology
• Milk
• Colostrum (can last up to 2 years post partum)
• Bloody/Guiac Postive in 30% women in 2nd/3rd trimester
• Hyperprolactnaemia: Neurogenic stimulation, medications, stress
• Exogenous/Endogenous Hormones, Endocrine abnormalities
• Medical & surgical conditions
• Papilloma
• Duct Ectasia
• Eczema of skin
• DCIS ( ductal carcinoma in situ) / Malignancy
Lactation
Physiologic
al
Pathologica
l

9. Etiology of Physiological Discharges
• Neurogenic
stimulation
• Stress
• Sleep
• Exercise
• Excessive
Stimulation
• High Midday
Protein Meal
• Medications
• • Hormones
• • Antidepressants
• • Antianxiolytics
• • H2Receptor
Antagonists
• • Phenothiazines
• • Amphetamines
• • Antiemetics
• • Danazol
• • INH
• • Opiates
• • Antifungals
• Medical & Surgical
• Conditions
• • Pituitary
Adenoma
• • Hypothyroidism
• • Herpes Zoster
• • Thoractomy scar
• • Hypernephroma
• • Bronchogenic
Carcinoma

10. Evaluation
Physical examination
Induced / spontaneous, B /L / Unilateral, Single /
multiple Duct, Color, Texture / Consistency
Examine for Lump, lympnodes,
Examine Subareolar tissue

11. Investigations
USG , Mammography, Ductography, Cytology, FNAC,
HPR
CEMRI, Direct / Indirect MR Ductography,
Intraductal Approach

16. Mammography
• Standard Imaging Technique
• Microcalcifications/Other signs of malignancy
But
Not useful for diagnosis of etiology of ND
But
High NPV and Specificity(94%)

17. USG
•Non invasive
•• Limitations in small lesions without dialation
•& with dense fatty tissue.
•• Duct Dilation, solid internal echoes, Duct wall
•thickening in central or subareolar areas.
•• Important for FNAC

18. ND CYTOLOGY
• Simple and useful
• • Controversial as aspirate is normally very less.
• • Recent Studied revealed Sensitivity of 85%
• and Specificity of 97%.
• • Should always be done

19. FNAC
• Quite Sensitive
• If Aspirate is less
• Indicated

20. DUCTOGRAPHY
Secreting Duct is identified Canulated
Dye is Injected
• More Sensitive than ND Cytology & MMG
But invasive, time consuming
complications
• Can’t Differentiate
between benign &
Malignant

21. CEMRI
•Increasingly being used.
•• Diagnostic Sensitivity is 86-100% for invasive
•Ca.
•• Diagnostic Sensitivity is 46-100% for
•intraductal Ca.
•• Useful for evaluation of ND with occult
•disease
•• Useful for differentiating Benign & Malignant

22. HPR
Haptoglobin-related protein
• Excision of duct

24. Duct Ectasia (periductal mastitis)
Benign Disease in middle aged to elderly females
Can mimic malignancy
Pathological feature:
Dilated duct → engorged with breast secretion → infection
→retroareolar abscess → fibrosis → nipple retraction.
Clinical features:
Non Cyclical Mastalgia.
Periareolar erythema.
Nipple discharge: thick & creamy or greenish brown.
Periareolar tender mass.
-Nipple retraction (when healing occurs by fibrosis).

25. • Etiology: Not known. Smoking is implicated in pathogenesis.
• Investigations:
• o Mammogram: opaque mass of dilated ducts & skin
indentation.
• - Cytology: for discharge
• Management:
- Infection: aspiration & antibiotic.
- Abscess: drainage.
- Severe discharge or recurrent
sepsis: mammadochectomy (nipple
ducts excised through a circumareolar
incision preserving the
nipple).

26. Intraduct papilloma
Benign
Occurring in middle-aged women.
Clinical features:
- Bloodstained discharge.
- Bleeding from a single duct orifice
- (pressure over a certain spot or the palpable mass).
- Small mass: NOT usually.
Investigation:
- Mammogram (exclude carcinoma).
- Cytology assessment.
Management:
- Duct orifice (bleeding) is identified: microdochectomy.
- If not: excision of the major nipple ducts.

27. Thank you