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Dr. T. T. Alagaratnam FRCS (Eng), FRCS

Dr. T. T. Alagaratnam FRCS (Eng), FRCS

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05/21/2012

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Dr.
T. T.
Alagaratnam
FRCS
(Eng),
FRCS
(Ed)Senior Lecturer, Dept,
of
SurgeryUniversity
of
Hong Kong
Discharge
From
The
Nipple
Summary
The
common causes
of a
discharge from
the
nipple
and a
brief outline
of
their
manage-ment
are
discussed.
Introduction
The
normal female breast secretes
a
smallquantity
of
fluid
which
is
discharged
at the
nipple. These small quantities
of
fluid
are
hardly ever noticed
by the
patient. Abnormal
dischargesare
invariably larger amounts whichusually leave stains
on the
patient's clothes.Another difference between physiological
and
pathological secretion is its colour.
Normal
breast
secretion
is
colourless
or
slightly
yellow.Abnormal secretions
are
more deeply yellow,milky,
brown,
or
blood
stained.
Once
an
abnormal discharge from
the
nipple
is
diagnosed,
the
next
consideration
is to
inspect
both nipples closely
and
look
for any
ulceration
or
eczema-like lesion.
Discharges
due
to
local lesions
in the
nipple must
be
distinguished from those associated
with
a
normal
nipple.
The
latter
are due to
causes
arising
from
the
breast tissue itself.
(A)
Discharges associated
with
an
abnormalnipple.
The
common causes
of
such
a
con-dition
are
(1)
Malignant ulceration
of the
nipple
This
is by far the
most
important lesion
one
must
be
aware
of.
Paget's disease
of
the
nipple presents
as a
small
area
of
ulceration
of the
nipple
and
areola;
it is
surrounded
by an
area
of
pigmentation
and
scaling which should
not be
confused
with
eczema.
Paget's
disease
is
always
associated
with
an
underlying
duct
carcinoma.
In
these patients,
a
biopsy
of
the
ulcerated
area
is
necessary
to
confirm
the
diagnosis
and
subsequentmanagement
is as for
carcinoma
of the
breast.
(2) Non
malignant
ulceration
— This is
usually
seen
in
young females;
the
condition
may
be
unilateral
or
bilateral;
it is due to
minor
recurrent
trauma
to the
nipple, usually
dueto
wearing
tight
brassieres. Occasionally
such
ulcerated nipples
may be
associated
with
symptoms
and
signs
of
infection
in
the
breast. Simple measures such
as
cleaning
the
nipple
with
an
antiseptic
and
applying
a
protective dressing,
will
permit
healing
to
occur.
(3)
True eczema
of the
nipple
This again
is
a
condition seen
in
young females.
Itinvariably
affects
both nipples
and
areolae
and
(in the
author's experience)
is
usually a
form
of
contact dermatitis
due
to
wearing
brassieres
made
of
nylon.
The
local
application
of 1%
hydrocortisone
cream
and a
change
to
cotton
or
silkclothing results
in a
rapid cure.
(B)
Discharge associated
with
a
normalnipple.
When there
is no
local lesion
in the
nipple to
account
for the discharge, then one
must infer
that
it is a
secretion from breasttissue. There are, however, three clinical con-ditions
in
which
the
abnormal discharge
may
be
due to
physiological causes.
(1)
Occasionally women
who
take oral con-
traceptivesmay be
troubled
by a
nipple
discharge
which
is
usually serous
or
milky
and
usually bilateral. The discharge is
never
blood
stained. Stopping
the
drug
usually cures
the
complaint.
(2)
Nipple discharge
may
occur
during
the
middle
or
last
trimester
of
pregnancy;
a
bloody discharge
may
occur
from
both
breasts
and
even occasionally
persist
during
the
period
of
lactation.
Reassur-
ance
is all
that
is
necessary
and in the
majority
of
cases
the
condition
usually
subsidies
after
delivery.
(3)
Rarely, young
women
with
rapidly
grow-
ing
breasts
may
develop
a
serous dis-charge
during
the
first
two days of a
menstrual period. Here again there
is no
special treatment
required.
1708
 
Discharge from
the
nipple
In
all
these instances,
the
nipple
discharge
is a
symptom
of
exaggerated proliferation
ofthe
duct
epithelium under
the
influence
of
hormones. They requirenospecial treatment.Fibrocystic disease of the breast is seldom if
ever
associated
with
a
nipple
discharge.
If
the conditions
listed
above have beenexcluded, then
it is
important
to
consider next
whether
the
nipple
discharge
is
associated
with
alumpin thebreast (Fig.1). Ifsuchalump
is
detected,
then
subsequent investiga-
tion
and
management
will
be
along
the
linesof any patient presenting
with
a
lump
in the
breast;
thenipple dischargeis now ofsecondary importance. When there
is noassociated
lump,
one
would
then proceedfurther to ascertain whether the discharge isfrom
a
single
duct,
or
diffusedly from
several
ducts. This can be done by the bed
side.
With
the
patient
lying
comfortably
on her
back, digital pressure
is
applied
with
the tip
of thefinger alongthecircumferenceof the
areola.
If
light
pressure elicits
a
discharge,then
the
position
on the
nipple
at
which
the
discharge was
seen
is
noted .Discharge from
a
single
duct
is always pathological, and itmerits
further investigation
in the
form
of aductogram (the
duct
in
question
is
cannulated
with
a
fine cannula
and an
X-Ray
taken afterinjection
of a
radio-opaque dye)
which
will
outline
the
lumen
of the
duct,
permitting
oneto
confirm
the
presence
of
single
or
multipleduct papillomas
or a
papillary type
of
breast
carcinoma.
It is
extremely difficult
to
dis-
tinguish
between
thelasttwo
conditions
by
the
bed
side.
Cytological examination of the
discharge
has been done but found to be
unhelpful.
Haagenson
has
recorded
a
false
negative rate
of 31 %
1
.
Distinction
between
benign
and
malignant papillomas
can
only
bedone
after excision of the affected duct
together
with
the related glandular tissue of
the
breast (Microdochectomy).
The
ductmust
be cut
open
and any
tumour presentmust
be
examined
by
frozen section. Benign
papillomas
require no further treatment.Malignant papillomas
will
need further surgery
as
for
malignant lesions
of the
breast.
If
it is ascertained by careful physical
examination
that the discharge is not from
one
particular duct but from several ducts
Nipple
discharge
Normal nippleLumppresent
No
lump
present
ulcerated
nipple
Paget's disease
Minor
recurrent
(Treat
as for
trauma
breast
cancer)
Eczema
of
nipple
Localised
to one
duct
From several
ductsI (Duct
ectasia
Haagenson's operation)
Duct
carcinoma
(Treat
as for
breast
cancer)Duct papilloma(Microdochectomy)
Fig.
1.
Management
of
nipple
discharge
1709

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