Nipple Discharge

CHAPTER 15
Evaluation of Nipple Discharge
She’s a little embarrassed. And she’s more than a little Benign nipple discharge (not milky) (Fig. 15-1) in pre-
nervous. She saw a spot of blood in her bra. Does she menopausal women is most commonly due to fibrocystic
have cancer? Her mammogram last month was normal, change in which cysts communicate with the ducts (Fig.
so everything must be fine. 15-2). In postmenopausal women, duct ectasia is the
most common cause. With duct ectasia, the ducts are
Don’t let this make you nervous. Figuring out who has dilated in the subareolar region and become attenuated
concerning versus benign discharge is actually pretty more posteriorly (Fig. 15-3).
straightforward. One of the most helpful things you can Worrisome discharge (Fig. 15-4) is due to an intra-
do now is go talk with her and examine her. Ask her to ductal papilloma 90% of the time (Fig. 15-5), but is due
show you the discharge. With a few questions, you can to ductal carcinoma in situ (DCIS) about 8% of the time
usually tell whether she needs reassurance or imaging. (Fig. 15-6). A single intraductal mass near the nipple is
(P.S. The mammogram is almost always normal.) most likely to represent a papilloma; however, the imaging
In a typical history for worrisome discharge a woman appearance is not definitive, and a tissue diagnosis is
notices a spot of blood in her bra or a wet spot on her needed. Multiple intraductal masses (see Fig. 15-6) are
nightgown upon awakening. Worrisome discharge is concerning for DCIS but may be due to papillomatosis
usually unilateral, but can occur in women with preexist- or even debris. Trauma (e.g., injury due to a motor vehicle
ing bilateral benign nipple discharge. It may occur only collision), core or surgical biopsy, and cyst aspiration are
once or a few times and seem to resolve. A typical history rare causes of bloody discharge. Occasionally, a cause is
for benign nipple discharge is discharge that is expressed not identified.
or occurs during mammographic compression and can be
any color except bloody. A warm bath or shower relaxes
the smooth muscle in the nipple, so discharge that only Evaluating Nipple Discharge
appears following bathing is not considered spontaneous
and is usually benign. Clinical history and examination are important in order
Discharge that is bloody is concerning, but so is serous to triage who needs blood work (milky), reassurance
discharge. If the discharge is yellow or clear, the fluid can (benign), or workup (worrisome). The first question to
be checked for the presence of blood using a urine dip- ask is how the patient noticed the discharge. This will tell
stick. A dipstick that turns green within the first 30 you if it is spontaneous or expressible. You will also want
seconds indicates blood products and should be consid- to know the color and duration of the discharge, and
ered a true positive. If you look at the dipstick later, it whether it is unilateral or bilateral. Women should also
will eventually turn green due to the lactoferrin that is be asked about medications that could explain milky
normally secreted in breast fluid, which is a false positive discharge and whether there is any recent history of
(Table 15-1). trauma.
Mammography may reveal suspicious calcifications
indicating DCIS as the cause, but is nearly always nega-
Etiology of Nipple Discharge tive. Sometimes a solitary dilated duct will correlate with
the offending duct. This finding is not very specific,
Milky discharge (galactorrhea) is not concerning for although it becomes more suspicious if it is new or
breast cancer but may be due to a brain tumor— increasing, associated with concerning calcifications, or
specifically a pituitary prolactinoma. Women with thyroid in a non-subareolar location. Don’t bother with spot
disorders can also have milky discharge because thyroid- compression or magnification views behind the nipple
stimulating hormone (TSH) can cross-talk with prolactin. unless an abnormality is suspected on the routine views.
Serum prolactin and TSH should be checked in women Ultrasound can be very useful for evaluating ductal
with milky discharge. Some medications can also result pathology (Fig. 15-7). The location of the discharging
in milky discharge, including psychotropic medications, orifice on the nipple can be helpful in guiding the ultra-
such as antidepressants, neuroleptics, and metoclo- sonography (US) examination. For example, if the orifice
pramide. These medications are dopamine antagonists, is on the lateral aspect of the nipple, it is likely that the
which stimulate prolactin production. abnormal duct system will also be in the lateral breast. If
Downloaded from ClinicalKey.com at ClinicalKey Global Guest Users on March 18, 2016. 401
For personal use only. No other uses without permission. Copyright ©2016. Elsevier Inc. All rights reserved.
402 SECTION IV DIAGNOSTIC EXAMINATIONS AND MANAGEMENT
TABLE 15-1 Distinguishing Worrisome

from Benign Nipple
Discharge
POTENTIALLY CANCEROUS PROBABLY BENIGN
Unilateral Often bilateral

Bloody or serous Yellow, green, black, milky
From a single orifice From multiple orifices
Spontaneous Expressible
FIGURE 15-3 Duct Ectasia on Galactogram. The patient had a few

spontaneous episodes of minimal serous discharge. Only duct ectasia is
seen on galactography. No further evaluation is necessary.
FIGURE 15-1 Benign Nipple Discharge. Multiduct green discharge.

The discharge was bilateral and not spontaneous.
FIGURE 15-2 Fibrocystic Changes on Galactogram. One large and

several small cysts are filling (arrows). This patient had serous, heme-
negative nipple discharge.
there is a known trigger point—a specific site that elicits

discharge on palpation—it can also be used to localize
the abnormal duct system. If an intraductal mass is identi-
fied on a galactogram, US can be performed to see if the
mass is amenable to wire localization using ultrasound B
guidance. However, US is poor in identifying peripheral FIGURE 15-4 Worrisome Nipple Discharge. A, Serous, single-duct
intraductal masses (Fig. 15-8), so if the US is negative, discharge that is heme-positive. B, The green color indicates blood in
additional evaluation will be necessary. the fluid on these urine dipsticks.
Galactography involves cannulation of the offending
duct and injection of contrast material. Central and
peripheral intraductal masses are equally well identified.
Downloaded from ClinicalKey.com at ClinicalKey Global Guest Users on March 18, 2016.
Chapter 15 Evaluation of Nipple Discharge 403
FIGURE 15-5 Large Single Intraductal Mass. The mass is centrally FIGURE 15-6 Multiple Intraductal Masses. Multiple intraductal
located on galactography (arrows). Diagnosis: intraductal papilloma. masses (yellow arrows) are present as well as abrupt duct termination
(blue arrows) on the galactogram. Incidental fibrocystic change is
present with filling of some benign cysts. Diagnosis: DCIS, high grade.
FIGURE 15-7 Intraductal Mass on US. Doppler flow confirms that the mass is solid and not debris. Diagnosis: papilloma.
A B
FIGURE 15-8 Multiple Intraductal Masses Not Seen on US. A, US shows a single proximal intraductal mass (arrow). B, Galactogram shows
multiple intraductal masses (arrows). Central duct excision showed papillomatosis.
CC ML
FIGURE 15-9 Air Introduced

During Galactogram. On the cra-
niocaudal (CC) view (A), two
small round intraductal lesions are
identified (arrows). On the medio-
lateral view (B), they both shift in
position to the nondependent duct A B
wall (arrow).
Also known as ductography, galactography is our proce-

dure of choice for evaluating nipple discharge. An abnor- T2
mal galactogram may show abrupt duct termination, a
single filling defect (intraductal mass), multiple filling
defects, or irregular narrowing of the duct lumen.
Air can be introduced into the duct inadvertently
through the galactography catheter (Fig. 15-9). Although
DCIS can present as tiny, round, intraductal masses, the
masses will not shift in position like air bubbles. Debris
can mimic intraductal masses as well.
Contrast-enhanced magnetic resonance imaging (MRI)
may be helpful in identifying papillomas and DCIS in
women with nipple discharge. The abnormal duct can A
sometimes appear hyperintense on the T2-weighted
sequences (Fig. 15-10). Postcontrast sequences reveal the T1 sub
lesion causing the discharge in about 90% of cases.
Although more expensive, MRI is a useful alternative if
the duct cannot be cannulated for galactography and US
is negative. Ductoscopy is a less common procedure that
is performed at a few institutions with reasonable success.
Managing the Abnormal

Galactogram or US
Nice job! You found an intraductal mass 3 cm behind the

nipple. It will need to be excised for definitive diagnosis. B
Now how will the surgeon excise the correct area? Here
are the options:
In central duct excision the lactiferous sinuses and
major ducts are removed from the subareolar region. This
includes the ductal structures within 1 to 2 cm from the
nipple. This therapeutic procedure will resolve the
patient’s symptom of nipple discharge but may or may
not be diagnostic, depending upon the location of the
causative lesion (Fig. 15-11). If the patient has an
FIGURE 15-10 MRI Evaluation of Nipple Discharge. In this patient,

there is high T2 signal in the duct (A) with a corresponding enhancing
intraductal mass on T1 (B, arrow). US identified a correlative mass C
(C, arrow). Histologic examination showed intraductal papilloma.
intraductal mass identified by US or galactography that Clip placement after galactogram using mammo-
is within 1 to 2 cm from the nipple, then central duct graphic guidance (Fig. 15-12) allows wire localization
excision is a good procedure. However, if our patient has and surgical excision when the timing is convenient
an intraductal mass that is 3 cm from the nipple, there is without repeating the galactogram. This is our typical
a good chance that it will not be removed during central strategy for intraductal masses identified on galactogra-
duct excision. phy that are more than 1 to 2 cm behind the nipple.
Subtraction
A B
FIGURE 15-11 False Negative Central Duct Excision. A, Galactogram shows multiple intraductal masses. Central duct excision showed a single
minute papilloma. Her subsequent MRI (B) shows segmental nonmass enhancement (open arrow) directly posterior to the central duct cavity
(arrow). Re-excision showed extensive DCIS, high grade.
CC LM CC CC CC
A B C1 C2 C3
CC ML
D1 D2 E
FIGURE 15-12 Clip Placement After Galactogram. A, Galactogram shows an intraductal mass 5 cm posterior to the nipple (arrow). The technique
is similar to wire localization. B, The breast is placed in an alphanumeric grid. A lateromedial approach was used in this case. The intraductal mass
is at 1.4 and B.7. The clip device is placed perpendicular to the skin. C, The breast is released from compression, and an orthogonal view is obtained
(a CC view in this case). The tip of the needle is pulled back to the location of the intraductal mass (arrow). D, The clip is placed. On the day of
surgery (several weeks later in this case), the clip is localized with a wire. E, Specimen radiograph documents removal of the clip. Histologic exami-
nation showed intraductal papilloma.
Ultrasound-guided wire localization is a useful alter-

native to mammographic wire localization if an intra- KEY POINTS
ductal mass is visible by US.
Core biopsy using either stereotactic guidance after a n Nipple discharge is caused by benign processes
galactogram or with ultrasound guidance will yield a in over 90% of cases but may be a presenting
definitive diagnosis in most women with an intraductal sign of malignancy.
mass, but will often not provide relief of the patient’s n The most suspicious presentation is spontaneous
symptoms. Excision is both diagnostic and therapeutic. bloody discharge. Serous discharge may also be
Immediate excision may be performed following galac- caused by malignancy. Galactography evaluates
tography with wire localization of the intraductal mass
the entire duct system and is useful in identifying
and injection of dye into the offending duct. With this
approach, galactography has to be performed only once. the location of ductal lesions and in guiding surgi-
The downside is that time in the operating room may be cal management.
n US is useful for identifying and localizing lesions
held unnecessarily if the galactogram is negative or
unsuccessful. of the central ducts.
Repeat galactogram on the day of surgery with local- n MRI can be used to evaluate nipple discharge
ization and injection of dye into the offending duct allows when galactography is unsuccessful and US is
more flexible scheduling of operating room time. negative or inconclusive.
However, it is sometimes difficult to repeat cannulation
of the same duct.
References
If the Attempt at Galactography Fails
Baker KS, Davey DD, Stelling CB. Ductal abnormalities detected with
Sometimes that duct orifice seems to know that you have galactography: Frequency of adequate excisional biopsy. Am J Roent-
a meeting at noon and will not relax. Warm compresses genol 1994;162:821-824.
and distracting conversation about family or other per- Cardenosa G, Doudna C, Eklund G. Ductography of the breast: Tech-
niques and findings. Am J Roentgenol 1994;162:1081-1087.
sonal interests may help the patient relax. If you still Gomez A, Mata JM, Donoso L, Rams A. Galactocele: Three distinctive
cannot cannulate the duct, another attempt can be made radiographic appearances. Radiology 1986;158(1):43-44.
in a week or two. Imaging with other modalities such as Hou MF, Huang TJ, Liu GC. The diagnostic value of galactography in
US and MRI can be used as well. However, do not let the patients with nipple discharge. J Clin Imaging 2001;25:75-81.
patient disappear. Just because the discharge goes away Nicholson BT, Harvey JA, Cohen MA. Nipple-areolar complex:
Normal anatomy and benign and malignant processes. Radiographics
does not mean that she does not have breast cancer. At a 2009;29(2):509-523.
minimum, we see our patients back for a unilateral ipsi- Tabar L, Dean PB, Pentek Z. Galactography: The diagnostic procedure
lateral mammogram in 6 months. of choice for nipple discharge. Radiology 1983;149:31-38.
CASE QUESTIONS
CASE 15-1. A lovely 84-year-old woman is waiting for you to perform her galactogram. When
you walk in the room, she is rubbing her temples. You ask her to tell you about her discharge
and she says, “I feel like I’m going to have a baby.” She has copious bilateral milky discharge.
Her mammogram is shown here. What is the most likely cause of her discharge? Does she need
a galactogram?
CASE 15-2. A 45-year-old woman has had several episodes of bloody discharge over the last
few months. What do think of her galactogram? How would you manage her?
CASE 15-3. This 64-year-old woman has noticed spots of blood on her bra. Her mammogram
is normal. She had a benign stereotactic biopsy 5 years ago. Here is her galactogram. What is
the most likely diagnosis? What is your recommendation?
CASE 15-4. A 55-year-old woman has heme-positive serous nipple discharge. How would you
interpret her galactogram?
CASE 15-5. A 32-year-old woman presents with right nipple discharge and a palpable lump
(triangle). What is the most likely diagnosis? What are your BI-RADS assessment and
recommendation?
CASE 15-6. A 69-year-old woman has noticed occasional damp spots on her nightgown over
the right breast. On examination, she has serous discharge from a single duct on the right nipple.
It tests heme-positive. Her mammogram is normal. A galactogram is attempted, but no discharge
could be expressed on the day that she presented for the test. What do you suggest?
This is a good story for pathologic discharge in a postmenopausal woman. Discharge severity
can wax and wane, so we must continue to pursue the cause even if there is currently no dis-
charge. If galactography cannot be performed, consider performing an MRI. She underwent
central duct excision showing atypical ductal hyperplasia (ADH). What do you think of her post-
operative MRI?
CASE 15-7. A 46-year-old woman is referred for evaluation of bloody discharge from the left
nipple. Magnification views of the left breast were obtained. How would you describe the find-
ings? What do you recommend? Galactography was performed. What are the findings?
CASE 15-8. A 63-year-old woman with a history of left mastectomy presents with new, spontane-
ous, clear and bloody discharge from the right nipple. Galactography was unsuccessful. Mam-
mography and US were negative. What do you recommend?
CASE 15-9. A 69-year-old woman presents with left nipple discharge. What are the mammo-
graphic findings?
CASE 15-10. A 49-year-old woman with history of benign ultrasound-guided core biopsy of a
complicated cyst in the left breast 9 months ago, now presents with a 5-month history of intermit-
tent left nipple bloody discharge. What do you think about her galactogram? What is the most
likely cause of her discharge?
CASE ANSWERS
CASE 15-1. Her mammogram is normal other than being very dense for her age. Her discharge
is almost certainly due to a pituitary prolactinoma given her symptoms of breast engorgement
and headache. She does not need a galactogram. She may, however, need a brain surgeon.
CASE 15-2. There is abrupt duct termination just beneath the nipple. Because this is so close to
the nipple, there is no reason to place a clip. This lesion should be easily removed by central
duct excision. If you are not sure whether the lesion would be excised during a central duct exci-
sion, see whether one of your surgical colleagues can review the case with you before the patient
leaves. The surgeon can let you know whether he or she would like a clip placed. Diagnosis:
papilloma.
CASE 15-3. There are multiple filling defects in the ductal system that are highly concerning for
DCIS. An irregularly narrowed duct segment is seen anteriorly (arrow in image). A clip can be
placed at the time of galactography to aid in localization. Diagnostic core biopsy can also be
performed. Diagnosis: DCIS.
CASE 15-4. There are multiple intraductal masses. The tiny defects in some areas should not be
confused with air bubbles (arrows). She had extensive DCIS.
CASE 15-5. There is an oval, circumscribed mass in the right breast that correlates with the
palpable finding. On US, this corresponds to an intraductal mass. Given the history of nipple
discharge and the young age, papilloma is a likely diagnosis. Tissue diagnosis is needed,
however. BI-RADS 4: Suspicious finding. Ultrasound-guided wire-localization was performed
showing intraductal papilloma. Excision is not only diagnostic but also therapeutic, resulting in
elimination of the discharge.
CASE 15-6. There is segmental nonmass enhancement in the right lateral breast. The subareolar
rim enhancing “lesion” is due to the seroma from her recent central duct excision. Histologic
finding: extensive DCIS, intermediate grade.
CASE 15-7. There are coarse, heterogeneous calcifications with segmental distribution in the
medial breast. These are suspicious, especially given the history of bloody discharge. There are
multiple intraductal filling defects as well as ductal narrowing and truncation. On the galactogram
the abnormal duct system corresponds to the location of the calcifications. There is also suspicion
of an irregular mass medially (arrow). US showed an abnormal duct segment in the medial breast,
and ultrasound-guided core biopsy revealed invasive ductal carcinoma.
CASE 15-8. MRI can frequently identify the cause of suspicious nipple discharge when
galactography is unsuccessful. In this case, there was segmental nonmass enhancement in the
central lateral breast, as shown on the postcontrast T1 fat-saturation images below. Diagnosis:
high-grade DCIS.
CASE 15-9. There is ductal dilatation in the lateral left breast. This is a nonspecific finding that
is usually insignificant but may be caused by papilloma(s) or DCIS. US images of the 1 o’clock
position of the left breast 5 cm from the nipple is shown below. How can you aid surgical
management?
A small intraductal lesion was identified on US that is most likely a papilloma. Because US may
miss more peripheral lesions, galactography can also be performed prior to surgery to determine
whether other lesions are present. Excision will be facilitated by preoperative wire localization
using ultrasound guidance. Diagnosis: papilloma.
CASE 15-10. On the galactogram, contrast is filling the duct and center of the cystic lesion that
underwent biopsy. Although very uncommon, bloody discharge can be due to prior surgery, core
biopsy, trauma, or even cyst aspiration.

Nipple Discharge

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Nipple Discharge

Uploaded by

Copyright:

Available Formats

CHAPTER 15

Evaluation of Nipple Discharge

TABLE 15-1 Distinguishing Worrisome

POTENTIALLY CANCEROUS PROBABLY BENIGN

Unilateral Often bilateral

FIGURE 15-3 Duct Ectasia on Galactogram. The patient had a few

FIGURE 15-1 Benign Nipple Discharge. Multiduct green discharge.

FIGURE 15-2 Fibrocystic Changes on Galactogram. One large and

there is a known trigger point—a specific site that elicits

FIGURE 15-9 Air Introduced

Also known as ductography, galactography is our proce-

Managing the Abnormal

Nice job! You found an intraductal mass 3 cm behind the

FIGURE 15-10 MRI Evaluation of Nipple Discharge. In this patient,

Ultrasound-guided wire localization is a useful alter-

You might also like

Nipple Discharge

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Nipple Discharge

Uploaded by

Copyright:

Available Formats

CHAPTER 15

Evaluation of Nipple Discharge

TABLE 15-1 Distinguishing Worrisome

POTENTIALLY CANCEROUS PROBABLY BENIGN

Unilateral Often bilateral

FIGURE 15-3 Duct Ectasia on Galactogram. The patient had a few

FIGURE 15-1 Benign Nipple Discharge. Multiduct green discharge.

FIGURE 15-2 Fibrocystic Changes on Galactogram. One large and

there is a known trigger point—a specific site that elicits

FIGURE 15-9 Air Introduced

Also known as ductography, galactography is our proce-

Managing the Abnormal

Nice job! You found an intraductal mass 3 cm behind the

FIGURE 15-10 MRI Evaluation of Nipple Discharge. In this patient,

Ultrasound-guided wire localization is a useful alter-

You might also like

Nice job! You found an intraductal mass 3 cm behind the