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Nipple Discharge

The appearance of a discharge from the nipple of a nonlactating woman is frightening out ofproportion to its medical significance. Nipple discharge is common and is rarely associated with

an underlying carcinoma. In one review of 270 subareolar biopsies for discharge coming from

one identifiable duct and without an associated breast mass, carcinoma was found in only 16patients (5.9%). In each of these cases the fluid either was bloody or tested strongly positive for

occult hemoglobin. In another series of 249 patients, breast carcinoma was found in 10 (4%). In8 of these patients a mass lesion coexisted with the discharge. In the absence of a palpable mass

or a suspicious mammogram, discharge is rarely associated with cancer.

It is important to establish whether the discharge comes from one breast or from both breasts,

whether it comes from multiple duct orifices or from just one, and whether the discharge is

grossly bloody or contains blood. A milky discharge from both breasts is termed galactorrhea. In

the absence of lactation or a history of recent lactation, galactorrhea may be associated withincreased production of prolactin. Radioimmunoassay for serum prolactin is diagnostic.

However, true galactorrhea is rare and is diagnosed only when the discharge is milky (contains

lactose, fat, and milk-specific proteins). Unilateral, nonmilky discharge coming from one ductorifice is surgically significant and warrants special attention ( Fig. 34-5 ). However, the

underlying cause is rarely a breast malignancy.

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Figure 34-5 Common physical findings during breast examination. A,Paget's disease of the nipple. Malignant ductal cells invadethe epidermis without traversing the basement membrane of either the subareolar duct or the epidermis. The disease appears as a

psoriatic rash that begins on the nipple and spreads off onto the areola and into the skin of the breast. B,Skin dimpling. Traction on

Cooper's ligaments by a scirrhous tumor is distorting the surface of the breast and producing a dimple best seen with angled indirectlighting during abduction of the arms upward. C,Nipple discharge. Discharge from multiple ducts or bilateral discharge is a common

finding in healthy breasts. In this case the discharge is from a single duct orifice and may signify underlying disease in thedischarging duct. In this patient a papilloma was the source of her symptoms. D,Peau d'orange (skin of the orange) or edema of theskin of the breast. This finding may be due to dependency of the breast, lymphatic blockage (from surgery or radiation), or mastitis.

The most feared cause is inflammatory carcinoma, in which malignant cells plug the dermal lymphatics (the pathologic hallmark ofthe disease).

The most common cause of spontaneous nipple discharge from a single duct is a solitaryintraductal papilloma in one of the large subareolar ducts under the nipple. Subareolar duct

ectasia producing inflammation and dilation of large collecting ducts under the nipple is common

and usually involves discharge from multiple ducts. Cancer is a very unusual cause of discharge

in the absence of other signs. In summary, nipple discharge that is bilateral and comes frommultiple ducts is not usually a surgical problem. Bloody discharge from a single duct, as depicted

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in Figure 34-5 , does require surgical biopsy to establish a diagnosis. Intraductal papilloma is

found in most of these cases.

Sumber : Sabiston