Bloody

Patient Presentation:A 42 year old white female came to the office

complaining of painless bloody discharge from her left nipple which had occurred suddenly.

The patient denied any breast pain or palpable lumps.

The patient does not have a family history of breast cancer and denies any trauma to the breast.

The remaining review of systems was negative including constitutional symptoms.

Physical ExamUpon physical exam the

patient’s breast was not erythematous or tender and no lumps were palpated.

The discharge retrieved from the left nipple tested heme positive.

The patient’s right breast was unremarkable as was the rest of her physical exam including her supraclavicular and axillary lymph nodes.

As shown here, Bertha will demonstrate the correct way to squeeze the nipple in hopes of retrieving discharge.

The patient had a routine mammogram which was completely normal.

The next step in our diagnostic process was for the patient to have a ductogram.

A ductogram is when contrast is injected into the affected milk duct and the duct is then x-rayed.

The patient’s ductogram revealed filling defects in the affected duct.

Does anyone know what could be

causing the patient’s bloody nipple discharge???

WELL…

Intraductal papillomas account for 90% of bloody nipple discharge (Falkenberry, 2002, 21)

2 main etiologies to rule out or in: intraductal papilloma and cancer

WARTS!! THEY’RE EVERYWHERE!!

Surgical measures are required as treatment and precaution incase the lesion is cancerous.

The nipple appeared very lobular at the time of surgery. A circumareolar incision was made ½ way around the nipple. The entire duct with the lesion of suspicion was excised from the breast. When examining the specimen, the duct was distended and full of papillomas. The specimen was sent to pathology for further evaluation. Nipple plastic reconstruction was performed to prevent inversion of the nipple. Subcuticular sutures were placed and the incision was closed with staples. There were no complications involved with the surgery.

Post-op subareolar excisional biopsy, the patient was doing very well. The incision site was clean and the nipple non-inverted. The pathology report read: intraductal papilloma with varying

degrees of infarction and duct was slightly inflamed.

• Intraductal papilloma is a benign finger-like growth (i.e. wart) inside the mammary ducts.

• Infarction with hemorrhage is thought to be the reason that papillomas produce a bloody discharge

• Discharge color can range from pink to rust to red and may come from one or more ducts.

• It is very important to test any nipple discharge for blood no matter the color. Some colored discharge may test heme negative whereas clear discharge may test heme positive.

• Usually found in the subareolar region, papillomas may be visible on imaging methods when the duct is widely distended. Mammographically most papillomas are not visible

• For further evaluation of nipple discharge it is recommended the patient under go a ductogram or ductography. A ductogram may reveal a dilated duct, filling defect or obstruction.

• Because intraductal papillomas can not be distinguished from cancer on any imaging method an excisional biopsy of the lesion is the definitive answer as cancer can not go unnoticed.

• After the pathology report is completed and the specimen of interest is an intraductal papilloma there is no specific treatment the patient must undergo.

Any Questions?

References:• http://www.nlm.nih.gov/medlineplus/ency/imagepages/17077.htm• http://www.obgyn.net/bh/images/Graphic16.jpg • http://www.bangkokhospital.com/images/img/breast06.jpg• http://www.bangkokhospital.com/images/img/breast05.jpg• Falkenberry, S. (2002). Nipple Discharge. Obstet Gynecol Clin North Am,

Vol. 29, p. 21-29• King, T., Carter, K., Bolton J., Fuhrman, G. (2000). A Simple Approach to

Nipple Discharge. Am Surg. Vol. 66, p. 960-965• Kopans, J., Daniel, B. (1998). Breast Imaging Edition 2. Philadelphia, PA:

Lippincott-Raven Publishers.• Sakorafas, G (2001). Nipple Discharge: Current Diagnostic and

Therapeutic Approaches. Cancer Treat Rev, Vol. 27, p. 275-282• Simmons, R., Adamovich T., Brennan M. (2003). Nonsurgical Evaluation of

Pathologic Nipple Discharge. Ann Surg Oncol. Vol 10, p. 113-116• Vargas H., Romero L., Chelbowski R. (2002). Management of Bloody Nipple

Discharge. Curr Treat Options Oncol. Vol. 3, p. 157-161