Nipple discharge in reproductive age group women

Dr. Sujata MittalSr. Consultant – Gynec. Oncology

PARAS HOSPITALS, GURGAON

Breast and Nipple discharge

Hormone dependent sweat gland Responds to emotions

Hence secretions PhysiologicalPathological

situation

Nipple Discharge: Anatomy & Physiology

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 liningMammary ducts are the seat of origin of Breast cancer and hence of significance. Stagnant pool

Anatomy & Physiology (Contd.)

Breast cancer studies have shown that majority of lesions are

multifocal within the

confines of single duct

Opportunity

Detect, Predict & TreatBC

Systematically via BLOOD At The WHOLE ORGAN The Individual ductal lobular structure

Partial list of Nipple Aspirate Fluids

Proteins Immunoglobulins Fats Hormones Electrolytes Cells

Alpha 1 lipoprotein IgA Lauric Prolactin Sodium Epithelial

Alpha 1 acid glycoprotein IgM Myristic Estrone Potassium Myoepithelial

Alpha 2 macroglobulin IgG H chain Myristoleic Estradiol Chloride Macrophages

Alpha 2 HS glycoprotein IgG L chain Palmitic DHEAS Calcium Neutrophils

Alpha 1 antitrypsin IgE Palmitoleic Progesterone Phosphate Lymphocytes

Trypsin IgD Cholesterol Growth hormone Mast Cells

Beta liprotein Cholesterol epoxides Testosterone Erythrocytes

Beta glycoprotein III TGF-α

Ceruloplasmin EGF

Definition of Discharge

When Secretions abundant/persistent enough to DISCHARGE SPONTANEOUSLY from DUCT ORIFICE DISCHARGE

Definition of discharge

If Ductal system is Normal Physiological

If Ductal system affected Pathological

Types of discharges associated with cancer

• Watery: 45%• Sanguineous: 25%• Serosanguinous: 12%• Serous: 6%

•Bloody: < 3%

Types of Discharges with etiology

Lactation

Physiological

Pathological

• 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/ Malignancy

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• CRF• Herpes Zoster• Thoractomy scar• Hypernephroma• Bronchogenic Carcinoma

Evaluation

Take Home Message

• Breast Manipulation• Normal Breast Secretions

Non spontaneous

•Unilateral Multiple Duct Benign F/U •Unilateral Single Duct Breast Path/BC USG+- Mammo If Normal Excise HPR

Spontaneous

•B/L Systemic Cause/ Galactorrhoea•Non Galactorrhoea Evaluate on principles of Unilateral

Spontaneous

Mammography

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

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

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

FNAC

Quite Sensitive

If Aspirate is less

Indicated

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

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.

HPR

• Excision of duct• Reference To Onco surgeon

Nipple Discharge

Q. Which of the following history questions is LEAST helpful in assessing woman with Breast discharge complaint?

1. Is the discharge spontaneous (comes out on its own) or only with expression of the nipple?

2. Is the discharge unilateral or bilateral?

3. What color is the discharge?

4. Is there pain associated with the discharge?

Duct Ectasia (periductal mastitis)

Benign Disease in middle aged to elderly femalesCan mimic malignancyPathological 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).

Duct Ectasia (Contd.)

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).

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.

Thank you