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EDITORIALS |
From the Division of Breast Surgical Oncology, Department of Surgery and Pathology, Central Arkansas Veteran’s Healthcare System, University of Arkansas for Medical Sciences, Little Rock, Arkansas.
Correspondence: Address correspondence to: V. Suzanne Klimberg, MD, Department of Surgery, University of Arkansas for Medical Sciences, 4301 West Markham, #725, Little Rock, AR 72205; Fax: 501-526-6191; E-mail: klimbergsuzanne{at}uams.edu
There is little we know about preoperative diagnosis of nipple discharge and this study1 along with others proves it. Nipple discharge, in general, is benign (>99%).2,3 Causes include in approximate descending order of frequency: lactation, pregnancy, postlactation, fibrocystic disease, intraductal papilloma, duct ectasia, nipple adenoma, infection, chronic mastitis, subareolar abscess, and probably least frequently by breast cancer (<1%).2 Ductography, ultrasound, and aspiration cytology are useful only when positive. Simmons et al.1 and others confirm their high false-negative rate and a small but somewhat consistent false-positive rate.4 Other tools not discussed include the emerging technologies of ductal lavage in combination with cytology and ductal endoscopy that may prove useful in the future.
The nature of the pathologic discharge as compared with that of the benign includes: spontaneity, unilaterality, single versus multiple ducts, and color of the discharge (serous or bloody versus milky, cheesy, purulent, green, black). Bilateral nonspontaneous, nonbloody discharge from multiple ducts is benign.5,6 A history of infection, endocrine disorders, pregnancy, or intake of drugs such as caffeine, nicotene, hormones, marijuana, antihypertensives, and cimetidine may indicate the cause of the benign discharge. Chronic milky discharge even years after breast-feeding is not uncommon. Chronic subareolar abscess is seen a majority of the time in the young (3rd and 4th decade) smoker. Ductal ectasia, a relatively unrecognized cause of benign nipple discharge, is seen in postmenopausal women.
Physical examination should characterize the color of the discharge, excluding palpable mass (chronic subareolar abscess or nipple adenoma) or changes in the nipple-areolar complex including signs of infection or skin changes such as seen with cancer. Pressure in a clockwise fashion around the areolar may help identify a specific site or duct that produces the discharge.
Gross examination and guaiac should be performed on all nipple discharge to reveal not only macroscopic but microscopic blood. Such routine examination may have increased the sensitivity of this method as compared with that of Simmons et al.1 Gram stain can be performed when there is a suspicion of infection. Examination of the nipple fluid under the office microscope will confirm fat in benign milky discharge. Cytological examination of nipple fluid is 
50% false-negative rate for cancer but was even less for Simmons et al.1,7 The problem with cytology is that you must have concordance with your clinical suspicion. That is you have to ignore clinically negative cytology in the face of a clinically suspicious nipple discharge. This is hard to quantify for any study. In any patient with potential endocrine abnormality prolactin, thyroid, and/or pregnancy tests should be performed.
Mammography is a must in any patient >40 to rule out associated underlying pathology. A negative mammogram should be ignored. Ultrasound can be used in the office when the discharge is not present at the time of examination of the patient. Ultrasound and cytology are useful but only when positive. The more cells that are obtained the more aggressive the technique (ductal lavage>aspiration>spontaneous nipple discharge).8 Ductography is abnormal almost 80% of the time yet not very specific.9 Cancer is more often located in the peripheral duct and has an irregular intraductal defect or obstruction as opposed to those patients with proximal ductal dilatation or torsion. Magnetic resonance imaging may be additive when suspicions are high and other tests are negative.
Successful treatment of nipple discharge is dependent on the correct diagnosis of the root cause. Most patients will be satisfied with reassurance and will respond to a decrease in methylxanthines (e.g., caffeine), nicotine, or other offending drugs with benign-appearing nipple discharges (bilateral, nonspontaneous, or bloody). Nipple discharge caused by chronic subareolar abscess is more difficult to treat. Biopsy should be taken with the initial drainage to rule out underlying cancer. Prevention of the typical recurrent episodes starts with withdrawal of nicotine and caffeine, progressing to chronic rotating antibiotics (e.g., erythromycin for 2 weeks of the month alternating monthly with doxycycline), danazol (100 ug twice daily), incision and drainage, and ductal excision. After multiple episodes some patients will opt for central mastectomy where the nipple-areolar complex is removed along with the immediate underlying ductal structures.
In pathological discharge, ductal excision is the only reliable way to both establish a diagnosis and control the discharge.5 Success is dependent on identifying the correct origin of ductal discharge. Clockwise palpation of the areolar, cannulation, or intraoperative ultrasound may help identify and direct excision. When a specific duct cannot be identified then nipple core biopsy or removal of the whole ductal system underneath the nipple-areolar complex is performed. Minimally invasive techniques for excision of benignities include image-guided vacuum-assisted core biopsy10 excision and in the future excision through the ductal endoscope.11
Received for publication December 23, 2002. Accepted for publication January 3, 2003.
REFERENCES
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