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Nipple Discharge

The appearance of a discharge from the nipple of a nonlactating woman is frightening out of
proportion 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 16
patients (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%). In
8 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 with
increased 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 duct
orifice is surgically significant and warrants special attention ( Fig. 34-5 ). However, the
underlying cause is rarely a breast malignancy.

Figure 34-5 Common physical findings during breast examination. A, Paget's disease of the nipple. Malignant ductal cells invade
the 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 indirect
lighting 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 the
discharging duct. In this patient a papilloma was the source of her symptoms. D, Peau d'orange (skin of the orange) or edema of the
skin 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 of
the disease).

The most common cause of spontaneous nipple discharge from a single duct is a solitary
intraductal 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 from
multiple ducts is not usually a surgical problem. Bloody discharge from a single duct, as depicted

in Figure 34-5 , does require surgical biopsy to establish a diagnosis. Intraductal papilloma is
found in most of these cases.
Sumber : Sabiston