In this episode of PodMD, breast and endocrine surgeon, Dr Susannah Graham tells us a little more about nipple discharge; causes, treatment and more.
Please note this is a machine generated transcription and may contain some errors.
*As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.
Dr Sean Mackay Today I’d like to welcome to the PodMd studio Dr Susannah Graham is an Australian trained breast and endocrine surgeon, with a special interest in oncoplastic breast surgery, breast reconstruction, thyroid surgery, parathyroid surgery and minimally invasive parathyroid surgery.
Today, we’ll be discussing the topic of breast lumps
*We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.
Susannah, thanks for talking with us on Pod MD today.
The topic of today’s discussion is breast lumps. Susannah, can you describe for our listeners what breast lumps technically are?
So nipple discharge is the release of fluid from the nipple. Um, again, it’s another really common breast symptom. Um, and in most cases is part of normal function of the breast. Uh, do you want me to do it again without the siren? Sorry. I apparently leave on a siren route even though I’m on the fifth floor. Um, okay. So nipple discharge is the release of fluid from the nipple. It’s a very common breast symptom and in most cases is part of the normal function of the breast rather than being caused by any abnormality or problem.
Um, nipple discharge in isolation. So that is without a lump or any other nipple change is very uncommonly a symptom of breast cancer. Um, discharged can come from one or a number of the ducts that open onto each nipple. And commonly there are up to about 15 or 20 milk ducts opening onto each nipple. Okay. So when then is liquid discharge abnormal? So, uh, sorry. Um, Oh, sorry. I wanted to add into the back of that. Um, so the primary goals of evaluation and management are to differentiate patients with benign nipple discharge from those with an underlying abnormality. Um, and then, sorry, can the next question be what are the features of nipple discharge?
When is nipple discharge abnormal?
So nipple discharge can be spontaneous or expressible. So spontaneous nipple discharge is fluid that comes out without any squeezing of the nipple or any pressure on the breast. And expressible a nipple discharge is fluid that only comes out when the nipple is squeezed or there’s pressure on the breast. So it’s important to differentiate between spontaneous versus, um, nipple discharge that occurs on expression. The other thing to differentiate between is whether the discharge is coming from one duct. So I am sorry whether the nipple discharge is in one breast, so unilateral or coming from both breasts, bilateral. Um, whether it’s coming from one duct.
So, uh, whether it’s coming from one duct or multiple ducts, so you need ductal or multi ductal. Um, hang on, I’m, I, I’m going mad. Hang on, hang on, hang on. So whether the duct, sorry. So rather than you need Octo, so whether it’s coming from one duct, so single duct, um, or whether it’s multi duct coming out of multiple ducts. Um, the other important question to find out, um, the other important thing to out is what color it is. So a nipple fluid is most commonly yellow, green or Milky. Um, and this is usually not a cause for concern, whereas discharge that’s bloodstained. Um, so, and that can either be bright red or darkish Brown, um, or Cirrus nipple discharge is more significant. So it’s difficult sometimes to tell what color it is. Um, because women don’t often sort of take notice. So, uh, putting some fluid on a white tissue can actually be helpful in differentiating what color the nipple discharge actually is.
Okay, great. Um, we’ll have to hash those on it, but can you tell us when Nick would discharge? Sure. Um, so spontaneous nipple, NIS spontaneous nipple discharge that is not related to pregnancy or breastfeeding is considered abnormal. Um, having said that, in most cases it’s due to a non cancerous or benign cause. However, um, spontaneous nipple discharge caused by an underlying pathological process in the breast is more likely to be from one breast. So unilateral confined to a single duct, um, and is more commonly clear or bloodstained. Always remember though, that nipple discharge associated with any other symptom in the breast such as a lump or ulceration or inversion of the nipple needs prompt investigation, even if it’s not spontaneous or bloodstained what causes abnormal.
What causes abnormal nipple discharge?
Um, so there are many causes of nipple discharge. Um, these include duct ectasia, duct papillomas, nipple, eczema, breast cancer, Paget’s disease of the nipple, hormonal causes and drugs and medication. Um, so to go into these in a little bit more detail. Um, duct ectasia is a condition where the milk ducts under the nipple enlarge. Um, and there’s inflammation of the walls of the ducts. It’s most common Lea in postmenopausal women. The duct discharge, uh, the nipple discharge caused by duct ectasia is usually from both breasts, is yellowish greenish, brownish in color, and usually comes from more than one duct. Um, in most cases, no treatments needed. But if the discharge is a nuisance, um, then surgical treatment can be considered to remove the ducts from behind the nipple.
Papilloma is probably the most common cause of a serious or bloodstained nipple discharge, um, which comes from one breast and from a single duct. Um, it may cause no symptoms or it may cause this nipple discharge. Um, rarely duct papillomas can be associated with breast cancer. Um, and sometimes they are difficult to diagnose on a needle biopsy and need to be removed surgically. Um, or sorry. And, uh, they can be difficult to diagnose confidently on a needle biopsy and need surgical removal in order to make a definitive diagnosis. So commonly duct papillomas are surgically removed in order to confirm the diagnosis. Nipple, eczema or dermatitis, um, can affect the skin of the nipple similarly to how it affects skin on any other part of the body. Um, and the treatment for it is the same as eczema anywhere else on the body with steroid based creams as the first line treatment. I think the important thing here is to um, ensure that, um, if there is any suspicion or first-line treatments are not responding quickly, that a punched biopsy or a skin biopsy of the nipple is performed, um, in order to differentiate between nipple, eczema and Paget’s disease of the nipple.
So Paget’s disease of the nipple is another cause of nipple discharge. Um, and what, uh, and in this case there’s ulceration or erosion of the nipple skin and that can be associated with a bloodstain nipple discharge. Paget’s disease of the nipple is a type of ductal carcinoma in sideshow in the Paget’s disease is a type of ductal carcinoma in sight two and can be associated with underlying invasive breast cancer as well. Um, and needs to be treated as, uh, with, uh, and so if, um, if it’s diagnosed, um, this should prompt referral to a specialist breast surgeon in order to, um, so that the patient can receive appropriate treatment, um, breast cancer as well as another uncommon cause of nipple discharge. So less than 5% of women with breast cancer have nipple discharge. Um, and I guess reassuringly from, um, the case of, uh, reassuringly for GPs. Most of these women have other symptoms such as a lump or new nipple inversion as well as the nipple discharge rather than nipple discharge in isolation. Um, hormonal causes and drugs and medications are other, um, common, um, causes for nipple discharge.
Um, and these are not associated with any sort of underlying breast pathology per se, um, but can require further investigation, um, to ensure that there’s no abnormality of the pituitary or thyroid gland. Um, and medications such as the oral contraceptive pill, hormone replacement therapy, um, and some medications used for treatment of nausea and depression and psychiatric disorders can be associated with, um, nipple discharge as a side effect.
What investigations should be performed for a patient with nipple discharge?
Um, yeah, so I think, um, you know, uh, with as with any breast symptom or thorough a triple assessment should be performed. Um, so starting with a clinical evaluation, a thorough history and physical examination, this should be followed by breast imaging. Um, so a bilateral breast ultrasound and mammography in the first instance, um, the [inaudible] [inaudible] if any abnormalities found on these investigations or on these tests, a biopsy might be recommended, a biopsy would be recommended. Um, and it would depend on what the imaging findings usually are as to what sort of biopsy should be performed.
I think it’s important to say that if, um, if there is pathological nipple discharge, I, uh, that is a single duct spontaneous nipple discharge that is Cirrus or bloodstained. Even in the absence of other physical examination findings or imaging findings, that specialist referral is recommended because often we will, um, the next investigation will be a surgical excision of that duct to ensure that there’s no underlying tissue abnormality.
How is nipple discharge treated?
Yeah, good question Sean. And so I think the thing to remember here is that it really relates back to what the underlying cause of the nipple discharge is. Um, in order to know what the treatment is. Um, sometimes it can be a matter of reassuring, um, the woman that this is physiological or you know, a benign, um, change that doesn’t necessitate any treatment. And as I said before, occasionally we will, um, offer treatment and in the form of duct excision if the nipple discharge is becoming worrisome or troublesome for the lady. Mmm. Otherwise, um, surgery for nipple discharge is, is warranted for cases where a significant abnormality like a papilloma or even, you know, breast cancer or DCIS is suspected. Um, as I said earlier, surgery is usually needed as well for any woman with bloodstains nipple discharge in the absence of any other abnormalities on examination, um, in order to confirm that there is no underlying or in order to assess for any underlying, um, tissue abnormality that may not be visible on investigations.
I think the other thing to remind patients is that if they have nipple discharge that is, um, on exp. So if we go, I guess maybe put this bit at the beginning. Um, so, so I think this is a really important, um, question Sean, because nipple discharge that’s diagnosed as physiological really requires no treatment. Um, it’s important for women to stop expressing or squeezing the nipple as this causes more fluid to be made. So, any fluid that they squeeze out will be replaced. Um, and so this sort of perpetuates the cycle of the nipple discharge. So usually the nipple discharge stops when women stop expressing any nipple discharge. That spontaneous bloodstained persistent and unrelated to pregnancy or breastfeeding should be investigated further. Um, and, um, and if any abnormalities found on these tests, we, um, we, we would recommend a biopsy. Um, if no abnormality is found, then we would go down the path of probably doing a diagnostic excision of the duct. This is called a microdiscectomy. Um, particularly in the case of single duct spontaneous nipple discharge. That is Cirrus or bloodstained. Um, and this is to ensure that there is no underlying abnormality causing the pathological nipple discharge.
Are there any new developments we should know about?
I sort of, um, um, so the, yeah, I guess the only thing I would say is, um, I, I think this isn’t a, so there are no new real developments so to speak. Um, I think the role of MRI, I think a question that people often have is whether an MRI is useful, um, in evaluating nipple discharge. Um, similarly, you know, I think MRI is an evolving imaging mode is an imaging modality that is, um, becoming increasingly used, um, in, uh, in, um, it’s, it’s a modality that’s being increasingly used in women with breast symptoms, um, particularly in the setting of the new, um, MBS numbers that have been introduced, um, that increase the usage of MRI, particularly in breast cancer. Um, and the use of MRI re and the, um, the indications that are now rebatable for breast cancer, uh, for the, the, the rebatable indications for breast MRI. Um, so I think the thing to remember about MRI though is that it’s a very sensitive test with really only moderate sense moderate. It is a very sensitive test with only moderate specificity. Um, so routine MRI for assessment of nipple discharge is not indicated because of the high rates of false positivity and somewhat limited availability of MRI guided biopsy.
When should a GP refer?
So, I think, uh, the obvious one is obvious is, um, any lady with a nipple discharge who has any underlying abnormality identified. Um, but then I think the important one to remember is the pathological nipple discharge in the absence of any underlying imaging findings.
What role does the GP play in the treatment of the condition?
I think the GP has a very important role. They need to, um, the GPs role is to differentiate between normal benign and abnormal diff nipple discharge in the first instance. Um, they’re crucial in performing the initial assessment, um, and then referral for appropriate investigations. Um, they also play a really important role in reassuring women, um, with normal or benign nipple discharge. Um, and then also referring women in, um, who have abnormal or pathological nipple discharge for appropriate further investigation and treatment.
Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on nipple discharge.
1. Nipple discharge is categorised as normal (lactation), benign (physiologic) or pathologic based on the characteristics of origin. Most nipple discharge is benign in origin.
2. Number two, pathologic nipple discharge is characterized by spontaneous, persistent, unilateral discharge limited to one duct. And that discharge can be serous or sero-sanguineous or sanguineous. So clear or bloodstained.
3. The workup of suspicious nipple discharge should include ultrasound and mammography to determine if are any underlying lesions. But pathological nipple discharge in the absence of imaging abnormalities should still be referred for specialist opinion.
Thanks for your time and the insights you’ve provided.
You’re most welcome. Thanks for having me.