What should be performed for a patient who has nipple discharge.By: Dr. Seyed Reza Samsamshariat

Note: The present slides can be used if the reference is mentioned.

Nipple discharge may occur in a male or in a non-lactating female and is the symptom caused by several situations. In males there is usually an endocrine abnormality and in females the etiologies are more variable.

By the way the nipple discharge represents an abnormal symptom and the underlying

disease should be diagnosed.

Different kinds of nipple dischare

Frankly bloody Bloody Purulent

Serous( yellow &

clear )Watery Milky

The causes of nipple discharge in women

Malignancy

Breast carcinoma

Benign lesions

Papilloma Ductectasia

Endocrine disturbance

s

Pituitary adenoma

•Fine needle aspiration biopsy

•Open biopsy

There is a mass in the breast exam

•Fine needle aspiration biopsy

•Open biopsy

A mass is found in

mamography

•Cytologic examination of the discharge

•Measurement of prolactin level in serum

There is not any

evidence of tumor

What is the next step for evaluation of nipple discharge in a non-lactating

woman?

How is the discharge of the nipple collected for cytopathologic

examination?With special pump With pressure on

areola

The benign lesions causing nipple discharge :

Ductectasia Papilloma Tuberculo

sis

Others(as fungal infections)

The prevalence of malignancy when nipple discharge is seen

• 0.83%

• 0.13%

• 3.96%

• 0.16%

Serous dischar

ge

Bloody dischar

ge

Purulent

discharge

Milky dischar

ge

The breast cancers which induce nipple discharge:

Ductal carcinoma

Paget’s disease

• 47%Diagnosis of cancer

• 45%Suspicious cancer

• 8%Wrong

diagnosis as a benign lesion

The sensitivity of the cytopathologic examination of the nipple discharge.

The Cytopathologic results of the nipple discharges were as below in women with breast carcinoma:

Except the cytopatologic examination of the nipple discharge the values of the other tests ( as biochemistry or microbiology) are

Inappreciable. Variation of biochemical parameters in non-malignant

and malignant discharge

Parameters Non-malignant malignant CEA (µg mL-1) 5.0 10.0 LDH (µ L-1) 50.0

120.0 Protein (mg dL-1) 20.0 10.0 Cholesterol (mg dL-1) 80.0 40.0 Triglyceride (mg dL-1) 45.0 20.0 Occult blood (%) 25.0 Nil

Cytopathology of the nipple secretion ( and touch imprint preparations of the biopsy samples) can predict the

patient’s survival who has breast cancer. The presence of the sex chromatin ( arrows ) in 20% or more of the malignant cells which are seen in the cythopathologic or touch imprint samples means a favorable behavior of tumor regardless of tumor grade or stage at the time of biopsy.

References:

1• Koss. Leopold G. Diagnostic

Cytology. 4th edition. Philadelphia. J.B. Lippincott Company. 1992. Volume 2. 1221-1232

2•www.allamericanpatriots.com/news_topics/tuberculosis•http://health.allrefer.com/health/tinea-cruris-fungus.html

• http://t1.gstatic.com/images?q=tbn:ANd9GcQupYvuGiY56UkPWALWDrOe2cCeXRtC6uBPx_lt3qs2V54Bv6Aj

3 •INTERNATIONAL JOURNAL OF AGRICULTURE & BIOLOGY•1560-8530/2001/03-2-195-196•http://www.ijab.org

4 • http://www.medscape.org/viewarticle/713539_7