- Mehra Golshan, MD
Mehra Golshan, MD
- Associate Professor of Surgery
- Harvard Medical School
- Dirk Iglehart, MD
Dirk Iglehart, MD
- Professor of Surgery
- Harvard Medical School
- Section Editor
- Anees B Chagpar, MD, MSc, MA, MPH, MBA, FACS, FRCS(C)
Anees B Chagpar, MD, MSc, MA, MPH, MBA, FACS, FRCS(C)
- Section Editor — Breast Surgery
- Associate Professor, Department of Surgery
- Yale University School of Medicine
Nipple discharge is the one of the most commonly encountered breast complaints . Approximately 50 to 80 percent of women in their reproductive years can express one or more drops of fluid [2,3] and 6.8 percent of women referred to a surgeon because of symptoms of a breast disorder have nipple discharge . Most nipple discharge is of benign origin.
The primary goals of evaluation and management are to differentiate patients with benign nipple discharge from those who have an underlying papilloma, cancer, or high-risk lesion, and to manage patients with underlying pathologic nipple discharge [5-7]. Isolated papillomas are usually benign, but can harbor areas of atypia or ductal carcinoma in situ (DCIS). (See "Breast ductal carcinoma in situ: Epidemiology, clinical manifestations, and diagnosis" and "Ductal carcinoma in situ: Treatment and prognosis".)
The clinical history is most helpful in distinguishing benign from suspicious or pathologic nipple discharge . Benign nipple discharge is usually bilateral, multiductal, and occurs with breast manipulation. Conversely, the risk of cancer is higher when the discharge is spontaneous, bloody or guaiac positive, unilateral, uniductal, associated with a breast mass, and/or occurs in a woman over 40 years of age.
The types of nipple discharge and how to evaluate and manage this common problem will be reviewed here.
TYPES OF NIPPLE DISCHARGE
Nipple discharge is categorized as normal milk production (lactation), physiologic nipple discharge, or pathologic (suspicious) based on the characteristics of presentation. Each category is discussed below.
- Hussain AN, Policarpio C, Vincent MT. Evaluating nipple discharge. Obstet Gynecol Surv 2006; 61:278.
- Isaacs JH. Other nipple discharge. Clin Obstet Gynecol 1994; 37:898.
- Hughes, L, Mansel, R, Webster, D, Gravelle, I. Benign disorders and diseases of the breast. London, WB Saunders 2000.
- Santen RJ, Mansel R. Benign breast disorders. N Engl J Med 2005; 353:275.
- Murad TM, Contesso G, Mouriesse H. Nipple discharge from the breast. Ann Surg 1982; 195:259.
- Jardines L. Management of nipple discharge. Am Surg 1996; 62:119.
- King TA, Carter KM, Bolton JS, Fuhrman GM. A simple approach to nipple discharge. Am Surg 2000; 66:960.
- Neville MC, McFadden TB, Forsyth I. Hormonal regulation of mammary differentiation and milk secretion. J Mammary Gland Biol Neoplasia 2002; 7:49.
- Buhimschi CS. Endocrinology of lactation. Obstet Gynecol Clin North Am 2004; 31:963.
- Leung AK, Pacaud D. Diagnosis and management of galactorrhea. Am Fam Physician 2004; 70:543.
- Morley JE, Dawson M, Hodgkinson H, Kalk WJ. Galactorrhea and hyperprolactinemia associated with chest wall injury. J Clin Endocrinol Metab 1977; 45:931.
- Gioffrè Florio M, Manganaro T, Pollicino A, et al. Surgical approach to nipple discharge: a ten-year experience. J Surg Oncol 1999; 71:235.
- Vargas HI, Vargas MP, Eldrageely K, et al. Outcomes of clinical and surgical assessment of women with pathological nipple discharge. Am Surg 2006; 72:124.
- Nelson RS, Hoehn JL. Twenty-year outcome following central duct resection for bloody nipple discharge. Ann Surg 2006; 243:522.
- Kooistra BW, Wauters C, van de Ven S, Strobbe L. The diagnostic value of nipple discharge cytology in 618 consecutive patients. Eur J Surg Oncol 2009; 35:573.
- Woods ER, Helvie MA, Ikeda DM, et al. Solitary breast papilloma: comparison of mammographic, galactographic, and pathologic findings. AJR Am J Roentgenol 1992; 159:487.
- Lewis JT, Hartmann LC, Vierkant RA, et al. An analysis of breast cancer risk in women with single, multiple, and atypical papilloma. Am J Surg Pathol 2006; 30:665.
- Valdes EK, Feldman SM, Boolbol SK. Papillary lesions: a review of the literature. Ann Surg Oncol 2007; 14:1009.
- Mercado CL, Hamele-Bena D, Oken SM, et al. Papillary lesions of the breast at percutaneous core-needle biopsy. Radiology 2006; 238:801.
- Sydnor MK, Wilson JD, Hijaz TA, et al. Underestimation of the presence of breast carcinoma in papillary lesions initially diagnosed at core-needle biopsy. Radiology 2007; 242:58.
- Ciatto S, Andreoli C, Cirillo A, et al. The risk of breast cancer subsequent to histologic diagnosis of benign intraductal papilloma follow-up study of 339 cases. Tumori 1991; 77:41.
- Seltzer MH, Perloff LJ, Kelley RI, Fitts WT Jr. The significance of age in patients with nipple discharge. Surg Gynecol Obstet 1970; 131:519.
- Klimberg VS. Nipple discharge: more than pathologic. Ann Surg Oncol 2003; 10:98.
- Simmons R, Adamovich T, Brennan M, et al. Nonsurgical evaluation of pathologic nipple discharge. Ann Surg Oncol 2003; 10:113.
- Chen L, Zhou WB, Zhao Y, et al. Bloody nipple discharge is a predictor of breast cancer risk: a meta-analysis. Breast Cancer Res Treat 2012; 132:9.
- KLINE TS, LASH SR. THE BLEEDING NIPPLE OF PREGNANCY AND POSTPARTUM PERIOD; A CYTOLOGIC AND HISTOLOGIC STUDY. Acta Cytol 1964; 8:336.
- Lafreniere R. Bloody nipple discharge during pregnancy: a rationale for conservative treatment. J Surg Oncol 1990; 43:228.
- Scott-Conner CE, Schorr SJ. The diagnosis and management of breast problems during pregnancy and lactation. Am J Surg 1995; 170:401.
- Maier WP, Rosemond GP, Harasym EL Jr, et al. Paget's disease in the female breast. Surg Gynecol Obstet 1969; 128:1253.
- Gray RJ, Pockaj BA, Karstaedt PJ. Navigating murky waters: a modern treatment algorithm for nipple discharge. Am J Surg 2007; 194:850.
- CRICO/RMF Breast care management algorithm 2009 in preparation. www.rmf.harvard.edu/bca (2004 version) (Accessed on March 1, 2009).
- Sickles EA. Galactography and other imaging investigations of nipple discharge. Lancet 2000; 356:1622.
- Adepoju LJ, Chun J, El-Tamer M, et al. The value of clinical characteristics and breast-imaging studies in predicting a histopathologic diagnosis of cancer or high-risk lesion in patients with spontaneous nipple discharge. Am J Surg 2005; 190:644.
- Ballesio L, Maggi C, Savelli S, et al. Adjunctive diagnostic value of ultrasonography evaluation in patients with suspected ductal breast disease. Radiol Med 2007; 112:354.
- Cardenosa G, Doudna C, Eklund GW. Ductography of the breast: technique and findings. AJR Am J Roentgenol 1994; 162:1081.
- Morrogh M, Morris EA, Liberman L, et al. The predictive value of ductography and magnetic resonance imaging in the management of nipple discharge. Ann Surg Oncol 2007; 14:3369.
- Orel SG, Dougherty CS, Reynolds C, et al. MR imaging in patients with nipple discharge: initial experience. Radiology 2000; 216:248.
- Hirose M, Nobusawa H, Gokan T. MR ductography: comparison with conventional ductography as a diagnostic method in patients with nipple discharge. Radiographics 2007; 27 Suppl 1:S183.
- Ciatto S, Bravetti P, Cariaggi P. Significance of nipple discharge clinical patterns in the selection of cases for cytologic examination. Acta Cytol 1986; 30:17.
- Morrow, M, Jordan, VC. Role of breast epithelial sampling techniques. In: Managing Breast Cancer Risk, Decker, BC (Ed), London 2003. p.138.
- Escobar PF, Crowe JP, Matsunaga T, Mokbel K. The clinical applications of mammary ductoscopy. Am J Surg 2006; 191:211.
- Kapenhas-Valdes E, Feldman SM, Cohen JM, Boolbol SK. Mammary ductoscopy for evaluation of nipple discharge. Ann Surg Oncol 2008; 15:2720.
- Moncrief RM, Nayar R, Diaz LK, et al. A comparison of ductoscopy-guided and conventional surgical excision in women with spontaneous nipple discharge. Ann Surg 2005; 241:575.
- Uchida K, Fukushima H, Toriumi Y, et al. Mammary ductoscopy: current issues and perspectives. Breast Cancer 2009; 16:93.
- Khan SA, Wolfman JA, Segal L, et al. Ductal lavage findings in women with mammographic microcalcifications undergoing biopsy. Ann Surg Oncol 2005; 12:689.
- Alcock C, Layer GT. Predicting occult malignancy in nipple discharge. ANZ J Surg 2010; 80:646.
- Dennis MA, Parker S, Kaske TI, et al. Incidental treatment of nipple discharge caused by benign intraductal papilloma through diagnostic Mammotome biopsy. AJR Am J Roentgenol 2000; 174:1263.
- Cabioglu N, Hunt KK, Singletary SE, et al. Surgical decision making and factors determining a diagnosis of breast carcinoma in women presenting with nipple discharge. J Am Coll Surg 2003; 196:354.
- TYPES OF NIPPLE DISCHARGE
- Physiologic nipple discharge
- - Medication related causes
- - Neurogenic stimulation
- Other causes
- Pathologic (suspicious) nipple discharge
- CLINICAL EVALUATION
- Physical examination
- - Bilateral discharge
- - Unilateral discharge
- Differential diagnosis
- - Straw-colored or clear transparent discharge
- - Grossly bloody discharge
- - Guaiac positive discharge
- - Staining of the bra without obvious nipple discharge
- DIAGNOSTIC EVALUATION
- Laboratory examination
- - Mammography
- - Ultrasound
- - Ductography
- - Magnetic resonance imaging
- - MR ductography
- Cytologic examination
- Ductal lavage
- Skin punch biopsy
- Medical treatment for physiologic nipple discharge
- Surgical treatment for pathologic nipple discharge
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS