Surgical management of pathologic nipple discharge
- Roshni Rao, MD
Roshni Rao, MD
- 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 third most common breast-related complaint, after breast pain and breast mass. During their reproductive years, up to 80 percent of women will have an episode of nipple discharge . Nipple discharge is categorized as normal milk production (lactation), physiologic nipple discharge, or pathologic (suspicious) nipple discharge. The most common causes of pathologic nipple discharge are benign intraductal papilloma (35 to 48 percent), ductal ectasia (17 to 36 percent), and carcinoma (5 to 21 percent) .
Surgical management of pathologic nipple discharge is discussed here. Other aspects of nipple discharge are discussed elsewhere. (See "Nipple discharge".)
DEFINITION OF PATHOLOGIC NIPPLE DISCHARGE
Pathologic nipple discharge is defined by the presence of one or more of the following:
●Unilateral nipple discharge
●Bloody nipple discharge
- Expert Panel on Breast Imaging:, Lee SJ, Trikha S, et al. ACR Appropriateness Criteria(®) Evaluation of Nipple Discharge. J Am Coll Radiol 2017; 14:S138.
- Hussain AN, Policarpio C, Vincent MT. Evaluating nipple discharge. Obstet Gynecol Surv 2006; 61:278.
- Onstad M, Stuckey A. Benign breast disorders. Obstet Gynecol Clin North Am 2013; 40:459.
- 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 (Accessed on March 01, 2009).
- Bahl M, Baker JA, Greenup RA, Ghate SV. Diagnostic Value of Ultrasound in Female Patients With Nipple Discharge. AJR Am J Roentgenol 2015; 205:203.
- El-Sayed ME, Rakha EA, Reed J, et al. Predictive value of needle core biopsy diagnoses of lesions of uncertain malignant potential (B3) in abnormalities detected by mammographic screening. Histopathology 2008; 53:650.
- Chang JM, Cho N, Moon WK, et al. Does ultrasound-guided directional vacuum-assisted removal help eliminate abnormal nipple discharge in patients with benign intraductal single mass? Korean J Radiol 2009; 10:575.
- Jaffer S, Nagi C, Bleiweiss IJ. Excision is indicated for intraductal papilloma of the breast diagnosed on core needle biopsy. Cancer 2009; 115:2837.
- Ahmadiyeh N, Stoleru MA, Raza S, et al. Management of intraductal papillomas of the breast: an analysis of 129 cases and their outcome. Ann Surg Oncol 2009; 16:2264.
- Maxwell AJ. Ultrasound-guided vacuum-assisted excision of breast papillomas: review of 6-years experience. Clin Radiol 2009; 64:801.
- Wei H, Jiayi F, Qinping Z, et al. Ultrasound-guided vacuum-assisted breast biopsy system for diagnosis and minimally invasive excision of intraductal papilloma without nipple discharge. World J Surg 2009; 33:2579.
- Jackman RJ, Nowels KW, Shepard MJ, et al. Stereotaxic large-core needle biopsy of 450 nonpalpable breast lesions with surgical correlation in lesions with cancer or atypical hyperplasia. Radiology 1994; 193:91.
- Darling ML, Smith DN, Lester SC, et al. Atypical ductal hyperplasia and ductal carcinoma in situ as revealed by large-core needle breast biopsy: results of surgical excision. AJR Am J Roentgenol 2000; 175:1341.
- Brem RF, Behrndt VS, Sanow L, Gatewood OM. Atypical ductal hyperplasia: histologic underestimation of carcinoma in tissue harvested from impalpable breast lesions using 11-gauge stereotactically guided directional vacuum-assisted biopsy. AJR Am J Roentgenol 1999; 172:1405.
- Hayes BD, O'Doherty A, Quinn CM. Correlation of needle core biopsy with excision histology in screen-detected B3 lesions: the Merrion Breast Screening Unit experience. J Clin Pathol 2009; 62:1136.
- Dillon MF, McDermott EW, Hill AD, et al. Predictive value of breast lesions of "uncertain malignant potential" and "suspicious for malignancy" determined by needle core biopsy. Ann Surg Oncol 2007; 14:704.
- Hermansen C, Skovgaard Poulsen H, Jensen J, et al. Palpable breast tumours: "triple diagnosis" and operative strategy. Results of a prospective study. Acta Chir Scand 1984; 150:625.
- Hermansen C, Skovgaard Poulsen H, Jensen J, et al. Diagnostic reliability of combined physical examination, mammography, and fine-needle puncture ("triple-test") in breast tumors. A prospective study. Cancer 1987; 60:1866.
- Martelli G, Pilotti S, Coopmans de Yoldi G, et al. Diagnostic efficacy of physical examination, mammography, fine needle aspiration cytology (triple-test) in solid breast lumps: an analysis of 1708 consecutive cases. Tumori 1990; 76:476.
- Weishaar J, Rummel WD, Kindermann G. [Demonstration of mammary ducts with water soluble contrast media (galactography) in secerning breasts. 1st results]. Fortschr Geb Rontgenstr Nuklearmed 1970; 112:1.
- Montroni I, Santini D, Zucchini G, et al. Nipple discharge: is its significance as a risk factor for breast cancer fully understood? Observational study including 915 consecutive patients who underwent selective duct excision. Breast Cancer Res Treat 2010; 123:895.
- Tabár L, Dean PB, Péntek Z. Galactography: the diagnostic procedure of choice for nipple discharge. Radiology 1983; 149:31.
- Cardenosa G, Doudna C, Eklund GW. Ductography of the breast: technique and findings. AJR Am J Roentgenol 1994; 162:1081.
- Kalisher L, Rickert RR, Sharo RJ. Solitary peripheral papilloma of the breast: a radiologic-pathologic correlation of a benign lesion that may mimic breast cancer on mammography. AJR Am J Roentgenol 1998; 171:605.
- 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.
- Nelson RS, Hoehn JL. Twenty-year outcome following central duct resection for bloody nipple discharge. Ann Surg 2006; 243:522.
- Lanitis S, Filippakis G, Thomas J, et al. Microdochectomy for single-duct pathologic nipple discharge and normal or benign imaging and cytology. Breast 2008; 17:309.
- Wong L, Chung YF, Wong CY. Microdochectomy for single-duct nipple discharge. Ann Acad Med Singapore 2000; 29:198.
- Al-Saleh N. Bilateral ductal carcinoma in situ (DCIS) in a male breast: a case report. Gulf J Oncolog 2011; :68.
- Kelly VM, Arif K, Ralston S, et al. Bloody nipple discharge in an infant and a proposed diagnostic approach. Pediatrics 2006; 117:e814.
- Reynolds A. Stereotactic breast biopsy: a review. Radiol Technol 2009; 80:447M.
- Love SM, Barsky SH. Anatomy of the nipple and breast ducts revisited. Cancer 2004; 101:1947.
- Ohtake T, Kimijima I, Fukushima T, et al. Computer-assisted complete three-dimensional reconstruction of the mammary ductal/lobular systems: implications of ductal anastomoses for breast-conserving surgery. Cancer 2001; 91:2263.
- Brookes MJ, Bourke AG. Radiological appearances of papillary breast lesions. Clin Radiol 2008; 63:1265.
- Ganesan S, Karthik G, Joshi M, Damodaran V. Ultrasound spectrum in intraductal papillary neoplasms of breast. Br J Radiol 2006; 79:843.
- Rusby JE, Brachtel EF, Michaelson JS, et al. Breast duct anatomy in the human nipple: three-dimensional patterns and clinical implications. Breast Cancer Res Treat 2007; 106:171.
- Williams FM, Bergin JD. Cardiac screening before noncardiac surgery. Surg Clin North Am 2009; 89:747.
- Siemssen OJ, Blichert-Toft M, Pedersen ML, et al. Mammography directed wire marking of nonpalpable breast lesions. A consecutive biopsy study of 100 patients. Acta Chir Scand 1981; 147:525.
- Jensen SR, Luttenegger TJ. Wire localization of nonpalpable breast lesions. Radiology 1979; 132:484.
- Kaufman CS, Jacobson L, Bachman B, Kaufman LB. Intraoperative ultrasonography guidance is accurate and efficient according to results in 100 breast cancer patients. Am J Surg 2003; 186:378.
- Rahusen FD, Bremers AJ, Fabry HF, et al. Ultrasound-guided lumpectomy of nonpalpable breast cancer versus wire-guided resection: a randomized clinical trial. Ann Surg Oncol 2002; 9:994.
- Thompson M, Henry-Tillman R, Margulies A, et al. Hematoma-directed ultrasound-guided (HUG) breast lumpectomy. Ann Surg Oncol 2007; 14:148.
- Smith LF, Henry-Tillman R, Harms S, et al. Hematoma-directed ultrasound-guided breast biopsy. Ann Surg 2001; 233:669.
- Rao R, Moldrem A, Sarode V, et al. Experience with seed localization for nonpalpable breast lesions in a public health care system. Ann Surg Oncol 2010; 17:3241.
- Hughes JH, Mason MC, Gray RJ, et al. A multi-site validation trial of radioactive seed localization as an alternative to wire localization. Breast J 2008; 14:153.
- Lavoué V, Nos C, Clough KB, et al. Simplified technique of radioguided occult lesion localization (ROLL) plus sentinel lymph node biopsy (SNOLL) in breast carcinoma. Ann Surg Oncol 2008; 15:2556.
- Mango VL, Wynn RT, Feldman S, et al. Beyond Wires and Seeds: Reflector-guided Breast Lesion Localization and Excision. Radiology 2017; :161661.
- Srivastava A, Griwan MS, Samaiyar SS, Sharma LK. A safe technique of major mammary duct excision. J R Coll Surg Edinb 1995; 40:35.
- Hadfield GJ. Further experience of the operation for excision of the major duct system of the breast. Br J Surg 1968; 55:530.
- HADFIELD J. Excision of the major duct system for benign disease of the breast. Br J Surg 1960; 47:472.
- Farion K, Osmond MH, Hartling L, et al. Tissue adhesives for traumatic lacerations in children and adults. Cochrane Database Syst Rev 2002; :CD003326.
- Morrogh M, Park A, Elkin EB, King TA. Lessons learned from 416 cases of nipple discharge of the breast. Am J Surg 2010; 200:73.
- Ma XP, Wang W, Kong Y, et al. A Novel Light-Emitting Wire Enhances the Marking and Visualization of Pathologic Mammary Ducts During Selective Microdochectomy. Ann Surg Oncol 2016; 23:796.
- Sakorafas GH. Nipple discharge: current diagnostic and therapeutic approaches. Cancer Treat Rev 2001; 27:275.
- Thevarajah S, Huston TL, Simmons RM. A comparison of the adverse reactions associated with isosulfan blue versus methylene blue dye in sentinel lymph node biopsy for breast cancer. Am J Surg 2005; 189:236.
- DEFINITION OF PATHOLOGIC NIPPLE DISCHARGE
- INITIAL APPROACH TO PATHOLOGIC NIPPLE DISCHARGE
- Palpable breast mass
- No palpable breast mass
- - Abnormal ultrasound or mammogram
- - Normal ultrasound and mammogram
- Unilateral discharge (bloody or nonbloody)
- - Galactography
- - Ductoscopy
- - Magnetic resonance imaging
- Bilateral bloody discharge
- PREOPERATIVE PREPARATION
- Surgical anatomy
- Anesthesia considerations
- SURGICAL TECHNIQUES
- Lesion not localized: Complete subareolar duct excision
- Lesion localized: Microductectomy
- POSTOPERATIVE CARE
- FOLLOW-UP CARE
- SUMMARY AND RECOMMENDATIONS