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45-year-old worried about nipple discharge

Dr Tanvir Jamil discusses

Dr Tanvir Jamil discusses

Case history

Samantha is a 45-year-old mother of three. She has had a nipple discharge for over three months. She thinks it came on after a fall at the gym but cannot be sure. She has been persuaded by her husband to have it checked. She does not have any family history of breast cancer.

Nipple discharge is not usually associated with serious pathology so does Samantha just need a bit of reassurance?

It's true that breast mass and occasionally pain are more commonly associated with breast disease, but nipple discharge may be a manifestation of breast cancer in almost 12 per cent of cases. It's also a huge source of anxiety and as such needs a very careful history and examination. Nipple discharge accounts for about 5 per cent of referrals to breast clinics.

Could she have false nipple discharge?

A true nipple discharge originates from the surface of the papillae and this can often be demonstrated with compression. A false nipple discharge is fluid that does not arise within the breast.

Causes for this include:

  • eczema
  • infected sebaceous cyst
  • nipple trauma
  • Montgomery's gland infection
  • cutaneous viral infection, eg herpes simplex, molluscus contagiosum
  • Paget's disease

With the exception of Paget's disease, these causes are not associated with breast cancer. Paget's refers to the presence of intraductal carcinoma of the breast associated with skin changes of the nipple or areola – usually unilateral. The skin lesion is often erosive and a bloody discharge is not uncommon. Interestingly not all patients with Paget's have a breast mass.

What is the significance of single-duct discharge?

Most breast cancers start as a unifocal lesion and involve just one breast segment, so patients have a single duct discharge – this is best seen via a magnifying glass. Palpate around the nipple-areola margin to see where compression causes a discharge.

Discharge that originates from multiple ducts is much less likely to be associated with breast cancer. This type of discharge may be caused by duct ectasia or breast infection. The former refers to dilatation of the large and intermediate breast ducts.

What about the nature of the discharge?

You can determine this by blotting drops of the discharge on white tissue. Look particularly at the colour at the margins of the blot. The discharge can then be roughly categorised. Various studies have assessed the frequency of association with breast cancer and nature of discharge (see table).

What should I be looking for in the examination?

Observation: asymmetry, change in breast contour, inverted nipple (new onset), local area of redness, skin retraction, Peau d'orange – indentation of skin over a mass that often looks like an orange peel.

On palpation look for breast mass, supraclacicular or axillary lymphadenopathy. The finding of a nipple discharge with a breast mass is very significant.

Are there any other significant associations?

Age is an important predictor of malignancy in women who present with nipple discharge alone:

  • Age <40 - risk of malignancy 3%
  • Age 40-60 - risk of malignancy 10%
  • Age >60 - risk of malignancy 32%

On examination Samantha has no associated breast masses.

Could she have galactorrhea?

In this condition the nipple discharge is bilateral, induced through stimulation, non-bloody, and multi-duct.

Is there a logical way to exclude the main causes of galactorrhoea?

If you look in a medical textbook, the causes of galactorrhoea run to several pages. The three main causes you need to consider are pregnancy, hypothyroidism and hyperprolactinaemia.

What do I need to do if my patient comes back with a high prolactin level?

All patients with hyperprolactinaemia need an MRI scan to exclude intracranial pathology. About 20 per cent of women with galactorrhoea will have a positive scan. This goes up to 35 per cent if the woman also has amenorrhoea. Occasionally, however, some pituitary adenomas are so small that they may escape imaging.

By this stage, however, you have probably referred your patient to a neurologist. They may elect to monitor her and look for development of signs and symptoms of a pituitary tumour and carry out regular scans.

Are there other causes for hyperprolactinaemia other than a pituitary tumour?

Many medications can cause a raised prolactin, although levels are usually much lower than in a pituitary adenoma:

  • antihypertensives: methyldopa, verapamil
  • psychiatric medications: chlorpromazine, haloperidol, perphenazine, sulpiride, fluphenazine
  • domperidone
  • cimetidine
  • oestrogens
  • metoclopromide

If a drug is the culprit, stopping medication should result in normalisation of prolactin levels and resolution of the galactorrhoea.

Lets get back to Samantha's case – thorough history and examination has revealed she has unilateral nipple discharge, no breast masses and no lymphadenopathy. It's difficult to tell if the discharge is single or multiple duct but it is slightly bloody.

Where do we go from here?

Any women presenting with a unilateral nipple discharge needs a mammogram. An abnormal mammogram will raise the suspicion of breast cancer. False-negatives are not uncommon. One study revealed a false negative rate of 9.5 per cent in nipple discharge.

So now what do I do?

That will probably be up to the surgeon running the breast clinic. Breast duct microendoscopy is a relatively new technique that allows direct visualisation of the ductal epithelia. A combination of brush cytology and microendoscopy may help decide if the nipple discharge is associated with breast cancer or not. If malignancy cannot be excluded or if the discharge is profuse and embarrassing, patients may be offered surgery – microdochectomy (surgical excision of the affected breast segment under general anaesthetic) for younger women; total duct excision may be offered to women aged over 45.

Tanvir Jamil is a GP in Burnham, Buckinghamshire, and a trainer

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