Spontaneous Unilateral Nipple Discharge ~ Algorithm 4
Breast Cancer Diagnostic Algorithms for Primary Care Providers
(Third Edition, June 2005)
Nipple
discharge is a common breast problem that has
been reported in 10-15% of women with benign
breast disease and in 2.5-3% of women with
breast cancer (Morrow, 2000). A nipple discharge
should be of concern when a woman reports it
as unilateral and
spontaneous (not in response to stimulation)
and staining her bra, bed sheet, or sleeping
garment.
Introduction to the work-up of Spontaneous Unilateral Nipple Discharge
~ Algorithm 4
Nipple discharge is a common breast problem that has been reported in 10-15% of women with benign breast disease and in 2.5-3% of women with breast cancer (Morrow, 2000). A nipple discharge should be of concern when a woman reports it as unilateral and spontaneous (not in response to stimulation) and staining her bra, bed sheet, or sleeping garment. Directly squeezing the nipple to express fluid promotes discharge and is not a routine part of the screening CBE in asymptomatic women. Using an aspiration pump will elicit a discharge from 50 to 80% of women without breast disease. Women should be advised to avoid checking themselves for discharge since benign discharge may resolve when the nipple is left alone (Morrow, 2000).
A number of conditions result in nipple discharge. Endocrine causes of galactorrhea include pregnancy, hypothyroidism and amenorrehic syndromes. Medications such as antihypertensives, oral contraceptives, phenothiazines, and tranquilizers may also cause nipple discharge. Milky discharge could be due to medications and the provider may want to consider ruling out this etiology prior to referral to a breast specialist.
Bilateral nipple discharge usually has a physiological cause, such as hyperprolactinemia leading to galactorrhea. It can also occur in breast disease that is bilateral, such as mammary duct ectasia. This is a benign condition occurring in postmenopausal women, characterized by dilation of the ducts, nipple secretions and periductal inflammation.
Every woman with a unilateral, spontaneous, clear, watery, serous, or bloody discharge should be referred for diagnostic imaging evaluation. Most mammograms in such instances are normal and should NOT deter surgical referral. Any discharge from a single duct is of concern. Multiple duct discharges are rarely caused by cancer (Florio, 2003). Any mammographic abnormality should correspond with the quadrant of the breast from which the discharge originates for it to be considered relevant to the cause of the discharge. Cytology in the assessment of nipple discharge is controversial and is generally not recommended as a first line investigation due to the high number of false negative results.
Flowchart Notes and Footer
NOTE 4A: A non-spontaneous discharge is not usually significant. It is more clinically relevant if a history of a spontaneous discharge is elicited. The patient should be asked whether she has noticed staining of her clothing. A true nipple discharge originates in one or more duct(s) (Apantaku, 2000). Inverted nipples, eczema, infection, etc can cause pseudo-nipple discharges.
NOTE 4B: It is important to determine if the nipple discharge is associated with a palpable mass. Any mass noted within 2 cm of the nipple is considered correlative (Sheen-Chen, 2001). Immediate referral for diagnostic imaging followed by surgical consultation is appropriate.
NOTE 4C: The diagnostic imaging abnormality should correspond with the quadrant from which the discharge originates (i.e. a radiographic abnormality that does not correlate to the discharge quadrant may represent a separate lesion). It is important to realize that a mammographic abnormality that corresponds to a palpable lesion may be a separate lesion that is not associated with the discharge. It may need a separate work-up and referral to a breast specialist.
NOTE 4D: Clinical re-evaluation of a woman with a BI-RADS® category 1 or 2 is recommended at 3 months and is intended to assure that the nipple discharge has resolved.
Footer:
*Diagnostic Imaging Evaluation should be accompanied by standard screening mammography of both breasts if screening mammography has not been conducted within the recommended timeframe. Diagnostic Imaging Evaluation will often include diagnostic mammogram and breast ultrasound, but can also include any radiographic imaging procedure recommended by the radiologist. A final BI-RADS category will be assigned to the case based on the results of all diagnostic imaging procedures. Women should return to routine screening once the diagnostic and/or treatment cycle is completed.
References
Apantaku, L. (2000). Breast cancer diagnosis and screening. American Family Physician , 62, 596-602, 605-6.
Florio, M. A., Fam, F., Giacombbe, G., Pollicino, A., Scarfo, P. (2003). Nipple discharge: personal experience with 2,818 cases. Chirurgia Italiana , 55(3), 357-363. Abstract obtained from PubMed, PMID: 12872570.
Morrow, M. (2000). Physical examination of the breast. In J. R. Harris, M. E. Lippman, M. Morrow, & C. K. Osborne, (Eds.), Diseases of the breast (2nd ed., pp. 67-70). Philadelphia: Lippincott, Williams and Wilkins.
Morrow, M. (2000). The evaluation of common breast problems. American Family Physician, 61, 2371-2378, 2385.
Sheen-Chen, S. M., Chen, H. S., Chen, W. J., Eng,
H. L., Sheen, C. W., Chou, F. F. (2001). Paget disease
of the breast - an easily overlooked disease? Journal
of Surgical Oncology, 76(4), 261-265.
Updated: May, 2008. |
