(April 6, 2009 - Insidermedicine) At the 2008 San Antonio Breast Cancer Symposium, we spoke with Dr. Sarah McLaughlin, Assistant Professor of Surgery at the Mayo Clinic in Jacksonville, Florida.
If I had unilateral nipple discharge...
Dr. McLaughlin: If you have unilateral nipple discharge it is important that you contact your medical provider or primary care physician, and they would make a referral to an appropriate person--probably a breast surgeon or a general surgeon who does breast procedures. The important things about women with unilateral nipple discharge is, number 1--that it is in fact unilateral. Bilateral nipple discharge does not carry nearly the same concern as unilateral. And then, from there, the question becomes: how long have you had it? Is it new? Is it bloody or clear? Is it from one duct within the nipple or from multiple ducts? And, how long has it been present but more importantly, is it spontaneous? Does it come on its own? Do you notice it on your bra/pajamas when you wake up in the morning? Or is it only with expressing the breast do you notice the nipple discharge.
What should I expect on physical examination?
Dr. McLaughlin: On physical examination, again, you're going to expect a full breast exam, a bilateral exam, multi-positional--meaning sitting up and lying down--and, essentially, they're going to feel not only the breast tissue itself but also, a very close examination in which they push on the breast to see if that nipple discharge can be elicited or recreated. The other thing that is very important is that, after the physical exam is performed, documentation of whether or not the discharge is bloody or clear, from a single duct or multiple ducts. It is important to make sure you have an updated mammogram that documents whether or not there's any other abnormalities within the breast.
What is the difference between milky and bloody discharge?
Dr. McLaughlin: Milky discharge is generally considered to be physiologic--so, any woman who's previously breast-fed may have a milky discharge for a long period of time, postpartum. A bloody nipple discharge suggests that there's something going on within the duct. When we have nipple discharge, again, the key things that we worry about are whether it's spontaneous, unilateral, single duct. Bloody or clear is kind of a gray area because the incidence of finding something is the same whether it's clear or bloody. When we have new onset unilateral single duct, spontaneous nipple discharge obviously every woman's concern is that it's cancer. But in most cases, it's a benign pathology. It's either an intraductal papilloma--which is like a benign polyp of the breast ducts--or it's what we call duct ectasia--which is just some elongation of the ducts that fill with debris that, when it is compressed or the pressure builds up, can elicit this discharge. Of course, the reason that women seek to have it evaluated is to rule out the possibility of breast cancer. Breast cancer, in this type of discharge, is found anywhere between 3% to 10% of the cases that are actually taken to the operating room and have procedures done to evaluate the ducts. It's really variable. The Mayo data would suggest it's only 3%. After a very informed discussion with your physician then you can make decisions about additional steps.
What tests will be ordered?
Dr. McLaughlin: Honestly, this very much depends on the institution or your physicians level of comfort with imagers and what that physician has available to them. You should have a mammogram, and if that mammogram is normal, many people would recommend an ultrasound of the ducts behind the nipple to see if they can see anything--a papilloma or some duct ectasia behind the nipple itself. That may be enough to explain what's causing it and also, help determine, if you have surgery, and whether or not another part of the breast needs to be evaluated as well. Some institutions also do duct-ectography--which is essentially inserting a little bit of dye into the duct itself. An x ray is then taken to kind of give you a map of the ductal system to see if there is something within the duct that could be causing these symptoms. The problem with that is that, again, it's very specific for who's doing the test. In other words, which physician is doing the test. And, half of the time, the test may be helpful and offer good information, while the other half of the time the data might be inconclusive or the test is unable to be performed--they can't get the needle in the duct the right way or the pictures aren't very good. Certainly, some institutions are better than others and it really depends on what you have available.
Dr. McLaughlin: If I had unilateral spontaneous nipple discharge from a single duct duct distribution, I would want to notify my physician and let them know that this is something new. In physical exam, they would document the occurrence of the nipple discharge as well as conduct appropriate imaging studies--certainly, a mammogram or possibly an ultrasound. At that point, there would be further discussion on whether the area should be excised.