The secretion of fluid from the nipple of a newborn baby or any mature woman is not unusual, nor is it a sign of breast pathology, says a textbook, Breast Diseases.
Nipple discharge is not an uncommon complaint. At one breast clinic, using a special suction device, researchers were able to demonstrate nipple secretion in 83 per cent of the consecutive breasts examined.
Statistically, only five percent of the patients with breast problems present with nipple discharge. But it is the third most common complaint after breast lumps and pain. Breast lumps with or without pain account for 70 to 80 per cent of complaints.
What information a physician wants when a patient presents with nipple discharge?
1. Is it spontaneous or elicited? If it is elicited then probably it is benign. To be significant, nipple discharge should be true, spontaneous, persistent and non-lactational.
2. Is it from one nipple or both nipples? If it is from both nipples then the chances of serious pathology is small.
3. Is it from one duct or multiple ducts? Discharge from one duct is of more concern than from multiple ducts.
4. What is the color and consistency of the discharge? If it is milky (galactorrhea), multicolored and sticky, or pus then it is probably benign. Pus needs to be drained and infection taken care of. Galactorrhea should be investigated for a pituitary tumor. A multicolored and sticky secretion is usually due to dilated ducts (duct ectasia) near the nipple.
5. Is the discharge surgically significant? Yes, if it is clear (watery), serous (yellowish), pink (blood stained) or bloody. It may indicate presence of a polyp in a duct, fibrocystic changes, pre-cancerous changes or cancer.
What about investigations?
A smear from the discharge can be sent for microscopic examination to see if there are any cancer cells. But it is not a very reliable test in this type of situation. A mammogram may or may not pick up a lump. Special x-ray of the nipple with dye in the duct (ductogram) can be helpful if it picks up a lump.
So, how do we know if the discharge is due to cancer? Quite often one can never be sure. But certain signs and symptoms may suggest presence of cancer in the breast if:
-the discharge is watery, serous, pink, or bloody
-it is accompanied by a lump
-it is from one nipple
-it is from one duct
-if mammogram is abnormal
-and if a woman is over 50 years of age.
In one series of 249 patients with nipple discharge, only four per cent of the patients had cancer of the breast. Nipple discharge due to cancer is not that common but one can never know until appropriate investigations, including surgical biopsy, says there is no cancer.
What is the surgical management?
Most surgeons will recommend breast biopsy for all women with persistent spontaneous single duct nipple discharge, whether it is serous or bloody. However there are exceptions, in pregnant women and women on birth control pill usually secretion is not pathological.
Spontaneous multiple duct nipple discharge may occur in several benign conditions. Surgery is usually recommended to relieve profuse discharge.
Although nipple discharge is often due to benign conditions, it should not be ignored. Appropriate consultation and investigation should be undertaken to make sure a serious pathology is not missed.
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