nipple discharge in reproductive age group women
TRANSCRIPT
Nipple discharge in reproductive age group women
Dr. Sujata MittalSr. Consultant – Gynec. Oncology
PARAS HOSPITALS, GURGAON
Breast and Nipple discharge
Hormone dependent sweat gland Responds to emotions
Hence secretions PhysiologicalPathological
situation
Nipple Discharge: Anatomy & Physiology
Mammary ducts lined by actively dividing epithelial cells which slough
Orifice of non lactating women blocked by keratin plug
Ductal system responds to estrogen, progesterone and prolactin.(Pituitary Gland)
Hormones interplay in Pregnancy, lactation and in non lactating women
Pathological discharge is caused by growth or proliferation of mammary ductal epithelial liningMammary ducts are the seat of origin of Breast cancer and hence of significance. Stagnant pool
Anatomy & Physiology (Contd.)
Breast cancer studies have shown that majority of lesions are
multifocal within the
confines of single duct
Opportunity
Detect, Predict & TreatBC
Systematically via BLOOD At The WHOLE ORGAN The Individual ductal lobular structure
Partial list of Nipple Aspirate Fluids
Proteins Immunoglobulins Fats Hormones Electrolytes Cells
Alpha 1 lipoprotein IgA Lauric Prolactin Sodium Epithelial
Alpha 1 acid glycoprotein IgM Myristic Estrone Potassium Myoepithelial
Alpha 2 macroglobulin IgG H chain Myristoleic Estradiol Chloride Macrophages
Alpha 2 HS glycoprotein IgG L chain Palmitic DHEAS Calcium Neutrophils
Alpha 1 antitrypsin IgE Palmitoleic Progesterone Phosphate Lymphocytes
Trypsin IgD Cholesterol Growth hormone Mast Cells
Beta liprotein Cholesterol epoxides Testosterone Erythrocytes
Beta glycoprotein III TGF-α
Ceruloplasmin EGF
Definition of Discharge
When Secretions abundant/persistent enough to DISCHARGE SPONTANEOUSLY from DUCT ORIFICE DISCHARGE
Definition of discharge
If Ductal system is Normal Physiological
If Ductal system affected Pathological
Types of discharges associated with cancer
• Watery: 45%• Sanguineous: 25%• Serosanguinous: 12%• Serous: 6%
•Bloody: < 3%
Types of Discharges with etiology
Lactation
Physiological
Pathological
• Milk• Colostrum (can last up to 2 years post partum)• Bloody/Guiac Postive in 30% women in 2nd/3rd trimester
• Hyperprolactnaemia: Neurogenic stimulation, medications, stress• Exogenous/Endogenous Hormones, Endocrine abnormalities• Medical & surgical conditions
• Papilloma• Duct Ectasia• Eczema of skin• DCIS/ Malignancy
Etiology of Physiological Discharges
Neurogenic stimulation• Stress
• Sleep
• Exercise
• Excessive Stimulation
• High Midday Protein Meal
Medications• Hormones• Antidepressants• Antianxiolytics• H2Receptor Antagonists• Phenothiazines• Amphetamines• Antiemetics• Danazol• INH• Opiates• Antifungals
Medical & Surgical Conditions• Pituitary Adenoma• Hypothyroidism• CRF• Herpes Zoster• Thoractomy scar• Hypernephroma• Bronchogenic Carcinoma
Evaluation
Take Home Message
• Breast Manipulation• Normal Breast Secretions
Non spontaneous
•Unilateral Multiple Duct Benign F/U •Unilateral Single Duct Breast Path/BC USG+- Mammo If Normal Excise HPR
Spontaneous
•B/L Systemic Cause/ Galactorrhoea•Non Galactorrhoea Evaluate on principles of Unilateral
Spontaneous
Mammography
• Standard Imaging Technique• Microcalcifications/Other signs of malignancy But Not useful for diagnosis of etiology of ND But High NPV and Specificity(94%)
USG
• Non invasive• Limitations in small lesions without dialation &
with dense fatty tissue.• Duct Dilation, solid internal echoes, Duct wall
thickening in central or subareolar areas.• Important for FNAC
ND CYTOLOGY
• Simple and useful• Controversial as aspirate is normally very less.• Recent Studied revealed Sensitivity of 85% and Specificity of 97%.• Should always be done
FNAC
Quite Sensitive
If Aspirate is less
Indicated
DUCTOGRAPHY
• Secreting Duct is identified Canulated
Dye is Injected • More Sensitive than ND Cytology & MMG
But invasive, time consuming complications
• Can’t Differentiate between benign & Malignant
CEMRI
• Increasingly being used.• Diagnostic Sensitivity is 86-100% for invasive
Ca.• Diagnostic Sensitivity is 46-100% for
intraductal Ca.• Useful for evaluation of ND with occult disease• Useful for differentiating Benign & Malignant.
HPR
• Excision of duct• Reference To Onco surgeon
Nipple Discharge
Q. Which of the following history questions is LEAST helpful in assessing woman with Breast discharge complaint?
1. Is the discharge spontaneous (comes out on its own) or only with expression of the nipple?
2. Is the discharge unilateral or bilateral?
3. What color is the discharge?
4. Is there pain associated with the discharge?
Duct Ectasia (periductal mastitis)
Benign Disease in middle aged to elderly femalesCan mimic malignancyPathological feature: Dilated duct → engorged with breast secretion → infection →
retroareolar abscess → fibrosis → nipple retraction. Clinical features: Non Cyclical Mastalgia. Periareolar erythema. Nipple discharge: thick & creamy or greenish brown. Periareolar tender mass. -Nipple retraction (when healing occurs by fibrosis).
Duct Ectasia (Contd.)
Etiology: Not known. Smoking is implicated in pathogenesis.Investigations: o Mammogram: opaque mass of dilated ducts & skin indentation. - Cytology: for discharge.
Management: - Infection: aspiration & antibiotic. - Abscess: drainage. - Severe discharge or recurrent sepsis: mammadochectomy (nipple
ducts excised through a circumareolar incision preserving the nipple).
Intraduct papilloma
Benign. Occurring in middle-aged women. Clinical features: - Bloodstained discharge. - Bleeding from a single duct orifice - (pressure over a certain spot or the palpable mass). - Small mass: NOT usually. Investigation: - Mammogram (exclude carcinoma). - Cytology assessment. Management: - Duct orifice (bleeding) is identified: microdochectomy. - If not: excision of the major nipple ducts.
Thank you